Bilateral breast desmoid-type fibromatosis, case report and literature review

BACKGROUND

Breast desmoid-type fibromatosis (BDF) is a rare mesenchymal tumor accounting for only 0.2% of solid breast tumors. It is classified as an intermediate tumor because it is locally aggressive but has no metastatic potential. Its diagnosis is often difficult because it shares many clinical and radiologic aspects with breast carcinomas and therefore relies on anatomopathological analysis which may be supplemented by genetic analysis. The treatment of BDF has considerably evolved in the past years. While surgery was the cornerstone of the management prior to the 2000s, recent data have shown the value of active surveillance (AS) from the time of diagnosis. Indeed, after 2 years of AS, the progression-free survival (PFS) of the disease is identical or superior to surgery. Moreover, spontaneous regression has been observed in 30% of patients undergoing AS. In case of disease progression, surgery can be considered on a case-by-case basis, as well as systemic treatments.

CASE DESCRIPTION

We present a case of bilateral BDF affecting a 20-year-old woman for whom the first suggested treatment was bilateral mastectomy with reconstruction. After a second opinion, the decision was revised and AS was initiated. Almost 3 years after the onset of AS, tumors have shown a continuous regression.

CONCLUSIONS

This case demonstrates the need for experience in the management of mesenchymal tumors to avoid overtreatment by mutilating surgeries which promote recurrence. Moreover, to our knowledge, very few cases of bilateral BDF have been published to date. It thus seemed relevant for us to report this rare case which supports the interest of AS for DF, as recently advised by the Desmoid Tumor Working Group guidelines.

Compound heterozygous mutations in the luteinizing hormone receptor signal peptide causing 46,XY disorder of sex development

Testosterone production by the fetal testis depends on a functional relationship between hCG and the LH/chorionic gonadotropin receptor (LHCGR). Failure of the receptor to correctly respond to its ligand leads to impaired sexual differentiation in males. A phenotypically female patient with pubertal delay had a 46,XY karyotype and was diagnosed with 46,XY disorder of sex development (DSD). Novel compound heterozygous LHCGR mutations were found in the signal peptide: a duplication p.L10_Q17dup of maternal origin, and a deletion (p.K12_L15del) and a p.L16Q missense mutation of paternal origin. cAMP production was very low for both the deletion and duplication mutations and was halved for the missense mutant. The duplication and missense mutations were both expressed intracellularly, but at very low levels at the cell membrane; they were most likely retained in the endoplasmic reticulum. The deletion mutant had a very limited intracellular expression, indicating impaired biosynthesis. There was reduced expression of all three mutants, which was most marked for the deletion mutation. There was also decreased protein expression of all three mutant receptors. In the deletion mutation, the presence of a lower-molecular-weight band corresponding to LHCGR monomer, probably due to lack of glycosylation, and a lack of bands corresponding to dimers/oligomers suggests absent ER entry. This novel case of 46,XY DSD illustrates how different LHCGR signal peptide mutations led to complete receptor inactivation by separate mechanisms. The study underlines the importance of specific regions of signal peptides and expands the spectrum of LHCGR mutations.

[Craniopharyngioma and Klinefelter syndrome during the pubertal transition: A diagnostic challenge]

Craniopharyngioma is the most common pituitary tumor in childhood. It can compromise the pubertal development because of its evolution or treatment. Syndrome of Klinefelter is the most common cause of hipergonadotrophic hypogonadism in males. The concomitant presentation of both entities is extremely low (1/109) and the pathophysiological association is questionned. We present the case of a 18-year-old Belgian patient. He had a diagnosis of craniopharyngioma in childhood and he presented with panhypopituitarism after radiotherapy and surgical treatment. At the age of 14, he started pubertal induction with gonadotropin therapy without clinical response. Asociación de craneofaringioma y síndrome de Klinefelter en la transición puberal: un desafío diagnóstico Craniopharyngioma and Klinefelter syndrome during the pubertal transition: A diagnostic challenge A genetic evaluation confirmed a homogeneous 47, XXY karyotype. Failure of exogenous gonadotropin therapy revealed the hidden association of primary and secondary hypogonadism, demonstrating the importance of the followup and a multidisciplinary approach in these patients.

Maintenance of Functional Human Cancellous Bone and Human Hematopoiesis in NOD/SCID Mice

Attempts were made to establish models to study interactions between marrow stromal cells and hematopoietic cells in vivo. The approach was to create a NOD-SCID-hu murine model of long-term human hematopoiesis by implantation of a human adult bone fragment. Nine to 12 weeks posttransplantation, human CD45+ cells were detected in the blood and the spleen of some mice. The histology of the human transplant showed that human bone fragment was viable at 9 weeks. Moreover, vessels of human origin, as assessed by immunohistochemical detection of human β2-microglobulin, were observed in the mouse tissue surrounding the transplanted human fragment.

