[A case of lymph nodes involvement in malakoplakia of the bladder]

This case illustrates the involvement of lymph nodes in a patient with histologically proven malakoplakia of the urinary bladder. The nodes appeared hyperdense at CT and hyperintense at MR.

[A case of primary signet ring cell adenocarcinoma of the bladder]

A case of primary signet ring cell carcinoma of the urinary bladder. This case of adenocarcinoma of the bladder including immunohistochemical study and autopsy demonstrates the diagnostic problems and the bad prognosis of these rare tumors.

Magnetic resonance imaging in patients with penile carcinoma

The aim of the study was to determine the role of pre-operative magnetic resonance imaging (MRI), with and without contrast enhancement, in patients with penile carcinoma. Nine patients with a penile cancer were studied. The staging of the tumours was performed by clinical examination, MRI and surgery, according to the TNM classification. Six patients had primary tumours, of clinical stage T1 (n = 1) and T2 (n = 5). Three other patients had been previously treated and presented with a local recurrence of clinical stage T2. Surface-coil MRI was performed at 0.5 T with T1 weighted sequences before and after gadolinium-DOTA, and T2 weighted sequences. MRI results were compared with the clinical and surgical findings. T1 weighted sequences did not clearly demonstrate the margins of the tumours. T2 weighted sequences were the more useful in five patients, whereas contrast enhanced T1 weighted sequences allowed better delineation of the lesions in only three patients. Therefore, an imaging protocol should include spin echo T2 weighted sequences. Clinical examination correctly staged six of nine tumours; MRI, seven of nine tumours and the combination of both examinations, eight of nine tumours. MRI provided good evaluation of tumoral invasion into the penile shaft.

Anatomic study of the lumbar region applied to multiplanar imaging techniques: importance and use of oblique vertical sections

This anatomic study of the lumbar region (as defined by Rouvière [11]) applied to multiplanar imaging techniques was carried out both in the cadaver and in vivo. The cadaver study (5 cases) consisted of anatomic sections (transverse, sagittal, frontal and oblique) and computerised three-dimensional reconstructions after CT studies on subjects injected with colored and radio-opaque latex. The in vivo study (4 cases) used MRI sections and three-dimensional ultrasound sections coupled with the pulsed doppler. The spatially referenced oblique vertical sections revealed the structures from unusual aspects, situating them amidst the retroperitoneal area with the maximum of topographic landmarks. The transposition of these results (obtained by sectional anatomy of the retroperitoneal region) to the new techniques of multiplanar formatting after MRI, ultrasound or CT data acquisition should optimise the investigation of certain retroperitoneal structures by specifying the ideal planes of section for each organ, while diminishing certain artefacts specific to acquisitions in the traditional planes of section. Oblique vertical sections seem eminently suitable for ultrasound location of the suprarenal compartments, study of the renal pedicles and topographic retroperitoneal location. This oblique vertical visualisation constitutes a fundamental resource for the development of video-monitored surgical procedures as it corresponds exactly to the axes of the access routes in percutaneous surgery of the kidney and the adjacent anatomic structures.

[The value of MRI in ruptures of the corpus cavernosum]

MRI has only recently been described in the evaluation of traumatic rupture of the corpora cavernosa. Our case report emphasises the perfect correlation between the MRI findings and the anatomical lesion. This examination therefore constitutes a valuable aid in the pretreatment assessment of rupture of the corpora cavernosa.

