Fluorescent labeling of dissociated fetal cells for tissue culture.

The ability to pre-label cells used in transplantation experiments would have the potential benefits of identification of cell type and associated processes and the analysis of graft migration in the host. We have used an in vitro tissue culture system as a model to test several fluorescent dyes for this application. Fetal rat hippocampal tissue (E17-E18) was dissociated and incubated in the presence of carboxyfluorescein ester (CFSE), rhodamine-B dextran amine (RBD), DiI, or rhodamine-labeled latex microspheres. Cells were cultured in defined medium for up to 1 month. Cells labeled with CFSE were initially bright but faded over several days. RBD labeled the soma of cells, but fluorescence intensity was lost over a period of a few weeks. Cells labeled with DiI possessed brilliant staining of neuronal processes for weeks. Latex microspheres brightly labeled the soma but not the processes of neurons; fluorescent debris and sterility were problems with this label. We conclude that CFSE and DiI have significant potential usefulness in vitro as markers of cell viability and process formation with mammalian fetal CNS cells, whereas RBD is much less permanent. Latex microspheres may be suitable for pre-labeling of cells for transplantation if purification and sterility can be enhanced over present preparations.


A gated differential amplifier for recording physiological responses to electrical stimulation.

Artifact from electrical stimulation imposes a problem for the recording of physiological responses to electrical stimulation. Here we describe a simple, low-cost, gated differential amplifier for the recording of physiological responses to electrical stimulation. The gain of the amplifier is set to 1 during electrical stimulation by setting the gate input to a high logic state to avoid overloading of the amplifier by the artifact. Following electrical stimulation, the gate input is set to a low logic state, resulting in a gain of 1000 for frequencies between 300 Hz and 25 kHz (-3 dB points). The gain at low frequencies (0-0.2 Hz) is held constant at 1 to avoid transients in the output signal arising from changes in gain at these frequencies. The gain of the amplifier following stimulation (gate low) was independent of the magnitude of the artifact and was therefore suitable for the measurement of neural field potentials with low impedance electrodes.


Antiprogestin drugs: research and clinical use in Sweden.

The Swedish experience indicates that the combination of RU 486 and vaginal or intramuscular administration of different prostaglandin analogues such as Cervagem, Sulprostone, and 15- methyl PGF2 alpha is a highly effective and safe non-surgical method to terminate early pregnancy. The combined treatment may also be used during the second trimester. In mid- and late second trimester abortion this procedure represents a simple, non-invasive, highly effective method. There are several possibilities by which RU 486 can be used as a contraceptive. We have shown that post-ovulatory administration of RU 486 will effectively inhibit implantation. If the preliminary results are confirmed, treatment with RU 486 once a month on day LH+2 may be an attractive alternative to present contraceptive technology.


RU 486: what physicians know, think and (might) do--a survey of California obstetrician/gynecologists.

The results of this informal survey indicate that a solid majority of California obstetricians and gynecologists are very interested in RU 486 and are following its story closely; that this majority is confident in the research already conducted on the drug, and feel that RU 486 should be made available at this time for both clinical practice and additional research; that many physicians already performing abortions would utilize RU 486 in their practices; and that a significant number of physicians not currently performing abortions would do so using RU 486, thus potentially increasing access to early abortion services in this country. However, strong support for RU 486 among American physicians has not yet had an appreciable impact on hastening the eventual availability of RU 486 in the United States.


Combined effects of ozone and cigarette smoke on airway responsiveness and vascular permeability in guinea pigs.

The effects of combined exposure to ozone and cigarette smoke on airway responsiveness and tracheal vascular permeability, compared with those of single exposure were examined in guinea pigs. Airway responsiveness was assessed by measuring the specific airway resistance (sRaw) as a function of increasing concentration of inhaled methacholine aerosol immediately, 5 hr, and 24 hr after exposure. In a parallel study, tracheal vascular permeability was quantified by measuring the tracheal extravasation of intravenously administered Evans blue dye. Neither exposure to 1 ppm ozone for 30 min nor 5 puffs of cigarette smoke increased airway responsiveness or vascular permeability at any time after exposure. Combined exposure to 1 ppm ozone for 30 min and 5 puffs of cigarette smoke caused airway hyper-responsiveness and increased vascular permeability immediately after exposure. Exposure to 1 ppm ozone for 90 min increased both airway responsiveness and vascular permeability immediately after exposure. Exposure to 10 puffs of cigarette smoke increased airway responsiveness but not vascular permeability immediately after exposure. Combined exposure to 1 ppm ozone for 90 min and 10 puffs of cigarette smoke increased both airway responsiveness and vascular permeability immediately after exposure. The combined exposure to ozone and cigarette smoke thus increased both airway responsiveness and tracheal vascular permeability to a greater extent than did exposure to a single agent, suggesting that a combination of air pollutants has a more deleterious effect both on airway responsiveness and on tracheal vascular permeability than does either agent alone in guinea pigs.


Self-administered chest physiotherapy in cystic fibrosis: a comparative study of high-pressure PEP and autogenic drainage.

Fourteen patients with cystic fibrosis were trained in 2 self-administered chest physiotherapy (PT) techniques: high-pressure PEP-mask physiotherapy (PEP), and autogenic drainage (AD). They then visited the clinic on 5 consecutive days, and, in a random order, performed 1 of the following: PEP, AD, PEP followed by AD (PEP-AD), AD followed by PEP (AD-PEP), and, no PT except for spontaneous coughing. Lung function was measured repeatedly before, during, and after PT; time needed for and sputum produced by each form of PT was recorded. PEP produced the highest amount of sputum, followed by PEP-AD, AD-PEP, and AD; all 4 forms of PT produced significantly more sputum than coughing. Lung function improved significantly after PEP, AD, and PEP-AD, but PEP-induced changes did not exceed those after AD. Within the investigated group, the PEP-induced lung function improvement per milliliter of sputum produced was significantly lower for those patients with airway hyperreactivity. The fact that the highest sputum yield with PEP was not reflected in higher PEP-effected lung function changes might thus be explained by PEP-induced bronchospasm in patients with airway hyperreactivity. PEP clears more sputum than AD or combined techniques; patients with airway hyperreactivity, however, should either prefer AD or should take a bronchodilator premedication before PEP.


Cellular sequence of tracheal repair in sheep after smoke inhalation injury.

The cellular repair process of injured tracheal epithelium is described for sheep after exposure to toxic smoke containing high concentrations of acrolein. Fourteen fasted 3-4-year-old ewes had a portion of their cervical trachea exposed to cotton smoke for 20 min and then were sacrificed at various time intervals ranging from 1 to 22 days after exposure. Within 1 day of injury, columnar epithelium sloughed intact from the trachea with a concomitant reduction of nearly 35% in the basal cell population. At 2 days of recovery, the cellularity of the epithelium had increased and mitotic figures were observed in some tracheal epithelial and gland cells. By 8 days, undifferentiated hyperplastic cells increased to 30/100 microns, differentiated nonciliated columnar cells first appeared, and the basal cell population returned to a normal count of 13 cells/100 microns. Thirteen days after exposure, the undifferentiated hyperplastic cell population had declined to 7 cells/100 microns, nonciliated columnar cells were at control values, and some ciliated cells were identified. At 18 and 22 days, epithelium was normal in appearance and the count was 13 cells/100 microns. Data suggest that because the columnar epithelium sloughs intact with the cilia remaining active, toxic smoke may affect their attachment to the basal lamina. Furthermore, the regeneration process involves differentiation of hyperplastic cells in which they elongate down to the basal lamina, thus re-establishing the integrity of tall epithelium in the sheep trachea.


Hypotonic solutions induce epithelium-dependent relaxation of isolated canine bronchi.

The present study was designed to investigate the effect of changes in osmolarity on the modulatory role of the respiratory epithelium on the underlying smooth muscle. Canine bronchial segments with or without epithelium were perfused intraluminally with modified Krebs-Ringer bicarbonate solution. The transluminal isometric tension was recorded by means of stirrups passed through the bronchial wall. During contractions to extraluminal carbachol, the tissues with epithelium exhibited epithelium-dependent relaxations to hypotonic solution given intraluminally. The level of relaxation was dependent on the osmotic pressure. No significant difference was noted between relaxations due to hypotonic solution made by mixing the Krebs-Ringer solution with distilled water and those made by decreasing the concentration of sodium chloride. The epithelium-dependent relaxations could not be blocked by the antagonists or blockers of cyclo-oxygenase, endothelium-derived relaxing factor, alpha-adrenoceptors, beta-adrenoceptors, and sodium channels. No evidence for the release of a relaxing factor into the bronchial lumen was found in bioassay study. When the preparation was stimulated with hypertonic solutions prepared by adding mannitol or urea, similar relaxations were induced in tissues with and without epithelium. These observations suggest that changes in osmolarity affect the responses of canine bronchi to carbachol and that the epithelium modulates the responses of airway to hypotonic solutions.


Spontaneous cluster formation of dendritic (veiled) cells and lymphocytes from skin lymph obtained from dogs with chronic lymphedema.

To examine the mechanism of spontaneous attachment of afferent lymph lymphocytes to dendritic cells (veiled), we sampled and tested cells from skin lymph in 3 dogs with chronic lymphedema. There were 3.3 +/- 2.8% veiled cells in clusters with lymphocytes in lymph obtained directly from dilated dermal lymphatics by percutaneous puncture. The number of ex vivo clusters forming in the collected lymph samples increased as a function of time and was temperature dependent. The ability of veiled cells to bind lymphocytes was independent of divalent cations but reduced by xylocaine and retinoic acid. Among various steroids tested only methylprednisolone showed an inhibitory effect on cluster formation. Indomethacin and acetylsalicylic acid had no blocking activity on cell binding. Moreover, no effect was seen by cyclosporin A and azathioprine. However, FK 506 had a potent inhibitory effect on spontaneous cluster formation. This study suggests that cluster formation by skin lymph veiled cells and lymphocytes is a spontaneous process which can be controlled in vitro.


Enhancement of cytotoxicity in mouse regional lymph nodes by local tissue injection of aclacinomycin A.