A vital region for human glycoprotein hormone trafficking revealed by an LHB mutation

Glycoprotein hormones are complex hormonally active macromolecules. Luteinizing hormone (LH) is essential for the postnatal development and maturation of the male gonad. Inactivating Luteinizing hormone beta (LHB) gene mutations are exceptionally rare and lead to hypogonadism that is particularly severe in males. We describe a family with selective LH deficiency and hypogonadism in two brothers. DNA sequencing of LHB was performed and the effects of genetic variants on hormone function and secretion were characterized by mutagenesis studies, confocal microscopy and functional assays. A 20-year-old male from a consanguineous family had pubertal delay, hypogonadism and undetectable LH. A homozygous c.118_120del (p.Lys40del) mutation was identified in the patient and his brother, who subsequently had the same phenotype. Treatment with hCG led to pubertal development, increased circulating testosterone and spermatogenesis. Experiments in HeLa cells revealed that the mutant LH is retained intracellularly and showed diffuse cytoplasmic distribution. The mutated LHB heterodimerizes with the common alpha-subunit and can activate its receptor. Deletion of flanking glutamic acid residues at positions 39 and 41 impair LH to a similar extent as deletion of Lys40. This region is functionally important across all heterodimeric glycoprotein hormones, because deletion of the corresponding residues in hCG, follicle-stimulating hormone and thyroid-stimulating hormone beta-subunits also led to intracellular hormone retention. This novel LHB mutation results in hypogonadism due to intracellular sequestration of the hormone and reveals a discrete region in the protein that is crucial for normal secretion of all human glycoprotein hormones.

Characterization of GPR101 transcript structure and expression patterns

We recently showed that Xq26.3 microduplications cause X-linked acrogigantism (X-LAG). X-LAG patients mainly present with growth hormone and prolactin-secreting adenomas and share a minimal duplicated region containing at least four genes. GPR101 was the only gene highly expressed in their pituitary lesions, but little is known about its expression patterns. In this work, GPR101 transcripts were characterized in human tissues by 5'-Rapid Amplification of cDNA Ends (RACE) and RNAseq, while the putative promoter was bioinformatically predicted. We investigated GPR101 mRNA and protein expression by RT-quantitative PCR (qPCR), whole-mount in situ hybridization, and immunostaining, in human, rhesus monkey, rat and zebrafish. We identified four GPR101 isoforms characterized by different 5'-untranslated regions (UTRs) and a common 6.1kb long 3'UTR. GPR101 expression was very low or absent in almost all adult human tissues examined, except for specific brain regions. Strong GPR101 staining was observed in human fetal pituitary and during adolescence, whereas very weak/absent expression was detected during childhood and adult life. In contrast to humans, adult monkey and rat pituitaries expressed GPR101, but in different cell types. Gpr101 is expressed in the brain and pituitary during rat and zebrafish development; in rat pituitary, Gpr101 is expressed only after birth and shows sexual dimorphism. This study shows that different GPR101 transcripts exist and that the brain is the major site of GPR101 expression across different species, although divergent species- and temporal-specific expression patterns are evident. These findings suggest an important role for GPR101 in brain and pituitary development and likely reflect the very different growth, development and maturation patterns among species.

Breast cancer in a male-to-female transsexual patient with a BRCA2 mutation

Breast cancer is rare in male patients. Certain predisposing factors, be they genetic (e.g., BRCA2 gene mutations) or hormonal (imbalance between estrogen and androgen levels), have been implicated in male breast cancer pathophysiology. Male-to-female (MtF) transsexualism is a condition that generally involves cross-sex hormone therapy. Anti-androgens and estrogens are used to mimic the female hormonal environment and induce the cross-sex secondary characteristics. In certain situations, the change in the hormonal milieu can be disadvantageous and favor the development of hormone-dependent pathologies, such as cancer. We report a case of a MtF transgender patient who developed breast cancer after 7 years of cross-sex hormonal therapy. The patient was found to be BRCA2 positive, and suffered recurrent disease. The patient was unaware of being a member of an established BRCA2 mutation-positive kindred. This represents the first case of a BRCA2 mutation predisposing to breast cancer in a MtF transgender patient.

[CONTROVERSIES REGARDING THE ACCURACY AND LIMITATIONS OF FROZEN SECTION IN THYROID PATHOLOGY: AN EVIDENCE-BASED ASSESSMENT]

