Linearly scaling computation of ddPCM solvation energy and forces using the fast multipole method

This paper proposes the first linear scaling implementation for the domain decomposition approach of the polarizable continuum model (ddPCM) for the computation of the solvation energy and forces. The ddPCM-equation consists of a (non-local) integral equation on the van der Waals or solvent accessible surface of the solute's cavity resulting in a dense solution matrix, and, in turn, one matrix-vector multiplication has a quadratic arithmetic complexity with respect to the number of atoms of the solute molecule. The use of spherical harmonics as basis functions makes it natural to employ the fast multipole method (FMM) in order to provide an asymptotically linear scaling method. In this paper, we employ the FMM in a non-uniform manner with a clusterization based on a recursive inertial bisection. We present some numerical tests illustrating the accuracy and scaling of our implementation.

AB0556 CHARACTERISTICS OF PATIENTS DIAGNOSED WITH UNDIFFERENTIATED CONNECTIVE TISSUE DISEASE

Background

Patients with undifferentiated connective tissue disease (UCTD) struggle with physical symptoms as well as diagnostic uncertainty.1 UCTD diagnosis requires exclusion of other connective tissue diseases (CTD). Prior studies use variable definitions of UCTD that do not account for updated classification criteria thus limiting generalizability.

Objectives

We identified characteristics associated with rheumatologist-diagnosed UCTD, applied strict exclusion criteria, and compared UCTD patients to those with criteria-defined CTD.

Methods

We recruited patients ≥18 years old seen between 2018-2022 who had rheumatologist-diagnosed UCTD with positive ANA and ≥1 sign/symptom of a CTD. We reviewed medical records to identify those who fulfilled ACR/EULAR-endorsed classification criteria for SLE, RA, SSc, Primary Sjögren’s, Idiopathic Inflammatory Myopathy, and 2006 Revised Sapporo Criteria for APS. We compared sociodemographic, clinical, serologic, and treatment variables between UCTD and CTD using chi-square, Fisher’s exact, and t-tests.

Results

Of 89 patients with rheumatologist-diagnosed UCTD (mean age 49.0 ± 13.7 years, 97.8% female, 66.3% White), 59 (66.3%) had UCTD and 30 (33.7%) had criteria-defined CTD (27 SLE, 3 SLE and RA, 1 RA, and 1 APS).

Patients in both groups had similar non-criteria manifestations, most commonly arthralgia (89.8% UCTD vs. 83.3% CTD, p=0.50) and fatigue (55.9% UCTD vs. 73.3% CTD, p=0.17). Compared to patients with CTD, those with UCTD were less likely to have nonerosive arthritis (27.1% vs. 56.7%, p=0.01) (Table 1).

Table 1.

Characteristics of Patients with UCTD or Criteria-Defined CTD

UCTD1 (n=57), N (%)CTD2 (n=32), N (%)p-valuesClinical3,4•,4nicalN (%))cs of Pa16 (27.1)17 (56.7)0.01•.0156.7) (%))cs of Patients with UCTD or Criteria31 (52.5)18 (60.0)0.65•.6560.0) (%))cs of Patient7 (11.9)4 (13.3)1.0•.013.3)) (%))cs of Patients with UCTD or Criteria-Defined C27 (45.8)14 (46.7)1.0•.0(46.7) (%))cs of Patien24 (40.7)11 (36.7)0.82Serology3•erology) (%))cs of Patients with UCTD or Criteria-Defined CTDth19 (32.2)19 (63.3)<0.01•0.013.3) (%))cs of Patien9 (15.3)13 (4.3)<0.01•0.01.3)) (%))22 (37.3)25 (83.3)<0.01•0.013.3) (%))cs of Patients w10 (16.9)6 (20.0))0.77•.770.0)) (%))cs of Patients with UCTD or Criteria-D6 (10.2)2 (6.7)0.71•.71.7))) (%))cs of Patients with UCTD or Criteria-Defined CTDther CTDs. Our fi18 (30.5)10 (33.3)0.81•.8133.3) (%))cs11 (18.6)6 (20.0)1.0

1. Do not fulfill ACR/EULAR classification criteria for SLE, RA, SSc, PSS, IIM, APS.

2. Diagnosed with UCTD and fulfill ≥1 set of listed CTD classification criteria.

3. Defined per listed classification criteria

4. Criteria with n≤5: fever, proteinuria/cellular casts, pulmonary hypertension, interstitial lung disease, dysphagia/esophageal dysmotility

Patients with UCTD were less likely than those with CTD to have any hematologic manifestation (lymphopenia, leukopenia, thrombocytopenia, or hemolytic anemia) (p=0.02), anti-dsDNA or anti-Smith antibodies (p<0.01), or hypocomplementemia (p<0.01). The frequency of RA, Sjogren’s, and APS-related serologies did not differ between groups (Table 1).

Compared to those with CTD, UCTD patients were less likely to have ever received systemic corticosteroids (71.2% vs. 96.7%, p<0.01); ever use of any disease-modifying antirheumatic drug (DMARD) was similar (35.6% vs. 46.7%, p=0.36).

Conclusion

Among patients diagnosed with UCTD, 66.3% met a stringent definition. Compared to those with criteria-defined CTD, UCTD patients had lower frequency of arthritis, hematologic abnormalities, SLE-specific antibodies, and hypocomplementemia. While use of DMARDs did not differ, UCTD patients were less likely to use systemic corticosteroids.

Rheumatologists diagnose UCTD even when criteria are met for other CTDs. Our findings suggest UCTD is nonetheless a distinct clinical entity; more rigorous characterization will enable generalizable prognostic and therapy trials.