The effect of local tissue injection of activated carbon particle adsorbing aclacinomycin A (ACR-CH) on the cytotoxicity in popliteal, inguinal, paraaortic, and axillary lymph nodes was investigated in mice. Aclacinomycin (0.2 mg/kg), a potent antineoplastic drug was injected subcutaneously into the footpad of mice in the form of ACR-CH or as an ACR solution. After a single injection of ACR-CH, the regional nodal cytotoxic response against mouse YAC-1 lymphoma cells was markedly increased and sustained for 7-10 days. The immune response was also increased after ACR solution but to a much lesser extent. These effects were found in popliteal, inguinal, and paraaortic lymph nodal effector cells but not in the more remote axillary nodes. Absorption of adherence cells largely abrogated the cytotoxic response. These results suggest that ACR-CH did not impair but rather stimulated nodal immunoregulatory cells. Potentially ACR-CH may enhance immune responsiveness of regional lymph nodes after subcutaneous administration while concomitantly curtailing neoplastic growth in these same lymph nodes.


Particle clearance from the canine pleural space into thoracic lymph nodes: an experimental study.

We instilled tungsten powder (CaWO4) into the pleural space of the dog and studied the kinetics and distribution of particle translocation from the pleural space to the thoracic lymph nodes over 1-7 days. We found that the transport of tungsten particles to regional lymph nodes was present at day 1, and reached its peak at day 3. In situ detection of tungsten by elemental particle analysis of lymph node sections by scanning electron microscopy complemented by light microscopy and X-ray analysis allowed precise mapping of the marker in the thoracic nodes. The first lymph nodes to become tungsten-laden was the parasternal group (day 1-3). From day 3 to 7 tungsten inclusions decreased in these parasternal nodes while moderately increasing in the remaining intrathoracic lymph nodes. Retrocardiac pleural folds containing numerous "milky spots" also accumulated prominent amounts of tungsten early after intrapleural injection of CaWO4. These data indicate that 1) particle translocation from the pleural space to regional lymph nodes is a rapid process and is first directed to the parasternal lymph nodal subgroup; 2) particle dissemination to virtually all other lymph nodes within the thorax follows thereafter; 3) retrocardiac pleural folds contribute to the clearance of particles from the pleural space.


Ultrasonography of extremity lymphedema.

Ultrasonography of the extremities was performed in 91 patients with unilateral or bilateral peripheral lymphedema of the arms or legs. Linear 3.5 to 10 mHz ultrasonographic linear probes were used in accordance with standardized procedure. The data demonstrated a volumetric increase of the lymphedematous limb with increased thickness of both the subcutaneous and subfascial (muscular) compartments consistent with fibrosclerosis in both compartments with chronic disease. Whereas dermal thickening was minimal, subcutaneous and subfascial changes were more prominent in primary than secondary lymphedema. By providing information about the volumetric and structural alterations with chronic lymphedema, ultrasonography safely and simply supplements conventional and isotopic lymphography in assessing patients with chronic lymphedema.


Mesenteric lymph node transplantation in syngeneic rats: changes in cellularity and architecture.

The cellular architectural and functional changes of transplanted mesenteric lymph nodes in rats were studied. After lymph nodes were transplanted with interruption of both the afferent and efferent lymphatics, the nodal cellular content gradually became depleted. One month after operation, the recirculating lymphocyte count in the transplanted node was only 3.5% of that in control nodes, whereas the number of mononuclear cells per mg tissue of transplanted node was only 28% of normal. In the transplanted nodal paracortex, the cells of high endothelial venules (HEV) became less prominent and gradually flattened altogether. In the transplanted nodal cortex, germinal centers and follicles also sharply decreased and later disappeared. Three months after transplantation, the normal compartmentalization of the transplanted nodes were no longer distinguishable. Regeneration of afferent lymphatics was not detected in transplanted nodes and the lack of circulating antigen and stimulated lymphocytes was probably responsible for the histological and functional involution of grafted mesenteric lymph nodes.


Autologous bone marrow transplantation in acute myelogenous leukemia.

Autologous bone marrow transplantation (ABMT) is a therapeutic approach that permits the administration of high-dose chemoradiotherapy followed by the infusion of the patient's own marrow, previously collected during remission and cryopreserved. In recent years, ABMT has been increasingly used as a treatment for acute leukemias. The mechanisms underlying leukemic relapse represent the most exciting and controversial aspects of ABMT. At least three factors may be responsible for leukemic relapse in patients receiving ABMT: (a) minimal residual disease; (b) leukemic cells reinfused with the graft; and (c) the lack of a graft-versus-leukemia effect. Techniques for pharmacological marrow decontamination, clinical results obtained with ABMT, and new perspectives opened by growth factors and cytokines are reviewed.


Antibody recognition of the tumor-specific b3-a2 junction of bcr-abl chimeric proteins in Philadelphia-chromosome-positive leukemias.

The reciprocal translocation between chromosome 9 and chromosome 22, as observed in chronic myeloid leukemia (CML) as well as in acute lymphoblastic leukemia (ALL), results in a 22q- chromosome, the so-called Philadelphia chromosome. The translocation event creates on the Philadelphia chromosome a fusion between two genes: bcr and abl. Depending on the localization of the breakpoint in the bcr gene different chimeric bcr-abl genes are generated, each encoding their own tumor-specific protein: e1-a2P190bcr-abl, b2-a2p210bcr-abl, or b3-a2P210bcr-abl. Especially in ALL, the presence of such a tumor-specific protein is highly associated with a poor prognosis. Detection of these proteins therefore has a strong clinical significance. In this study a polyclonal antiserum, termed BP-2, was raised against a synthetic peptide, corresponding to the tumor-specific 'fusion-point' epitope of the b3-a2P210bcr-abl protein. The specificity of BP-2 for the bcr-abl joining region in b3-a2P210bcr-abl is demonstrated by means of peptide inhibition studies in combination with immunoprecipitation. In addition we show the reactivity of BP-2 with bcr-abl proteins in leukemic cells of a Philadelphia-chromosome-positive ALL patient.


Feasibility of the fluorometric microculture cytotoxicity assay (FMCA) for cytotoxic drug sensitivity testing of tumor cells from patients with acute lymphoblastic leukemia.

The automated fluorometric microculture cytotoxicity assay (FMCA) was used for chemotherapeutic drug sensitivity testing of fresh and cryopreserved tumor cells from patients with acute lymphoblastic leukemia (ALL) at diagnosis and relapse. The technique success rate was 87% for fresh and 81% for cryopreserved samples. Up to 16 different cytotoxic drugs were routinely tested, but neither asparaginase nor methotrexate produced dose-response related cell kill. FMCA data showed good correlation to the well established Disc assay and the drug sensitivity reported by the FMCA was in good agreement with known clinical activity. Samples from children and initial ALL tended to be more drug sensitive than those from adults and ALL at relapse, respectively. For 36 samples clinical outcome was correlated to the quartile position in comparison to all other samples for the most in vitro active drug actually given to the patient. For patients with samples in the first, second, third, and fourth quartiles, the probabilities of complete remission were 89, 57, 38, and 0%, respectively. Using the median value as cut-off line, the sensitivity and specificity of the assay were 87 and 62%, respectively. It is concluded that the FMCA with a minimum of effort and with high success rate report clinically relevant drug sensitivity profiles for ALL.


Differences in DNA fingerprints of continuous leukemia-lymphoma cell lines from different sources.

The genetic stability of human cell lines in long-term culture has been tested by DNA fingerprinting a panel of 31 different continuous cell lines from patients with leukemias or lymphomas. Duplicates of the same cell line obtained from different sources, subclones of cell lines, and samples of cell lines at different passage levels were studied. In most cases the fingerprints of duplicates of the same cell line remained perfectly preserved even after long-time passaging. However, in five cases there were notable differences between individual fragments of corresponding fingerprints. We have found four cases of mislabeled and/or cross-contaminated cell lines so far. Taken together, our results indicate that DNA fingerprinting qualifies as a very reliable means of cell line identification which allows the detection of mislabelling or contamination and of genetic variation among subclones.


Mitogenic effects of human recombinant insulin on B-cell precursor acute lymphoblastic leukemia cells.

Insulin and the insulin-like growth factors (IGF-I, IGF-II) constitute a family of peptides capable of stimulating diverse cellular responses, including cell proliferation. In order to determine the effects of these peptides on malignant cells, we analyzed the expression and function of insulin, IGF-I, and IGF-II receptors on B-cell precursor acute lymphoblastic leukemia (BCP ALL) cell lines, utilizing competitive binding, affinity crosslinking, and cell proliferation assays. The BCP ALL cells bound to each peptide with mean specific binding for 125I-insulin, 125I-IGF-I, and 125I-IGF-II of 19.6%, 7.1%, and 4.3% of radioligand added, respectively. Competitive binding to intact cells demonstrated that 125I-IGF-I was displaced by IGF-I = IGF-II >> insulin, 125I-IGF-II was displaced by IGF-II > insulin = IGF-I, and 125I-insulin was displaced by insulin >> IGF-II > IGF-I. These data were remarkable for the potency of IGF-II displacement of 125I-IGF-I and 125I-insulin. Affinity crosslinking of radioligands to SUP-B2 cell membranes demonstrated the high affinity insulin and IGF-I (type 1 IGF) receptors. IGF binding proteins were also present in BCP ALL cell membrane preparations. In the cell proliferation studies, insulin stimulated a 50-130% increase in leukemic cell growth with a half-maximal concentration of 0.1-3.0 ng/ml in three BCP ALL cell lines. The proliferative response to insulin was blocked by the addition of an insulin receptor antibody. However, no response was observed with IGF-I, and IGF-II was only weakly mitogenic with a proliferative response noted at 100 ng/ml. Thus, while BCP ALL cells possess receptors for insulin and IGF-I, only the insulin receptor mediated a proliferative response.


Expression of the serglycin gene in human leukemic cell lines.

The expression of the human serglycin gene was determined in nine human leukemic cell lines, representing a spectrum of erythrocytic, megakaryocytic, monocytic, granulocytic, and lymphocytic potentialities. By Northern blot analysis, a 1.4 kb transcript was characterized in some of these cell lines, using a cDNA probe coding for human serglycin. Five of these cell lines, HEL, U-937, HL-60, K-562, and KU-812 were treated with phorbol myristic acetate to induce differentiation. Under these conditions the expression of the serglycin gene was modulated compared to the non-induced cells. HL-60, K-562, and KU-812 were also induced with dimethyl sulfoxide and retinoic acid; variations in serglycin transcript level were also observed. The present investigation establishes, at the nucleic acid level, the ability of various cells mimicking different stages in the developmental pathways of the haemopoietic lineage to synthesize proteoglycans belonging to the serglycin family. The results reported here led us to conclude that serglycin expression is closely associated with the haemopoietic cell differentiation pathway. The putative functions of serglycin in the haemopoietic system are briefly discussed.