Anatomical bases of percutaneous surgery for calculi in horseshoe kidney

Horseshoe kidney is a renal fusion which combines three anatomic abnormalities: ectopia, malrotation and vascular changes. These anomalies can be recognised separately to varying degrees in unfused kidneys. Necessary modifications of the standard technique for percutaneous nephrolithotomy (PNL) are directly deducible from analysis of the anatomic data of the imaging of horseshoe kidneys. We report our experience with 5 patients (7 kidneys) who underwent PNL for calculi in horseshoe kidneys. The percutaneous approach was performed under ultrasound and fluoroscopic monitoring. In situ disintegration by ultrasonic lithotripsy and nephrostomy drainage were necessary in all cases. Modifications of the standard PNL procedure are related to the anatomic changes. The lower abdominal position of a horseshoe kidney necessitates upper or middle calyceal puncture, while the malrotation necessitates a more posterior puncture. Monitoring of the puncture needle by fluoroscopy as it is advanced postero-anteriorly is more difficult and the risk of the surgeon's hand entering the radiation path is increased. The renal pelvis is deep and a long endoscope may be required. Aberrant segmental vessels may create potential hazards. The majority of problems in location can be avoided by use of an ultrasonically guided needle. Percutaneous nephrolithotomy is the treatment of choice for calculi in horseshoe kidneys for the following reasons: the high incidence of recurrent lithiasis in horseshoe kidney and the complexity of repeated surgical approaches diminish the acceptable results of open surgery; difficulties in focussing on the calculi and drainage problems militate against the success of extracorporeal shock wave lithotripsy (ESWL); PNL has a good success rate and the least morbidity.

[Emphysematous pyelonephritis associated to urogenital tuberculosis]

Emphysematous pyelonephritis is a rare condition which in most cases occurs as a result of Escherichia coli infection of the urinary tract in patients known as being diabetic. The gas-filled abscesses carry a high mortality rate, especially when the antibiotic treatment is not combined with early surgery. We report a case where the failure of medical treatment led to curative nephrectomy. Unusually, diabetes was revealed by the pyelonephritis. Another particularity of this case was that the emphysematous pyelonephritis was associated with genitourinary tuberculosis. This association, of which no other example could be found in the literature, is discussed.

Staging of esophageal carcinoma: comparison of results with endoscopic sonography and CT

We compared the results of endoscopic sonography and CT in the preoperative staging of 46 patients with esophageal carcinoma studied prospectively. All patients had surgery and 44 had pathologic examination of the mediastinal and celiac lymph nodes. The results of CT and endoscopic sonography were compared with surgical and pathologic findings. A total of 51 tumors were found in 46 patients. Sonographic estimation of tumor extension through the different layers of the esophagus was correct in 37 (73%) of all 51 tumors and in 22 (85%) of the 26 tumors in which the examination was complete. The echoendoscope (13-mm diameter) could not pass through the tumor in 23 cases (50%). Infiltration to adjacent organs was found in 15 cases at surgery. In four of these 15, the extension was detected by CT; in seven of the 15 cases, it was detected by sonography. False-negative determination of tumor extension occurred with endoscopic sonography in patients with stenotic tumor. There were no false-positive results with either CT or endoscopic sonography. For detection of mediastinal lymph-node involvement, the sensitivity of CT was 48%. The sensitivity of sonography was 50% if metastatic nodes unexplored by sonography were included, or 84% if only cases in which stenosis was passed were considered. Statistical comparison revealed that sonography was superior to CT for the detection of metastases to lymph nodes. CT and endoscopic sonography provide complementary information. When the echoendoscope can be maneuvered past the tumor, sonography can be used accurately to define extension through the layers of the esophagus, extension to the adjacent organs, and involvement of the lymph nodes. When the tumor cannot be passed by the echoendoscope, CT is superior to sonography for detection of mediastinal extension.

[From lymphangioma to lymphangiomatosis. Apropos of 10 cases]

Seven cases of lymphangioma and 3 cases of diffuse lymphangiomatosis have been studied with computed tomography (CT). In the 7 cases of local involvement, the tumor was located in the mediastinum (3 cases), the mesentery (2 cases), the spleen (1 case), and the pelvis (1 case). The disease was diffuse in 3 cases, involving the mesentery, the pelvis, the posterior mediastinum, the retroperitoneal space and the bones in the first case; in the second case, lymphangiomatosis was located in the posterior mediastinum, the spine (T12 and L3) and the right iliac wing; the third case showed diffuse involvement of the posterior mediastinum and of the spleen. The CT study allows suspecting the disease when it demonstrates an encapsulated tumor with liquid or fatty density and thin walls enhancing with contrast. Other, less typical appearances may be observed, which should not lead to challenging this diagnosis. The CT exploration provides a complete assessment of the lesions, including the detection of tumors not seen on plain radiographs. In addition, CT is useful for the prognosis since it identifies the diffuse forms, which are naturally prone to aggravation, or recurrence when surgery has been indicated. Lymphangioma and lymphangiomatosis seem to be different forms of the same abnormality of the lymphatic system, either local or scattered.

