Endometrial Carcinomas With Subclonal Loss of Mismatch Repair Proteins: A Clinicopathologic and Genomic Study

Subclonal loss of mismatch repair (MMR) proteins has been described in a small subset of endometrial carcinomas (ECs), but the genomic basis for this phenomenon has received limited attention. Herein, we retrospectively evaluated all ECs with MMR immunohistochemistry (n=285) for subclonal loss, and in those (n=6), performed a detailed clinicopathologic and genomic comparison of the MMR-deficient and MMR-proficient components. Three tumors were FIGO stage IA, and one each stage IB, II, and IIIC2. Patterns of subclonal loss were as follows: (1) 3 FIGO grade 1 endometrioid carcinomas with subclonal MLH1/PMS2, MLH1 promoter hypermethylation, and no MMR gene mutations; (2) POLE -mutated FIGO grade 3 endometrioid carcinoma with subclonal PMS2, and PMS2 and MSH6 mutations limited to the MMR-deficient component; (3) dedifferentiated carcinoma with subclonal MSH2/MSH6, as well as complete loss of MLH1/PMS2, MLH1 promoter hypermethylation, and PMS2 and MSH6 mutations in both components; (4) dedifferentiated carcinoma with subclonal MSH6, and somatic and germline MSH6 mutations in both components, but with a higher allele frequency in MMR-deficient foci. Recurrences occurred in 2 patients, one consisted of the MMR-proficient component from a FIGO 1 endometrioid carcinoma, while the other was from the MSH6 -mutated dedifferentiated endometrioid carcinoma. At the last follow-up (median: 44 mo), 4 patients were alive and disease-free and 2 were alive with disease. In summary, subclonal MMR loss reflects subclonal and often complex genomic and epigenetic alterations, which may have therapeutic implications and therefore must be reported when present. In addition, subclonal loss can occur in both POLE -mutated and Lynch syndrome-associated ECs.

[Evaluation of technical skills in surgical training]

INTRODUCTION

technical skills acquisition is considered to be of paramount importance in surgical training. Yet, formal assessment of technical skills is the weakest and less developed area. Currently available resources to evaluate technical skills are largely subjective, and lack of validity and reliability. Direct observation, one of the most frequently used methods, is largely biased by interpersonal subjectivity and personality traits. We propose the creation and use of a new procedure-specific tool for objective assessment of technical skills in surgery to evaluate validity and reliability.

MATERIALS AND METHODS

laparoscopic cholecystectomy and Lichstenstein's inguinal hernia repair were the chosen procedures. Three groups of comparison were defined according to surgical expertise: initial, intermediate, and experts. Surgeries were videorecorded in real time without identification of the patient or the surgeon. Tapes without any posterior edition were assigned to two expert surgeons in a blind and randomized sequence. A newly proposed procedure-specific rating scale was used for evaluation, as well as Reznick's OSATS global scale. Kruskal-Wallis non-parametric test was used to assess validity. p < 0,05 was considered statistically significant. Chronbach's? values> 0.8 granted reliability.

RESULTS

from April 2010 to December 2012 36 laparoscopic cholecystectomies and 31 inguinal hernia repairs were recorded. Significant difference was found among groups of comparison for every item (p<0.05). Crhonbach's ? was largely over 0,80 for both procedures. There was no significant difference between the assessments of the two raters. There was no significant difference between our newly proposed procedure-specific instrument and Reznick's OSTATS.

DISCUSSION

the objective assessment of technical skills in surgery is feasible and useful. The tool we proposed showed construct validity and reliability. Video recording of surgical procedures grants durability over time to an ephemeral phenomenon. The objectivity is based on the explicit statements and quantification of every step to be evaluated, and the blind randomization and anonymous treatment of the sample. Sharing the same quality criteria between evaluators is of paramount importance to reach satisfactory results. The process of evaluation always implies a shortened view of the reality.

Transfer of bovine blastocysts derived from short-term in vitro culture of low quality morulae produced in vivo

The aim of this study was to evaluate if blastocysts arising from in vitro culture of Grade 3 bovine morulae produced in vivo can promote acceptable pregnancy rates when transferred into recipients. Embryos of different stages and qualities were recovered from superovulated Bos taurus and B. indicus donors. Grade 3 morulae were cultured in either Holding Plus or TCM-199 (supplemented with 10% bovine fetal serum) media for 24 h at 38.5 degrees C. After this culture period, the resulting blastocysts were morphologically classified (Grades 1, 2 and 3) and transferred into recipients previously synchronized with the donors. Non-cultured Grades 1 and 3 morulae were used as control. Pregnancy diagnosis was carried out 60 days after embryo transfer and the data were analysed by logistic regression, considering variables, such as embryo quality (Grade), donor breed, culture medium, donor-recipient synchrony and seasonality. Embryo quality was the only variable, showing significant effect on the pregnancy rate. Pregnancy rates for non-cultured Grade 1 and 3 morulae, and blastocysts arising from cultured Grade 3 morulae were 58.1% (n = 31), 17.1% (n = 35) and 51.1% (n = 47), respectively (p < 0.05). There were no statistical differences between non-cultured Grade 1 morulae and cultured blastocysts. Pregnancy rates for Grades 1 (65.0%) and 2 (60.0%) were higher than Grade 3 (29.4%) cultured blastocysts (p < 0.05). It was concluded that short-term in vitro culture is a very convenient method of identifying morphologically low quality morulae with higher chances of continuing development after the transfer into recipients.