Production of tumor necrosis factor-alpha in human long-term marrow cultures from normal subjects and patients with acute myelogenous leukemia: effect of recombinant macrophage colony-stimulating factor.

We have recently reported that normal long-term marrow cultures (LTMC) treated with recombinant human macrophage colony-stimulating factor (rhCSF-1), as well as LTMC from patients with acute myelogenous leukemia (AML), produce a soluble activity capable of inhibiting hemopoietic colony formation in semisolid cultures. In the present study, we have found that such an activity is produced, both in normal and AML LTMC, by an adherent, nonfibroblastic cell population (most likely macrophages), and also by blast cells developed in AML LTMC. The presence of the inhibitory activity correlated with increased levels of tumor necrosis factor (TNF) in the culture supernatants. Part of the activity (30%) produced in rhCSF-1-treated normal LTMC was neutralized in colony assays by anti-TNF alpha monoclonal antibody. In contrast, the soluble inhibitory activity from AML LTMC was completely neutralized by anti-TNF alpha. However, addition of anti-TNF alpha (every 72 h, from day 0 to 21, at 125 ng/ml) to AML LTMC resulted in only partial neutralization of the inhibitory activity, indicating that production of TNF alpha is just one of the mechanisms by which normal hemopoiesis is inhibited in AML LTMC, and that other factors are involved in this process. In keeping with this idea, we found very high levels of prostaglandin E, a hemopoietic inhibitor, in the supernatant of cultures that contained the soluble inhibitory activity. Interestingly, rhCSF-1 showed opposite effects on TNF production in normal (up-regulation) and AML (down-regulation) LTMC, which suggests the presence of functionally abnormal, leukemia-derived macrophages in AML LTMC.


Effects of interferon-alpha (IFN) on the expression of interleukin 1-beta (IL-1), interleukin 6 (IL-6), granulocyte-macrophage colony-stimulating factor (GM-CSF) and tumor necrosis factor-alpha (TNF) in acute myeloid leukemia (AML) blasts.

Interferon-alpha (IFN) induces the enzyme 2-5 oligoadenylate synthetase (2-5 AS) in cells from patients with hairy cell leukemia and B-cell chronic lymphocytic leukemia and this is associated with a breakdown of certain species of cytokine messenger (m)RNA via the activation of a latent ribonuclease. We have studied the expression of the cytokines interleukin 1-beta (IL-1), interleukin 6 (IL-6), granulocyte-macrophage colony-stimulating factor (GM-CSF), and tumour necrosis factor alpha (TNF) as well as of the ribonuclease activator 2-5 AS in the presence and absence of IFN in acute myeloid leukaemia (AML) blast cells from 26 patients. Before monocyte and T-cell depletion there was no expression of IL-1, IL-6 or GM-CSF, and only three of 13 patients studied expressed TNF mRNA. After cell depletion one or more cytokine was expressed in 31-62% of the 26 patients. Expression of one or more mRNA for IL-1, IL-6, GM-CSF and TNF after 18 h incubation was detected in 16 of 26 patients (63%) and this was particularly so in French-American-British (FAB) subtypes M4 and M5. Eight of nine patients with IL-6 mRNA expression and seven of 10 with IL-1 mRNA expression were in the FAB subtypes M4 and M5. Twenty-two of 26 patients showed induction of 2-5 AS mRNA in response to IFN in vitro. Exposure to IFN resulted in reduction of IL-1 mRNA in nine of 12 cases, of IL-6 mRNA in eight of nine, and GM-CSF mRNA in five of seven cases. TNF mRNA was unaffected by IFN despite 2-5 AS induction in 12 of 13 patients expressing this cytokine. In the presence of exogenous IFN, cells from six of seven patients studied showed inhibition of 3H-thymidine incorporation into DNA. DNA synthesis could also be abrogated in six of seven patients with anti-IL-1 monoclonal antibodies (MoAb) and in two of seven with anti-IL-6 MoAb. This inhibitory effect could be reversed in all patients when anti-IL-1 or anti-IL-6 was given in combination with their corresponding cytokine. These data suggest that IFN may exert a therapeutic effect in a proportion of AML patients by blocking IL-1 and IL-6 mediated growth, consequent on activation of the ribonuclease activator 2-5 AS.


L4415: further characterization of the rat model for human acute lymphocytic leukemia.

The biological properties of a transplantable lymphocytic leukemia, L4415 in the WAG/Rij rat, are described. The radiation-induced L4415 leukemia is characterized as a relatively slowly growing, non-immunogenic, immature T-cell leukemia which shows a reproducible growth pattern upon intravenous (i.v.) transfer. Survival time following i.v. inoculation is inversely related to the number of leukemic cells in the inoculum, which allows a quantitative estimate in terms of log leukemic cell kill of the effect of treatment. The first signs of leukemic growth are found in the bone marrow, the spleen, and the liver. Leukemic cells can be detected in the peripheral blood 13 days after inoculation. Due to replacement of normal hemopoietic tissue by leukemic cells and their number increasing exponentially thereafter, normal hemopoiesis is inhibited in the later stages of the disease as indicated by severe thrombocytopenia and anemia. Death is caused by a combination of splenic rupture, gastrointestinal and pulmonary hemorrhage, and impaired functions of heavily infiltrated organs. Hepatosplenomegaly and lymphadenopathy are prominent features at autopsy. Cyclophosphamide- and radiosensitivity of the clonogenic leukemic cells have been determined, a 2.9 log cell kill could be induced by single dose cyclophosphamide inoculation and a dosage giving a surviving fraction of 0.37 (D0) of 0.99 Gy with an extrapolation number (N) of 8.5 were calculated. Based on these data, the L4415 rat leukemia may be regarded as a relevant model for human acute lymphocytic leukemia and may thus serve to explore new treatment strategies.


Interferon treatment for hairy cell leukemia: an update on a cohort of 69 patients treated from 1983-1986.

This report documents the follow-up information on 69 hairy cell leukemia (HCL) patients treated with interferon alpha-2b (IFN) as primary treatment from 1983-86. Follow-up through October 1991 shows only 11 patients have died. Forty-one of the 57 patients completing the intended 12 or more months of initial IFN treatment were eventually considered IFN failures. Thirty-nine required retreatment (38 received a second course of IFN and one received pentostatin). Two patients died without further therapy for HCL. The median time to interferon failure was 33 months. Sixteen patients are alive and have not required further treatment after completing their initial 12 or more months of interferon. Eight patients underwent a third course of interferon therapy at a median time after completion of a second course of IFN of 1.3 years. Seven patients developed a second malignancy; three of these patients developed a high-grade lymphoma between 3.5 and 6.5 years after initiation of interferon therapy. We conclude that although interferon provides excellent palliation, most patients will eventually require further treatment with interferon or chemotherapy. Future trials in HCL must be aware of second malignancies as a common cause of death.


Phase I study of recombinant human interferon gamma in children with relapsed acute leukemia.

Fourteen children (ages 2-15 years) with acute leukemia in relapse were treated with daily recombinant interferon gamma for 14 days by subcutaneous injections at fixed dose levels of 0.1, 0.25, 0.5, or 0.75 mg/m2 (1.0, 2.5, 5.0, or 7.5 x 10(6) units/m2) without intrapatient escalation. Patients received a second 14-day course of therapy followed by thrice weekly administration unless there were signs of progressive disease or grade 3 or 4 toxicity. Side effects in the 13 evaluable patients included fever (n = 10), fatigue (9), decreased Karnofsky performance score (8), hypertriglyceridemia (8), myalgia (5), weight loss > 5% (4), elevated liver transaminases (4), and abdominal pain (3). There was only one grade 4 toxicity: one of the six patients at the 0.5 mg/m2 dose level developed reversible acute renal failure. One patient died of gastrointestinal hemorrhage due to disease-related refractory thrombocytopenia. One child had an oncolytic response and two others stable disease for 138 and 148 days. An appropriate dose level for phase II studies in children is 0.5 mg/m2 per day.


Homoharringtonine is safe and effective for patients with acute myelogenous leukemia.

Homoharringtonine (HHT) is a cephalotaxine alkaloid with reported efficacy in acute myelogenous leukemia (AML). In a phase II trial, we evaluated HHT 5 mg/m2 by continuous infusion daily for 9 days in patients with relapsed or refractory acute leukemia and blastic phase of chronic myelogenous leukemia (BLCML). Sixty-six patients were entered. There were 40 males and 26 females with a median age of 41 years (range 15-81). Of 43 patients with relapsed AML, seven achieved a complete remission (16%, 95% confidence interval 5%-27%). Although 11 patients with AML primarily resistant to an anthracycline/cytarabine combination did not respond, two of three patients primarily resistant to low-dose cytarabine achieved complete remission. No patients with acute lymphoblastic leukemia, biphenotypic leukemia, or BLCML responded. Hypotension during the administration of HHT was the most difficult toxicity encountered, requiring multiple interruptions of therapy in several patients and the administration of intravenous saline. Fluid retention and weight gain occurred in 29% of patients. Transient asymptomatic hyperglycemia was observed in 63% of patients. Other toxicity was mild and included nausea and vomiting, diarrhea, mucositis, hepatic dysfunction, and cardiac arrhythmias. As expected, severe myelosuppression occurred in all patients. HHT is well tolerated, but with unique problems associated with administration. It has demonstrable efficacy in pre-treated patients with AML, but its role in the treatment of this disease remains to be defined.


Homoharringtonine in combination with cytarabine for patients with acute myelogenous leukemia.

Homoharringtonine (HHT) is one of several cephalotaxine alkaloids that has shown clinical efficacy in patients with acute myelogenous leukemia (AML). In a phase I trial we evaluated cytarabine 100 mg/m2 by continuous infusion daily for 7 days in combination with four dose levels of HHT ranging from 1.5-5 mg/m2 by continuous infusion daily for 7 days to see if an effective regimen could be developed. Twenty-two patients with relapsed and/or primary refractory AML were treated. Seventeen males and five females were treated, with a median age of 40 years (range 19-63). There were five remissions in 14 patients with relapsed AML and none of eight responders in patients with primary refractory AML. None of the three patients treated at 1.5 mg/m2 dose level of HHT responded. Of three patients treated at the 3 mg/m2 dose level, there was one complete remission. At both 4 mg/m2 and 5 mg/m2, two of eight patients achieved complete remission. Four of the five remissions occurred in patients with acute promyelocytic leukemia. Drug induced pancytopenia was universal, and hypotension and fluid retention were more common at the higher dose levels. Other toxicity was mild and included nausea, vomiting, diarrhea, and mucositis. No significant hepatic, renal, or cardiac toxicity was seen. We conclude that the dose of HHT 4 mg/m2 for 7 days by continuous infusion in combination with cytarabine is safe for patients with AML; and this combination is appropriate for a phase II evaluation.


