Combined score of Y chromosome loss and T-cell infiltration improves UICC based stratification of esophageal adenocarcinoma

Background

Staging, especially clinical lymph node staging in esophageal adenocarcinoma has only moderate sensitivity and specificity. Therefore, we evaluated combined molecular markers to predict prognosis.

Patients and methods

890 tumor tissue samples were obtained from patients who underwent surgery for esophageal adenocarcinoma with curative intent. These were stained by tissue micro array for 48 markers which are associated with tumorigenesis and correlated with clinical data (TNM-staging, overall survival) by multivariate Cox regression.

Results

Two markers (preserved Y chromosome and high grade of (CD3+) T-cell infiltration) were found to be significantly and independently associated with better overall survival. We formed a score (called CY score) from the two markers. The more markers are positive and thus the higher the score (ranging from 0 to 2), the better the overall survival, independently of UICC. Moreover, we developed a combination score of the UICC and CY score based on cluster analysis. Patients with a UICC stage of III with the presence of both traits (CY=2) can be assigned to a better prognosis group (group II), whereas patients with a UICC stage of I without both traits (CY=0) must be assigned to a worse prognosis group (group II). Therefore, patients in stage I with adverse molecular signature might benefit of multimodal therapy.

Conclusion

In summary, the CY score adds prognostic information to the UICC stage based on tumor biology in esophageal adenocarcinoma and warrants further evaluations in independent clinical cohorts.

Distinct distribution patterns of exercise-induced natural killer cell mobilisation into the circulation and tumor tissue of patients with prostate cancer

The mobilization and activation of natural killer (NK) cells have been proposed as key mechanisms promoting anti oncogenic effects of physical exercise. Although mouse models have proven that physical exercise recruits NK cells to tumor tissue and inhibits tumor growth, this preclinical finding has not been transferred to the clinical setting yet. In this first-in-human study, we found that physical exercise mobilizes and redistributes NK cells, especially those with a cytotoxic phenotype, in line with preclinical models. However, physical exercise did not increase NK cell tumor infiltrates. Future studies should carefully distinguish between acute and chronic exercise modalities and should be encouraged to investigate more immune responsive tumor entities.

Post-transplant Malignancies Show Reduced T-cell Abundance and Tertiary Lymphoid Structures as Correlates of Impaired Cancer Immunosurveillance

PURPOSE

An increased risk to develop cancer is one of the most challenging negative side effects of long-term immunosuppression in organ transplant recipients and impaired cancer immunosurveillance is assumed as underlying mechanism. This study aims to elucidate transplant-related changes in the tumor immune microenvironment (TME) of cancer.

EXPERIMENTAL DESIGN

Data from 123 organ transplant recipients (kidney, heart, lung, and liver) were compared with historic data from non-immunosuppressed patients. Digital image analysis of whole-section slides was used to assess abundance and spatial distribution of T cells and tertiary lymphoid structures (TLS) in the TME of 117 tumor samples. Expression of programmed cell death 1 ligand 1 (PD-L1) and human-leucocyte-antigen class I (HLA-I) was assessed on tissue microarrays.

RESULTS

We found a remarkably reduced immune infiltrate in the center tumor (CT) regions as well as the invasive margins (IM) of post-transplant cancers. These differences were more pronounced in the IM than in the CT and larger for CD8+ T cells than for CD3+ T cells. The Immune-score integrating results from CT and IM was also lower in transplant recipients. Density of TLS was lower in cancer samples of transplant recipients. The fraction of samples with PD-L1 expression was higher in controls whereas decreased expression of HLA-I was more common in transplant recipients.

CONCLUSIONS

Our study demonstrates the impact of immunosuppression on the TME and supports impaired cancer immunosurveillance as important cause of post-transplant cancer. Modern immunosuppressive protocols and cancer therapies should consider the distinct immune microenvironment of post-transplant malignancies.

CD86+ Antigen-Presenting B Cells Are Increased in Cancer, Localize in Tertiary Lymphoid Structures, and Induce Specific T-cell Responses

The role of B cells in antitumor immunity and their impact on emerging immunotherapies is increasingly gaining attention. B-cell effector functions include not only secretion of antibodies, but also presentation of antigens to T cells. A physiologic B-cell subset with immunostimulatory properties was described in humans, defined by a high expression of CD86 and downregulation of CD21. We used multicolor flow cytometry and IHC to elucidate abundance and spatial distribution of these antigen-presenting B cells (BAPC) in blood (peripheral blood mononuclear cells, PBMC) and tumor samples of 237 patients with cancer. Antigen-specific T-cell responses to cancer testis antigens were determined using tetramer staining and sorted BAPCs in FluoroSpot assays for selected patients. We found that BAPCs were increased in the tumor microenvironment of 9 of 10 analyzed cancer types with site-specific variation. BAPCs were not increased in renal cell carcinoma, whereas we found a systemic increase with elevated fractions in tumor-infiltrating lymphocytes (TIL) and PBMCs of patients with colorectal cancer and gastroesophageal adenocarcinoma. BAPCs were localized in lymphoid follicles of tertiary lymphoid structures (TLS) and were enriched in tumors with increased numbers of TLSs. BAPCs isolated from tumor-draining lymph nodes of patients with cancer showed increased percentages of tumor antigen-specific B cells and induced responses of autologous T cells in vitro. Our results highlight the relevance of BAPCs as professional antigen-presenting cells in tumor immunity and provide a mechanistic rationale for the observed correlation of B-cell abundance and response to immune checkpoint inhibition.