Effect of sildenafil on non-adrenergic non-cholinergic neurotransmission in bovine penile small arteries

The purpose of the present study was to investigate the effect of the phosphodiesterase isoenzyme V inhibitor, sildenafil, on non-adrenergic non-cholinergic neurogenic relaxations of intracavernous isolated penile small arteries. Dense plexes of nerve fibres immunoreactive for neural nitric oxide (NO) synthase were observed in the adventitia-media junction of the penile small arteries. In 5-hydroxytryptamine-contracted preparations, the inhibitor of NO synthase, N(G)-nitro-L-arginine (L-NOARG), and of soluble guanylyl cyclase, 1H-[1,2,4]oxadiazolo[4,3,-a]quinoxalin-1-one (ODQ), reduced the electrical field stimulation-induced relaxations. Sildenafil and exogenous NO induced relaxations of penile small arteries. Sildenafil enhanced NO and vasoactive intestinal peptide-induced relaxations. Moreover, sildenafil increased the duration of the relaxations elicited by electrical field stimulation in penile small arteries and corpus cavernosum tissue. In the presence of L-NOARG, sildenafil only at supratherapeutic concentrations reduced the prazosin-sensitive contractions elicited by EFS in penile small arteries. Neurogenic NO-mediated and guanylyl cyclase-dependent relaxations of penile small arteries and corpus cavernosum tissue, considered to be associated with the vasodilatation leading to erection, are selectively enhanced by an inhibitor of phosphodiesterase V.

Biphasic response to histamine in rabbit penile dorsal artery

The effects of specific histamine agonists and antagonists on isolated rabbit penile dorsal artery segments were explored using in vitro isometric techniques. Histamine caused the constriction of both precontracted and resting segments. In precontracted arterial rings treated with the H1 receptor antagonist mepyramine, histamine evoked a vasodilatation, followed by contraction at higher concentrations. The vasoconstrictor effect of histamine and the H1 receptor agonist, 2-pyridylethylamine (PEA) on preparations under conditions of basal tone, was competitively antagonized by mepyramine (10(-9)-10(-8) M). The relaxant effect of histamine, unmasked by mepyramine, was abolished by cimetidine. Dimaprit, the H2 receptor agonist, provoked a relaxation of precontracted segments that was also competitively inhibited by cimetidine (10(-6)-10(-5) M). Selective H3 receptor activation with the agonist (R)alpha-methylhistamine (10(-10)-10(-4) M) produced no effect in penile dorsal artery. The biphasic response to histamine was unaffected by endothelium removal or the nitric oxide inhibitor NG-nitro-L-arginine methyl ester (L-NAME) (3 x 10(-4) M) and its precursor, L-arginine (3 x 10(-4) M). Similarly, the cyclooxygenase inhibitor, indomethacin (3 x 10(-6) M) and a combination of Ca2+-activated K+ channel blockers apamin (5 x 10(-7) M) and charybdotoxin (10(-7) M) showed no effect on the histamine-induced relaxation or contraction. In conclusion, contraction, the predominant effect of histamine, is mediated by the activation of H1 receptors that mask the relaxant effect brought about by H2 receptors. Both these effects appear to be mediated by direct action on the smooth muscle, with no participation of nitric oxide or cyclooxygenase products or Ca2+-activated K+ channels.

[Treatment of giant cell tumors. Resection-unicondyle reconstruction]

The authors report 4 cases, 3 involving a femoral condyle one the lower extremity of the humerus treated by resection followed by massive grafting.

Peripheral neuropathy detected on electrophysiological study as first manifestation of metachromatic leucodystrophy in infancy

A case of infantile metachromatic leucodystrophy is described in which symptoms started at 1 year of age with weakness and hypotonus in the lower extremities. The electrophysiological status was typical of a polyneuropathy, showing fibrillation and a reduction of the nerve conduction velocity to 30 percent of the average for normal children of the same age. Clinical signs of a central lesion and mental regression were not evident until a year later. Nerve biopsy showed metachromatic granules in the phagocytes and in the Schwann cells, confirming the diagnosis of metachromatic leucodystrophy. In peripheral neuropathy in infancy without obvious cause, a nerve biopsy is the most appropriate method for diagnosis of the metachromatic leucodystrophy.