High-dose cytosine arabinoside remission induction for acute myelogenous leukemia: comparison of two regimens of remission maintenance.

We report a single institution sequential trial of two maintenance treatment regimens for patients with acute myelogenous leukemia (AML). A total of 175 consecutive patients with AML received initial remission induction therapy with high-dose cytosine arabinoside (ara-C) and glucocorticoids. For the initial 63 patients (group A), the control population, planned maintenance treatment was with conventional-dose ara-C given over 4 days for up to 18 months. The subsequent 107 patients (group B) had planned maintenance therapy of up to 6 courses of daunorubicin, ara-C and prednisone and daily cis-retinoic acid for up to two years. The presenting features of group A and B patients were similar as were the response to remission induction, 60 and 52%, respectively. Severe neurological toxicity was encountered once after high-dose ara-C; no drug-related deaths occurred during maintenance treatment. Median duration of remission for group B patients was 9.9 months compared with 5.5 for group A (p = 0.0685). Median survival duration for the two groups was similar, 9.1 months for group A and 10.4 for group B. Survival of patients in group B who attained a complete remission was significantly better than that of patients in group A (p = 0.0439). The studies confirm our initial experience with remission induction using single agent high-dose ara-C and suggest a positive role for maintenance therapy in AML.


Effect of high-dose methotrexate on plasma hypoxanthine and uridine levels in patients with acute leukemia or non-Hodgkin lymphoma in childhood.

We investigated the effect of high dose methotrexate (HDMTX) therapy on plasma hypoxanthine (Hx) and uridine (UR) concentrations in 12 children with acute lymphoblastic leukemia (ALL) or non-Hodgkin lymphoma (NHL). The initial plasma Hx level before the first administration of HDMTX (1 g/m2) was significantly higher in patients (25.5 +/- 17.5 microM) than that in healthy adult controls (4.0 +/- 1.4 microM). By 48 or 72 hours after the beginning of MTX infusion, the Hx concentration had decreased to 7.9 +/- 7.7 microM and 4.7 +/- 4.1 microM, respectively. This decrease of plasma Hx concentration after MTX infusion was also observed with the second course of HDMTX (3 g/m2) therapy. On the other hand, the plasma UR level did not change significantly. The in vitro treatment with 2 microM MTX of hypoxanthine-guanine phosphoribosyltransferase (HGPRT)-deficient mutant cells selected from HL-60 lowered the excretion of Hx into the culture medium. These data suggest a possible new explanation of the synergism of HDMTX and 6-thiopurines, for example 6-mercaptopurine and 6-thioguanine, since plasma Hx is considered to counteract 6-thiopurine toxicity through competition at the level of HGPRT.


Third complementarity determining region (CDR III) sequence analysis in childhood B-lineage acute lymphoblastic leukaemia: implications for the design of oligonucleotide probes for use in monitoring minimal residual disease.

The genetic sequence of the third complementarity determining region (CDR III) of the immunoglobulin heavy chain (IgH) gene was analysed in 55 rearranged alleles from 36 children presenting with B-lineage acute lymphoblastic leukaemia (ALL). This confirmed the unique nature of these rearrangements. However, contrary to the hypothesis that the CDR III is produced by a random process of rearrangement, biased utilisation of diversity (D) segments and of joining (J) regions 4, 5 and 6 was demonstrated. Moreover, preferred sequence boundaries were seen in J regions 1 to 5 and were suggested at the 3'-end of certain D regions, notably D21/9 and DK1. Similar patterns of rearrangement have been noted in normal B-lymphocyte clones. Together with relatively limited N nucleotide addition, these factors may restrict the potential sequence variability at the D-N-J junction. The occurrence of clonal progression by secondary gene rearrangements, such as V-V replacement, favours the use of this site when designing clone-specific oligonucleotide probes for use in monitoring minimal residual disease (MRD). In cases where biased features of D-J rearrangement are shared by both the leukaemic and normal B-lymphocyte clones this could reduce the sensitivity of these probes in detecting low levels of residual disease.


Mosaicism of trisomy 12 in chronic lymphocytic leukemia detected by non-radioactive in situ hybridization.

Cytogenetic analysis using banding techniques of B-chronic lymphocytic leukemia (CLL) is hampered by the difficult in vitro proliferation of these tumor cells. For detection of specific cytogenetic aberrations these problems can be overcome with non-radioactive in situ hybridization (ISH). ISH may especially be applied for the detection of trisomy 12, which is the most frequent cytogenetic aberration in CLL. Sixty-seven patients with CLL, four normal controls and one lymphoblastoid B-cell line with a trisomy 12 were studied using a chromosome 12 specific probe. To determine the hybridization properties of the CLL cells, all samples were also hybridized with probes specific for chromosomes 1 and 8. All leukemias were analyzed by immunocytochemistry to determine the proportion of tumor cells. Eight cases (11%) showed a trisomy 12. After correction for the number of tumor cells, it was demonstrated that in almost all cases (7 out of 8), the aberration was present in a proportion of the tumor cells (between 30 and 72%). Except for one patient this mosaicism persisted with long-term follow-up. We conclude that the in vivo incidence of trisomy 12 in CLL is approximately 11%, and that trisomy 12 occurs in most instances in only a subpopulation of the leukemic cells. Both findings suggest that trisomy 12 in CLL is a late event.


Relapse as acute monoblastic leukemia (AML-M5) of t(6;9) acute myeloblastic leukemia (AML-M2).

Two patients with acute myeloblastic leukemia with t(6;9)(p23;q34) translocation and classified as AML-M2 relapsed as acute monocytic leukemia (AML-M5). Trisomy 8 was found associated with t(6;9) at that time in both patients. Such changes in differentiation of leukemic cells have not previously been reported in this subtype of AML and add data favoring the pluripotent nature of the stem cell involved in leukemia with t(6;9).


Pathology and immunology of acute leukemia.

Tremendous advances in our understanding of acute leukemia have been made through the development of new technologies and close collaboration between immunologists, molecular biologists, and clinical oncologists. These technological advances have included the development of monoclonal antibodies (MoAb) reactive with surface antigens on leukemic cells which can help confirm the lineage and diagnosis of acute leukemia. More importantly, MoAb in conjunction with morphology and cytochemical stains have led to the identification of FAB-MO and the more common recognition of FAB-M7. MoAbs have also helped define prognostic groups, e.g., T-cell leukemia, mature B-cell leukemia, and rare groups such as CD7+ AML. However, the greatest advances in our understanding of acute leukemia has occurred with the application of genetic techniques. Disregulation of genes responsible for normal growth and differentiation initiates the molecular events that lead to the transformation and proliferation of cells recognized clinically as leukemia. Non-random cytogenetic abnormalities apparently contribute to this gene disregulation and specific abnormalities are associated with clinically important subgroups. In acute lymphoblastic leukemia (ALL), the t(9;22), t(1;19), and t(4;11) appear to have a poor prognosis. In acute myeloblastic leukemia (AML), -7/7q-;-5/5q-, 11q23 abnormalities have poor outcomes while t(15;17) and in some series t(9;11), t(8;21), and inv(16) have a good response to therapy. Molecular studies of somatic cell (immunoglobulin and T-cell receptor) gene rearrangements have assisted in the diagnosis and classification of ALL. The application of the polymerase chain reaction technique to specific gene rearrangements has provided a useful approach to minimal residual disease. Specific gene activation (N-myc, evi-1) or fusion genes such as the alpha retinoic acid receptor (alpha RAR) and pml have been identified as the specific cause of some cases of leukemia. The cloning of specific chromosomal breakpoints identified in leukemia (as has been done for CML) will result in specific probes which can be used to make the diagnosis rapidly at the molecular level. Because of the tremendous number of recent developments, this paper will focus only on major developments that will soon have a clinical impact.


Autoimmunity and auto-immune syndromes associated with and preceding the development of lymphoproliferative disorders.

In this report the association of autoimmunity and autoimmune syndromes with lymphoproliferative disorders (LPD) is described in 15 patients. Non-Hodgkin's lymphoma (NHL) developed in 10 patients, Hodgkin's disease (HD) in 3 and chronic lymphocytic leukemia (CLL) in two. In most instances clinical and laboratory phenomena preceded the development/diagnosis of these disorders. Manifestations ranged from the presence of autoantibodies in the serum to the presence of both ill defined or incomplete autoimmune syndromes including cold urticaria, Raynaud's phenomenon, cold agglutinin disease, thyroiditis, nephrotic syndrome and vasculitis to typical systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and even one of scleroderma. It is suggested that in some patients (in)complete clinical manifestations of autoimmunity may precede the development of lymphoid neoplasias. The link between autoimmunity and lymphoproliferative disorders is briefly discussed.


Cytogenetics and oncogenes.

There is abundant evidence that leukemia arise through somatically acquired genetic changes. Familial or congenital predisposition is rarely involved. These genetic changes are often visible as chromosomal aberrations. Molecular analyses of the DNA sequences rearranged in leukemia has demonstrated the presence of cellular oncogenes which are modified (fused, mutated, truncated) by the specific translocations. This results in a disturbance of the delicate balance between proliferation and differentiation and constitute a major step towards cell transformation. Some of these genetic rearrangements have been analyzed in depth, but the exact defect that causes leukemia is often not yet understood. Meanwhile these studies have increased our knowledge of normal cell proliferation and differentiation and provided us with new tools for diagnosis and for developing more specifically targeted treatment. An example would be the production of antibodies that recognize specifically the new chimeric proteins. Oncogenesis is a complex and multiple step process that proceeds by acquisition of successive genetic insults. The different steps do not necessarily occurs following a predetermined order, although some secondary changes are preferentially induced by a given first mutation. In leukemia, sequential changes in karyotype are well documented but molecular makers for tumor progression have not yet been systematically investigated. This is one of our many challenges for the future.


Immunotherapy of minimal residual disease in conjunction with autologous and allogeneic bone marrow transplantation (BMT).