Expression of Immune Checkpoint Regulators IDO, VISTA, LAG3, and TIM3 in Resected Pancreatic Ductal Adenocarcinoma

Pancreatic cancer features elaborate mechanisms of immune evasion. The potential of new immune molecules was explored to restore the antitumor immune response. If these immune molecules are associated with poor survival, specific drugs could take effect. Here, we analyze the expression of VISTA, LAG3, IDO, and TIM3 on tumor-infiltrating lymphocytes (TILs) and its impact on patient survival. We analyzed 153 pancreatic cancer patients from the prospectively managed database of the multicentered PANCALYZE study. Immunohistochemistry on a tissue microarray assessed VISTA, LAG3, IDO, and TIM3 expression of TILs from the patients undergoing primary resection. Complementarily, we analyzed publicly available transcriptomic data (n = 903). Successful completion of chemotherapy, and lymph node status were independent predictors of survival in the multivariate analysis of the clinicopathologic parameters. Fifteen tumors were exclusively VISTA-positive, thirteen tumors expressed VISTA together with TIM3, and ten tumors expressed VISTA together with IDO. Patients featuring tumors with high numbers of IDO-positive TILs had better patient survival (p = 0.037). VISTA, LAG3, and TIM3 expression did not correlate with survival. The analysis of publicly available data did not show survival differences. Tumors rarely co-express more than two immune molecules at the same time, and VISTA is most frequently co-expressed. Although IDO generally inhibits T-cell proliferation, a high expression of IDO was associated with improved survival. We expect immune checkpoint inhibitors against VISTA, LAG3, and TIM3 to be inefficient in a clinical application.

Sex-specific prognostic effect of CD66b-positive tumor-infiltrating neutrophils (TANs) in gastric and esophageal adenocarcinoma

BACKGROUND

Tumor-associated neutrophils (TANs) have recently been identified as a relevant component of the tumor microenvironment (TME) in solid tumors. Within the TME TANs mediate either tumor-promoting or tumor-inhibiting activities. So far, their prognostic relevance remains to be determined. This study aims to evaluate the prognostic relevance of TANs in different molecular subtypes of gastric and esophageal adenocarcinoma.

METHODS

We analyzed a total of 1118 Caucasian patients divided into gastric adenocarcinoma (n = 458) and esophageal adenocarcinoma cohort (n = 660) of primarily resected and neoadjuvant-treated individuals. The amount of CD66b + TANs in the tumor stroma was determined using quantitative image analysis and correlated to both molecular, as well as clinical data.

RESULTS

An accumulation of TANs in the tumor stroma of gastric carcinomas was associated to a significant favorable prognosis (p = 0.026). A subgroup analysis showed that this effect was primarily related to the molecular chromosomal instable subtype (CIN) of gastric carcinomas (p = 0.010). This was only observed in female patients (p = 0.014) but not in male patients (p = 0.315). The same sex-specific effect could be confirmed in adenocarcinomas of the esophagus (p = 0.027), as well as in female individuals after receiving neoadjuvant therapy (p = 0.034).

CONCLUSIONS

Together, we show a sex-specific prognostic effect of TANs in gastric cancer within a Caucasian cohort. For the first time, we showed that this sex-specific prognostic effect of TANs can also be seen in esophageal cancer.

GATA binding protein 6 (GATA6) is co-amplified with PIK3CA in patients with esophageal adenocarcinoma and is linked to neoadjuvant therapy

Purpose

Driver mutations are typically absent in esophageal adenocarcinoma (EAC). Mostly, oncogenes are amplified as driving molecular events (including GATA6-amplification in 14% of cases). However, only little is known about its biological function and clinical relevance.

Methods

We examined a large number of EAC (n = 496) for their GATA6 amplification by fluorescence in situ hybridization (FISH) analyzing both primary resected (n = 219) and neoadjuvant treated EAC (n = 277). Results were correlated to clinicopathological data and known mutations/amplifications in our EAC-cohort.

Results

GATA6 amplification was detectable in 49 (9.9%) EACs of our cohort. We observed an enrichment of GATA6-positive tumors among patients after neoadjuvant treatment (12,3% amplified tumors versus 6,8% in the primary resected group; p = 0.044). Additionally, there was a simultaneous amplification of PIK3CA and GATA6 (p < 0.001) not detectable when analyzing other genes such as EGFR, ERBB2, KRAS or MDM2. Although we did not identify a survival difference depending on GATA6 in the entire cohort (p = 0.212), GATA6 amplification was associated with prolonged overall survival among patients with primary surgery (median overall-survival 121.1 vs. 41.4 months, p = 0.032). Multivariate cox-regression analysis did not confirm GATA6 as an independent prognostic marker, neither in the entire cohort (p = 0.210), nor in the subgroup with (p = 0.655) or without pretreatment (p = 0.961).

Conclusions

Our study investigates the relevance of GATA6 amplification on a large tumor collective, which includes primary resected tumors and the clinically relevant group of neoadjuvant treated EACs. Especially in the pretreated group, we found an accumulation of GATA6-amplified tumors (12.3%) and a frequent co-amplification of PIK3CA. Our data suggest an increased resistance to radio-chemotherapy in GATA6-amplified tumors.

Deep Learning Predicts HPV Association in Oropharyngeal Squamous Cell Carcinomas and Identifies Patients with a Favorable Prognosis Using Regular H&E Stains

PURPOSE

Human papillomavirus (HPV) in oropharyngeal squamous cell carcinoma (OPSCC) is tumorigenic and has been associated with a favorable prognosis compared with OPSCC caused by tobacco, alcohol, and other carcinogens. Meanwhile, machine learning has evolved as a powerful tool to predict molecular and cellular alterations of medical images of various sources.