Palpable thyroid nodules are present clinically in 4-7% of the population and their prevalence increases to 50%-67% when using high-resolution neck ultrasonography. By contrast, thyroid carcinoma (TC) represents only 5-20% of these nodules, which underlines the need for an appropriate approach to avoid unnecessary surgery. Frozen section (PS) has been used for more than 40 years in thyroid surgery to establish the diagnosis of malignancy. However, a controversy persists regarding the accuracy of FS and its place in thyroid pathology has changed with the emergence of fine-needle aspiration (FNA). A PubMed Medline and SpringerLink search was made covering the period from January 2000 to June 2012 to assess the accuracy of ES, its limitations and indications for the diagnosis of thyroid nodules. Twenty publications encompassing 8.567 subjects were included in our study. The average value of TC among thyroid nodules in analyzed studies was 15.5 %. ES ability to detect cancer expressed by its sensitivity (Ss) was 67.5 %. More than two thirds of the authors considered PS useful exclusively in the presence of doubtful ENA and for guiding the surgical extension in cases confirmed as malignant by FNA; however, only 33% accepted FS as a routine examination for the management of thyroid nodules. The influence of FS on surgical reintervention rate in nodular thyroid pathology was considered to be negligible by most studies, whereas 31 % of the authors thought that FS has a favorable benefit by decreasing the number of surgical re-interventions. In conclusion, the role of FS in thyroid pathology evolved from a mandatory component for thyroid surgery to an optional examination after a pre-operative FNA cytology. The accuracy of FS seems to provide no sufficient additional benefit and most experts support its use only in the presence of equivocal or suspicious cytological features, for guiding the surgical extension in cases confirmed as malignant by FNA and for the identification of other potentially confusing intraoperative findings.

Concomitant nodal involvement by Langerhans cell histiocytosis and Hodgkin's lymphoma

A 10-year-old girl with a family history of Hodgkin's lymphoma presented with a 2 month history of cervical lymphadenopathy and weight loss. Biopsy indicated concomitant nodal involvement by Langerhans cell histiocytosis and Hodgkin's lymphoma. Such an association is rare, especially so in children, but is not an isolated phenomenon, thereby prompting the question of whether Langerhans cell histiocytosis is a reactive or a neoplastic process.

[Alpha interferon induced hyperthyroidism: a case report and review of the literature]

Treatment with alpha interferon in hepatitis C triggers a thyroid autoimmunity in a variable percentage of cases (2-8%). This complication raises some questions about its screening, the possibility to continue anti-viral therapy and thyroid treatment. Alpha interferon has an immunomodulatory effect on the thyroid, but also an inhibitory effect on thyroid hormone synthesis. This explains the occurrence of cases of thyroid dysfunction, which often remain undetected because of their latency. Factors predicting thyroid dysfunction with interferon use are: female sex, history of thyroid disease and previous autoimmunity. Several clinical aspects are encountered including hypothyroidism (the most frequent depending on the series) and hyperthyroidism related to Graves' disease. For their detection, a cooperation between general practionners, gastroenterologists and endocrinologists is mandatory thyroid function tests are requested before, during and after treatment,with alpha interferon. Therapeutic aspects of thyroid disorders range from simple monitoring to symptomatic treatment, such as thyroxine prescription in the presence of hypothyroidism. Antithyroid drugs radioactive iodine or thyroid surgery are used in cases of severe or persistent Graves' disease induced by alpha interferon.

A novel inactivating mutation of the LH/chorionic gonadotrophin receptor with impaired membrane trafficking leading to Leydig cell hypoplasia type 1

OBJECTIVE

The LH/chorionic gonadotrophin receptor (LHCGR) is a G protein-coupled receptor (GPCR) that plays a central role in male sexual differentiation, regulation of ovarian follicular maturation, ovulation and maintenance of corpus luteum and pregnancy, as well as maintenance of testicular testosterone production. Mutations in the LHCGR gene are very rare. The aim of this work was to study the clinical and molecular characteristics of a rare familial LHCGR mutation.

METHODS

Five affected members of a family, including a phenotypically female, but genotypically male (46,XY), patient with Leydig cell hypoplasia type 1 and four genotypically female siblings with reproductive abnormalities, were studied genetically. Cell trafficking studies as well as signalling studies of mutated receptor were performed.

RESULTS

The five affected patients were all homozygous for a novel mutation in the LHCGR gene, a deletion of guanine in position 1850 (1850delG). This resulted in a frameshift affecting most of the C-terminal intracellular domain. In vitro studies demonstrated that the 1850delG receptor was completely incapable of transit to the cell membrane, becoming trapped within the endoplasmic reticulum. This could not be rescued by small-molecule agonist treatment or stimulated intracellularly by co-expression of a yoked human chorionic gonadotrophin.

CONCLUSIONS

This novel LHCGR mutation leads to complete inactivation of the LHCGR receptor due to trafficking and signalling abnormalities, which improves our understanding of the impact of the affected structural domain on receptor trafficking and function.

McCune-Albright syndrome: a detailed pathological and genetic analysis of disease effects in an adult patient

CONTEXT

McCune Albright syndrome (MAS) is a clinical association of endocrine and nonendocrine anomalies caused by postzygotic mutation of the GNAS1 gene, leading to somatic activation of the stimulatory α-subunit of G protein (Gsα). Important advances have been made recently in describing pathological characteristics of many MAS-affected tissues, particularly pituitary, testicular, and adrenal disease. Other rarer disease related features are emerging.