Recent investigations in animal models of human lymphoid and myeloid leukemia suggest that induction of immune-mediated antitumor effects is feasible at the stage of minimal residual disease (MRD) using allogeneic immunocompetent lymphocytes following initial reconstitution with T cell depletion and/or activation of reconstituting syngeneic or allogeneic immune cells by recombinant interleukin-2 (rIL2). Pilot clinical trials in patients with leukemias and lymphomas at high risk to relapse following autologous bone marrow transplantation (BMT) suggest that beneficial antitumor effects may be achieved at the stage of MRD by home immunotherapy as soon as hematopoietic reconstitution occurs using rIL2 (Cetus) and alpha interferon (Roferon A) (Hoffmann LaRoche). Although results obtained from our open trial seem encouraging, prospective randomized trials and longer observation periods are needed in order to confirm immune-mediated antitumor effects in conjunction with autologous BMT in patients with malignant hematological disorders at high risk to relapse. Likewise, it seems that amplification of anti-leukemia effects following allogeneic BMT is feasible by post-transplant infusion of donor's peripheral blood lymphocytes for prevention and/or treatment of relapse.


Selective metaphasic arrest of erythroblasts by vincristine in patients receiving high doses of recombinant human erythropoietin for myelosuppressive anemia.

As an introduction to a Satellite Symposium on the utilization of recombinant human erythropoietin (rHu-EPO) in hematology (Leukemia & Lymphoma 1992; 7 (Suppl.2): 94-100) a contribution to its mechanism of action was presented, and is published here. In three patients with advanced Hodgkin's disease treated with combination chemotherapy (MOPP) incorporating vincristine, and receiving at the same time a fixed daily dose of 8000 U of rHu-EPO subcutaneously for 10 to 15 days because of myelosuppressive anemia, myeloaspirates were performed one week before and 24 hours after the administration of vincristine. A dramatic accumulation of arrested metaphases in all stages of erythroblasts was found, while there was no augmentation of granulocytic metaphases. This is a further confirmation, following a previous contribution (Marmont AM: Haematol 1991; 76, 251-255), of the demonstration in man of the combined effects of erythropoietin as an erythroid mitogen and vincristine as a mitotic blocker.


Expression of adhesion molecules in lymphoproliferative disorders.

We review the role of adhesion molecule expression on malignant lymphoid cells as delineated by experimental studies and clinical observation. Adhesion molecules of the Ig superfamily, integrins, selectins, and the lymphocyte homing receptor CD44 mediate cell-to-cell and cell-to-extracellular matrix interactions. These molecules have been investigated with the aim (i) of defining certain biological features of the malignant cells, (ii) of providing a rationale to understand tumor organization, metastasis and organ specificity, and (iii) of detecting disease subsets and prognostic groups.


Cellular and molecular studies on the early stages of human hematopoietic differentiation in culture of pure progenitors.

Methodology has been developed that enables virtually complete purification and recovery of early hematopoietic progenitors from human adult blood, a minority of which is multipotent and endowed with self-renewal capacities, i.e., exhibits stem cell properties. This report briefly reviews: (i) the key steps involved in the progenitor purification and assay procedure; (ii) the characterization of "pure" progenitors at the level of membrane antigen pattern and response to HGFs; (iii) the development of a liquid suspension culture for the pure progenitors, which allows synchronized and selective erythroid or GM differentiation, and hence may be utilized for the analysis of molecular mechanisms underlying early and late stages of hematopoiesis; (iv) the study of the expression and modulation of HGFRs expressed on progenitors.


Combined effect of very early intensification and prolonged post-remission chemotherapy in patients with AML.

The study combines the effects of prolonged postremission chemotherapy with that of very early intensification. 900 adult patients at all ages with newly diagnosed AML uniformly received TAD for induction and consolidation followed by monthly myelosuppressive maintenance for 3 years. In patients of 60+ years with persistent bone marrow blasts a second TAD course was given. In all patients of less than 60 years a second induction course started on day 21 even in aplasia with no blasts. Second induction was randomly either TAD or HAM. In the younger age group 69% attained CR and similar in the two arms the CR rate after 5 years is 35%. Including the 50% patients attaining CR in the higher age group the CR rate after 5 years is 32%. In 40 patients receiving allogeneic BMT and 21 patients receiving autologous BMT in first CR relapse free survival is similar to that from chemotherapy alone in a matched pair analysis. We conclude that age adapted very early intensification followed by prolonged postremission chemotherapy represents a therapeutic progress.


Leukemic cell kill in autologous bone marrow transplantation: in vivo or in vitro?

Both the contribution of high dose chemo-radiotherapy ("conditioning treatment") prior to autologous bone marrow transplantation (ABMT) and "purging" of autologous marrow grafts to the prevention of leukemia relapse are being addressed in the present communication. Based on both preclinical and clinical studies, it is concluded that cures achieved after ABMT are mainly due to effective eradication of residual leukemic cells in the host. The chance that leukemia will relapse is due to leukemic cells reinfused with the graft is estimated to be less than 10%.


Has IL2 a role in the management of minimal residual disease for acute leukemia?

Based on pre-clinical findings and on more recent preliminary in vivo data it has been suggested that immunotherapy with Interleukin 2 (IL2) may be employed in the treatment of acute leukemia patients. Here we shall discuss the biological and clinical observations which indicate that this innovative therapeutic approach may play a role in the management of minimal residual disease.


Tissue plasminogen activator for treatment of livedoid vasculitis.

Livedoid vasculitis, a hyalinizing vasculopathy, is characterized by extensive formation of microthrombi and deposition of fibrin in the middermal vessels, which result in epidermal infarction, ulceration, and formation of stellate scars. In a prospective study of nonhealing ulcers in patients with livedoid vasculitis, we found a high incidence of anticardiolipin antibodies, lupus anticoagulants, increased levels of plasminogen activator inhibitor, and low levels of endogenous tissue plasminogen activator (t-PA) activity. This procoagulant tendency and decreased fibrinolysis may provide an explanation for the occlusive vasculopathy often noted in biopsy specimens from these patients. On the basis of these findings, we proposed that fibrinolysis with recombinant t-PA would lyse microvascular thrombi, restore circulation, and promote wound healing. In six patients who had nonhealing ulcers caused by livedoid vasculitis and in whom numerous conventional therapies had failed, low-dose t-PA (10 mg) was administered intravenously during a 4-hour period daily for 14 days. Five of the six patients had dramatic improvement; almost complete healing of the ulcers occurred during hospitalization, and tissue oxygenation, as measured by transcutaneous oximetry, increased. The one treatment failure was due to rethrombosis of the microvasculature; this patient was subsequently re-treated but with concurrent anticoagulation, and her leg ulcers healed. We conclude that daily administration of a low dose of t-PA is safe and effective treatment for nonhealing ulcers due to occlusive vasculopathy.


Medullary thyroid carcinoma: clinicopathologic features and long-term follow-up of 65 patients treated during 1946 through 1970.

We retrospectively reviewed the medical records of 65 consecutive patients with medullary thyroid carcinoma, who had had their primary surgical treatment at the Mayo Clinic during the years 1946 through 1970. Of these patients, 58 had sporadic and 7 had familial medullary thyroid carcinoma. Thyroid nodules were the most common initial manifestation. Near-total thyroidectomy was the most frequent initial operation. Survival was affected by the following factors: male sex, familial inheritance, size of the tumor, stage of the tumor (American Joint Committee on Cancer), and completeness of initial resection of the tumor. The mean duration of follow-up was 23.5 years, and the maximal follow-up was 36 years. Among 52 patients without initial distant metastatic involvement and with complete resection of the tumor, 20-year survival free of distant metastatic lesions was 81%. Overall 10- and 20-year survival rates were 63% and 44%, respectively. Because of the substantial morbidity and mortality associated with medullary thyroid carcinoma, early diagnosis and thorough initial resection of the tumor are important.


Immunofluorescent staining for mast cells in idiopathic pulmonary fibrosis: quantification and evidence for extracellular release of mast cell tryptase.

In many diseases, retrospective analysis for determining the presence of mast cells has been difficult because of their loss of metachromatic staining properties once tissue has undergone formalin fixation. We quantified mast cells in peribronchiolar tissue of idiopathic pulmonary fibrosis (IPF) and in normal human lung by using rabbit antiserum to human mast cell tryptase. In lung biopsy specimens from 15 patients with IPF, the mean number of mast cells per high-power field in connective tissue directly adjacent to the lumen of small airways (0.5 to 2 mm in diameter) and other fibrotic foci was 29.9 +/- 10.8 in comparison with 13.7 +/- 3.5 in 16 normal controls (P < 0.001). In addition, mast cells in cases of IPF had an altered appearance--irregularity of the plasma membrane and release of extracellular tryptase. We conclude that the number of mast cells is increased in IPF and that the altered appearance of the mast cells suggests that they are activated and undergoing degranulation.


The pituitary gland in patients with breast carcinoma: a histologic and immunocytochemical study of 125 cases.

Pituitary glands obtained at autopsy of 125 women with disseminated breast carcinoma were studied to determine whether pituitary prolactin cell abnormalities (hyperplasia or adenoma) might be involved in the pathogenesis of breast carcinoma. In addition, we studied 85 pituitary glands obtained from unselected, consecutive autopsies in women without breast carcinoma but who died of other diseases (control group). The frequency of lactotroph hyperplasia was slightly higher in patients with breast carcinoma than in the control group, but the difference was not statistically significant, nor were differences in the frequency and size of pituitary adenomas, prolactin-producing or otherwise. No correlation was found between the presence of lactotroph hyperplasia or prolactin-producing adenomas (or both) and such factors as the patient's age, bilaterality of the carcinoma, previous treatment with tamoxifen citrate or oophorectomy, stage of disease, or survival. The frequency of breast carcinoma metastatic to the pituitary gland was higher in the study group than in the control group; however, the difference was not statistically significant. No preferential site of metastatic involvement in the pituitary gland was noted. Relative proportions of other lesions such as infarcts, cysts, lymphocytic infiltrates, and basophilic invasion were similar in the study and control groups. This study indicates that accumulation of prolactin cells, whether hyperplastic or adenomatous, cannot be considered a major risk factor for the genesis or progression of breast carcinoma.


Pathology of surgically excised primary cardiac tumors.