EXPERIMENTAL DESIGN

We generated a deep learning-based HPV prediction score (HPV-ps) on regular hematoxylin and eosin (H&E) stains and assessed its performance to predict HPV association using 273 patients from two different sites (OPSCC; Giessen, n = 163; Cologne, n = 110). Then, the prognostic relevance in a total of 594 patients (Giessen, Cologne, HNSCC TCGA) was evaluated. In addition, we investigated whether four board-certified pathologists could identify HPV association (n = 152) and compared the results to the classifier.

RESULTS

Although pathologists were able to diagnose HPV association from H&E-stained slides (AUC = 0.74, median of four observers), the interrater reliability was minimal (Light Kappa = 0.37; P = 0.129), as compared with AUC = 0.8 using the HPV-ps within two independent cohorts (n = 273). The HPV-ps identified individuals with a favorable prognosis in a total of 594 patients from three cohorts (Giessen, OPSCC, HR = 0.55, P < 0.0001; Cologne, OPSCC, HR = 0.44, P = 0.0027; TCGA, non-OPSCC head and neck, HR = 0.69, P = 0.0073). Interestingly, the HPV-ps further stratified patients when combined with p16 status (Giessen, HR = 0.06, P < 0.0001; Cologne, HR = 0.3, P = 0.046).

CONCLUSIONS

Detection of HPV association in OPSCC using deep learning with help of regular H&E stains may either be used as a single biomarker, or in combination with p16 status, to identify patients with OPSCC with a favorable prognosis, potentially outperforming combined HPV-DNA/p16 status as a biomarker for patient stratification.

Tumor budding assessed according to the criteria of the International Tumor Budding Consensus Conference determines prognosis in resected esophageal adenocarcinoma

Only few studies examined the prognostic effect of tumor budding in esophageal adenocarcinomas so far. However, different quantification approaches were used, so results cannot be directly compared. Recently, the International Tumor Budding Consensus Conference (ITBCC) published consensus criteria for the evaluation of tumor budding in colorectal cancer, which we applied in our study. Hematoxylin and eosin (H&E) and cytokeratin (AE1/AE3) stained whole tissue slides of 104 resected esophageal adenocarcinomas were evaluated. The mean count of tumor buds was analyzed in one high power field according to the ITBCC criteria and assigned to budding groups Bd1-3. Tumor budding was significantly associated with a worse overall survival. Regardless of the quantification approach, an increased number of tumor buds was significantly associated with reduced overall survival (OS) (H&E: HR = 1.05 (95% CI 1.029-1.073), p < 0.001; cytokeratin: HR = 1.073 (95% CI 1.045-1.101), p < 0.001). In multivariable analysis tumor budding according to ITBCC criteria on H&E stained slides was an independent prognostic factor. Tumor budding, according to ITBCC criteria, is an independent prognostic factor in resected esophageal adenocarcinoma. Prospective studies using ITBCC criteria are useful in the near future to validate our results.

Cell type-specific transcriptomics of esophageal adenocarcinoma as a scalable alternative for single cell transcriptomics

Single‐cell transcriptomics have revolutionized our understanding of the cell composition of tumors and allowed us to identify new subtypes of cells. Despite rapid technological advancements, single‐cell analysis remains resource‐intense hampering the scalability that is required to profile a sufficient number of samples for clinical associations. Therefore, more scalable approaches are needed to understand the contribution of individual cell types to the development and treatment response of solid tumors such as esophageal adenocarcinoma where comprehensive genomic studies have only led to a small number of targeted therapies. Due to the limited treatment options and late diagnosis, esophageal adenocarcinoma has a poor prognosis. Understanding the interaction between and dysfunction of individual cell populations provides an opportunity for the development of new interventions. In an attempt to address the technological and clinical needs, we developed a protocol for the separation of esophageal carcinoma tissue into leukocytes (CD45+), epithelial cells (EpCAM+), and fibroblasts (two out of PDGFRα, CD90, anti‐fibroblast) by fluorescence‐activated cell sorting and subsequent RNA sequencing. We confirm successful separation of the three cell populations by mapping their transcriptomic profiles to reference cell lineage expression data. Gene‐level analysis further supports the isolation of individual cell populations with high expression of CD3, CD4, CD8, CD19, and CD20 for leukocytes, CDH1 and MUC1 for epithelial cells, and FAP, SMA, COL1A1, and COL3A1 for fibroblasts. As a proof of concept, we profiled tumor samples of nine patients and explored expression differences in the three cell populations between tumor and normal tissue. Interestingly, we found that angiogenesis‐related genes were upregulated in fibroblasts isolated from tumors compared with normal tissue. Overall, we suggest our protocol as a complementary and more scalable approach compared with single‐cell RNA sequencing to investigate associations between clinical parameters and transcriptomic alterations of specific cell populations in esophageal adenocarcinoma.

[Young male patient with unusual space-occupying lesion of the lower eyelid]

BACKGROUND

A space-occupying lesion of the eyelid in young adults is often a sign of an inflammation, a trauma or a benign neoplasm. The aim of this case report is to demonstrate a rare basal cell carcinoma, which presumably already arose in adolescence without further high-risk factors.

METHODS

A 28-year-old male patient presented for a second opinion on a painless swelling of the right lower eyelid. According to the patient's history the swelling had been present since the age of 16 years and originally resembled a molluscum contagiosum. An ophthalmologist in private practice made the diagnosis of a suspected trichoepithelioma. The extended patient history revealed a blood coagulation disorder. The clinical ophthalmological examination revealed a nodular space-occupying lesion with a border wall and telangiectasia. The further ophthalmological examination was bilaterally inconspicuous. Due to the suspicion of a malignant process, an operation was promptly carried out using local anesthesia with complete tumor excision and pedicled flap plasty as well as a histopathological investigation to confirm the diagnosis.