OBJECTIVE

The objective of the investigation was to study the pathological and genetic findings of MAS on a tissue-by-tissue basis in classically and nonclassically affected tissues.

DESIGN

This was a comprehensive autopsy and genetic analysis.

SETTING

The study was conducted at a tertiary referral university hospital.

PATIENTS

An adult male patient with MAS and severe disease burden including gigantism was the subject of the study.

INTERVENTION(S)

Interventions included clinical, hormonal, and radiographic studies and gross and microscopic pathology analyses, conventional PCR, and droplet digital PCR analyses of affected and nonaffected tissues.

MAIN OUTCOME MEASURE

Pathological findings and the presence of GNAS1 mutations were measured.

RESULTS

The patient was diagnosed with MAS syndrome at 6 years of age based on the association of café-au-lait spots and radiological signs of polyostotic fibrous dysplasia. Gigantism developed and hyperprolactinemia, hypogonadotropic hypogonadism, and hyperparathyroidism were diagnosed throughout the adult period. The patient died at the age of 39 years from a pulmonary embolism. A detailed study revealed mosaiscism for the p.R201C GNAS1 mutation distributed across many endocrine and nonendocrine tissues. These genetically implicated tissues included rare or previously undescribed disease associations including primary hyperparathyroidism and hyperplasia of the thymus and endocrine pancreas.

CONCLUSIONS

This comprehensive pathological study of a single patient highlights the complex clinical profile of MAS and illustrates important advances in understanding the characteristics of somatic GNAS1-related pathology across a wide range of affected organs.

A clinically novel AIP mutation in a patient with a very large, apparently sporadic somatotrope adenoma

Heterozygous germline inactivating mutations in the aryl hydrocarbon receptor-interacting protein (AIP) gene lead to pituitary adenomas that most frequently present in the setting of familial isolated pituitary adenoma syndrome, usually as somatotropinomas and prolactinomas. More recently, they have been found in a significant percentage of young patients presenting with pituitary macroadenoma without any apparent family history. We describe the case of a 19-year-old man who presented with a gigantic somatotropinoma. His family history was negative. His peripheral DNA showed a heterozygous AIP mutation (p.I13N), while tumor tissue only had the mutated allele, showing loss of heterozygosity (LOH) and suggesting that the mutation caused the disease.

[Aero-digestive tract squamous intra-epithelial neoplasia]

Aero-digestive tract squamous intra-epithelial neoplasia is a disease whose genetic and epigenetic features lead to clinical signs and well codified histologic features. This publication aims to review the molecular alterations which have been identified in these lesions, to clarify the clinical manifestations and to discuss the proposed histological classification.

[A left intraventricular mass]

We report the case of a 29-years-old male presenting with a large mass inserted at the hypokinetic apex of the left ventricle. Without any early regression under anticoagulant therapy and taking into account recent neurological manifestations, surgical extraction was decided. The mass corresponded to a chronic thrombus lying on a non-transmural myocardial necrosis. This case gives us the opportunity to review all causes of intracardiac masses.

[Herpes hepatic failure during the third quarter of pregnancy]

Acute liver diseases of pregnancy are common and usually transient and reversible. Given the number of different possible diagnoses, performing a large biological screening and a proper iconographic documentation is key. It makes sure no etiology fatal to the mother and her fetus is missed.

Characterization of spontaneous bone marrow recovery after sublethal total body irradiation: importance of the osteoblastic/adipocytic balance

Many studies have already examined the hematopoietic recovery after irradiation but paid with very little attention to the bone marrow microenvironment. Nonetheless previous studies in a murine model of reversible radio-induced bone marrow aplasia have shown a significant increase in alkaline phosphatase activity (ALP) prior to hematopoietic regeneration. This increase in ALP activity was not due to cell proliferation but could be attributed to modifications of the properties of mesenchymal stem cells (MSC). We thus undertook a study to assess the kinetics of the evolution of MSC correlated to their hematopoietic supportive capacities in mice treated with sub lethal total body irradiation. In our study, colony-forming units – fibroblasts (CFU-Fs) assay showed a significant MSC rate increase in irradiated bone marrows. CFU-Fs colonies still possessed differentiation capacities of MSC but colonies from mice sacrificed 3 days after irradiation displayed high rates of ALP activity and a transient increase in osteoblastic markers expression while pparγ and neuropilin-1 decreased. Hematopoietic supportive capacities of CFU-Fs were also modified: as compared to controls, irradiated CFU-Fs significantly increased the proliferation rate of hematopoietic precursors and accelerated the differentiation toward the granulocytic lineage. Our data provide the first evidence of the key role exerted by the balance between osteoblasts and adipocytes in spontaneous bone marrow regeneration. First, (pre)osteoblast differentiation from MSC stimulated hematopoietic precursor's proliferation and granulopoietic regeneration. Then, in a second time (pre)osteoblasts progressively disappeared in favour of adipocytic cells which down regulated the proliferation and granulocytic differentiation and then contributed to a return to pre-irradiation conditions.