Between 1957 and March 1991, 106 patients with 110 neoplasms that originated in the heart were treated surgically at the Mayo Clinic and had pathologic material available for review. The study group consisted of 39 male and 67 female patients, who ranged in age from 2 to 80 years. Benign atrial myxomas (64 in the left atrium and 16 in the right atrium) were the most commonly encountered neoplasm. The other benign tumors were nine fibromas, five lipomatous tumors, seven valvular fibroelastic papillomas, and one cardiac hamartoma (so-called oncocytic cardiomyopathy). In addition, eight patients had a primary cardiac malignant lesion: angiosarcoma, leiomyosarcoma, and malignant fibrous histiocytoma in two patients each and sarcoma (not otherwise specified) and osteogenic sarcoma in one patient each. The angiosarcomas originated in the right atrium, and the other malignant tumors originated in the left atrium. The histologic feature that most frequently predicted an adverse clinical outcome was the presence of mitotic figures, although highly cellular tumors and those with necrosis also tended to have a malignant course.


Humoral hypercalcemia associated with a dysgerminoma.

A 16-year-old girl sought medical attention at the Mayo Clinic because of a 4.5-kg weight loss, hypercalcemia, and a pelvic mass. Preoperatively, the level of the beta-subunit of human chorionic gonadotropin was 147 IU/liter. After a brief period for observation and hydration, abdominal exploration revealed a stage III dysgerminoma; total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. Within the dysgerminoma, syncytial giant cells expressed human chorionic gonadotropin-positive immunostaining in the cytoplasm. Postoperatively, the value of the beta-subunit of human chorionic gonadotropin decreased rapidly. The patient received whole-abdomen irradiation 4 weeks postoperatively, after which the level of calcium returned to normal. The patient has been free of disease for more than 7 years.


Cutaneous micrographic surgery: Mohs procedure.

Skin cancer is an increasingly serious public health issue that affects a high percentage of the population. Surgical resection is still standard treatment for skin cancer, but for difficult cases, cutaneous micrographic surgery, originally described by Mohs, is our preferred technique because of the routine methodic accuracy for evaluation of the surgical margin, the high rate of oncologic cure, and the tissue-sparing quality of the procedure. We report the Mayo Clinic experience with cutaneous micrographic surgery from July 29, 1986, through June 30, 1991, which consisted of 3,355 cases (principally basal cell and squamous cell carcinoma). Herein we discuss practical concerns about this procedure: duration of the technique, reconstruction, cure rates, tumors best treated by cutaneous micrographic surgery, and cost. In addition, we review the Mayo Clinic multidisciplinary management of difficult skin cancers.


Cyclosporine treatment of inflammatory bowel disease.

Numerous uncontrolled studies and one controlled trial of cyclosporine therapy suggest that this selective inhibitor of cell-mediated immunity may be of benefit in patients with chronically active Crohn's disease. In addition, uncontrolled studies indicate that cyclosporine may be useful in the following settings: fistulous Crohn's disease; corticosteroid sparing in Crohn's disease; severe ulcerative colitis; and refractory proctosigmoiditis. The major advantages of cyclosporine therapy are apparent efficacy in patients with refractory disease and a rapid onset of response. Nevertheless, the incidence of relapse is high after cyclosporine therapy is discontinued, and this outcome is not prevented by low-dose maintenance therapy. Furthermore, the frequency of occurrence of cyclosporine-related side effects during treatment of patients with inflammatory bowel disease is high; paresthesias and hypertrichosis are the two most common adverse effects reported in the literature. Although the potential for permanent renal damage is of concern, serious, irreversible toxicity seldom occurs. Ongoing clinical trials will provide additional information about the efficacy and safety of cyclosporine for the aforementioned indications.


Gestational diabetes mellitus: now is the time for detection and treatment.

The extent of universal screening for gestational diabetes and the incidence of gestational diabetes mellitus (GDM) by diagnosis were analyzed in four primary-care sites. The medical records of 798 women were reviewed to identify the presence of historical risk factors, familial determinants, and biophysical attributes associated with GDM and to determine whether screening and diagnostic tests consistent with national criteria had been completed, as well as to obtain the method of delivery and the weight and overall medical status of the infants. Of the 798 women, less than 60% underwent screening. Overall, 1.5% of the women were diagnosed with GDM, seven of whom were identified through screening. Eighty-nine infants were classified as large for gestational age, 61 of whom weighed more than 4,000 g. Of these 61 infants with macrosomia, 61% were born to women who either were not screened or had negative screening results. Most of these women had risk factors consistent with GDM. The likelihood that a substantial proportion of these women would have delivered normal-sized infants had they undergone proper screening, diagnosis, and treatment prompted us to conclude that universal screening for GDM should be adopted.


Mitral valve operation in postinfarction rupture of a papillary muscle: immediate results and long-term follow-up of 22 patients.

The long-term clinical outcome was assessed in 22 patients (15 men and 7 women; mean age, 68 years) who underwent mitral valve replacement or repair for acute mitral regurgitation due to postinfarction rupture of a papillary muscle during the period 1981 through 1990 at the Mayo Clinic. All but three patients underwent operation within the first 3 weeks after acute myocardial infarction. The perioperative mortality was 27%, and the estimated actuarial survival rate at 7 years postoperatively was 47% and 64% for the entire group and for the patients who survived the operation, respectively. The concomitant performance of a coronary artery bypass grafting procedure was the only factor identified that improved both immediate and long-term survival. Patients with a decreased preoperative left ventricular ejection fraction (less than 45%) had somewhat greater short-term and long-term mortality than did those with a left ventricular ejection fraction of 45% or more, but the difference was only of borderline statistical significance. Other factors such as age, sex, severity of coronary artery disease, preoperative existence of congestive heart failure, and timing of the operation in relationship to occurrence of the infarction had no effect on survival. Of the 13 long-term survivors, 10 had significant clinical improvement in comparison with their preoperative state.


A prospective randomized comparison of epidural infusion of fentanyl and intravenous administration of morphine by patient-controlled analgesia after radical retropubic prostatectomy.

In a prospective, randomized study, continuous infusion of epidural fentanyl citrate (group E) was compared with patient-controlled intravenously administered morphine sulfate (group P) for analgesia in 66 men after radical retropubic prostatectomy. Although both methods provided satisfactory analgesia, the mean comfort level scores were lower (that is, greater comfort) in group E than in group P at all observation times. The difference in mean resting comfort level scores between groups E and P was statistically significant (P < or = 0.05) at 9 of the 11 observation times. In addition, significant differences in comfort level scores were noted at 8 of the 11 observation times during deep breathing, 5 of 11 during coughing, and 3 of 9 during ambulation. Maximal and minimal comfort level scores recorded by each patient during the course of the study were significantly lower (that is, less pain) in group E than in group P for all four categories of activity. The percentage of patients who reported no pain was significantly higher in group E than in group P at 9 of 11 observation times during resting and 5 of 11 observation times during deep breathing. No significant differences were noted in side effect profiles or duration of hospital stay. In summary, when two effective methods of analgesia used after radical retropubic prostatectomy were compared prospectively, patients who received epidural infusion of fentanyl were more comfortable than those with patient-controlled intravenous administration of morphine, as evidenced by lower mean, maximal, and minimal comfort level scores and a greater proportion of patients with complete relief of pain.


Predictors of outcome after percutaneous endoscopic gastrostomy: a community-based study.

Percutaneous endoscopic gastrostomy (PEG) is used to provide nutrition for patients who are unable to eat but have a functionally intact gut. Clinical guidelines for PEG are uncertain and have been derived mainly from referral practices. We performed a population-based cohort study in 97 residents of Olmsted County, Minnesota, referred for PEG between January 1982 and December 1988 to determine complications, duration of tube feeding, and survival. Follow-up continued until death or February 1990. Inpatient and outpatient records were reviewed to determine indications, comorbid conditions, level of consciousness, and limitations in activities of daily living. Outcomes determined after referral for PEG included type and number of complications, tube removal, and survival. Statistical methods used included Kaplan-Meier and proportional hazards regression analyses. PEG placement was successful in 94% of patients. Although complications occurred in 70% of patients, they usually were minor (88%) and most occurred within 3 months. In 24 patients, tubes were removed because eating was resumed. The probability of surviving 30 days, 1.5 years, and 4 years after referral for PEG was 78%, 35%, and 27%, respectively. The major causes of death within and after 30 days were pneumonia, heart disease, and vascular disease of the central nervous system. An increased risk of death after referral for PEG placement was associated with older age, male gender, diabetes, and specific indications for PEG. If validated in other population-based studies, these predictors of survival after referral for PEG placement could be used to identify patients with a low probability of survival who may not benefit from PEG.


Importance of breast biopsy incision in final outcome of breast reconstruction.

Currently, breast cancer is one of the most common malignant lesions among women in North America--it occurs in one in every nine such women. Approximately 180,000 cases will be diagnosed this year. During the past 3 years at the Mayo Clinic, approximately 4,000 breast biopsies were performed. In approximately 20% of such biopsy specimens, a malignant lesion will be identified. Surgeons should be aware of the current possibilities in breast reconstruction and should consider the cosmetic result in the placement of breast biopsy incisions. Even lesions in the superior or inferior portions of the breast are accessible through generous periareolar incisions. The biopsy incision should be within the confines of a possible skin excision for mastectomy to avoid creating two scars if the specimen proves cancerous. The choice of site for the biopsy incision, however, should never jeopardize the treatment of the cancer. Appropriate preoperative planning will ensure optimal cosmetic and therapeutic results in the management of breast lesions.


Cemented versus noncemented total hip arthroplasty--embolism, hemodynamics, and intrapulmonary shunting.

Bone cement implantation syndrome is characterized by hypotension, hypoxemia, cardiac arrhythmias, cardiac arrest, or any combination of these complications. It may result from venous embolization that occurs in conjunction with intramedullary hypertension in the femur during insertion of the prosthesis in patients undergoing cemented total hip arthroplasty (THA). Intramedullary hypertension does not occur in patients undergoing noncemented THA. In this study, we sought to compare embolization between patients undergoing cemented and noncemented THA and to determine whether this state resulted in cardiorespiratory deterioration. In this prospective investigation of 35 patients undergoing elective THA, we used transesophageal echocardiography and invasive hemodynamic monitoring, and in 12 of them, we monitored distribution of pulmonary ventilation and perfusion intraoperatively. Embolization was significantly greater after insertion of the prosthesis in patients undergoing cemented than in those undergoing noncemented THA. Cemented THA was also associated with decreased cardiac output and increased pulmonary artery pressure and pulmonary vascular resistance. Increases in ventilation-perfusion mismatching, however, could not be demonstrated 30 minutes after insertion of the femoral prosthesis. Intraoperative monitoring for embolism may help physicians assess patients in whom cardiorespiratory function deteriorates during THA.


