Treatment of advanced renal cell carcinoma with tumor lysate pulsed IL-12 secreting autologous dendritic cells

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Background: We have conducted a clinical phase I trial to evaluate feasibility and safety of dendritic cell-based immunotherapy in patients with advanced renal cell carcinoma (RCC). As opposed to previous cancer vaccination studies, dendritic cells were specifically enabled to secrete interleukin 12 (IL-12). Methods: Patients with advanced RCC (n = 11) received six weekly intranodal vaccinations with autologous monocyte-derived dendritic cells (mDCs). MDCs were loaded with autologous tumor cell lysate and were specifically stimulated to secrete IL-12 to polarize type-1 T-helper lymphocytes (Th1) and to directly present tumor antigens to cytotoxic T lymphocytes (CTL). Results: There was no significant treatment-related toxicity and no clinical evidence of autoimmunity. Vaccination was very well tolerated. Five patients had stable disease for at least five months, while four patients had progressive disease. Two patients with early clinically significant disease progression had to be excluded before completion of the treatment. In addition, we could detect enhanced anti-tumor immunity in vitro comparing immune response before versus after cancer vaccination. Conclusions: Our findings indicate that cancer vaccination with IL-12 secreting mDCs is well tolerated and has potential clinical and clear immunological effects in patients with advanced RCC.

No significant financial relationships to disclose.

[Stroke management on general medical departments. A multicenter study in Austria]

BACKGROUND AND OBJECTIVE

Despite the claimed superiority of Stroke Units a majority of patients with acute stroke is still treated on general medical departments in many countries. In Austria 90 % of 121 medical departments state that they take care of stroke patients routinely or at least sometimes. Therefore, our aim was to evaluate whether stroke management on medical wards meets up-to-date standards.

PATIENTS AND METHODS

55 medical departments all over Austria participated in a prospective multicenter registry documenting diagnostics, treatment and the in-hospital course of unselected patients admitted with an acute stroke according to a standardised protocol.

RESULTS

1100 patients, 56 % female, with a median age of 75 years were assessed. Median hospital stay was 14 days. In 96 % a cranial computer tomogram was performed. 81 % of cerebral lesions were ischemic, 10 % haemorrhagic. Only 10 % had no risk factor or accompanying medical disease. 31 % suffered at least one medical and 18 % one neurological complication (p = 0.00000003). In-hospital mortality was 17 %, functional outcome was poor in 27 % (Rankin scale [RS] 4 or 5) and good in 56 % (RS 0-3). 74 % of discharged patients could leave to their home, 13 % were transferred to a nursing home and 13 % to a rehabilitation center. 95 % of surviving patients left on either an antiplatelet or an anticoagulant medication and 73 % received antihypertensives.

CONCLUSION

Outcome of stroke patients treated on general medical departments seems to be fairly comparable to that commonly reported by neurological Stroke Units. Further improvements may be obtained by implementation of integrated "mixed assessment" units into medical departments.

[Histological diagnosis of inflammatory skin diseases. Use of a simple algorithm and modern diagnostic methods]

The histological diagnosis of inflammatory skin diseases on a day-to-day routine basis poses the difficult task to characterise a dynamic clinical process by histomorphological analysis of one single lesion. Very complex algorithms which are meant to lead to the correct diagnosis are difficult to use. To facilitate the process and reduce the number of algorithms the following method is proposed: 1. Histological examination under low power Definition of lesions altered by scratching 2. Localisation of the significant pathological alterations as follows: Changes in epidermis and dermis Blister formation Changes in dermis/subcutis without characteristic changes in the epidermis Changes mainly in the subcutis 3. Closer examination using a simple algorithm and planning of further investigations following defined criteria: In the case of changes in epidermis and dermis definition of spongiotic, psoriasiform or lichenoid dermatitis (Abb. 1). In the case of blister formation definition of the blister following the given algorithm (Abb. 1). In the case of changes in dermis/subcutis without characteristic changes in the epidermis after exclusion of vasculitis and lymphoma definition of the main pattern as lymphocytic, neutrophilic, eosinophilic, lymphoplasmocytic or granulomatous and following the given algorithm (Abb. 2). In the case of changes mainly in the subcutis after exclusion of vasculitis and lymphoma definition of the main pattern of panniculitis as septal or/and lobular (Abb. 2). Exclusion of PAS positive microorganisms and checking if the general pattern fits into infectious correlation. Use of clinicopathological correlation.