References

[1]Siegel CH, et al. J Clin Rheumatol 2021 Mar 5. doi: 0.1097/RHU. 0000000000001714

Disclosure of Interests

None declared

POS0715 QUANTIFYING THE PSYCHOSOCIAL IMPACT OF UNDIFFERENTIATED CONNECTIVE TISSUE DISEASE (UCTD)

Background:

Only half of patients diagnosed with SLE fulfill classification criteria; the rest have “SLE-like” illnesses such as UCTD. SLE patients are known to experience impaired health-related quality of life (HRQoL) and significant anxiety, depression, and fatigue,1 yet the psychosocial aspects of UCTD are less established. In a qualitative study, we found that most UCTD patients had engaged in psychotherapy and felt additional support was needed.2

Objectives:

Using multiple validated instruments, this study aims to quantify the psychosocial impact of UCTD.

Methods:

The Hospital for Special Surgery UCTD and Overlap Registry includes UCTD patients aged ≥ 18 years with ANA ≥ 1:80 and ≥ 1 sign or symptom of rheumatic disease who do not fulfill classification criteria for a defined CTD. We administered the 36-Item Short Form Health Survey (SF-36), General Anxiety Disorder-7 (GAD-7), Beck Depression Inventory (BDI), and Fatigue Severity Scale (FSS) to all patients to assess HRQoL, anxiety, depression, and fatigue. Instruments were scored based on established algorithms and results were summarized using predefined scales and severity thresholds.

Results:

The composite questionnaire was administered to 85 UCTD patients and completed by 75 (97.3% female, 60% white, mean age ± SD 48.8 ± 13.6 years). The SF-36 Physical Component Summary mean score was 37.8 and Mental Component Summary mean score was 41.1. Across the 8 SF-36 subscales, mean scores were lowest for role limitations due to physical health (39.3) and vitality (39.7) and highest for physical functioning (67.2), role limitations due to emotional health (67.1), and mental health (67.1). Approximately half of UCTD patients reported anxiety (GAD-7 ≥ 6); 20% had moderate/severe anxiety (GAD-7 ≥ 10). The prevalence of depression (BDI ≥ 14) was 26.7%; 13.3% had moderate/severe depression (BDI ≥ 20). Fatigue (FSS ≥ 3) was reported by 82.8% of patients (median FSS score of 4.7) [Table 1].

Table 1.

Psychosocial Survey Scores of Patients with Undifferentiated Connective Tissue Disease (n=75)

36-Item Short Form Health Survey (SF-36)Range 1-100 – Mean (SD)*Physical Component Summary∘Physical functioning∘Role-Physical∘Bodily PainoGeneral Health38.2 (11.2)67.2 (26.3)39.3 (46.3)49.5 (22.1)42.9 (21.5)Mental Component Summary∘Vitality∘Social Functioning∘Role-EmotionaloMental Health41.3 (10.7)39.7 (21.7)59.3 (25.9)67.1 (41.9)67.1 (18.3)Generalized Anxiety Disorder-7 (GAD-7)Range 0-21 – N (%)**None [0-5]Mild [6-10]Moderate [11-15]Severe [16-21]38 (50.7)22 (29.3)14 (18.7)1 (1.3)Beck Depression Inventory (BDI)Range 0-63 – N (%)**Minimal [0-13]Mild [14-19]Moderate [20-28]Severe [29-63]55 (73.3)10 (13.3)7 (9.3)3 (4.0)Fatigue Severity Scale (FSS) Range 1-7 – Median (IQR)**4.7 (1.5)

*Higher number indicates better health state. **Higher number indicates greater severity.

Conclusion:

UCTD patients have significantly impaired HRQoL and a high prevalence of anxiety, depression, and fatigue, suggesting substantial psychosocial impact of UCTD comparable to that reported in SLE.3,4 Impaired HRQoL in UCTD is driven to similar degrees by aspects of physical and mental health. In future studies, we will compare age- and sex- matched UCTD to SLE patients and longitudinally evaluate psychosocial metrics alongside clinical trajectories.

References:

[1]Dietz B, Katz P, Dall’Era M, et al. Major depression and adverse patient-reported outcomes in systemic lupus erythematosus: Results from a prospective longitudinal cohort. Arthritis Care Res. 2021;73(1):48-54.

[2]Siegel CH, Kleinman J, Barbhaiya M, et al. The psychosocial impact of undifferentiated connective tissue disease on patient health and well-being: A qualitative study. J Clin Rheumatol. In press.

[3]Gu M, Cheng Q, Wang X, et al. The impact of SLE on health-related quality of life assessed with SF-36: A systemic review and meta-analysis. Lupus. 2019;28(3):371-382.

[4]Zhang L, Fu T, Yin R, Zhang Q, Shen B. Prevalence of depression and anxiety in systemic lupus erythematosus: A systematic review and meta-analysis. BMC Psychiatry. 2017;17(1).

Acknowledgements:

This project was supported by the Barbara Volcker Center for Women and Rheumatic Diseases and the Robin J. Sillau Memorial Research Fund for Connective Tissue Disease. Dr. Barbhaiya is supported by the Rheumatology Research Foundation Investigator Award.