[Breast cancer: the interest of pathological classification]

The breast pathology includes a large array of entities for which macroscopic and microscopic analysis remains fundamental. Tissue and cell morphology allows in most cases the distinction between benign or malignant tumours and therefore provides the clinicians with essential information for the therapeutic strategy. In the Pathology laboratory, immunohistochemistry and molecular biology have improved the specificity of the diagnosis and have introduced new prognostic and predictive markers for tumour management. The last edition of the WHO classification, released in 2003, distinguishes 21 varieties of invasive carcinoma and 2 categories of intraepithelial neoplasia based on the morphology and immunohistochemical profile. Other diseases can affect the breast, although much less frequently, such as Paget's disease of the nipple, phyllode tumours, sarcomas, lymphomas... These diseases will not be reviewed here.

[Angiosarcoma in chronic lymphoedema: a case of Stewart-Treves syndrome]

The Stewart-Treves Syndrome is defined as an angiosarcoma (very aggressive malignant tumor originating from endothelial cells) appearing in a specific clinical setting. This tumor develops in patients suffering from chronic lymphedema of the upper limb following mastectomy and axillary lymph node dissection for breast cancer. The diagnosis relies on medical history, clinical examination and a histological assesment (biopsy or resection). This syndrome represents a rare clinical entity. Unfortunately, the prognosis is poor. A large surgical resection is the treatment of choice if the patient is a candidate for a surgical resection with a curative intent Radiotherapy is sometimes used as a palliative local treatment. Chemotherapy is only used in more advanced cases, not curable by surgery alone.

[Allergic bronchopulmonary aspergillosis associated with strongyloidiasis]

We report the case of a 58-year-old woman who suffered from progressive respiratory distress syndrome. Strongyloides stercoralis was disclosed in tracheal aspirations. A high serum level of antibodies directed to Aspergillus fumigatus was also found. Diagnosis, prevalence, microbiology, clinical consequences and treatment of strongyloidiasis are discussed. We also revisit to the diagnose criteria of allergic bronchopulmonary aspergillosis and his differential diagnosis. The puzzling aspect of this case was the association of two different diseases and the concern about the prevalence of strongyloidiasis in our regions.

Human bone marrow adipocytes block granulopoiesis through neuropilin-1-induced granulocyte colony-stimulating factor inhibition

Adipocytes are part of hematopoietic microenvironment, even though up to now in humans, their role in hematopoiesis is still questioned. We have previously shown that accumulation of fat cells in femoral bone marrow (BM) coincides with increased expression of neuropilin-1 (NP-1), while it is weakly expressed in hematopoietic iliac crest BM. Starting from this observation, we postulated that adipocytes might exert a negative effect on hematopoiesis mediated through NP-1. To test this hypothesis, we set up BM adipocytes differentiated into fibroblast-like fat cells (FLFC), which share the major characteristics of primitive unilocular fat cells, as an experimental model. As expected, FLFCs constitutively produced macrophage colony stimulating factor and induced CD34(+) differentiation into macrophages independently of cell-to-cell contact. By contrast, granulopoiesis was hampered by cell-to-cell contact but could be restored in transwell culture conditions, together with granulocyte colony stimulating factor production. Both functions were also recovered when FLFCs cultured in contact with CD34(+) cells were treated with an antibody neutralizing NP-1, which proved its critical implication in contact inhibition. An inflammatory cytokine such as interleukin-1 beta or dexamethasone modulates FLFC properties to restore granulopoiesis. Our data provide the first evidence that primary adipocytes exert regulatory functions during hematopoiesis that might be implicated in some pathological processes. Disclosure of potential conflicts of interest is found at the end of this article.

Carcinoid tumor of the appendix: A consecutive series from 1237 appendectomies

AIM: To report the experience of the CHU Sart Tilman, University of Liège, Belgium, in the management of appendiceal carcinoid tumor.

METHODS: A retrospective review of 1237 appendectomies performed in one single centre from January 2000 to May 2004, was undertaken. Analysis of demographic data, clinical presentation, histopathology, operative reports and outcome was presented.

RESULTS: Among the 1237 appendectomies, 5 appendiceal carcinoid tumors were identified (0.4%) in 4 male and 1 female patients, with a mean age of 29.2 years (range: 6-82 years). Acute appendicitis was the clinical presentation for all patients. Four patients underwent open appendectomy and one a laparoscopic procedure. One patient was reoperated to complete the excision of mesoappendix. All tumors were located at the tip of the appendix with a mean diameter of 0.6 cm (range: 0.3-1.0 cm). No adjuvant therapy was performed. All patients were alive and disease-free during a mean follow-up of 33 mo.

CONCLUSION: Appendiceal carcinoid tumor most often presents as appendicitis. In most cases, it is found incidentally during appendectomies and its diagnosis is rarely suspected before histological examination. Appendiceal carcinoid tumor can be managed by simple appendectomy and resection of the mesoappendix, if its size is ≤ 1 cm.