Benign fibrous histiocytoma (dermatofibroma) of the face: clinicopathologic and immunohistochemical study of 34 cases associated with an aggressive clinical course

Thirty-four cases of fibrous histiocytoma (dermatofibroma) arising on the face are reported. These neoplasms occurred frequently in females (24 female, 10 male) and showed a broad age range (12 to 85 years; mean: 43.6 years, median: 41 years). The neoplasms originated on the forehead (nine cases), the cheek (eight cases), the eyebrow (four cases), the temporal region (three cases), the nose (two cases), and the ear (one case); in seven cases the location face was given only. Five of 27 cases with follow-up information (median: 5 years) recurred locally; in one case four recurrences were excised within 8 years. The majority of cases extended into the subcutis and deep soft tissue including striated muscle (50% of cases). Histologically, only the minority of cases was composed entirely of histiocytoid and spindle-shaped tumor cells arranged in a storiform growth pattern. In many cases cellular fascicles and bundles of spindle-shaped tumor cells were noted in addition to classical morphological features of fibrous histiocytoma. A moderate mitotic rate (mean: 2.97 mitoses in 10 HPFs) was observed, and in few cases increased atypia was evident. Frank tumor necrosis and/or vascular invasion were not identified. Immunohistochemical studies revealed Factor XIIIa positivity in 13 out of 17, focal CD68 positivity in 6 out of 10, and alpha-smooth muscle actin positivity in 16 out of 19 cases tested. These lesions should be distinguished from dermatofibrosarcoma protuberans, including its fibrosarcomatous variant, leiomyosarcoma, and low-grade myofibroblastic sarcoma. Cases of fibrous histiocytoma of the face have to be excised with wider margins in comparison with examples of classical fibrous histiocytoma occurring on the extremities because of diffuse infiltration, involvement of deeper structures, and an increased rate of local recurrences.

Propagation analysis of self-convergent beam width and characterization of hard-edge diffracted beams

For a laser beam diffracted by a hard-edge aperture, propagation of the beam width, defined by the second-order moment of its irradiance distribution truncated according to the self-convergent-width criterion, obeys the familiar hyperbolic law. It is demonstrated numerically that, with the self-convergent-width approach, the beam-propagation parameters for three beam types (Gaussian, Hermite-Gaussian, and flattened Gaussian) diffracted by hard-edge apertures can be determined with the second-moment-based procedure that is recommended by the present draft standard only for unapertured laser beams.

Cystic sebaceous tumors as marker lesions for the Muir-Torre syndrome: a histopathologic and molecular genetic study

Cystic sebaceous tumors (CST) are well-circumscribed, large, deeply located dermal sebaceous proliferations with a cystic growth pattern. We identified 12 CST in 8 of 19 patients with Muir-Torre syndrome (MTS). We interpret CST as a tumor spectrum with clearly benign cystic sebaceous adenomas at one end and proliferative atypical cystic sebaceous tumors at the other. When examining these proliferative atypical tumors on morphologic criteria alone, the possibility of an evolving cystic sebaceous carcinoma cannot be excluded. We have not observed recurrences or metastases, indicating that these lesions are not highly malignant carcinomas. In 10 of 12 cases of CST, we examined microsatellite instability (MSI). All 10 examined examples of CST from patients with MTS showed MSI characteristic for hereditary nonpolyposis colorectal cancer (HNPCC), which is caused by autosomal dominant inherited DNA mismatch repair (MMR) defects. Mutational analysis of the MMR genes hMSH2 and hMLH1 had revealed different germline mutations in the hMSH2 gene in three of six examined patients with MTS with CST. We then found four more CST in patients without a history of internal malignancy. All four CST exhibited MSI. By mutational analysis in one of these patients we identified a truncating germline mutation in the MMR gene hMLH1. We conclude that CST is a marker for the mismatch repair-deficient subtype of MTS with a high risk for later internal malignancies. By recognizing CST, the histopathologist can suggest the great likelihood of MTS to the clinician.

