True adenomas of the cardia: a case series of 3 patients

BACKGROUND/AIM

True adenomas of the cardia appear to be extremely rare lesions. There are no data on the natural history and histopathological background of these lesions. We report 3 patients with true adenomas of the cardia.

METHODS AND RESULTS

Three patients with polypoid masses at the cardia below the Z-line were submitted to a tertiary referral center for further diagnosis and therapy. In 2 of the 3 cases Barrett's esophagus with low-grade intraepithelial neoplasia was assumed on the basis of histopathological examination of biopsy specimens taken from the surface of the lesions. Polypectomy was performed in all 3 cases. In 2 of the 3 cases the final histopathological diagnosis of low-grade adenoma of the cardia could only be established after complete removal of the polypoid masses.

CONCLUSIONS

Adenomas of the cardia can be mistaken for dysplasia arising from Barrett's esophagus, if the diagnosis is based on endoscopic biopsies only. It is, therefore, reasonable to completely remove any suspicious lesions by endoscopy not only for therapeutic but also for diagnostic reasons.

Clinical trial: persistent gastro-oesophageal reflux symptoms despite standard therapy with proton pump inhibitors - a follow-up study of intraluminal-impedance guided therapy

BACKGROUND

Persistent gastro-oesophageal reflux disease (GERD), despite proton pump inhibitor (PPI) therapy, is a common problem. Combined pH/impedance monitoring (pH/MII) enables detection of reflux episodes. Aim To identify patients with objective episodes of persistent reflux and second, to evaluate the effect of modified therapy based on the results of pH/MII.

METHODS

In all, 143 patients were examined with pH/MII because of GERD-symptoms resistant to PPI-therapy. Patients with pathological pH/MII (group 1) and with normal results (group 2) were identified. Therapy modifications were evaluated after a minimum follow-up of 3 months.

RESULTS

In 56 of 143 (39.1%) patients, pathological findings in pH/MII were identified. Therapy was escalated in 33/52 patients (group 1) and in 30/71 patients (group 2). Escalating therapy led to symptomatic relief in 90.9% of the patients in group 1 and 43.3% of the patients in group 2 (P < 0.001).

CONCLUSIONS

GERD symptoms refractory to PPI-therapy could be objectively identified with pH/MII in almost 40% of all patients. Furthermore, escalating anti-reflux therapy if pH/MII was pathological is associated with a significantly higher rate of successful treatment compared to the patients with normal findings. Therefore, pH/MII facilitates a more focussed therapeutical approach to patients with PPI-resistant GERD.

[Functional dyspepsia]

Functional dyspepsia is the most common form of dyspepsia met with in the GP's office and in routine internistic medicine. The symptoms are unspecific: Postprandial or early satiation, epigastric discomfort/pain. To establish the diagnosis, organic disorders must first be carefully excluded. To date, no pathophysiological explanation for such complaints is available, and treatment is purely symptomatic, for example, administration of a proton pump inhibitor or a prokinetic drug, or even psychotherapy.

A rare case of primary rectal rhabdomyosarcoma in an adult

We report an extremely rare case (1:200 000) of primary rectal rhabdomyosarcoma (RMS) in an adult. In the literature, this case report is the first one dealing with an adult patient. The diagnosis was assessed by computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), endoscopy and histological examination. Neoadjuvant systemic chemotherapy with adriamycin and isofosfamide followed by anterior rectum resection was performed. This article should implicate RMS as a rare differential diagnosis of atypical rectal tumours in adults.

Assoziation eines segmentalen Budd-Chiari-Syndroms mit einem Hypereosinophilensyndrom

We report a rare case of hypereosinophilic syndrome associated with a partial obstruction of the hepatic veins (Budd-Chiari syndrome). The case was assessed by ultrasonic examination, computed tomography and magnetic resonance tomography. We postulate an association because endothelium damage and thrombosis is reported in hypereosinophilic syndromes. Elevated liver enzymes in a patient with hypereosinophilic syndrome could be associated with a Budd-Chiari syndrome.