[Thyroid nodules]

Thyroid nodules are commonly encountered in clinical practice. They are present in 4 to 7% of the population by neck palpation and 30 to 50% by ultrasonography. Most are benign and could be neglected by the clinician and his patient. However, 5% of nodules are malignant, requiring surgical treatment; therefore, an exhaustive evaluation is needed. The diagnostic approach includes physical examination, laboratory analysis, ultrasonography, radioisotope imaging, and fine needle aspiration. This article, based on the literature and the authors'experience, provides recommandations for thyroid nodule management.

[How do you investigate an elevated calcitonin level?]

This article describes a case of lung cancer with associated hypercalcitoninemia in a man with a goitre. The case raises the problem of the differential diagnosis between medullary thyroid carcinoma and a neuroendocrine neoplasm with ectopic calcitonin secretion. The article first reviews the physiology of calcitonin, then outlines the diagnostic tests that are required to investigate hypercalcitoninemia and finally discusses the interpretation of test results.

Primary sarcoma of an abdominal aortic aneurysm

Primary tumors of the aorta are extremely rare and the diagnosis is made most often after surgery or autopsy. Because clinical symptoms of abdominal sarcoma are similar to those of occlusive or aneurysmal disease, aortic sarcomas are frequently mistaken for these lesions. The imaging findings are frequently nonspecific and therefore do not allow a definitive preoperative diagnosis. We report a case of an epithelioid angiosarcoma in the vessel wall of an abdominal aortic aneurysm.

Murine Bone Marrow Stromal Cells Sustain In Vivo the Survival of Hematopoietic Stem Cells and the Granulopoietic Differentiation of More Mature Progenitors

The study of the human hematopoietic system would be facilitated by availability of a relevant animal model. Because the medullar microenvironment is made of different types of cells, interactions between hematopoietic cells and stromal cells are difficult to analyze in detail. As an approach for establishing an in vivo model to dissect these interactions, we grafted murine bone marrow fibroblastic cells (MS-5 cell line) with hematopoietic cells into the kidney capsule of syngenic mice. To identify the origin of cells present in the graft, we used green fluorescent protein-stable transfected MS-5 cells for the transplantation. To analyze the evolution of stromal cells and identify hematopoietic cells able to develop in these conditions, we performed morphology, histochemistry, and immunohistology on tissue sections at different times after transplantation. When injected alone, MS-5 cells differentiate into adipocytes. When injected with a bone marrow suspension or with isolated CD45+ cells (leukocytes), the stromal cells keep their fibroblastic morphology and their alkaline phosphatase expression and sustain granulopoiesis. When injected with hematopoietic stem cells called c-kit+ Sca-1+ Lin- suspension, clusters of hematopoietic cells are also observed: They do not present any granulopoietic activity and do not belong to B or T population nor to erythroid lineage. They are quiescent, induce bone marrow recovery and survival of lethally irradiated recipients, are able to form macroscopic colonies in the spleen, and are able to form very few colonies in vitro, suggesting that they are hematopoietic stem cells. In conclusion, our results show that reticular fibroblastic stromal cells MS-5 sustain the survival of stem cells and are not able to induce their differentiation. However, they can control differentiation, proliferation, and/or survival of hematopoietic cells engaged in myeloid lineage.

[Alveolar echinococcosis]

Alveolar echinococcosis is a serious parasitic disease, leading to large hepatic lesions. It must be distinguished from cystic echinococcosis, or hydatic cyst, caused by Echinococcus granulosus. Early diagnosis may allow surgical removal of the lesions by segmental hepatectomy, the only curative treatment. Parasitostatic medical treatment with albendazole may promote stabilization of the disease. Until recently, Belgium was considered a country at very low risk for alveolar echinococcosis, as no human case was reported, despite up to 51% of fox infection in southern Belgium autopsy series. Recently four patients presented with alveolar echinococcosis at the University Hospital Center of Liege, leading to the fear of a possible alveolar echinococcosis endemy in southern Belgium. Two of these patients underwent curative hepatectomy, but the other two had already pulmonary metastases at diagnosis and received palliative albendazole therapy. This article presents these cases, and reviews the clinical features of this parasitic disease.

Endemic alveolar echinococcosis in Southern Belgium?

