Minor tumour shrinkage in nonfunctioning pituitary adenomas by long-term treatment with the dopamine agonist cabergoline

OBJECTIVE

The purpose of this study was to define safety and efficacy of medical therapy in the treatment of nonfunctioning pituitary tumours.

DESIGN

We studied thirteen patients with a clinically nonfunctioning pituitary macroadenoma for response to cabergoline treatment for 1 year. Twelve/13 patients were already operated and had residual or recurrent tumours.

METHODS

We determined the outcome of treatment by visual perimetry, computed tumour size measurement in MRI and hormonal response (changes in pituitary function, reduction of alpha-subunit).

RESULTS

Seven/13 patients on cabergoline had a tumour shrinkage above 10% of the initial tumour volume. In 4 patients, this tumour shrinkage was correlated to an increasing distance of the tumour to the optic chiasm. Only 2/9 patients with visual field defects before therapy showed improvements in visual acuity under cabergoline. No significant side effects of the therapeutical regimens were observed. Neither LH and/or FSH expression in the tumour cells nor the reduction of the alpha-subunit serum levels by medical therapy was correlated to tumour shrinkage.

CONCLUSION

Given that these patients had advanced disease which makes it difficult to find significant therapeutic effects, medical therapy with potent dopamine agonists such as cabergoline may evolve as a novel therapeutic option in a subgroup of patients with clinically nonfunctioning tumours declining operation and radiotherapy.

[Hepatocellular carcinoma in an additional pedunculated liver lobe in the lower abdomen: differential diagnosis problems]

The case described is that of a 36 years old patient with a known tumor in her lower abdominal cavity which has been observed to increase in size for the passed 16 years. Intraoperatively, one observed a very rare finding of an extra liver lobe of the left liver lobe and located in the lower abdominal cavity. Located within is a multifocal therapeutically treatable hepatocellular cancer.

[Differential diagnostic problems of hepatocellular carcinoma in an abnormal additional liver lobe in the lower abdomen]

This case report describes a 36 years old patient with a known tumor in her lower abdominal cavity which increased in size in the last 16 years. Intraoperatively an additional liver lobe of the left liver located in the lower abdominal cavity was found in combination with a multifocal hepatocellular carcinoma which could be treated curatively.

The dispute about the external sphincter and the urogenital diaphragm

PURPOSE

Basic scientific facts, such as anatomical structures, are rarely subjected to critical reappraisal. Nevertheless, several clinical phenomena exist which are inconsistent with the description of the anatomy of the so-called external sphincter muscle and urogenital diaphragm.

MATERIALS AND METHODS

We performed a global examination of the anatomy of the entire lower urinary tract in 50 male autopsy specimens. For comparison magnetic resonance imaging of the same regions was performed on 12 healthy patients.

RESULTS

Direct comparison of the results of both methods revealed the exact same topography of the bladder neck. The external sphincter or musculus sphincter urethrae is an independent morphological unit separated from the surrounding pelvic floor muscles by connective tissue.

CONCLUSIONS

The musculus transversus perinei profundus or deep transverse perineal muscle, which is believed to constitute the major element of the urogenital diaphragm, does not exist. There is histomorphological evidence that the external sphincter consists of a striated (musculus sphincter urethrae transversostriatus) and smooth muscle (musculus sphincter urethrae glaber) component.

Inflammatory pseudotumor of the ureter and the urinary bladder

Inflammatory pseudotumor (IPS) of the urinary bladder was first described in 1980. We report four cases of IPS which occurred during the last four years. One tumor occurred in the bladder of a 49-year-old woman five months after abdominal hysterectomy of uterine leiomyomas, two tumors in a 35- and 39-year-old woman, respectively, without antecedental surgical intervention (though one with recidive after six months). The fourth occurred in a 64-year-old male in the proximal ureter by pyelonephritis. Two cases were initially diagnosed at frozen section during operative treatment, the others on paraffine section after immunohistochemical examination. Two cases showed an aberrant expression of cytokeratines. There is no evidence of recidive tumor within a mean follow up of 25 months (12-49 months). Features to differentiate benign from malignant spindle cell lesions of the lower urinary tract are the absence of atypical mitoses, significant cytologic atypia, absence of necroses within the tumor (rather on its surface), no destructive growth at the tumor margins and low cellularity. Usually, IPS show a submucosal edematous area with a deeper, highly cellular component. The clinical history of a recent bladder operation or gynecologic surgery is of upmost importance in making the diagnosis of IPS. Complete surgical excision, either by transurethral resection or partial cystectomy appears to be curative for IPS.

Improved nuclear magnetic resonance microscopic visualization of joint cartilage using liposome entrapped contrast agents

RATIONALE AND OBJECTIVES

After intraarticular application of gadolinium (Gd)-DTPA the visualization cartilage surface roughness is limited because of diffusion into the cartilage. To improve the sensitivity of magnetic resonance (MR) arthrography to diagnose cartilage surface abnormalities, the authors have tested liposome-entrapped contrast agents.