RESULTS

The histopathological investigation revealed underlying infiltrates of a basaloid tumor with bale-shaped trabecular growth, sometimes with peripheral palisading of the cells. The cells were predominantly monomorphic with isolated pleomorphic nuclei and sometimes enclosed mitoses. Immunohistochemically the cells were strongly positive for BerEP4 and negative for epithelial membrane antigen (EMA). The diagnosis of a nodular basal cell carcinoma of the right lower eyelid was made. All incision margins were free of tumor cells (R0 resection). In the dermatological screening no further manifestations were detected.

CONCLUSION

Despite the occurrence of a space-occupying lesion of the eyelid in a young adult patient and also with no further risk factors, in addition to an inflammatory event and a benign tumor, a malignant disease, such as a basal cell carcinoma should also be taken into consideration. A tissue biopsy or complete excision with subsequent histological examination including an immunohistochemical analysis are essential for differentiation from other tumor entities.

Elevated X-linked inhibitor of apoptosis protein (XIAP) expression uncovers detrimental prognosis in subgroups of neoadjuvant treated and T-cell rich esophageal adenocarcinoma

Background

Molecular markers predicting survival in esophageal adenocarcinoma (EAC) are rare. Specifically, in favorable oncologic situations, e.g. nodal negativity or major neoadjuvant therapy response, there is a lack of additional risk factors that serve to predict patients’ outcome more precisely. This study evaluated X-linked inhibitor of apoptosis protein (XIAP) as a potential marker improving outcome prediction.

Methods

Tissue microarrays from 362 patients that were diagnosed with resectable EAC were included in the study. XIAP was stained by immunohistochemistry and correlated to clinical outcome, molecular markers and markers of the cellular tumor microenvironment.

Results

XIAP did not impact on overall survival (OS) in the whole study collective. Subgroup analyses stratifying for common genetic markers (TP53, ERBB2, ARID1A/SWI/SNF) did not disclose any impact of XIAP expression on survival. Detailed subgroup analyses of [1] nodal negative patients, [2] highly T-cell infiltrated tumors and [3] therapy responders to neoadjuvant treatment revealed a significant inverse role of high XIAP expression in these specific oncologic situations; elevated XIAP expression detrimentally affected patients’ outcome in these subgroups. [1]: OS XIAP low: 202 months (m) vs. XIAP high: 38 m; [2]: OS 116 m vs. 28.2 m; [3]: OS 31 m vs. 4 m).

Conclusions

Our data suggest XIAP expression in EAC as a worthy tool to improve outcome prediction in specific oncologic settings that might directly impact on clinical diagnosis and treatment of EAC in the future.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5722-1) contains supplementary material, which is available to authorized users.

First reported case of a collision tumor composed of pancreatic adenocarcinoma and retroperitoneal liposarcoma: a case report

BACKGROUND

Collision tumors are rare cases with two different tumor entities growing synchronously. While adenocarcinoma of the pancreas is the most common pancreatic tumor with an incidence of 10 per 100.000, retroperitoneal liposarcoma remains very rare. This is the first report of a collision tumor between these two tumor entities.

CASE PRESENTATION

Demographic details: The tumor was diagnosed in a 64 male Caucasian patient. Besides atrial fibrillation, arterial hypertension and a hypothyroidism there is no relevant medical history especially no history of cancer. Clinical details: During a routine check-up an unclassified tumor of the pancreatic tail was diagnosed. The lab showed no pathologies. Tumor markers were negative for carbohydrate antigen 19-9 and 72-4 (CA 19-9, CA 72-4) and carcinoembryonic antigen (CEA). Alpha-fetoprotein (AFP) and neuron specific enolase (NSE) were both elevated (AFP 97kU/l, (< 5,8kU/l) and NSE 30,0 μg/l (16,4 μg/l)). A computed tomography-guided core needle biopsy was performed which revealed a low-grade liposarcoma (G1). A CT scan showed no metastases. A surgical resection was recommended by the interdisciplinary tumor board.

INTERVENTIONS

A systematic left sided retroperitoneal compartment resection including en-bloc-left sided pancreatectomy, splenectomy, nephrectomy, hemicolectomy, adrenalectomy, partial gastrectomy and partial resection of the diaphragm was performed. Pathology revealed a collision tumor consisting of pancreatic adenocarcinoma that was classified pT3, pN2 (11/33 ece+) L1 V0 Pn0, R0; G2 [UICC Stage III] and a liposarcoma pT2, pN0 (0/33) L0 V0 Pn0, G1 [UICC Stage Ib]. The postoperative tumor board recommended an adjuvant chemotherapy with gemcitabine and capecitabine for the locally advanced pancreatic adenocarcinoma.

OUTCOME

At the latest follow-up (1 year after surgery) the patient was in good clinical condition and without evidence of tumor recurrence.

CONCLUSION

Collision tumors are rare and difficult to diagnose. This is the first description of a collision tumor composed of pancreatic adenocarcinoma and retroperitoneal liposarcoma. The reported case demonstrates that inconsistent diagnostic results (e.g. imaging and pathology) should raise suspicion concerning the diagnosis. Awareness of these rare cases might protect us from underdiagnosing patients and therefore leading to better patient care. There is evolving evidence that will lead to more personalized treatment options for somatic BRCA mutated pancreatic cancer.