Disclosure of Interests:

None declared

Prospective study of bone mineral density and metabolism in patients with chronic hepatitis C during pegylated interferon alpha and ribavirin therapy

The importance of osteoporosis as a complication of end-stage liver disease is well known. However, significant osteopenia may occur in earlier stages of chronic hepatitis C (CHC). Furthermore, antiviral therapy may influence bone metabolism. Thirty patients with CHC genotype 1 infection and without established cirrhosis were treated with peginterferon-alfa and ribavirin. Dual-energy x-ray absorptiometry was performed at baseline, after 48 weeks of therapy, and by the end of a 24-week follow-up period. Bone mineral density (BMD), T-scores, and Z-scores were assessed. Serum C-terminal propeptide of type I collagen (CICP) and osteocalcin levels were measured. Thirteen patients had osteopenia (43%) and osteoporosis was present in four patients (13%). Antiviral therapy led to significant on-treatment increases of lumbar spine and hip BMD (P < or = 0.05) as well as T-scores (P < or = 0.05) and Z-scores (P < or = 0.01) irrespective of subsequent treatment response. Further analyses showed that in patients with sustained virological response (n = 19) most parameters remained highly above baseline values by the end of the 24-week follow-up period, while patients with virological relapse (n = 11) had decreases of BMD, T-scores and Z-scores thereafter that did not differ from baseline. Serum CICP and osteocalcin levels decreased during therapy. Osteocalcin levels remained below baseline in sustained responder, but showed an increase in relapsers by the end of the 24-week follow-up (P < or = 0.05). Osteopenia is detectable in a substantial proportion of CHC patients without established cirrhosis. Antiviral therapy leads to an on-treatment increase of BMD, which may last in those patients who achieve a sustained virological response.

[Adrenalectomy after snowboard fall. A pheochromocytoma becomes clinically apparent in an unusual way]

A 33-year-old snowboarder fell and underwent radiological examination, which was suspicious for a vertebral body fracture. Accidentally we found a tumour of the left suprarenal gland. Two days after the fall, he developed a hypertensive crisis with peak blood pressure levels up to 280/120 mmHg. Further endocrinologic testing indicated a pheochromocytoma which was confirmed by post-operative histology. The fall is supposed to have activated the pheochromocytoma. The course of examinations and significance of the tumour are described.

[Disease entities caused by or involving the mononuclear phagocyte system]

In this review article we present an overview over the different functions of the mononuclear phagocyte system including different celltypes, i.e. monocyte, macrophage, epitheloid cells, Langhans cells and different dendritic cells. Further, diseases in which mononuclear macrophages are directly or indirectly involved are discussed. The review also discusses causes of monocytosis and monocytopenia along with non-malignant and malignant diseases, in which the mononuclear phagocyte has a crucial role.

Features and preliminary results of prostate cancer screening in Canton Aargau, Switzerland

OBJECTIVE

To report the results from Switzerland's participation in the ERSPC from 1998; importantly, epidemiological data showed that Switzerland has one of the highest rates of morbidity and mortality from prostate cancer in the world. The local study protocol was accepted by the ethical committee and after the successful pilot study phase, the centre joined the ERSPC.

SUBJECTS AND METHODS

From September 1998 to June 2003 10 300 men accepted an invitation for the study and were then randomized 1:1 into an active screening arm (assessed by testing prostate-specific antigen, PSA) or a control group (no intervention). The re-screening interval is 4 years and is ongoing (beginning in September 2002). The study protocol includes offering a prostate biopsy when the total PSA is >3.0 ng/mL (the main study protocol in agreement with ERSPC requirements) or when the total PSA is 1-3 ng/mL and the free-to-total PSA ratio <20% (side study protocol).

RESULTS

During the first 3 years of screening 3562 men aged 55-70 years were screened; 395 (11.1%) of all participants had a total PSA of >3 ng/mL and 251 (7.4%) were eligible for the side-study. In all, 599 (17.2%) of 3562 accepted a prostate biopsy (93% of 646); 120 cases of prostate cancer were detected (3.4% detection rate). The incidence was 2.5% in main study group (positive predictive value, PPV, 24%) and 0.9% in side study group (PPV 13.6%). In radical prostatectomy specimens the cancers were mostly 'significant' (92% in main study group and 87% in side-study group).

CONCLUSIONS

A randomized screening study for prostate cancer is feasible in Switzerland. A longer follow-up is needed to address within the ERSPC the primary hypothesis (that there will be a reduction in mortality in the active screening arm) and to determine the level of over/under-diagnosis and over/undertreatment in the active screening and control arms, respectively.

[Secondary syphilis with ocular manifestations and oral ulceration]

In this case-report we describe a patient who was first seen with a painless lesion of the chin. Despite treatment with antibiotics and steroids it didn't heal. Later on, painful ulcerations of the mouth, perianal itching lesions and a central skotoma appeared. In the hospital--course a syphilitic infection with multiple oral ulcerations and occular infestation was diagnosed. The lesion on the chin was interpreted as the primary chancre as a time--correlation of its appearance and the time of exposition could be documented. The epidemiology, the diagnostic measures are described. We outline the manifestations of syphilis and their change in our time and discuss therapeutic regimes.

Prospective detection of clinically relevant prostate cancer in the prostate specific antigen range 1 to 3 ng./ml. combined with free-to-total ratio 20% or less: the Aarau experience

PURPOSE

Little is known about the incidence rate and clinical relevance of prostate cancer in a low prostate specific antigen (PSA) level. In a prospective PSA based screening study we investigated the incidence and clinicopathological features of prostate cancer that occurred within PSA range 1 to 3 ng./ml. when the free-to-total ratio was 0.20 or less.

MATERIALS AND METHODS

Men participating in the Aarau, Switzerland, section of the European Randomized Study of Screening for Prostate Cancer between October 1998 and July 2000 were included in the study. As a side study, all men with PSA between 1 and 3 ng./ml. and free-to-total ratio 0.20 or less were invited to undergo further evaluation with ultrasound guided sextant prostate biopsy.