Collateral circulation is an independent radiological predictor of outcome after thrombolysis in acute ischaemic stroke

We tested the hypothesis that the type of vascular occlusion, recanalisation and collateralisation are predictive of outcome after thrombolytic therapy in acute ischaemic stroke. We carried out angiography and local intra-arterial (97) or systemic (14) thrombolysis within 6 h of the onset in patients with an ischaemic stroke in the territory of the internal carotid artery. Early ischaemic signs (EIS) on pretreatment CT and angiographic findings were classified and analysed in relation to clinical outcome at 3 months. A favourable outcome (Barthel index [BI]>/= 90) was found in 40% of patients with an occlusion of the middle cerebral artery trunk whereas intracranial occlusion of the internal carotid artery ("carotid T occlusion") was followed by death or severe disability (BI<50) in 87%. Significant univariate predictors of favourable outcome were occlusion type ( P<0.01), recanalisation ( P<0.01) and collateralisation ( P<0.01). However, multivariate analysis revealed a significant relationship only between collateralisation and favourable outcome (odds ratio 5.9, 95% confidence interval 1.3-26.7, P=0.02). EIS were not predictive in either case. Occlusion type and recanalisation, are related to outcome only if adequate collateralisation prevents infarction until recanalisation occurs.

Endometrial expression and secretion of interleukin-6 throughout the menstrual cycle

Previous findings revealing reduced endometrial interleukin-6 (IL-6) mRNA expression in patients with recurrent early abortions gave rise to the analysis of IL-6 synthesis in the human endometrium, and how it relates to concentrations in uterine secretions. Endometrial tissues and uterine secretions were collected from patients undergoing hysterectomy. Expression of IL-6 receptor and gp130 mRNA (n = 28) in total endometrium, of IL-6 mRNA in endometrial epithelial and stromal cells, and CD45-positive leukocytes were investigated by RNAase protection assay throughout the cycle. IL-6 protein was assessed in endometrial tissue by immunohistochemistry (n = 32) and in uterine secretions by enzyme-linked immunosorbent assay (ELISA) (n = 33). IL-6 mRNA was expressed at low levels in the proliferative phase, and expression increased progressively in the secretory phase. The increase was attributed to epithelial and stromal cells and leukocytes. Concentrations of IL-6 protein in endometrial glands and in uterine secretions were low in the proliferative phase, and increased 5-10-fold in the mid- to late secretory phase. mRNA expression of IL-6 receptor and gp130 remained constant in total endometrium throughout the menstrual cycle. High concentrations of IL-6 in the mid-secretory phase, the putative implantation window, and a further increase in the late secretory phase, the premenstrual period, support a role of IL-6 in the regulation of endometrial functions.

Endometrial osteopontin, a ligand of beta3-integrin, is maximally expressed around the time of the "implantation window"

OBJECTIVE

To analyze endometrial mRNA and protein expression of osteopontin and its receptor, beta3-integrin, throughout the menstrual cycle.

DESIGN

Study by immunohistochemistry, RNase protection assay, and ELISA.

SETTING

Academic research unit.

PATIENT(S)

Forty-five regularly cycling women without endometrial pathology.

INTERVENTION(S)

Expression of endometrial osteopontin and beta3-integrin mRNA was analyzed by RNase protection assay in endometrium, endometrial epithelial cells, stromal cells, and endometrial leukocytes (CD45) and by immunohistochemistry in frozen sections of endometrium throughout the menstrual cycle. Concentration of osteopontin was studied in uterine secretions by ELISA.

MAIN OUTCOME MEASURE(S)

mRNA and protein expression of osteopontin and beta3-integrin.

RESULT(S)

Osteopontin mRNA and protein was weakly expressed in the proliferative phase and maximally expressed in the mid to late secretory phases in endometrium, endometrial epithelial cells, and endometrial leukocytes and in uterine secretions. Beta3-integrin mRNA and protein were expressed in stromal cells throughout the menstrual cycle and were maximally expressed in epithelial cells in the mid to late secretory phases.

CONCLUSION(S)

Expression of osteopontin and its receptor, beta3-integrin, in human endometrial glands and osteopontin secretion into the uterine cavity around the time of the "implantation window" suggest a role for these proteins in endometrial function and implantation.

Cortical fibroblast culture from human biopsies

BACKGROUND

Tubulointerstitial fibrosis is an integral part of progressive renal disease. Human cortical fibroblasts are believed to be key effector cells in fibrogenesis. Thus, a reliable culture of these cells is necessary for studies of their pathophysiology.

METHODS

Cortical fibroblast culture from routine kidney biopsies were analyzed and the cells were characterized. Indirect immunofluorescence staining was done after the first passage for cytokeratin, vimentin, alpha-smooth muscle actin, CD 44, CD 54, CD 68, collagen types I, III, and HLA-DR. We then assessed the utility of the putative fibroblast markers CD 90, prolyl-4-hydroxylase (P4H) and F1b in simultaneous stainings of tubular epithelial cells.