[BRCA diagnostics of ovarian cancer : Molecular tumor testing since the introduction of PARP inhibitor therapy]

Approximately 9000 women are diagnosed with ovarian cancer in Germany each year. The most common subtype is high-grade serous ovarian cancer. A relevant proportion of these tumors are associated with mutations in the breast and ovarian cancer susceptibility genes (BRCA1 and BRCA2) representing highly penetrant tumor suppressor genes with autosomal inheritance and play a crucial role in DNA repair mechanisms. These patients have predominantly germline mutations and less frequently have somatic BRCA mutations. Tumors harboring BRCA mutations show a significant improvement in progression-free survival under therapy with poly(adenosine diphosphate ribose) polymerase (PARP) inhibitors. In 2015 the first PARP inhibitor was approved for the therapy of high-grade serous ovarian cancer with BRCA mutations. Mutation analysis can be performed on formalin-fixed paraffin-embedded (FFPE) tumor tissue within a few days.

White-Light or Narrow-Band Imaging Colonoscopy in Surveillance of Ulcerative Colitis: A Prospective Multicenter Study

BACKGROUND & AIMS

Early detection of neoplastic lesions is essential in patients with long-standing ulcerative colitis but the best technique of colonoscopy still is controversial.

METHODS

We performed a prospective multicenter study in patients with long-standing ulcerative colitis. Two colonoscopies were performed in each patient within 3 weeks to 3 months. In white-light (WL) colonoscopy, stepwise random biopsy specimens (4 biopsy specimens every 10 cm), segmental random biopsies (2 biopsy specimens in 5 segments), and targeted biopsy specimens were taken. In NBI colonoscopy, segmental and targeted biopsy specimens were taken. The sequence of WL and NBI colonoscopy was randomized.

RESULTS

In 36 of 159 patients enrolled (22.6%), 54 lesions with intraepithelial neoplasia (IN) were found (51 low-grade, 3 high-grade). In WL colonoscopy we found 11 IN in stepwise biopsy specimens, 4 in segmental biopsy specimens, and 15 in targeted biopsy specimens. In NBI colonoscopy 7 IN were detected in segmental biopsy specimens and 24 IN were detected in targeted biopsy specimens. Almost all IN were found with one technique alone (κ value of WL vs NBI, -0.86; P < .001). Statistically equivalent numbers of IN were found in NBI colonoscopy with targeted and segmental biopsy specimens as in WL colonoscopy with targeted and stepwise biopsy specimens, but with fewer biopsy specimens (11.9 vs 38.6 biopsy specimens, respectively; P < .001), and less withdrawal time was necessary (23 vs 13 min, respectively; P < .001).

CONCLUSIONS

Stepwise biopsy specimens are indispensable in WL colonoscopy. The combination of targeted and segmental biopsy specimens in the NBI technique is as sensitive as targeted together with stepwise biopsy specimens in WL colonoscopy, but requires fewer biopsy specimens and less time. The highest sensitivity should be reached by combining the WL and NBI techniques by switching between the modes.

[Schwannoma in the epipharynx: a rare differential diagnosis]

There are many benign and malignant tumors of the epipharynx, which makes differential diagnosis difficult. As a very rare differential diagnosis, a schwannoma is possible. The origin of the tumor is most likely a small branch of a sensitive nerve of the glossopharyngeal nerve or the trigeminus nerve. A clear differentiation in the MRI scan is often not possible; especially differentiation from MPNST (malignant peripheral nerve sheath tumors) is difficult. To confirm the diagnosis and exclude malignancy, every tumor in the epipharynx should be surgically excised if possible, even if the patient has no discomfort.

[Alcohol and pregnancy--embryopathy and alcohol effects]

Fetal alcohol syndrome (FAS) is a specific polydystrophic pattern of malformations with the following diagnostic criteria: 1. Maternal alcohol dependence or alcohol abuse during pregnancy. 2. Pre- and postnatal deficiency of growth in weight, height and head circumference. 3. Multiple minor and major anomalies recognizable mainly at a typical face. 4. Structural injuries and changes at the central nervous system with complex brain dysfunction combining elements of cognitive impairments, behavioral disturbance and neurological damage. Fetal alcohol effects (FAE) or so-called "alcohol-related neurodevelopmental disorders" (ARND) with predominant neurotoxic effects and a large spectrum of cerebral dysfunctions are manifold more frequent than the full-blown FAS. These remain mostly unrecognized, overlooked and they are difficult to be diagnosed, the symptoms being unspecific. Alcohol in pregnancy is nowadays the most important and the most frequent toxic substance for the embryo and the fetus and one of the most frequent causes of mental retardation. The longlasting and irreversible consequences refer to school development, social maturation, social behaviour and later life-style. The diagnosis is based on the careful maternal history and on the clinical findings; there are no biochemical parameters of assessment. The risk of addiction development in these children is assumed to be more than 20 percent.

Fetal alcohol syndrome (FAS) in dermatology: an overview and an evaluation

Certain skin disorders are affected by alcohol abuse. Maternal alcohol abuse during pregnancy also gives rise to a typical malformation pattern in the child with a varying degree of severity (grade I-III). The diagnosis of fetal alcohol syndrome (FAS) is based on the detailed history of the maternal alcohol consumption in combination with the clinical, morphological, intellectual and psychosocial development of the child. The behavior of the child is also of diagnostic value. The grade of severity of the FAS can be determined during the first three years of life on the basis of a scoring system. In addition to medical care and surgical treatment of associated disorders, early support for the mental development of the child is of immense importance. Furthermore, the medical, social and psychological care of the mother must be considered. In the field of dermatology, knowledge about the pathomechanism of FAS is also important for its prevention in unborn children. Women of childbearing age presenting with dermatological signs of possible alcohol abuse, should alert the dermatologist to the possible risk to the child of FAS. Familiarity with FAS and the ability to recognise its clinical features are important for the adequate treatment and support of the affected child and for the mother suffering from alcohol disease, in cooperation with other treating doctors.