RESULTS

Overall, 168 (7.8%) participants fulfilled inclusion criteria. A total of 158 (94%) patients underwent prostate biopsy, and prostate cancer was detected in 17 (10.8%). There were no statistically significant differences between prostate cancer and benign prostatic hyperplasia in regard to patient age (60.7 versus 59.8 years), prostate volume (23.9 versus 23.0 cc), PSA (1.98 versus 1.86 ng./ml.), free-to-total ratio (0.161 versus 0.160), PSA density (0.089 versus 0.076 ng./ml.) or PSA transition zone density (0.33 versus 0.24 ng./ml., respectively). Median Gleason score was 5 on prostate biopsy versus 6 on retropubic prostatectomy specimen. Of the 14 patients who underwent surgery there were positive lymph nodes in 1, stage pT3b Gleason 7 disease in 1, and pathologically organ confined Gleason 5 in 2, Gleason 6 in 5 and Gleason 7 in 5. Mean tumor volume was 1.01 cc (range 0.02 to 5.17). There were 2 (14.3%) insignificant (less than 0.2 cc, Gleason grade 3 or less), 1 (7.1%) minimal (less than 0.5cc, Gleason grade 3 or less) and 11 (78.6%) clinically relevant and potentially harmful cancers.

CONCLUSIONS

There is a significant number of prostate cancer cases diagnosed at PSA as low as 1 to 3 ng./ml. A majority of these tumors are clinically significant. This free-to-total ratio range may be helpful for identifying prostate cancer. The "window of opportunity" for detection of curable cancer may change in populations with higher life expectancy towards lower PSA. Lack of specificity and characterization of tumor aggressiveness remains an unsolved issue for PSA.

Combined copy status of 18q21 genes in colorectal cancer shows frequent retention of SMAD7

Deletions of chromosome band 18q21 appear with very high frequency in a variety of carcinomas, especially in colorectal cancer. Potent tumor suppressor genes located in this region encode transforming growth factor beta (TGF-beta) signal transducers SMAD2 and SMAD4, and inactivation of either one leads to impaired TGF-beta-mediated cell growth/apoptosis. Following the assignment of SMAD7 to 18q21, we first refined the SMAD7 gene position within this region by genetically mapping SMAD7 between SMAD2 and SMAD4. Further, to compare the respective frequencies of genetic alterations of these three SMAD genes in colorectal cancer, we undertook a large-scale evaluation of the copy status of each of these genes on DNA samples from colorectal tumor biopsy material. Among a subset of 233 DNA samples for which data were available for all four genes, SMAD4, SMAD2, and the nearby gene DCC showed high deletion rates (66%, 64%, and 59%, respectively), whereas SMAD7 was deleted in only 48% of the tumors. Unexpectedly, we found some gene duplications; SMAD7 appears to be more frequently amplified (10%) than the three other genes (4-7%). Compiled data for SMAD genes in each tumor show that the most common combination (26% of all the tumors) consists of the simultaneous deletions of SMAD2 and SMAD4 associated with normal diploidy or even duplication of SMAD7. Since SMAD7 normally counteracts SMAD2 and SMAD4 in TGF-beta signaling, we hypothesize that the tumor might not benefit from simultaneous SMAD7 inactivation, thereby exerting selective pressure to retain or even to duplicate the SMAD7 gene.

Malakoplakia of the colon in an infant with severe combined immunodeficiency (SCID) and charge association

We report on malakoplakia of the colon observed in a six month old girl in a setting of severe combined immunodeficiency (SCID) and a malformational syndrome termed CHARGE association. By the age of six months, hemorrhagic diarrhea had developed, and multiple ulcers were seen at colonoscopy. The biopsy specimen showed ulcerating malakoplakia. Immunodeficiency was primarily reflected by deprivation of CD4 cells in the peripheral blood, and CT scans failed to detect structures consistent with a normal thymus. There were also polylymphadenopathy and chronic erythroderma. The lymph node showed extreme hypoplasia of the follicular cortex and marked expansion of the paracortex. B cell counts progressively declined, and plasma cells were absent both in intact mucosa of the colon and in a lymph node. The patient died at eighteen months of respiratory failure following recurrent airway infections. Pediatric malakoplakia of the colon, though rare, may be regarded as an example of opportunistic bacterial infection in an immunocompromised host. Combined immunodeficiency (CID) has to be considered in such instances, in particular when malformational syndromes coexist affecting the development of the thymus.

[Pathogenetic and clinical aspects of low estradiol level in the man]

To elucidate a possible role of low estradiol (E2) levels in blood serum of men, normal values were determined in 91 healthy men (age 20-75 years), classified as high or low complaint-index due to a psychological questionnaire. Statistical analysis gave no correlation of estradiol levels to age or complaint index in normal men whereas testosterone (T) could be significantly correlated to complaint-index (p < 0.01) and free testosterone (fT) could be significantly correlated to age (p < 0.001) and complaint-index (p < 0.01). T and E2 were determined in 1370 clinical patients with various urological diseases, T, fT and E2 in 1261 ambulant patients. In 72/1370 (5.2%) and 76/1261 (6%) patients, low E2-levels (< 10 pg/ml) were found in blood serum. In 56/76 (74%) patients with low E2-levels, T or fT was simultaneously low. Isolated low E2-levels were found in 20/1261 (1.6%) patients. In clinical patients, no special urological disease correlated to low E2-levels. Due to these results, low E2 levels in men are in most cases the result of low testosteron levels. The adequate hormonal treatment in men is therefore the replacement of testosteron. Substitution of E2 in men is at that time an experimental therapy, that is limited on selected cases.

[CT- and ultrasound-guided biopsies: prospective comparison of fine-needle aspiration with true-cut biopsy in 103 patients]

PURPOSE

A prospective comparison of FNAB and TCB was performed in an identical set of patients and lesions.

METHODS

In 103 patients focal lesions were biopsied by US- or CT-guidance with at least one FNAB and TCB each. Complications were registered and documented. Cytological and histological specimens were evaluated independently. A final diagnosis was then attempted by consensus.

RESULTS

A total of 253 punctures was performed with sufficient tissue in 72.8% (FNAB) and 85.4% (TCB) of the cases. Diagnosis was possible in 68% (FNAB) and 80.6% (TCB). After combined evaluation of both specimens the diagnostic yield increased to 91.3%. Minor complications without clinical sequelae were observed in 21 patients.