A new application of BCG antibody for rapid screening of various tissue microorganisms

BACKGROUND

In routine dermatopathology there is growing demand for a simple, fast, cost-effective, and highly sensitive screening tool for the detection of microorganisms.

OBJECTIVE

Our purpose was to determine whether immunostaining with polyclonal anti-Mycobacterium bovis (BCG), which is known for its interspecies cross-reactivity, is a suitable screening method for many common microorganisms in dermatopathologic specimens.

METHODS

A total of 254 formalin-fixed, paraffin-embedded skin specimens of viral, protozoal, fungal, and bacterial infections were stained with appropriate histochemical stains and with anti-BCG.

RESULTS

Anti-BCG labeled bacteria and fungi with high sensitivity and minimal background staining, but did not react with spirochetes, viruses, or protozoa (Leishmania). The quality and sensitivity of anti-BCG staining were superior to conventional histochemical stains.

CONCLUSION

Because of its cross-reactivity with many bacteria and fungi as well as its high sensitivity and minimal background staining, the anti-BCG immunostain is a promising screening tool for the detection of the most common bacterial and fungal microorganisms in paraffin-embedded skin specimens.

Absence of anaplastic lymphoma kinase (ALK) and Epstein-Barr virus gene products in primary cutaneous anaplastic large cell lymphoma and lymphomatoid papulosis

The prevalence of the t(2;5)(p23;q35) and/or anaplastic lymphoma kinase (ALK) gene products in cutaneous anaplastic large cell (ALC) lymphomas and a potential precursor lesion, lymphomatoid papulosis (LyP), is controversial. ALK gene products, which are absent from normal lymphohaematopoietic cells, are a phenotypic marker of lymphomas carrying the t(2;5). We used in situ hybridization and immunohistology to screen 14 cutaneous ALC lymphomas, 21 cases of LyP, and one nodal ALC lymphoma associated with LyP for ALK gene products. ALK gene products were not detectable in these cases. In contrast, ALK gene products were found in a lymphonodal ALC lymphoma with subsequent extension to the skin and in t(2;5)-positive cell lines. Detection of the Epstein-Barr virus (EBV)-encoded small nuclear transcripts (EBER), and of immunoglobulin light chain transcripts served to check for the presence of cellular RNA in the tissue sections. EBER transcripts were found in scattered reactive lymphoid cells, but not in atypical or tumour cells. ALK gene expression and EBV infection seem to be a rare finding in cutaneous ALC lymphomas and LyP. This points to a molecular aetiology of primary cutaneous ALC lymphomas and LyP distinct from that of extracutaneous CD30+ lymphoproliferative disease. Detection of the t(2;5) or ALK gene products in cutaneous lymphoproliferative lesions therefore requires exclusion of extracutaneous ALC lymphoma in such patients.

Cutaneous adult myofibroma: a vascular neoplasm

Infantile myofibromatosis is a distinctive type of fibromatosis that usually develops during the immediate perinatal period. There are variants with solitary and multiple tumors. Lesions confined to the skin, soft tissue, and bone carry a good prognosis, showing spontaneous regression. The prognosis, however, is much less favorable when visceral lesions are present and the outcome may be fatal. Only recently it became obvious that there is an adult counterpart of infantile myofibromatosis, characterized by solitary lesions that have a predilection for involve the dermis and show no tendency to regression, although they have an entirely benign biological behavior. These lesions have been named cutaneous myofibroma or solitary myofibroma of adults. We have studied the clinical, histopathological and immunohistochemical characteristics of 53 examples of cutaneous adult myofibroma. In addition, 2 cases were examined ultrastructurally. The patients were mostly adults with ages ranging from 6-83 years. The lesions presented as solitary, usually painless nodules of variable duration on the skin, usually located on the extremities. Histopathologically, four patterns were identified: nodular or cellular type, multinodular or biphasic type, leiomyoma-like or fascicular type, and vascular type. A correlation between the histopathologic pattern and the lesional age was observed: vascular type of cutaneous adult myofibroma in early lesions, nodular and multinodular lesions in fully developed lesions, and leiomyoma-like or fascicular type in late lesions. Immunohistochemically, the spindle cells were desmin negative, but expressed immunoreactivity for vimentin, pan-smooth muscle actin, and alpha-smooth muscle actin. Ultrastructurally, neoplastic cells showed characteristics of undifferentiated mesenchymal cells with features of fibroblasts, myofibroblasts and pericytes. Primitive vascular formations were seen in the form of irregular clefts between adjoining cells. We conclude that cutaneous adult myofibroma is a little-known benign vascular neoplasm probably derived from myopericytes.