Molecular interactions in the "GAT" idiotypic network: an approach using synthetic peptides

In order to approach some of the dominant epitopes which are recognized in the GAT (Glu60 Ala30Tyr10)n random terpolymer, a variety of peptides containing 7 to 14 residues were synthesized using glutamic acid and tyrosine as building blocks, and thus were able to mimic determinants common to GAT and GT (Glu50Tyr50)n. One decapeptide and on dodecapeptide were found to inhibit GT-mAb1 (or mAb1') binding to the same extent as GAT. Antibodies were also raised against synthetic peptides which reproduced the sequence of the 6 CDR of the germline anti-GAT Ab1 antibody. Antibodies were obtained against all peptides except L1, and were shown to recognize the native Ab1-Fab. Surprisingly, some of these antibodies also recognized GAT, i.e. anti-L2, anti-H2 and anti-H3, an observation which speaks in favour of a triggering of the idiotypic network at the Ab3 level. Finally, a monoclonal antibody derived from an immunization with an Ab2-D region synthetic peptide was found to be of the Ag+Id- type. Sequence data indicate that the light chain at least is completely different from that the of Ab1/Ab1', which uses only a very precise pair of V germline genes.

Novel V genes encode virtually identical variable regions of six murine monoclonal anti-bromelain-treated red blood cell autoantibodies

The variable (V) region sequences of six immunoglobulin M (IgM, kappa) monoclonal autoantibodies that recognize bromelinized isologous red blood cells, obtained by fusions of peritoneal cells from NZB or CBA/J nonimmunized mice with BALB/c myeloma cells, were determined by direct mRNA sequencing. The V regions of the light chains (VL) are almost identical with one another, as are the V regions of the heavy chains (VH), which, however, differ by six linked-base substitutions, depending on the strain of mice producing the autoantibodies. Such variations may reflect allelic differences. The VH segments determined have no obvious correspondence to any VH genes identified so far. They may belong to the small VH group 4, where 73% homology, at the most, can be calculated at the protein level for codons 1 to 94. Alternatively, the VH regions may be members of a new group of VH sequences not previously found. The V kappa regions appear closely homologous to members of the V kappa-9 subgroup of myeloma proteins of unknown antigen-binding specificity. The joining segments, J kappa and JH, used by the autoantibodies investigated, originate from the J kappa 2 and JH1 germ-line gene segments, respectively. The nine base-long diversity segments, D, derive from one member of the germ-line D gene SP2 family.

Novel V genes encode virtually identical variable regions of six murine monoclonal anti-bromelain-treated red blood cell autoantibodies

The variable (V) region sequences of six immunoglobulin M (IgM, kappa) monoclonal autoantibodies that recognize bromelinized isologous red blood cells, obtained by fusions of peritoneal cells from NZB or CBA/J nonimmunized mice with BALB/c myeloma cells, were determined by direct mRNA sequencing. The V regions of the light chains (VL) are almost identical with one another, as are the V regions of the heavy chains (VH), which, however, differ by six linked-base substitutions, depending on the strain of mice producing the autoantibodies. Such variations may reflect allelic differences. The VH segments determined have no obvious correspondence to any VH genes identified so far. They may belong to the small VH group 4, where 73% homology, at the most, can be calculated at the protein level for codons 1 to 94. Alternatively, the VH regions may be members of a new group of VH sequences not previously found. The V kappa regions appear closely homologous to members of the V kappa-9 subgroup of myeloma proteins of unknown antigen-binding specificity. The joining segments, J kappa and JH, used by the autoantibodies investigated, originate from the J kappa 2 and JH1 germ-line gene segments, respectively. The nine base-long diversity segments, D, derive from one member of the germ-line D gene SP2 family.