CONCLUSION

A diagnostic strategy with the combined use of FNAB and TCB increases the diagnostic yield in image-guided punctures. Even though this approach needs at least two separate punctures, the complication rate does not increase.

Metastasis to the nasal tip from a cervical carcinoma

We report on a patient with a red-violaceous swelling of her nasal tip which turned out to be a primary metastasis of a cervical carcinoma. Only 2 patients with metastatic lesions in the nose from cervical carcinoma have been reported. The clinical features are presented, and the differential diagnosis is discussed.

Localized hyperplastic gastropathy of the mucous cell- and mixed cell-type (localized Ménétrier's disease): a report of 11 patients

Clinical and pathologic findings in five women and six men with the rare localized form of hyperplastic gastropathy of the mucous cell-(foveolar) or mixed cell-(mucous cell and glandular) type are reported. Upper abdominal discomfort, loss of appetite, loss of weight, and anemia were the principal symptoms. Preoperative hypoproteinemia was documented in two patients. Gross findings consisted of a circumscribed area of giant folds, well demarcated from the surrounding normal-appearing mucosa, located predominantly in the corpus in six patients and predominantly in the antrum in four patients. Histologically they corresponded to an increase in the epithelial cell mass principally of mucous cells with elongated and sometimes cystically dilated foveolae, accompanied by a mild inflammatory infiltrate. This so-called localized form of hyperplastic gastropathy has been known since the first description of the disease but has gained relatively little attention in the literature. However, its recognition seems diagnostically important and pathogenetically interesting. Etiology, pathogenesis, and the natural history are mostly unknown. Five of the 11 patients had concomitant adenocarcinoma of the stomach. In four of them the carcinoma was not located within but outside the area of hyperplasia. Because of that and because of a rather unusual accumulation of other tumors of the gastrointestinal tract in these patients, it is suggested that localized hyperplastic gastropathy could be an indicator of an increased risk for gastrointestinal tumors in general more than a possibly premalignant lesion by itself.

Germ-line mutations of the p16INK4(MTS1) gene occur in a subset of patients with hepatocellular carcinoma

The molecular mechanisms of hepatocarcinogenesis are poorly understood. Only very recently has there been a suggestion of familial hepatocellular carcinoma (HCC). We have analyzed the status of the p16INK4(MTS1) gene, a cyclin-dependent kinase inhibitor, in 26 patients with HCC of different etiologies. Four patients carried hemizygous germ-line point mutations of the p16INK4(MTS1) gene, suggesting the existence of familial HCC involving this gene. The wild-type allele was lost in the tumor in 2 of these 4 patients. Three of the patients carrying a germ-line mutation had non-cirrhosis-associated HCC. No somatic mutations of p16INK4(MTS1) were observed in the 26 cases of HCC. The most common somatic alteration of the p16INK4(MTS1) gene in HCC was de novo methylation, which was detected in 48% of the cases. Low levels (21%) of p16INK4(MTS1) gene allele loss were observed. Altogether, these results indicate that alteration of the p16INK4(MTS1) gene plays an important role in the genesis of HCC.

[Panniculitis mesenterialis, a rare disease]

Panniculitis mesenterialis is an illness of the mesenterium of the small intestine and is not familiar to all clinical physicians. The rare reports in the literature mostly describe a good outcome with a few cases ending lethal. Pathologists paying attention to detect panniculitis during postmortem examination report about an incidence of about 1%. This discrepancy may be based on the fact that only extended changes of the mesenterial fat tissue cause symptoms. The pathological base consists in extensive necrosis of fat tissue with fibrosis of the mesenterium. Aetiology is unknown, diagnosis is usually made during laparotomy. There is no specific treatment, prognosis is generally good.

[Necrotizing sialometaplasia of the nasal cavity]

In the present paper we report two cases of "necrotizing sialometaplasia" in uncommon locations. The relevant literature is reviewed. Necrotizing sialometaplasia is self-limiting and is characterized by necrosis and squamous pseudohypertrophy. Typically occurring in the minor salivary glands of the oral mucosa, our cases appear to be the sixth and seventh cases of involvement of the nasal cavity reported in the literature. Owing to the similarity of histological findings, the term "sialometaplasia" is also used for this disorder. This rare disease is a benign process but may be misdiagnosed as mucoepidermoid or squamous cell carcinoma. Therefore, the possibility of this disease in the nose should again be presented. Both of our cases show that with a histological examination considering defined morphological findings, the diagnosis of necrotizing sialometaplasia can be verified and a diagnosis of a carcinoma can be excluded. Especially with regard to radical and possibly unnecessary invasive therapeutic procedures we emphasize the importance of considering "necrotizing sialometaplasia" as part of the differential diagnosis of nasal lesions.

Pancreatic acinar cell carcinoma. An analysis of cell lineage markers, p53 expression, and Ki-ras mutation

In a series of 22 pancreatic acinar cell carcinomas, including two acinar cystadenocarcinomas, cellular differentiation was analyzed by immunocytochemistry and electron microscopy. In addition, overexpression of p53 protein and Ki-ras codon 12 mutation was studied. Four of the 20 noncystic acinar cell carcinomas showed a pure acinar pattern, nine an acinar-solid, and seven a solid pattern. All tumors stained for at least one of the following pancreatic acinar markers: trypsin (21 of 22), lipase (19 of 22), chymotrypsin (13 of 22), phospholipase A2 (nine of 22), and pancreatic stone protein (19 of 22). One-third of the tumors expressed neuroendocrine markers (synaptophysin, eight of 22; chromogranin A, six of 21) and duct cell markers (CA19.9, nine of 21; B72.3, six of 21). Cellular coexpression of trypsin and synaptophysin was demonstrated in one tumor. Electron microscopy revealed zymogen granules (nine of nine). In only one of 16 tumors a Ki-ras mutation at codon 12 was found, whereas in none of 19 tumors could overexpression of p53 protein be demonstrated. The results suggest that acinar cell carcinomas show obvious capacity to differentiate into several directions, but nevertheless constitute an entity different from ductal adenocarcinomas or endocrine tumors.