[Fetal alcohol syndrome in adulthood. A long-term study]

BACKGROUND AND OBJECTIVE

Maternal alcohol addiction in pregnancy causes fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE) in children. At present, little is known about the physical, mental, and social long-term consequences in adulthood.

PATIENTS AND METHODS

Since 1974, 52 children with FAS and FAE, all born to alcohol dependent mothers, were prospectively followed up from birth to adulthood. Height, weight and head circumferences were based on percentile standards; mental and school development were assessed by school reports and by intelligence subtests. By structural interviews, occupational and social follow-up were assessed.

RESULTS

Growth retardation continued mainly in severely affected adults with underweight in 26%, underheight in 30%, and microcephaly in 46%. They mostly lived in foster families, only 6/52 were able to live independently. In 56% special schools for handicapped and mentally disabled were attended. In most cases (37/52), simple occupations without vocational training were practised.

CONCLUSIONS

It is mainly the neurotoxic effects of alcohol in pregnancy that have longlasting developmental significance in adults. Because of the dysmorphic changes over time, it is difficult to diagnose FAS and FAE only in adulthood.

Lectin-induced increase in clonogenic growth of haematopoietic progenitor cells

The galactoside-specific plant lectin, Viscum album agglutinin (VAA-I) increases cellular parameters of natural host defence. It also binds to a variety of haematopoietic cells, including progenitors. We investigated whether VAA-I has a stimulatory effect on haematopoietic progenitor cells. Peripheral blood progenitor cells from 7 healthy volunteers were cultured in a colony assay with VAA-I plus erythropoietin (EPO) and stem cell factor (SCF). At 50 pg/ml VAA-I induced a significant increase in the cytokine-dependent clonogenic growth (52% in median, p < 0.05). In another set of experiments purified CD34+ cells were isolated from the bone marrow aspirate of 4 patients with non-metastatic breast cancer using fluorescence-activated cell sorting. Binding to CD34+ cells was demonstrated by using directly fluorescence-conjugated VAA-I. Co-incubation with D-galactose significantly abrogated this effect. CD34+ cells were cultured in the presence of EPO, SCF, interleukin-3, granulocyte/monocyte colony-stimulating factor and granulocyte colony-stimulating factor. VAA-I alone had no measurable effect on the clonogenic growth of the isolated cells. However, at concentrations of 100 and 250 pg/ml VAA-I increased the cytokine-dependent proliferation and differentiation of CD34+ cells by a median of 75 and 85%, respectively. The results show that VAA-I binds to haematopoietic progenitor cells and has a co-stimulatory effect on their proliferation.

Polarity reversal improves defibrillation efficacy in patients undergoing transvenous cardioverter defibrillator implantation with biphasic shocks

The purpose of this study was to determine the influence of polarity reversal on DFT in patients undergoing implantation of nonthoracotomy defibrillators with biphasic shocks. Previous studies have shown higher defibrillation efficacy with using the distal electrode as anode implantation of nonthoracotomy defibrillators and monophasic shocks. However, it is as yet unclear whether biphasic shock defibrillation will also be influenced by polarity reversal. Using a transvenous lead system with a proximal electrode in the superior caval vein and a distal electrode in the RV apex, 27 patients undergoing defibrillator implantation were randomized to DFT testing "initial" (distal electrode = cathode) or "reversed" polarity (distal electrode = anode). Defibrillation energy was reduced stepwise until defibrillation failure occurred. At this point, polarity was switched and testing continued until the lowest energy requirement was determined for both polarities. With reversed polarity, DFT was 11.1 +/- 5.7 J versus 13.3 +/- 5.8 J with polarity (P = 0.033). This means a 17% reduction of the DFT. In 10 patients, the threshold was lower with reversed, whereas in 3 patients it was lower with initial polarity. In conclusion, changing electrode polarity in transvenous implantable defibrillators with biphasic shocks may significantly influence defibrillation energy requirements. Therefore, polarity reversal should always be attempted before considering patch implantation.

Congenital heart disease in the 48,XXYY syndrome

We report on an infant with severe tetralogy of Fallot, bilateral preauricular pits, and a 48,XXYY chromosomal complement. This case and evidence collected from the literature suggest that congenital heart disease may occur in the 48,XXYY syndrome more frequently than currently appreciated.

[Pulmonary varicose veins. Case report and review of the literature]

Pulmonary varicosis is a rare, presumably congenital localized dilatation of a pulmonary vein which is often associated with cardiac disease. We describe a case featuring enlargement of a pulmonary varix after mitral valve replacement, caused by mitral regurgitation, and discuss diagnostic possibilities, differential diagnosis and various development of this vascular malformation. A detailed review of the literature is given.

[Alcohol in pregnancy and fetal heart damage]

Alcohol abuse and addiction during pregnancy can induce damage of the heart muscle and heart defects in the offspring. Between 1973 and 1991 216 children with fetal alcohol syndrome were diagnosed and examined for congenital heart defects. In 63 children (= 29,1%) heart defects were present, established mainly by heart catheterization and/or echocardiography. Most frequently ventricular septal defects (24/63) and atrial septal defects (23/63) occurred, less frequent were AV-defects (3), PDA (3), Fallots teralogy (5), and other malformations (5). Biopsy during heart surgery in 3 children revealed histological and electron microscopic changes of alcohol-cardiomyopathy. Heart defects are predominantly found in children with higher degree of severity concerning the clinical syndrome, less frequently in alcohol effects (4/38 = 11%). Alcohol in pregnancy, even in the course of so called social drinking, usual drinking and binge drinking has to be considered as an essential and preventable co-factor within the multifactorial etiology of congenital heart defects.