Allergic reactions to latex among health-care workers.

With the emergence of the acquired immunodeficiency syndrome (AIDS) epidemic and the practice of protecting health-care workers from all body fluids, the use of rubber gloves has increased, as has occupational allergy to latex among health-care workers. During 1991, 49 Mayo Medical Center employees sought assessment and treatment of rhinitis, conjunctivitis, contact urticaria, contact dermatitis, asthma, or eczema thought to be related to exposure to latex. Most of these persons had a history of atopy and worked in areas where rubber gloves were used and changed frequently. Of the 49 subjects, 34 had positive results of skin tests to latex products, and the sera from 19 of 35 persons tested contained increased latex-specific IgE antibodies. Employees with sensitivity to latex (and co-workers in the immediate areas) should use vinyl gloves and should notify their own health-care providers of their sensitization. Changes in job assignment may be necessary for some persons.


Use of the internal mammary artery for myocardial revascularization in a patient with radiation-induced coronary artery disease.

A 9-year-old boy with clinical stage IIA Hodgkin's disease underwent radiotherapy to the neck and mediastinum. Twenty-two years later, he sought medical attention because of angina pectoris. Cardiac catheterization revealed proximally located high-grade stenoses of the left main, left anterior descending, circumflex, and right coronary arteries. He underwent coronary artery bypass grafting with use of the left internal mammary artery to the left anterior descending coronary artery and reversed saphenous vein grafts to the circumflex and right coronary arteries. The postoperative course was uncomplicated. Previous radiotherapy to the mediastinum should be considered a risk factor for the development of premature coronary artery disease. Surgical revascularization is the preferred method of management. A combination of an internal mammary artery graft and a saphenous vein graft should be used in young patients.


Pancreatic pseudocyst that compressed the inferior vena cava and resulted in edema of the lower extremities.

To our knowledge, edema of the lower extremities has not previously been reported as a sign of a pancreatic pseudocyst. In this case report, we describe a 66-year-old man in whom such a lesion compressed the inferior vena cava and caused pronounced leg swelling. After drainage of the pseudocyst, the edema did not recur. Although the most well-known complications of pancreatic pseudocyst are pain, hemorrhage, rupture, infection, and obstruction of adjacent viscera, bilateral edema of the lower extremities can be the initial manifestation of this lesion.


Dermatologic manifestations of human immunodeficiency virus infection.

Human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS) have become major health problems in the United States, and patients with manifestations of these diseases are seen by physicians in all areas of medicine. Cutaneous manifestations develop in as many as 92% of HIV-positive persons. Familiarity with these manifestations facilitates early diagnosis and enhances the care of HIV-infected patients. The spectrum of mucocutaneous disorders in these patients includes an acute exanthem, multiple infections, neoplastic processes, and miscellaneous disorders. Herein we review the most common and the most specific dermatologic manifestations associated with HIV infection, which often are atypical, more severe, or less responsive to treatment than the corresponding diseases encountered in non-HIV-infected persons.


Results of a randomized controlled trial of carotid endarterectomy for asymptomatic carotid stenosis. Mayo Asymptomatic Carotid Endarterectomy Study Group.

We undertook a randomized controlled trial designed to compare the effects of carotid endarterectomy with medical treatment using low-dose aspirin in patients with asymptomatic carotid stenosis. During 30 months of recruitment, 71 randomized and 87 eligible nonrandomized patients participated in a follow-up protocol. The total ipsilateral perioperative stroke and death rate was 0% among randomized patients and 3% among nonrandomized patients, and the major stroke and death rate was 0% for both groups. Too few cerebral ischemic events occurred to judge the comparative effectiveness of carotid endarterectomy versus low-dose aspirin for asymptomatic carotid stenosis. The trial was terminated early because of a significantly higher number of myocardial infarctions and transient cerebral ischemic events in the surgical group than in the medical group. Most of the events were not temporally related to the surgical procedure, but there was evidence that these events could have related to the absence of aspirin use in the surgical group. These observations reinforce the appropriateness of the use of aspirin throughout the perioperative period and beyond (unless contraindications exist) in patients with asymptomatic carotid stenosis who undergo carotid endarterectomy.


Ischemic cholangitis in hepatic allografts.

In this report, our objectives are to introduce the term "ischemic cholangitis" as an etiologic designation and to describe its manifestations. Herein we use the label "ischemic cholangitis" as a collective term for ischemic bile duct necrosis, cholangitis caused by ischemia but without necrosis, and biliary fibrosis as a manifestation of ischemic damage. The condition was observed in 12 allografts, either at the time of retransplantation (9 cases) or at autopsy (3 cases). Ischemic cholangitis involved primarily perihilar extrahepatic and intrahepatic bile ducts. The findings included duct necroses (eight cases), strictures (four cases), and cholangiectases (four cases); some of these features coexisted. In addition, complicating ascending cholangitis and cholangitic abscesses were noted in three cases. Ischemic cholangitis was caused by hepatic artery thrombosis (in nine patients) or stenosis (in one) or by occlusion of parabiliary arteries by fibrointimal proliferations, probably attributable to old thromboses (in two, in conjunction with associated foam cell arteriopathy in one). Biopsy specimens before retransplantation or autopsy were obtained in 11 patients, only 1 of whom had an infarct as direct evidence of ischemia. Nine patients had evidence of biliary obstruction or bile flow impairment; in two cases, specimens were normal or nondiagnostic relative to cholangitis. Features of cellular rejection associated with the manifestations of bile flow impairment and ischemia were noted in five cases. Thus, biopsy features that suggest biliary obstruction, with or without cellular rejection, may be a manifestation of ischemic cholangitis. We conclude that ischemic cholangitis is an important cause of cholestatic graft failure but that this type of cholangitis is difficult to diagnose because of its misleading biopsy manifestations.


Health risk behaviors and medical sequelae of childhood sexual abuse.

The relationship between childhood sexual abuse and subsequent health risk behaviors and medical problems was examined in 511 women who had used a family practice clinic in a rural midwestern community during a 2-year period (1988 and 1989). These women completed a questionnaire that assessed various health risk behaviors--smoking, drinking, drug abuse, number of sexual partners, and age at first intercourse--and a medical symptom checklist that assessed 38 medical problems related to major systems of body function, the somatization scale from the SCL-90, a screen for sexual abuse, and a brief measure of social support. The results indicated that sexually abused women, who represented 22.1% of the sample, reported significantly more medical problems, greater levels of somatization, and more health risk behaviors than did the nonabused women. More severe abuse (for example, penetration or multiple abusers) correlated with more severe problems. Extent of social support correlated inversely with the number of gynecologic problems reported in the sexually abused group. Fewer than 2% of the sexually abused women had discussed the abuse with a physician. To identify and assist victims of sexual abuse, physicians should become experienced with nonthreatening methods of eliciting such information when the medical history is obtained.


Leiomyosarcoma of the stomach: determinants of long-term survival.

To determine factors associated with a favorable long-term prognosis in gastric leiomyosarcoma, we retrospectively reviewed the medical records of 93 Mayo Clinic patients with this biopsy-proven tumor diagnosed during the 25-year period from 1964 through 1988. Six patients who had Carney's triad (gastric epithelioid leiomyosarcoma, pulmonary chondroma, and functioning extra-adrenal paraganglioma) were excluded from data analysis. The other 87 patients participated in follow-up until death or for a median duration of 5.8 years for those who were alive at the conclusion of the study. The most common symptoms at the time of initial assessment were abdominal pain (51%), melena (36%), and weight loss (16%). Most often, the tumor was located in the greater curvature (25%), fundus (20%), or lesser curvature (16%) of the stomach. Two percent of patients had tumors at multiple sites. All 87 gastric leiomyosarcomas were histologically confirmed; 38% were grade 1, 37% were grade 2, and 25% were either grade 3 or grade 4. Metastatic involvement was noted in 15% of patients at the time of diagnosis. The 5- and 10-year survival rates were 45% and 34%, respectively, and the 5- and 10-year tumor recurrence rates were 57% and 65%, respectively. Variables that were associated with long-term survival were low histologic grade of the tumor, absence of metastatic lesions, and small tumor size (P < 0.01); variables such as site of the tumor, initial symptoms, age, and sex provided no significant additional prognostic information.


Conditions associated with carpal tunnel syndrome.

With use of a comprehensive medical records-linkage system, we identified the comorbid conditions and risk factors in the residents of Rochester, Minnesota, who had a diagnosis of carpal tunnel syndrome during 1961 through 1980. In 43.2% of the 1,016 patients, no associated conditions were found on review of the medical records, whereas associated conditions were documented in 56.8%. The most frequent of these conditions were Colles' fracture, rheumatoid arthritis, hormonal agents or oophorectomy (or both), diabetes mellitus, and, among men, occupations that involved excessive use of the hands. Rheumatoid arthritis, diabetes mellitus, and pregnancy were significantly more frequent among the study patients with carpal tunnel syndrome than in the general population of Rochester, Minnesota. The standardized morbidity ratio was 3.6 for rheumatoid arthritis, 2.3 for diabetes mellitus, and 2.5 for pregnancy. The population attributable risk for pregnancy among women 15 to 44 years old was 7.0%. The standardized morbidity ratio for polymyalgia rheumatica was not significantly increased.


Tibia vara in a patient with Bardet-Biedl syndrome.

The Bardet-Biedl syndrome is characterized by polydactyly, hypogonadism, obesity, mental retardation, and retinitis pigmentosa. Several other skeletal findings include hip dysplasia, short stature, and skull deformities. The patient described in this report has the classic findings of Bardet-Biedl syndrome in conjunction with tibia vara and irregular physes of the lower extremities.


Isolated antral narrowing associated with gastrointestinal cryptosporidiosis in acquired immunodeficiency syndrome.

A 33-year-old man with human immunodeficiency virus infection had severe protracted diarrhea. Radiologic assessment disclosed narrowing of the gastric antrum. Biopsy specimens revealed diffuse Cryptosporidium infection of the antral mucosa. Isolated antral narrowing due to Cryptosporidium gastritis should be added to the list of gastrointestinal complications associated with acquired immunodeficiency syndrome (AIDS).