[Solid and cystic pancreatic tumor]

The solid and cystic tumor of the pancreas (also called pancreatic cystic tumor of the pancreas) is a very rare tumor of the pancreas, which we meet mainly in younger women. The tumor was described for the first time in 1981 and since that time there were published more than 150 cases. It is a matter of a potentially malign tumor with low malign characteristics. By radical exstirpation most of the patients can be healed definitely. Long-term controls are yet necessary although recidives are rare (4-7%), but are described up to 10 years after the first treatment. Also singular cases with synchronous metastasis of the liver are mentioned. Except of abdominal volume increase the tumor gives little trouble. The diagnosis is placed with ultrasonography resp. with a computer-tomogram and ensured by needle cytology. The therapy consists in the radical exstirpation with resection of the left pancreas in case of location on the left side, with Whipple operation in case of localisation in the head of the pancreas.

Immune-mediated type A gastritis and glomerulonephritis

The first two cases reported in the literature of patients with immune-mediated type A gastritis with microcarcinoids (as part of a polyglandular syndrome type II in one) in combination with chronic glomerulonephritis are presented. Immune-mediated type A gastritis appears to be another immunologic disorder that can be associated with chronic glomerulonephritis.

[Adenosarcoma of the uterus]

A case of a 67-year old woman with adenosarcoma of the uterus is reported. Adenosarcoma is a mixed mesodermal tumour with a low malignant potential. It is characterised by a benign glandular and a malignant stromal component. Adenosarcomas are usually treated by hysterectomy with bilateral salpingo-oophorectomy. Patients with myometrial invasion have an increased risk of recurrence. It may be appropriate, to consider adjuvant chemotherapy or radiation treatment for these patients.

Studies on the Thomsen-Friedenreich antigen in human colon with the lectin Amaranthin. Normal and neoplastic epithelium express only cryptic T antigen

The lectin Amaranthin has been shown to be highly specific for the galactose beta 1,3 N-acetylgalactosamine-alpha and sialic acid alpha 2,3 galactose beta 1,3 N-acetylgalactosamine-alpha sequence which represents the Thomsen-Friedenreich (T) antigen and its cryptic form, respectively. Previously, we demonstrated the usefulness of gold-labeled Amaranthin for the histochemical detection of the T antigen and its cryptic form. Application of the galactose oxidase (GO)-Schiff sequence abolished lectin binding to the T antigen but not its cryptic form, and therefore permitted their differentiation. In the present study we have analyzed by light and electron microscopy the distribution and subcellular localization of Amaranthin binding sites in normal, dysplastic and neoplastic colonic epithelium. Furthermore, a monoclonal antibody raised against synthetic galactose bera 1,3 N-acetylgalactosamine-alpha-bovine serum albumin was applied as a reagent for the T antigen. In normal colonic mucosa, two different Amaranthin staining patterns existed: (a) reactivity restricted to the lower portion of the crypts which was principally observed in the left colon, and (b) reactivity along the entire length of the crypts and in the surface epithelium with goblet cell staining in the upper portion of the crypts which was principally observed in the right colon. This Amaranthin staining was resistant to GO-Schiff treatment. No immunostaining with the monoclonal anti-T antigen was observed. Investigation of transitional mucosa, adenocarcinomas of different degrees of differentiation and mucinous carcinomas as well as adenomas with different degrees of dysplasia all revealed positive Amaranthin staining. The lectin staining was resistant to GO-Schiff treatment, and immunolabeling with the monoclonal antibody against the T antigen was absent. These results indicate that only the cryptic form of the T antigen is expressed in normal, dysplastic and neoplastic human colonic epithelium.

Expression of alpha 2,6-linked sialic acid residues in neoplastic but not in normal human colonic mucosa. A lectin-gold cytochemical study with Sambucus nigra and Maackia amurensis lectins

Increased sialylation of cell surface glycoconjugates has been demonstrated in malignant tumors and shown to be correlated with the invasive and metastatic growth of colon carcinoma cells. The authors have applied the Maackia amurensis lectin, which interacts with alpha 2,3-linked sialic acid, and the Sambucus nigra I lectin specific for alpha 2,6-linked sialic acid. In human colon, alpha 2,3-linked sialic acid was detectable in normal and transitional mucosa as well as in adenomas with different degrees of dysplasia and in carcinoma. In contrast, alpha 2,6-linked sialic acid as visualized with Sambucus nigra I lectin was found only in severe dysplasia and carcinoma. Thus expression of binding sites for Sambucus nigra I lectin was associated with the occurrence of histologic features of malignancy. It is concluded that malignant transformation in human colonic epithelium is accompanied by the de novo expression of an alpha 2,6 sialyl-transferase. These findings provide the basis for more detailed studies of the possible role of cell surface glycoconjugates bearing alpha 2,6-linked sialic acid in growth behavior of human colonic epithelial cells.

Surgical pathology of gastrinoma. Site, size, multicentricity, association with multiple endocrine neoplasia type 1, and malignancy

Specimens from the pancreas and duodenum of 26 patients with sporadic Zollinger-Ellison syndrome (ZES) and 18 patients with multiple endocrine neoplasia type 1 (MEN-1) and hypergastrinemia (17 with ZES) were screened immunocytochemically for gastrinomas. Location, size, multicentricity, and malignancy of the gastrinomas were evaluated. The MEN-1 patients had gastrinomas in the duodenum (nine of 18), pancreas (one of 18), and periduodenal lymph nodes (two of 18). No gastrinoma was identified in six patients. Most duodenal gastrinomas were multiple (five of nine) and smaller than 0.6 cm (six of nine). Lymph node metastases were present in eight of 12 patients. All 26 patients with sporadic ZES had a solitary gastrinoma; 14 were found in the pancreas and had a diameter greater than 2 cm. Ten patients had a duodenal gastrinoma, two with a diameter less than 0.6 cm. In two patients, only periduodenal "lymph node gastrinomas" were detected. Eighteen of the sporadic gastrinomas were malignant. These results suggest that duodenal location and multicentricity of gastrinomas are associated with the MEN-1 syndrome, and solitary gastrinomas, either in the pancreas or the duodenum, are predominantly seen in sporadic ZES.