[Eye manifestations of fetal alcohol syndrome]

Alcohol is the most frequent and most important teratogenic agent causing mental and physical retardation in childhood. The alcohol fetal syndrome is characterized by pre- and postnatal growth retardation, hypotonia, hyperactivity, microcephalus, mental retardation and typical craniofacial malformations. The latter includes short palpebral fissures, a poorly developed philtrum, thin upper lip vermillion, short mandibles, a flattened midface structure and dysplastic ears. Ophthalmological signs occur in 90% and include epicanthus, ptosis, myopia, optic nerve hypoplasia and tortuous retinal vessels. Microphthalmus, coloboma and Peters' anomaly have also been described. Five children with alcohol embryopathy are presented. The histopathological findings of the enucleated eye of a 6th child with alcohol embryopathy which was sent to us for examination and which revealed an anterior staphyloma with Peters' anomaly is also described. Ophthalmologists should be aware of alcohol in pregnancy as a preventable cause of eye malformation.

[Are children with alcohol embryopathy latent alcoholics? A study of the risk for developing dependence]

Within 3 years 48 caretakers and parents of children with fetal alcohol syndrome were asked about the childrens experience and contact with alcohol. The children were mainly raised in foster and adoptive families (40/48 cases), where usually moderate or restricted consumption of alcohol was common. The children were between 4-18 years (means = 7; 5) of age. In 5 children alcohol consumption was observed once or several times. Some children showed signs of increased desire for drinking alcohol. A substance related addiction was never observed until now. Nevertheless the risk of addiction development has to be considered as dangerous in any case of fetal alcohol syndrome. All conditions and risk factors for addiction development are present: a) Hereditary factors in the family of origin. b) Early use and adaption in the prenatal period by maternal drinking. c) The social surroundings and family. d) The particular structure of personality in these children, characterised by uncritical behavior, mental retardation, emotional instability and easy seduction. The risk of addiction development can be estimated to 30%. In a society of lacking alcohol prohibition it will be impossible to keep alcohol away from the children. As in dry alcoholics the children have to learn "to live in association with alcohol without drinking it". Besides it is important for the parents, that they learn to help their child to cope with the danger of alcohol. This ist possible by means of information, strengthening of a positive self-image and faith in the child's capacity for insight.

[Mild forms of alcoholic embryopathy following excessive use of alcohol]

Within 15 years 171 children with fetal alcohol syndrome were diagnosed. Eight children showed an unusual low susceptibility to the harmful effects of alcohol in utero with mild expression of fetal alcohol syndrome or so-called alcohol effects, inspite of excessive maternal drinking (more than 180 gs alcohol per day). Increased tolerance of alcohol might be explained by two mechanisms: 1. By metabolic adaptation, mainly by swift increase of alcohol metabolizing; 2. by biochemical and structural adaptation at cellular membranes after chronic alcohol ingestion. The grade of severity in fetal alcohol syndrome does not depend on the amounts of alcohol but mainly on the development of metabolic and morphological tolerance and adaptation.

[Congenital alcoholic cardiomyopathy in 3 children]

Three cases of congenital alcoholic cardiomyopathy and cardiac defects in children are described. The mothers were heavy spirits drinkers. One child had a ventricular septal defect, two had Fallot's tetralogy, all requiring operation. At open-heart surgery left-ventricular myocardial biopsies were obtained in all three children. Histological and electronmicroscopic examination revealed primary toxic and hypotrophic changes, which differed from those seen in alcoholic cardiomyopathy of the adult. The cells, their nuclei and the myofibrils had reduced diameters. The mitochondria were damaged to differing extent. The myofibrils were arranged in parallel and some had contraction bands and ruptures. The sarcoplasmic reticulum was dilated and had vacuoles. The cell surface penetrated into the interstitial tissue. All these changes could have resulted from inhibited embryofetal cell growth and cytotoxic damage by alcohol during pregnancy. It would seem that alcoholic cardiomyopathy occurs only in extreme forms of alcohol abuse during pregnancy. The prognosis is as yet unknown.

[Rupture of a coronary artery aneurysm in mucocutaneous lymph node syndrome (Kawasaki syndrome). Demonstration of the coronary aneurysms by 2-dimensional echocardiography]

A further case of mucocutaneous lymphnode syndrome (MCLS) in infancy with multiple aneurysms both of the coronary arteries and systemic arteries is presented. Aged four months the male infant died of rupture of an aneurysm of the right coronary artery causing a hemopercardium. The aneurysms both of the coronary and systemic arteries were diagnosed intra vitam by 2-dimensional echocardiography.