Intubation of critically ill patients.

Respiratory failure is one of the most common causes for admission to an intensive-care unit. Any patient with loss of central nervous system control of breathing, neuromuscular respiratory failure, or impairment of gas exchange may require tracheal intubation and mechanical ventilation. Tracheal intubation provides a conduit for ventilatory support, maintains the patency of an airway that has potential for obstruction, protects the airway from the contents of the stomach, and allows access to the trachea for pulmonary hygiene. Although the mechanics of intubation are easily learned, many factors must be considered in critically ill patients. Herein we summarize the principles of tracheal intubation in acutely ill patients.


Cardiac transplantation: surgical considerations and early postoperative management.

The limited availability of donor hearts is the major constraint to the expanded application of cardiac transplantation. As many as 25% of potential recipients will die before a donor becomes available. Since 1986, hospitals that receive Medicare and Medicaid funds have been required to ask family members of all brain-dead patients who are potential donors whether they have considered organ donation. The United Network for Organ Sharing is responsible for the national organ procurement and transplantation network as well as the national organ transplantation scientific registry. The increasing occurrence of multiorgan donation is amplifying the demands for intensive-care management of donors. Donor and recipient are matched on the basis of ABO blood group and body size. The donor operation can be performed in any standard operating room. Although the maximal acceptable ischemic time for a donor heart is 4 to 6 hours, briefer preservation times result in better hemodynamic performance after transplantation and a significantly lower 30-day mortality. The technique of choice in most medical centers is orthotopic cardiac transplantation. Postoperatively, most patients remain in the intensive-care unit for 1 or 2 days and in the hospital for 1 to 2 weeks. Standard intensive-care procedures after transplantation, including nursing and cardiovascular management as well as the treatment of failure of the donor heart, are reviewed. A comprehensive educational program for patients and their families should optimize the outcome after heart transplantation. The overall charges for heart transplantation averaged $114,000 in 1987, 80% of which were hospital charges.(ABSTRACT TRUNCATED AT 250 WORDS)


Techniques of immunosuppression after cardiac transplantation.

Modulation of the normal immune response is the major challenge for successful organ transplantation. Cardiac allograft rejection is primarily the result of activation of T cells. Most currently used immunosuppressive agents mainly affect the T-cell-mediated limb of the immune system. Immunosuppressive strategies can be considered to have three goals: (1) prophylaxis against rejection early after cardiac transplantation, (2) long-term maintenance prophylaxis, and (3) treatment of acute rejection. The extent of immunosuppression needed varies with the time after transplantation and the rejection profile of the individual patient. The goal is to provide sufficient immunosuppression to retard rejection without causing undesirable side effects, including infection and neoplasms.


Pitfalls of "bench surgery" and autotransplantation for renal cell carcinoma.

Under certain circumstances, extracorporeal surgical treatment ("bench surgery") followed by autotransplantation is indicated for renal cell carcinoma. During a 10-year period, 20 patients (16 men and 4 women) underwent bench surgery and attempted autotransplantation for renal cell carcinoma at our institution. The autotransplantation was successful in 16 patients but unsuccessful in 4 because of postoperative renal vascular thrombosis or extensive tumor involvement, which resulted in inadequate renal vein for anastomosis. Of the 16 patients who underwent successful autotransplantations, 4 (25%) subsequently had locally recurrent renal cell carcinoma (a mean of 35 months after initial autotransplantation). Only 6 of the 16 patients who underwent successful autotransplantation were ultimately free of both carcinoma and dialysis. Although an ex vivo surgical procedure can be beneficial for certain patients with renal cell carcinoma, computed tomographic scanning of the autotransplantation site should be performed every 3 to 6 months postoperatively for early detection of local tumor recurrence.


Early-stage squamous cell carcinoma of the glottic larynx managed with radiation therapy.

Between January 1975 and December 1985, 45 patients with carcinoma in situ or invasive squamous cell carcinoma of the glottic larynx received radiation therapy at the Mayo Clinic. Local control in the entire group of 45 patients was 84% (in 6 of 6 with carcinoma in situ and in 32 of 39 with invasive cancers). Three of seven patients (43%) with local recurrences underwent successful larynx-preserving surgical procedures; thus, the rate of laryngeal preservation was 91%. In our study of several treatment factors, including the duration of treatment, type of treatment (continuous course versus split course), photon energy (60Co versus 4-MV photons versus 6-MV photons), total dose, and dose per fraction, we found that only total dose of 6,300 cGy or more was associated with significantly improved local control (in 35 of 38 patients [92%]). Two patients (4%) died of uncontrolled delayed nodal metastases, one of which was preceded by a local recurrence. Severe laryngeal edema developed in two patients, associated with recurrent glottic carcinoma in one of them. No larynx was lost because of complications. In our current treatment recommendations, patients receive a total dose of 6,300 cGy in 28 fractions of 225 cGy each, administered in a continuous course with use of 6-MV photons.


Clinical performance of parathyroid hormone immunometric assays.

Three immunometric assays of parathyroid hormone (PTH)--a commercial immunoradiometric assay, an in-house immunoradiometric assay, and an immunochemiluminometric assay--were evaluated in 50 patients with surgically proven primary hyperparathyroidism. Of these patients, 43 had increased values with the commercial assay (sensitivity, 86%), whereas 45 patients had increased concentrations with both the in-house immunoradiometric and the in-house immunochemiluminometric assays (sensitivities, 90%). Because of the results of this comparison study, we confidently chose the immunochemiluminometric assay as our routine assay; this assay was evaluated retrospectively in 361 patients with surgically proven primary hyperparathyroidism. In 45 patients, PTH values were below the upper limit of normal (sensitivity, 88%). The results indicate that the sensitivities of current immunometric assays are approximately 90%. Twenty patients who had hypercalcemia associated with malignant involvement were assessed with the immunochemiluminometric assay. Of these 20 patients, 19 had subnormal PTH values, and 1 had a value within the normal range. In contrast, in the past, PTH values determined with radioimmunoassays have often been in the normal range for such patients. Thus, an immunometric PTH assay is superior to a radioimmunoassay in the differential diagnosis of hypercalcemia associated with malignant disease.


Dirofilaria immitis: a rare, increasing cause of pulmonary nodules.

Dirofilariasis is an unusual but increasing cause of solitary pulmonary nodules. In this study, we reviewed the entire experience with dirofilariasis at our institution. Five such patients were identified. In all patients, the Dirofilaria immitis infection manifested as a solitary pulmonary nodule, and all patients underwent thoracotomy for diagnosis. None required systemic treatment. D. immitis is found in dog, cat, wolf, coyote, and fox populations throughout the United States, but the highest concentrations have been noted in the eastern, southeastern, and southern coastal states. The distribution of human cases of D. immitis infection has a similar pattern. Pulmonary dirofilariasis should be included in the differential diagnosis of peripheral noncalcified pulmonary nodules, especially in endemic areas.


Weight change and serum lipoproteins in recipients of renal allografts.

Hyperlipoproteinemia is common in recipients of renal allografts. In this study, serum lipids and some possible contributing factors--weight gain, weight relative to ideal body weight, daily dose of prednisone, serum creatinine, 24-hour urinary protein, and diabetes mellitus--were assessed in 100 patients. At the end of the first year after transplantation, 57 of the 100 patients had total serum cholesterol concentrations of 240 mg/dl or more--40 of 75 patients without diabetes and 17 of 25 with diabetes. The mean values for weight gain (11.2 kg) and actual weight relative to ideal body weight (19.4 kg) were significantly greater (P = 0.029 and P = 0.01, respectively) in the subgroup of patients without diabetes who had total serum cholesterol values of 240 mg/dl or more at 1 year after transplantation than in those with values of less than 240 mg/dl. The daily dose of prednisone and the serum creatinine levels were similar in these two subgroups. The 24-hour urinary protein measurements were greater at 1 month than at 1 year in both patients with and those without diabetes. Perhaps the initial dietary advice for patients who have undergone renal transplantation should emphasize control of total caloric intake; subsequently, intake of cholesterol and fat can be modified in those patients who have persistent hyperlipoproteinemia.


Fluorescent in situ hybridization: use of whole chromosome paint probes to identify unbalanced chromosome translocations.

By identifying structural chromosome anomalies, the clinical cytogenetics laboratory can play a critical role in the diagnosis and treatment of patients with birth defects. Although many new staining techniques have been developed throughout the years to aid in the detection of anomalous chromosomes, some abnormalities still pose a special challenge to cytogeneticists. This difficulty is especially evident in patients with an abnormal chromosome that does not produce a recognizable banding pattern by conventional staining techniques. We describe a recently discovered method of identifying chromosomes by using whole chromosome-specific DNA probes and fluorescent in situ hybridization and provide examples of how this new procedure facilitated the identification of chromosome abnormalities in two patients with multiple birth defects.


Fistulous pseudoaneurysm complicating surgical accessory pathway interruption for Wolff-Parkinson-White syndrome.

Pseudoaneurysms of the left ventricle are unusual operative complications that have commonly been associated with replacement of the mitral valve. In this report, we describe a 31-year-old man who was referred to our institution because of atypical chest pain. He had previously undergone three operations for ablation of an accessory pathway because of Wolff-Parkinson-White syndrome. A pseudoaneurysm of the left ventricle was noted on transesophageal echocardiography, biplanar left ventriculography, and ultrafast cine computed tomography of the heart. Elective surgical repair was successful. Although rare, this case demonstrates an unusual but potentially serious complication of surgical treatment of Wolff-Parkinson-White syndrome.


Occult cardiac tamponade detected by transesophageal echocardiography.

Transesophageal echocardiography is a safe, minimally invasive procedure that should be considered when the diagnosis of cardiac tamponade is a possibility and when conventional methods fail to provide conclusive diagnostic information. In this report, we describe a 74-year-old man in the intensive-care unit whose condition was unstable postoperatively because of an occult loculated pericardial effusion and cardiac tamponade. Routine noninvasive and invasive monitoring, including hemodynamic monitoring and transthoracic echocardiography, failed to confirm definitively the suspected diagnosis of cardiac tamponade. In addition, because of the hemodynamic instability of the patient, transporting him for definitive tests (such as fast computed tomographic scanning of the mediastinum, which could not be performed at the bedside) for assessment of cardiac tamponade was relatively contraindicated. In our patient, the diagnostic information obtained by transesophageal echocardiography may have been lifesaving.