[Post-traumatic arthritis of the wrist caused by an intra-articular foreign body]

The authors report the case of a 12 year-old child presenting with post-traumatic arthritis of the wrist with intra-articular metallic foreign bodies. The trauma was initially considered to be benign, not operated on and forgotten by the child and its family. Excision of a synovial granuloma was followed by a favorable outcome.

[Left inferior vena cava. Ultrasonic diagnosis]

A case of left infrarenal vena cava is detected by ultrasonography and confirmed inferior cavography. Embryogenesis of the inferior vena cava aids understanding of this type of congenital anomalies. Ultrasonographic diagnosis is based on the absence of right infrarenal vena cava, the presence of a vascular structure left to the abdominal aorta an a normal hepatic segment of inferior vena cava.

The idiotypic network and the internal image: possible regulation of a germ-line network by paucigene encoded Ab2 (anti-idiotypic) antibodies in the GAT system

Heavy and light chain variable regions from eight monoclonal Ab2 (anti-idiotypic) antibodies of the GAT antigen, a (Glu60 Ala30 Tyr10)n co-polymer, have been analyzed by direct mRNA sequencing. Three mAb2s were directed against private idiotopes and used various VH-D-JH and Vk-Jk combinations. By contrast, the five 'anti-public' mAb2 antibodies used a very restricted repertoire, including all gene segments. Interestingly, within their D regions, Glu-Glu-Tyr or Tyr-Tyr-Glu sequences were reminiscent of the original (GAT) antigen and may act as possible internal images. A striking observation was that two mAb2 antibodies shared the same V-D-J sequence although derived from separate fusions. As this D sequence, 33 nucleotides long, has not been described so far, it is suggested that it may be encoded by a new germ-line D gene, acting as a crucial regulatory element in a GAT germ-line idiotypic network. An alternative model that may lead to the construction of this D segment by 'odd' rearrangements from pre-existing already reported sequences is also presented.

A structural basis for the internal image in the idiotypic network: antibodies against synthetic Ab2-D regions cross-react with the original antigen

In the idiotypic cascade initiated by the random terpolymer (Glu60Ala30Tyr10)n or "GAT", we have identified, in the D region of Ab2 antibodies, either Glu-Glu-Tyr or Tyr-Tyr-Glu sequences which mimic GAT immunodominant epitopes, thus suggesting a structural basis for the internal image. Peptides containing the two D-region characteristic sequences were then synthesized and coupled to BSA. In mice, they elicited antibodies, a fraction of which recognized GAT. These observations speak in favour of the localization of an internal image of the GAT antigen in the D region of Ab2 antibodies.

[Primary lymphoma of the liver: an uncommon disease. Ultrasonic and x-ray computed tomographic aspects. Apropos of a case with review of the literature]

Although the very rare primary non-Hodgkin's lymphoma is resectable and responds to chemotherapy it has a very poor prognosis since the outcome was rapidly fatal in 7 of the 11 cases reported in the literature. Particular features in a patient with a primary non-Hodgkin's lymphoma of cirrhotic liver were the association of portal hypertension and portal thrombosis related to tumor invasion. Findings on ultrasound imaging and histologic diagnosis from guided needle puncture biopsy appear to be previously unreported aspects of this affection.

The internal image and the structural idiotypic network (Ab1, Ab2, Ab3) in the GAT system

The GAT repertoire expressed at the different levels of the classical idiotypic cascade Ag----Ab1----Ab2----Ab3 has been analysed by direct nucleotide sequencing of H- and L-enriched mRNA. Ab1 and Ab3 expressing the major public idiotypes used similar, if not identical, VH and VK genes. The VH Ab3 of the Ab1 type (Ab1') appeared highly conserved. Ab2 also use a small number of germ-line genes. The D region of Ab2 is of particular interest since it contains either a Tyr-Tyr-Glu or a Glu-Glu-Tyr sequence, characteristic of the GAT major determinants. It is therefore suggested that this D region contains the internal image of the antigen. A large number of VH germ-line genes have been isolated and sequenced. They all pertain to the VH-II family, which contains a large number of members, some of them being very close in sequence.