Surgery of coarctation of the aorta: a nine-year review of 253 patients

From 1973 to 1982, 253 patients--164 males and 89 females--underwent an operation for coarctation of the aorta in our clinic. Of the patients 72.3% presented with a circumscribed lesion and 58.5% with associated congenital cardiovascular defects. Resection with end-to-end anastomosis was performed in 138 patients (54.5%). Seventy-four patients (29.3%) had vascular graft prosthesis, 1.2% underwent the Clagett's operation, 9.1%, the indirect isthmoplasty and the rest (5.9%), the subclavian flap plastic. Ventricular fibrillation led to the intraoperative death of 3 infants with associated intracardiac and multiple somatic defects. The operative mortality was high in children under 15 months (13.2%), 1% in all the others taken together and 0% in all cases without concomitant lesions. Paraplegia occurred in only one patients (0.4%). One hundred twenty-eight patients were followed-up over a mean period of 3.6 years. The systolic and diastolic pressures decreased by a mean of 30 mmHg and 15 mmHg respectively. Eighty-seven patients (68%) had normal blood pressure at the time of examination. The rest (41 patients) had persistent postoperative hypertension necessitating medical management. The surgical technique elected did not influence the level and incidence of persistent postoperative hypertension, rather the level of the preoperative systolic right arm-to-leg pressure gradient (SPG) related closely to the incidence of persistent hypertension. Thirty patients (23.4%), among whom were 24 children under 10 years--some of them with preductal hypoplasia--presented with an SPG above 20 mmHg.(ABSTRACT TRUNCATED AT 250 WORDS)

Concentrations of prostaglandin E2 and F2 alpha in the cardiovascular system of infants with persisting patent ductus arteriosus

The distribution of prostaglandin E2 and F2 alpha was examined in the peripheral veins and in several positions of the cardiovascular system before and after the blood had passed through the lungs in 37 infants. Prostaglandin E2 varied from 0.25 +/- 0.09 ng/ml to 0.44 +/- 0.09 ng/ml when measured in the pulmonary artery, the ductus arteriosus, the right atrium, the right ventricle, the left atrium, the left ventricle, the inferior vena cava and the descending aorta. Prostaglandin F2 alpha was much higher in these positions of the cardiovascular system. The range was 0.99 +/- 0.36 ng/ml to greater than 2.0 ng/ml. The vascular tissues produced virtually identical high amounts of prostaglandin E2 and F2 alpha, but there were no significant differences in prostaglandin E2 and F2 alpha, concentrations, in venous blood as well as in systemic arterial blood. The results suggest that prostaglandin E2 is not responsible for the persisting patency of the ductus arteriosus in infants. There is no explanation for the increased prostaglandin F2 alpha concentrations in these patients.

[Diverticulum of the brachiocephalic trunk--angiographic image and embryologic significance]

A diverticulum of the brachiocephalic trunk is described in 5 children with unilateral absence of the pulmonary artery, in a child with tetralogy of Fallot, and in an other child with Bland-White-Garland syndrome. The diverticulum is a remnant of a contralateral ductus arteriosus, which cLosed after birth and represents the origin of the distal part of the sixth aortic arch.

Absent pulmonary artery. A hint to its embryogenesis

Cardiac catheterization was performed in nine patients with unilateral absence of a pulmonary artery. Aortography revealed a diverticulum of the innominate artery in five of six patients in whom the aortic arch and absent pulmonary artery were on opposite sides. It is suggested that the diverticulum indicates fetal systemic blood supply to the affected lung through the distal part of the sixth aortic arch, which--consisting of ductal tissue--obliterated after birth, leaving the diverticulum where the ductus joins the innominate artery.

[Heart conotruncal malformations. Significance of conal development and connection]

In order to improve clarity in definition and classification 320 cases of conotruncal malformations were examined. At present time the hypothesis of conal development (Van Praagh 1972) and the segmental approach to diagnosis contributed the most to better understanding and differentiation. In complex defects the identification of cardiac segments and spatial relations of their components is not sufficient for classification. On the basis of ventriculoarterial connection a classification is easily to achieve.

[Cardiotoxic effect of the tocolytic agent fenoterol (partusisten) in the neonate (author's transl)]

Forty-two children of mothers treated with beta-adrenergic drugs were investigated cardiologically during a period of 3 1/2 years. Eleven neonates were seen to suffer from severe toxic myocardiopathy associated with heart failure. The mothers had in part been given excessive fenoterol doses for 13 weeks on the average. One child died of regressive myocardial alterations as confirmed by autopsy. Suspicion of toxic myocardiopathy was suggested in another 16 children. Related to the very large number of mothers treated with tocolytic agents, fenoterol-induced myocardiopathy so far appears to be rare. In agreement with other reports, however, our observations suggest the possibility of severe, even perilous myocardial damage. Therefore, the indication and dosage of fenoterol should be subjected to more rigid criteria than so far applied.

Type and frequency of cardiac defects in embryofetal alcohol syndrome. Report of 16 cases

Within a period of 3 years, 56 infants and children with embryofetal alcohol syndrome have been detected and examined for heart defects. All children were from mothers who had been addicted to alcohol even during pregnancy and they showed a typical pattern of malformations, as described by Lemoine et al. (1968) and Jones et al. (1973). In 16 cases cardiovascular malformations were confirmed by heart catheterisation or pathological examination. The overall incidence of heart defects in this syndrome was 29 per cent. The incidence rises to nearly 50 per cent in the more severe types of this syndrome. Atrial septal defects were found to be the most common heart defect (10 out of 16 cases); ventricular septal defects and other variable malformations occurred less frequently. The high incidence of heart defects indicates that alcoholism during pregnancy has to be considered as a serious and preventable cause of congenital heart disease.

[Propranolol in Fallot's tetralogy: hemodynamic investigations and their clinical use (author's transl)]

During heart catheization in 32 non-selected patients with Fallot's Tetralogy the reaction of O2-saturation, right-to-left-shunt and of cineangiocardiography to 0.2 mg/kg propranolol i.v. was tested. Nine of 32 patients reacted favourably to propranolol. Of these 6 were put on a long term-medication of 2 to 3 mg/kg propranolol orally. Only 1 patient did not respond satisfatorily. The effect of propranolol and hemodynamic results are compared with the literature and discussed. In Fallot's Tetralogy propranolol medication without previous testing ist not recommended: without previously established exact diagnosis it can be dangerous even.