RESULTS

During the study period, 49 biopsy cores were cultured and cortical fibroblasts could be successfully established in 21 cases (42.9%). There was no relation between the success rate of culture and the degree of interstitial fibrosis, but an association was seen with the time of completion of the first passage. There was a negative correlation between the extent of scarring and the percentage of cytokeratin positive cells (r = -0.66, p < 0.001). All primary fibroblasts were negative for factor VIII, HLA-DR, CD 68, and cytokeratin. They expressed alpha-smooth muscle actin and collagen types I and III to variable degrees. There was a robust correlation between the percentage of alpha-smooth muscle actin positive cells and interstitial scarring but no such association with collagen type I or type III positive cells. The three putative fibroblast markers did not prove useful in differentiating between tubular epithelial cells and fibroblasts. However, since only fibroblasts stained positive for CD 90 and negative for cytokeratin, these two markers may suffice to distinguish fibroblasts from other renal cellular elements.

CONCLUSIONS

Cortical renal fibroblasts can be easily cultured from kidney biopsy cores, though the success rate of pure cultures is below 50%. Staining for CD 90 and cytokeratin may suffice for initial characterization of these cells.

TGF-beta 1 induces proliferation in human renal fibroblasts via induction of basic fibroblast growth factor (FGF-2)

BACKGROUND

The prognosis of primary renal disease is often dependent on the degree of tubulointerstitial scarring. Scarring is caused by proliferation and excessive matrix production of renal fibroblasts and possibly other cellular elements. Transforming growth factor-beta (TGF-beta) is the most important cytokine for the induction of matrix synthesis in the kidney. However, its effects on renal fibroblast proliferation have not been determined. We have recently demonstrated that the expression of basic fibroblast growth factor (FGF-2) is robustly up-regulated in human kidneys with tubulointerstitial fibrosis and that FGF-2 is a potent inducer of fibroblast proliferation. The present study examined the interaction between TGF-beta 1 and FGF-2 in human renal fibroblasts.

METHODS

Experiments were performed on a transformed medullary fibroblast line and on primary cortical kidney and skin fibroblasts isolated from human biopsies. mRNA levels of FGF-2 and TGF-beta 1 were analyzed by Northern blot analyses. Changes in protein expression were examined by immunoblots and enzyme-linked immunosorbent assay (ELISA). Bromodeoxyuridine incorporation assays and cell counts were used to analyze cell proliferation. The expression of cell cycle-regulatory proteins cyclin-dependent kinase (cdk) 2 and the cdk inhibitor p27(kip1) were determined by immunoblots.

RESULTS

Stimulation of renal fibroblasts with FGF-2 resulted in no change of TGF-beta 1 mRNA expression, whereas incubation of the cells with TGF-beta 1 induced FGF-2 mRNA up to 3.51 +/- 0.21-fold after six hours. This increase could be blocked almost completely by the addition of cyclohexamide, indicating that the process is in large part dependent on protein synthesis. The up-regulation in FGF-2 mRNA expression was paralleled by de novo detection of FGF-2 protein in the supernatant, peaking after 12 to 24 hours, as determined by Western blot and ELISA, whereas cellular protein was only increased up to 2.1-fold. Interestingly, both methods detected release of FGF-2 protein to the supernatant already at three hours, indicating a role for TGF-beta1 in directly releasing preformed FGF-2. Since TGF-beta 1 induced FGF-2, which results in fibroblast proliferation, we hypothesized that TGF-beta1 may cause fibroblast proliferation mediated by FGF-2. This hypothesis was verified by cell proliferation assays demonstrating that stimulation of renal fibroblasts with TGF-beta1 resulted in an up to 3.21 +/- 0.28-fold increase in bromodeoxyuridine incorporation and a 1.95 +/- 0.16-fold increase in cell number after 72 hours. This mitogenic effect of TGF-beta1 could be blocked completely by the addition of a neutralizing antibody to FGF-2 or the tyrosine kinase inhibitor tyrphostin AG1296, which blocks FGF receptor (FGFR) tyrosine kinase activity. Conversely, a neutralizing antibody to epidermal growth factor (EGF) or the tyrphostin B42, which inhibits EGF receptor signal transduction, had no effect. Interestingly, a neutralizing antibody to PDGF had only minor effects in primary kidney fibroblasts but reduced TGF-beta 1-induced proliferation considerably in primary skin fibroblasts. Finally, TGF-beta1-induced proliferation in kidney fibroblasts was paralleled by a robust increase in cdk 2 protein expression up to 72 hours, whereas p27(kip1), whose activity is maintained by TGF-beta in epithelial cells, was down-regulated up to 48 hours.

CONCLUSIONS

Our studies demonstrate, to our knowledge for the first time, that TGF-beta1 induces proliferation in human renal fibroblasts and that this process is mediated largely by FGF-2. The induction of proliferation by TGF-beta 1 via induction of FGF-2 may play an important role in the autonomy of renal fibroblast growth and thus in the pathogenesis of human fibrogenesis.