[Desmoplastic malignant melanoma. Clinical and histopathologic results of a study in 34 patients]

Clinical and histopathological findings of 34 cases of desmoplastic malignant melanoma (DMM) are summarized and compared to the literature. DMM develop mostly in sun damaged skin of elderly patients, they are rare and often nonpigmented tumors that are difficult to diagnose clinically. In all cases the tumor parameters showed level IV or V melanomas (level IV: 55.9%, level IV-V: 14.7%, level V: 29.4%) and the tumor thickness measured 3.85 mm +/- 2.31 mm (1.0-11.0 mm). In 22 cases, the follow-up time was between 2 and 7 years. Local recurrences were observed in 7 ( = 31.8%) patients, metastases in 4 ( = 18.2%) and tumor-related deaths in 3. The prognosis for our patients seems to be slightly better than that described in the literature. The main reason is an improved histological diagnosis of this special type of melanoma. Using immunohistochemical staining with anti-S100 antibody it is possible to establish the melanocytic nature of these fibrotic spindle cell tumors earlier that is, in small initial biopsies, and tumor margins can be defined more accurately. As a consequence, surgery is done earlier and is more likely to be curative.

Algebraic approach to characterizing paraxial optical systems

The paraxial propagation formalism for ABCD systems is reviewed and written in terms of quantum mechanics. This formalism shows that the propagation based on the Collins integral can be generalized so that, in addition, the problem of beam quality degradation that is due to aberrations can be treated in a natural way. Moreover, because this formalism is well elaborated and reduces the problem of propagation to simple algebraic calculations, it seems to be less complicated than other approaches. This can be demonstrated with an easy and unitary derivation of several results, which were obtained with different approaches, in each case matched to the specific problem. It is first shown how the canonical decomposition of arbitrary (also complex) ABCD matrices introduced by Siegman [Lasers, 2nd ed. (Oxford U. Press, London, 1986)] can be used to establish the group structure of geometric optics on the space of optical wave functions. This result is then used to derive the propagation law for arbitrary moments in eneral ABCD systems. Finally a proper generalization to nonparaxial propagation operators that allows us to treat arbitrary aberration effects with respect to their influence on beam quality degradation is presented.

[Differences between plaque-like variants of dermatofibrosarcoma protuberans and plaque-like dermal fibromatosis (dermatomyofibroma)]

On the basis of two cases the differences between the plaque-like variant of dermatofibrosarcoma protuberans (PDFSP) and the plaque-like dermal fibromatosis (synonym: dermatomyofibroma; PDF) are presented. PDFSP and PDF are two clinically very similar dermal fibrous proliferations, but differentiation is important because of their different therapy and prognosis. Histologically and immunohistochemically PDFSP and PDF can be recognized as separate entities.

[Acquired benign myofibroma of the skin (adult myofibroma)]

Adult myofibroma is an acquired skin tumour that is histologically identical to infantile myofibroma. Histologically, four tumour variants can be distinguished: leiomyoma type, cellular spindle cell type, haemangiopericytoma or glomus type, and biphasic type. Practical help in diagnosis is supplied by the hamartomatous composition of the leiomyoma-type, hyalinized spindle cell whorls, endothelium-lined haemangiopericytoma-like vascular channels, and desmin-negative, muscle-actin-positive myofibroblasts, which may show spindle cell or undifferentiated mesenchymal cell differentiation. The tumours clinically present as firm, occasionally bluish cutaneous or subcutaneous nodules. Adult myofibroma should be recognized as a distinct benign neoplasm, most probably of vascular origin. Clinicians and dermatopathologists must be aware that lesions identical to those of infantile myofibroma can occur in adults.