Surgical pathology of gastrinoma. Site, size, multicentricity, association with multiple endocrine neoplasia type 1, and malignancy

Specimens from the pancreas and duodenum of 26 patients with sporadic Zollinger-Ellison syndrome (ZES) and 18 patients with multiple endocrine neoplasia type 1 (MEN-1) and hypergastrinemia (17 with ZES) were screened immunocytochemically for gastrinomas. Location, size, multicentricity, and malignancy of the gastrinomas were evaluated. The MEN-1 patients had gastrinomas in the duodenum (nine of 18), pancreas (one of 18), and periduodenal lymph nodes (two of 18). No gastrinoma was identified in six patients. Most duodenal gastrinomas were multiple (five of nine) and smaller than 0.6 cm (six of nine). Lymph node metastases were present in eight of 12 patients. All 26 patients with sporadic ZES had a solitary gastrinoma; 14 were found in the pancreas and had a diameter greater than 2 cm. Ten patients had a duodenal gastrinoma, two with a diameter less than 0.6 cm. In two patients, only periduodenal "lymph node gastrinomas" were detected. Eighteen of the sporadic gastrinomas were malignant. These results suggest that duodenal location and multicentricity of gastrinomas are associated with the MEN-1 syndrome, and solitary gastrinomas, either in the pancreas or the duodenum, are predominantly seen in sporadic ZES.

[Gallbladder morphology after extracorporeal shockwave lithotripsy of gallstones with the MPL-9000]

The effects of extracorporeal spark-gap shockwave lithotripsy (ESWL) on human gallbladder-morphology are barely known. We studied the gallbladders of nine patients cholecystectomized 5 to 166 days after ESWL. Patients were treated one to three times receiving a mean of 1928 +/- 693 shockwaves per treatment, with a total of 3375 +/- 1307 per patient. Control gallbladders were of randomly selected patients after plain cholecystectomy (age and sex-matched). There was no difference in pathomorphology of the two groups. No signs of trauma related damage (hemorrhage, necrosis, ulceration, scar, or hemosiderin deposits) other than from surgical manipulation were found. Predominant pathomorphological changes were signs of chronic cholecystitis due to gallstone disease. In conclusion, spark-gap ESWL did not induce deleterious morphological damage to the gallbladder, although large numbers of shock waves were applied.

[The histological diagnosis of chronic gastritis. A German proposal for an integrated nomenclature]

The Gastrointestinal Pathology Study Group of the German Pathological Society has drawn up a proposal for a unifying nomenclature for the graduation and classification of gastritis. The severity of chronic gastritis is divided into 4 grades (minimal, light, moderate and severe) and the activity of the process is characterized by 3 grades (grade 1, 2 and 3 activity). In addition, the presence or absence of Helicobacter pylori (formerly Campylobacter pylori), the extent and type of intestinal metaplasia, and the degree of glandular atrophy are recorded. To the two already well established types of gastritis (type A and type B) a third type is added, type C gastritis due to biliary reflux or other chemical, mechanical or toxic influences.

[The pathology of insulinoma and gastrinoma. The location, size, multicentricity, association with multiple endocrine type-I neoplasms and malignancy]

The pathology of insulinoma and gastrinoma was studied in 81 patients (31 men, 50 women, mean age 48.4 years) suffering from persistent hyperinsulinaemic hypoglycaemia, and in 44 patients (28 men, 16 women, mean age 48.5 years) with Zollinger-Ellison syndrome. Insulinomas were seen in the pancreas of all patients with persistent hyperinsulinaemic hypoglycaemia. In 70 of the 81 patients the insulinoma was solitary, whereas six patients had multiple insulinomas. In five patients with multiple endocrine neoplasia type I, multiple endocrine tumours of the pancreas were visible, only one of them in each case being an insulinoma. 75% of all insulinomas were less than 2 cm in size and 15% were malignant. 18 of the 44 Zollinger-Ellison syndrome patients also had multiple endocrine neoplasia type I. Nine of these patients presented with duodenal gastrinomas which were often multiple and smaller than 0.5 cm. The gastrinoma was located in the pancreas of one of the patients with multiple endocrine neoplasia, in two patients in lymph nodes, and no gastrinoma was identified in the specimens from six patients. 33% of the duodenal gastrinomas had metastasised. Solitary gastrinomas were found in all 26 patients with sporadic Zollinger-Ellison syndrome, 14 being located in the pancreas (diameter over 2 cm in eight cases) and ten in the duodenum (diameter less than 1 cm in seven cases). 16 of these gastrinomas were malignant.

Gastrinomas in the duodenums of patients with multiple endocrine neoplasia type 1 and the Zollinger-Ellison syndrome

In patients with multiple endocrine neoplasia type 1 (MEN-1), gastrinomas are common and thought to occur predominantly in the pancreas. We describe eight patients with MEN-1 and hypergastrinemia (seven with the Zollinger-Ellison syndrome) in whom we searched for neuroendocrine tumors in the pancreas and duodenum. Tumors were found in the proximal duodenum in all eight patients: solitary tumors (diameter, 6 to 20 mm) in three patients and multiple microtumors (diameter, 2 to 6 mm) in the other five. Paraduodenal lymph-node metastases were detected in four patients. Immunocytochemical analysis revealed the presence of gastrin in all the duodenal tumors and in their lymph-node metastases. In contrast, no immunoreactivity for gastrin was present in the endocrine tumors found in the seven pancreatic specimens available for study, except for one tumor with scattered gastrin-positive cells. In four of the six patients whose duodenal gastrinomas were removed, serum gastrin levels returned to normal; in the other two patients gastrin concentrations decreased toward normal. We conclude that in patients with MEN-1 and the Zollinger-Ellison syndrome, gastrinomas occur in the duodenum, but the tumors may be so small that they escape detection.