Basic fibroblast growth factor expression is increased in human renal fibrogenesis and may mediate autocrine fibroblast proliferation

BACKGROUND

Interstitial fibroblasts play a critical role in renal fibrogenesis, and autocrine proliferation of these cells may account for continuous matrix synthesis. Basic fibroblast growth factor (FGF-2) is mitogenic for most cells and exerts intracrine, autocrine, and paracrine effects on epithelial and mesenchymal cells. The aims of the present studies were to localize and quantitate the expression of FGF-2 in normal and pathologic human kidneys and to study the in vitro effects of FGF-2 on proliferation, differentiation, and matrix production of isolated cortical kidney fibroblasts.

METHODS

FGF-2 protein expression was localized by immunofluoresence double labelings in normal and fibrotic human kidneys. Subsequently, interstitial FGF-2 labeling was determined semiquantitatively in 8 normal kidneys and 39 kidneys with variable degrees of interstitial fibrosis and was correlated with the morphometrically determined interstitial cortical volume. In addition, FGF-2 expression was quantitated by immunoblot analysis in three normal and six fibrotic kidneys. FGF-2 mRNA was localized by in situ hybridizations. Seven primary cortical fibroblast lines were established, and expression of FGF-2 and FGF receptor-1 (FGFR-1) were examined. The effects of FGF-2 on cell proliferation were determined by bromodeoxyuridine incorporation and cell counts, those on differentiation into myofibroblasts by staining for alpha-smooth muscle actin, and those on matrix synthesis by enzyme-linked immunosorbent assay for collagen type I and fibronectin. Finally, proliferative activity in vivo was evaluated by expression of MIB-1 (Ki-67 antigen).

RESULTS

In normal kidneys, FGF-2 expression was confined to glomerular, vascular, and a few tubular as well as interstitial fibroblast-like cells. The expression of FGF-2 protein was increased in human kidneys, with tubulointerstitial scarring correlating with the degree of interstitial fibrosis (r = 0.84, P < 0.01). Immunoblot analyses confirmed a significant increase in FGF-2 protein expression in kidneys with interstitial scarring. In situ hybridization studies demonstrated low-level detection of FGF-2 mRNA in normal kidneys. However, FGF-2 mRNA expression was robustly up-regulated in interstitial and tubular cells in end-stage kidneys, indicating that these cells are the source of excess FGF-2 protein. Primary cortical fibroblasts express FGF-2 and FGFR-1 in vitro. FGF-2 induced a robust growth response in these cells that could be blocked specifically by a neutralizing FGF-2 antibody. Interestingly, the addition of the neutralizing antibody alone did reduce basal proliferation up to 31.5%. In addition, FGF-2 induced expression of alpha-smooth muscle actin up to 1.6-fold, but no significant effect was observed on the synthesis of collagen type I and fibronectin. Finally, staining for MIB-1 revealed a good correlation of interstitial FGF-2 positivity with interstitial and tubular proliferative activity (r = 0.71, P < 0.01 for interstitial proliferation, N = 30).

CONCLUSIONS

Interstitial FGF-2 protein and mRNA expression correlate with interstitial scarring. FGF-2 is a strong mitogen for cortical kidney fibroblasts and may promote autocrine fibroblast growth. Expression of FGF-2 correlates with interstitial and tubular proliferation in vivo.

Regression of human metastatic renal cell carcinoma after vaccination with tumor cell-dendritic cell hybrids

Reports of spontaneous regressions of metastases and the demonstration of tumor-reactive cytotoxic T lymphocytes indicate the importance of the host's immune system in controlling the devastating course of metastatic renal cell carcinoma. Recent research indicates that immunization with hybrids of tumor and antigen presenting cells results in protective immunity and rejection of established tumors in various rodent models. Here, we present a hybrid cell vaccination study of 17 patients. Using electrofusion techniques, we generated hybrids of autologous tumor and allogeneic dendritic cells that presented antigens expressed by the tumor in concert with the co-stimulating capabilities of dendritic cells. After vaccination, and with a mean follow-up time of 13 months, four patients completely rejected all metastatic tumor lesions, one presented a 'mixed response', and two had a tumor mass reduction of greater 50%. We also demonstrate induction of HLA-A2-restricted cytotoxic T cells reactive with the Muc1 tumor-associated antigen and recruitment of CD8+ lymphocytes into tumor challenge sites. Our data indicate that hybrid cell vaccination is a safe and effective therapy for renal cell carcinoma and may provide a broadly applicable strategy for other malignancies with unknown antigens.