[Pigmented Paget's disease and pigmented breast cancer metastasis. Clinical and histologic simulation of malignant melanoma of the breast]

Pigmented epidermotropic breast carcinoma has to be included in the differential diagnosis of pigmented lesions of the breast. Two rare cases of pigmented Paget's disease and pigmented metastatic breast carcinoma are presented, which mimicked malignant melanoma in both clinical and histological criteria.

[Plaque-like dermal fibromatosis]

Plaquelike dermal fibromatosis with a preference for the periaxillary region is described in 22 women, 1 man and 2 boys before puberty. The lesions grew slowly but relentlessly and measured up to 5 cm in diameter. No recurrences after excision have occurred to date. Histologically there is bandlike proliferation throughout the stratum reticulare consisting of well-differentiated, highly cellular fibrous tissue.

Pseudomalignant erosion in hyperplastic gastric polyps

Six cases of hyperplastic gastric polyps are described that, in the region of the eroded head, revealed strikingly atypical mesenchymal cells. These disseminated cells with marked nuclear pleomorphism and also atypical mitotic figures, undergoing direct transition to typical granulation tissue, are considered to be particularly activated mesenchymal cells. In a single case in which only excisional biopsy was performed, these cells were found to persist over a lengthy period, while in endoscopic-biopsy follow-ups of the polypectomized cases, these cells were subsequently no longer detectable. In four of the cases, the polyp was located in the region of the cardia, so that a traumatic factor may possibly be considered as having some causal relevance. In particular when biopsy excisions are performed, the differential diagnosis of this polyp with its endoscopic and histologic appearance of a tumor-like lesion, from epithelial and mesenchymal malignancies, as also from neural tumors, can be difficult.

[Telangiectatic anastomoses polyp of the stomach]

Teleangiectatic polyps (TP) of the stomach arise from granulation OFFsue mostly in elderly people in the area of gastrojejunostomy decades after surgery. During endoscopy usually polyps of a size up to 2 cm can be found with a diffuse erosion of the surface and bleeding immediately upon being touched; this may cause the clinical symptomatology of acute gastric bleeding or chronic anemia as a consequence of blood loss. TP has to be differentiated in the first line from gastric carcinoma. Therapy is difficult especially in patients with big polyps because of the bleeding tendency, 5 case reports of TP are given.

[Communicative and social behavior of speech disordered children]

The spheres covering behaviour disorders, social behaviour and communicative behaviour of speech impaired pupils which until now have been analyzed on a more theoretical level, ought to be studied using psychometric testing procedures and an esperimental observational situation in order to gain base data with which to set up a concrete catalogue of aims (learning program) based on the deficits thereby obtained. The study took place at the special school in Esslinger-Berkheim (Baden-Wurttemberg). By taking into account relevant specialized literature and the results of other studies, the following general hypotheses were advanced, namely, that the communication of speech handicapped children is troubled in respect of its content and relation, and that their social behaviour shows more egoistic than cooperative features. In order to determine social motivations and attitudes, we used Muller's "Social Motivation Test" (SMT) and Jorger's "Group test for the social attitude" (S-E-T). Due to the inconsistency between the attitudes measured by means of psychometric methods and the sbusequent free and genuine behaviour, an observational situation was developed during which the pupils, either in pairs or in groups of four and using puppets, took turns in thinking up a story, discussing the plot, roles, etc. and finally putting on the play. The whole was then analyzed by means of tape recordings and film shots, the interaction of the communicating partners being analyzed and categorized in two separate assessment stages: communicative behaviour and social behaviour. The pragmatic axioms of P. Watzlawick, the communication researcher, functioned as theoretical background. Flanders's linear time diagram was used as assessment system. Communicative and social learning aims were prepared in accordance with confirming hypotheses to enable a "preliminary area" for the practical work in (special) education to be defined. In addition, a rough outline was made of the conditional areas pertaining to social and communicative education of the speech impaired for the purpose of carrying out a systematic change.