[Experimental pancreatic duct occlusion with polyurethane]

Pancreatic transplantation requires an effective method to manage exocrine secretion. A new technique to eliminate the exocrine function of the pancreas by obstruction of the duct with polyurethane was investigated in terms of function, outcome and morphology. Polyurethane is an alcoholic solution of block copolymers with the property of polymerizing within 5-10 min. In this study the in-situ pancreatic tail model in dogs was utilized, the pancreatic duct was cannulated and injected with 2-3 ml of polyurethane. As a result, complete atrophy and fibrosclerosis of the exocrine tissue was obtained leaving islets well vascularized and functioning for the entire experimental periods. All animals remained normoglycemic and showed normal K-values. Amylase levels were found to be maximally elevated at 24 h and returned to normal within 2 weeks after duct occlusion. Insulin, glucagon and somatostatin levels remained normal. Because of its ability to effect a complete occlusion of the pancreatic ducts with subsequent atrophy of the exocrine gland and without notable disturbance of endocrine function, we feel that polyurethane solution is superior to previously used materials for this purpose.

[Campylobacter pylori colonization of the antrum: effect of gastrin, somatostatin, pancreatic polypeptide and neurotensin]

Campylobacter pylori (C.p.) infection is often found in patients with antral gastritis and peptic ulcer disease. Pathophysiological links are still unclear, and we therefore tested the hypothesis whether C.p. affects the gastrointestinal peptides and thus influences gastric acid secretion and protective factors. 94 patients were examined by upper GI endoscopy and blood analyzed for gastrin, somatostatin, pancreatic polypeptide and neurotensin. Biopsies of antral mucosa were investigated for C.p. in urease testing, culture and microscopy. C.p. was found in 42 patients (45%). In microscopy all of these patients had chronic gastritis (100%). A significant increase in gastrin uninfluenced by C.p. was found in patients with antral gastritis (normal: 6.4 +/- 0.7, [n = 27]; gastritis without C.p.: 18.4 +/- 5.9 [p less than 0.02], [n = 7]; gastritis with C.p.: 10.7 +/- 2.2, [n = 22]). Somatostatin, pancreatic polypeptide and neurotensin showed no difference.

Coincidence of fundic glandular hyperplasia and carcinoma of the stomach

Eight patients with stomach cancer are described who had also a striking glandular hyperplasia of the fundic mucosa adjacent and remote from the tumor. Five of the eight patients were young women (30 to 37 years of age). The tumors were poorly differentiated carcinomas and six of the eight patients have died of their disease. None of the patients had clinical evidence of endocrine dysfunction including the Zollinger-Ellison syndrome. Immunohistochemistry revealed cells with endocrine differentiation in five of eight tumors, and in two tumors gastrin producing cells were found. Five of seven patients showed increased numbers of antral G-cells. In two patients numerous endocrine (chromogranin-positive) cells were present in the fundic mucosa, specific products of which could not be identified with the antigens tested. No satisfactory explanation exists for this coincidence and its apparent predominance in young female patients. It may be that endocrine substances are responsible for this fundic hyperplasia and that they may also act as promotors of tumor growth.

Zollinger-Ellison syndrome, duodenal carcinoid (gastrinoma), and hyperthyroidism

A 43 year old man is presented who suffered from the association of a toxic adenoma of the thyroid gland and a Zollinger-Ellison syndrome (ZES) due to a metastasizing duodenal gastrinoma. There were no other signs of a multiple endocrine neoplasia syndrome, type I (MEN-I). The patient presented here shows that the association of ZES and thyroid disease may also occur in patients with sporadic ZES.

Localization of proinsulin and insulin in human insulinoma: preliminary immunohistochemical results

We have carried out an immunohistochemical investigation of 15 human insulinomas applying monoclonal antibodies specifically recognizing proinsulin and insulin. Our results demonstrate that the epitopes unique to proinsulin and insulin can be detected with the respective monoclonal antibodies using the protein A-gold technique after routine formaldehyde fixation and paraffin embedding of the tissues. The immunostaining pattern for proinsulin and insulin in the insulinomas was different from the observed in B cells of pancreatic islets present in the adjacent normal pancreas. Furthermore, the pattern of immunostaining was found to vary from tumor to tumor. These findings strongly suggest the possibility of a disturbed proinsulin to insulin conversion in human insulinomas.

Biopsy pathology of the gastrointestinal tract in human immunodeficiency virus-associated disease: a 5 year experience in Zürich

Patients with human immunodeficiency virus (HIV)-associated disease are subject to a wide variety of unusual opportunistic infections and to the development of malignant tumours. These complications frequently manifest themselves within the gastrointestinal tract and endoscopic biopsies may contribute to their diagnosis. The results of 63 such biopsies from 28 patients are reviewed in this study. The diagnoses made included: upper gastrointestinal tract candidiasis (n = 6); cytomegalovirus infection of large intestine (n = 2); cryptosporidiosis (n = 1); spirochaetosis (n = 2); Kaposi's sarcoma (n = 4); malignant lymphoma (n = 3); and anal carcinoma (n = 2). Many of the specimens also showed inflammatory changes with no demonstrable aetiological agent. No specific pattern could be recognized for HIV infection per se.