Until now, Belgium has been considered as a low-risk country for alveolar echinococcosis. However it was recently demonstrated by necropsy series that, in some parts of southern Belgium (Wallonia), up to 51% of the red foxes (Vulpes vulpes) may be infected by E. multilocaris. The authors, working in a university hospital in southern Belgium, described in 2002 the first autochthonous Belgian case of hepatic alveolar echinococcosis. More importantly, in 2004, they diagnosed three other patients with alveolar echinococcosis. One underwent surgical resection, but two others had bilateral pulmonary involvement at time of definite diagnosis. Palliative albendazole therapy was initiated. These patients had been diagnosed with hepatic mass from unknown origin for several months. The previous experience with the first case allowed the authors to consider and to confirm alveolar echinococcosis diagnosis, made by pathology and/or serological tests and imaging. These four patients with alveolar echinococcosis were living either in the Liege or the Luxembourg province. Considering the high prevalence of E. multilocaris infection of red foxes and the recent increase of the fox population due to rabies vaccination in southern Belgium, and also the presence of E. multilocaris infection of red foxes in northern Belgium, it is likely that not only Wallonia, but also maybe the whole Belgium, may face endemic alveolar echinococcosis in the next years.

Increased IL-6 and TGF-beta1 concentrations in bronchoalveolar lavage fluid associated with thoracic radiotherapy

PURPOSE

To assess, in lung cancer patients, the effects of thoracic radiotherapy (RT) on the concentrations of transforming growth factor-beta(1) (TGF-beta(1)) and interleukin-6 (IL-6) in the bronchoalveolar lavage (BAL) fluid.

METHODS AND MATERIALS

Eleven patients with lung cancer requiring RT as part of their treatment were studied. BAL was performed bilaterally before, during, and 1, 3, and 6 months after RT. Before each BAL session, the patient's status was assessed clinically using pulmonary function tests and an adapted late effects on normal tissue-subjective, objective, management, analytic (LENT-SOMA) scale, including subjective and objective alterations. The National Cancer Institute Common Toxicity Criteria were used to grade pneumonitis. The TGF-beta(1) and IL-6 levels in the BAL fluid were determined using the Easia kit.

RESULTS

The TGF-beta(1) and IL-6 concentrations in the BAL fluid recovered from the irradiated areas were significantly increased by thoracic RT. The increase in TGF-beta(1) levels tended to be greater in the group of patients who developed severe pneumonitis. In the BAL fluid from the nonirradiated areas, the TGF-beta(1) and IL-6 concentrations remained unchanged.

CONCLUSION

The observed increase in TGF-beta(1) and IL-6 concentrations in the BAL fluid recovered from the irradiated lung areas demonstrated that these cytokines may contribute to the process leading to a radiation response in human lung tissue.

Marrow stromal cell recovery after radiation-induced aplasia in mice

PURPOSE

The identification of fibroblast-like cells of the marrow stroma by means of alkaline phosphatase (ALP) cytochemistry reveals delicate ALP-positive structures interspersed among haematopoietic cells and arranged in a loosely meshed network. These cells are often referred to as 'reticular' cells and the network they form is known as the 'ALP network'. The purpose was to analyse the evolution of this ALP network in relation to haemopoietic regeneration after whole-body irradiation.

MATERIALS AND METHODS

The total surface occupied by ALP-positive processes revealed by means of ALP cytochemistry was expressed as a ratio of the total marrow area. ALP-positive cells were counted using nuclei as the defining unit. Cell proliferation was analysed by the detection of bromodeoxyuridine (BrdU) incorporation. Fat cells were identified by oil red O staining and alpha-glycerophosphate dehydrogenase (alpha-GPDH) activity.

RESULTS

The ALP network and ALP-positive cell number began to increase 24 h after 4-Gy irradiation to reach a maximum after 72 h, when the bone marrow was almost completely empty of haemopoietic cells. This increase was in advance of haemopoietic recovery and was not due to cell proliferation. A decrease in the ALP network occurred in parallel with an increase in haemopoiesis and was accompanied by a transient increase in fat cells on day 7.

CONCLUSIONS

These data indicate that the recovery of the ALP network, which is partially due to the recruitment of ALP- positive cells, occurs in advance of the haemopoietic recovery and that the equilibrium between fat cells and ALP-positive cells seems to be controlled by haemopoietic cells.

[Clinical case of the month. Constipation and abdominal mass syndrome in a 51-year-old patient]

A 51-year old patient consults for abdominal swelling and persistent constipation. Clinical exploration shows the presence of a left iliac fossa tumor corresponding to a papillary serous adenocarcinoma of the fallopian tube after macroscopic and microscopic examination. The diagnostic and therapeutic problems caused by this rare gynecologic tumor are discussed.

Fluorodeoxyglucose positron emission tomography and somatostatin receptor scintigraphy for diagnosing and staging carcinoid tumours: correlations with the pathological indexes p53 and Ki-67

We performed this study in order to evaluate the diagnostic accuracy of whole-body fluorodeoxyglucose positron emission tomography (FDG PET) imaging and somatostatin receptor scintigraphy (SRS) for localizing primary carcinoid tumours and evaluating the extent of the disease. A secondary aim was to correlate those findings with the histological characteristics of the lesions. FDG PET was performed in 17 patients and SRS in 16. All patients had pathologically proven carcinoids. All lesions were verified by histopathological analysis or by follow-up. Ki-67 and p53 expression were assessed as an indicator of the tumours' aggressiveness. FDG PET correctly identified 4/7 primary tumours and 8/11 metastatic spreads, as compared to six and 10 respectively, for SRS. Most tumours were typical carcinoids with low Ki-67 expression. No correlation was found between the histological features and the tracer's uptake. We conclude that SRS remains the modality of choice for evaluating patients with carcinoid tumours, regardless of their proliferative activity. FDG PET should be reserved to patients with negative results on SRS.