METHODS

Using paramagnetic contrast agents (Gd-DTPA and manganese chloride) free and entrapped in liposomes, respectively, high resolution MR imaging investigations were performed at 7.1 tesla on intact pig temporomandibular and rabbit knee joints.

RESULTS

After intraarticular injection of the liposome-entrapped contrast agents an excellent contrast between cartilage surface and joint space was achieved. Diffusion of the contrast agent into the cartilage layer was prevented and the visualization of the cartilage surface was improved markedly. Small mechanically and enzymatically induced cartilage lesions could be assessed reliably.

CONCLUSIONS

Intraarticular injection of liposome-entrapped contrast agents can improve the potential of MR arthrography concerning the detection of early osteoarthritic cartilage changes.

[Nuclear magnetic resonance tomography examinations of the urogenital diaphragm in comparison with corresponding histomorphologic findings (the controversy concerning the musculus transversus perinei profundus)]

The transversus perinei profundus muscle is a well known structure in found anatomical textbook. Fibers of this muscle are believed to form the so-called external urethral sphincter (musculus sphincter urethrae). Recently histomorphologic investigations have shown that there is no muscular connection between the musculus sphincter urethrae (external sphincter) and the muscle system of the pelvic floor. Furthermore, the external sphincter was found to be divided into parts: the transversely striated part (musculus sphincter urethrae transversostriatus) and the smooth part (musculus sphincter urethrae glaber). Similar to histomorphologic investigations, contrast-enhanced MR imaging has shown the musculus sphincter urethrae to be surrounded by fatty and connective tissue only. Neither in MRI nor in anatomical slices can any connection between the urethral sphincter and the muscle system of the pelvic floor to be found. Thus, on the basis of the results presented in this work it is concluded that the musculus transversus perinei profundus does not exist in the form described in textbooks.

[Acute abdomen in extensive thrombosis in the inferior vena cava collateral circulation]

Variations of the inferior vena cava (IVC) because of either embryonal malformations or postthrombotic changes are not uncommon. The clinical symptoms include repetitive thrombotic events. We report on an atypical case of acute abdomen resulting from thrombotic occlusion of the IVC and the right renal vein as well as of the collateral vessels.

[Thrombolysis of an extensive venous thrombosis of the lower body in an anomaly of the vena cava inferior]

HISTORY AND CLINICAL FINDINGS

A 41-year-old man was admitted to hospital for acute pain in the right flank. At first urolithiasis was suspected but excluded by sonography and excretion urography. Computed tomography (CT) was performed because of increasing pain and swelling of the left leg. It showed bilateral thrombosis of the deep leg and pelvic veins as well as of the infrarenal inferior vena cava (IVC) and the right renal vein. The patient's general condition was impaired. The circumference of the left leg was greater than that of the right by 5 cm 15 cm above the knee joint space and both legs had marked varicosities with congestive dermatitis.

INVESTIGATIONS

The concentration of the thrombin-antithrombin complex was 13.4 micrograms/l, D-dimer 124 micrograms/l, prothrombin fragment F1+2 3,5 nmol/l and fibrin monomere 27.7 micrograms/ml, as expression of a manifest thrombosis. CT with contrast medium demonstrated the previously sonographically shown extent of the thrombosis. In addition the hepatic IVC segment was absent. The azygos vein was enlarged and there was an extensive collateral circulation.

TREATMENT AND COURSE

Systemic thrombolysis (streptokinase for 3 days, then urokinase) for 11 days dissolved the thrombi and CT now demonstrated complete recanalization of the caudal deep vein system and the IVC abnormality (absence of hepatic segment). After intravenous thrombolysis oral anticoagulation with phenprocoumon was started and will be continued all the patient's life.

Complex pattern of alternative splicing generates unusual diversity in the leader sequence of the chicken link protein mRNA

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Complex pattern of alternative splicing generates unusual diversity in the leader sequence of the chicken link protein mRNA

We report here the isolation of the 5' end and the promoter region of the gene for chicken cartilage link protein, and demonstrate extensive heterogeneity of the leader sequence arising from differential utilization of multiple splice sites within the 5'-most exon. The 500-base pairs (bp) exon 1 consists of solely untranslated sequence and is followed by an intron greater than 33 kilobase pairs (kb). Together, the five exons predict a gene size longer than 100 kb. Multiple transcription initiation sites were mapped 34, 46, 56, 66 and 76 bp downstream of a TATA-like motif. Sequence analysis revealed that in addition to the non-spliced variant, multiple mRNA species were generated by alternative splicing resulting in the exclusion of 92, 166, 170, 174 and 263 nucleotides (nt), respectively, from exon 1. Polymerase chain reaction confirmed the existence of various splice forms, and showed cell type- and developmental stage-specific expression for one group of them. Secondary structure predictions indicated that the leaders of the splice forms could form stable hairpin structures with different free energies of formation (up to delta G = -110 kcal/mol), suggesting translational control. The splice variant detected in the largest amount had the least stable predicted hairpin (delta G = -31.7 kcal/mol).