[Synovial metastases from colonic cancer presenting as arthritis of the knee. Characterization by 18FDG PET scan]

A case of carcinomatous monoarthritis involving the left knee due to colonic adenocarcinoma is described. Large recurrent synovial effusion, that will be later hematic, lytic lesion of the bones and chondrolysis were noted. Knee positron emitting tomography scan using FDG (FDG-PET) revealed a diffuse increased uptake in soft tissues assumed to be synovium, the hypertrophy of which was identified by ultrasonography. Whole body PET scan showed extensive lymph node, visceral and bone metastases, suggesting that the increase in the synovium could also be of metastatic origin. The final diagnosis of synovial carcinomatosis secondary to the known colonic adenocarcinoma was confirmed by histological analysis of biopsies obtained by arthroscopy. A review of the literature is realised. To our knowledge, this is the first synovial metastasis studied by FDG-PET.

Extensive inflammatory pseudotumor of the pituitary

A 40-yr-old female presented with an extensive lesion of the sellar area and the sphenoid sinus, spreading to the optic nerves and associated with pachymeningitis. Histological findings were consistent with an inflammatory pseudotumor, and steroid treatment allowed the disappearance of all the lesions. Inflammatory pseudotumors of the pituitary are very rare. This case appears unique with regard to the extension of the lesions and the dramatic response to medical treatment. The differential diagnosis of inflammatory lesions of the pituitary is difficult. It relies mainly on histological analysis and includes sarcoidosis, Wegener's granulomatosis, histiocytosis (Langerhans, Rosai-Dorfman, and Erdheim-Chester diseases) and lymphocytic hypophysitis.

Nicardipine protocol for CABG using the radial artery clinical and angiographic data

The routine use of arterial grafts in coronary surgery is facilitated by peroperative adjunction of antispasmodic drug to reduce the event of spasm. Diltiazem has been favoured in most clinical studies devoted to the radial artery graft. The aim of this study was to assess the efficacy of a spasm preventing protocol associating hydrostatic dilation of the graft with a diluted solution of papaverine and nicardipine infusion, starting preoperatively and continued postoperatively in i.v. and per os forms. Between September 1996 and March 1997, a consecutive series of 50 patients underwent myocardial revascularization using the radial artery. The radial artery was prepared by hydrostatic dilation with papaverine (1%) and nicardipine was administrated at 0.25 microgram/kg/min and titrated according to the arterial systemic pressure. Operative mortality was 4% (sepsis). There was no evidence of perioperative MI nor hypoperfusion syndrome. Mean CKMB level at 18 hours was 36 micrograms/l. No ischaemic anomalies of the ECG were detected. Angiography performed in the last 20 patients showed a 98% (51/52) permeability rate for all graft; 19/20 radial grafts (95%) were patent. One radial graft presented a 50% stenosis at the proximal anastomosis, and another a moderate spasm (40%) in the middle part of the conduit. This study confirms that the radial artery conduit can be used with satisfactory results for routine coronary artery bypass. The use of nicardipine allows the control the vasoreactivity of the radial graft without totally obviating at least angiographic spasm. This drug is easy to titrate, and well tolerated in association to beta-blockers in the routine perioperative management of the coronary patients.

Translocation (16;17)(q22;p13) is a recurrent anomaly of aneurysmal bone cysts

Recently, Panoutsakopoulos et al. (1999) reported 2 cases of aneurysmal bone cysts with a recurrent (16;17)(q22;p13) translocation. We present here two additional cases harboring the same translocation as well as additional chromosomal changes.

[Extensions of mitral valve repair techniques: surgery for endocarditis and valvular tumors]

Mitral valve repair has demonstrated its superiority over valve replacement. Mitral valve repair constitutes the optimal therapeutic option in case of degenerative dystrophic, rheumatic, congenital or ischemic mitral valve disease. These surgical techniques can also be successfully and advantageously applied in case of bacterial endocarditis or tumoral valvular disease. We report a case of staphylococcal endocarditis and another case of posterior leaflet fibroelastoma to show the place of conservative mitral surgery in these unusual indications.

[Anatomic clinical case. Septic state in a patient with chronic obstructive lung disease]

Invasive aspergillosis is a mycelial infection, associated in 15 to 30% of cases with a malignant hemopathy or with other types of cancers. It also constitutes a complication induced by high dosage corticotherapy or long term antibiotherapy. On the occasion of an autopsy of invasive aspergillosis, we review the anatomo-clinical entities associated with aspergillus, the etiopathogenic factors and the diagnostic difficulties.