Socioeconomic deprivation is associated with decreased survival in patients with acute myeloid leukemia

BACKGROUND

Socioeconomic deprivation is associated with poor prognosis in patients with solid tumors. However, few studies have assessed the association between socioeconomic parameters and prognosis in Acute Myeloid Leukemia (AML), and these report conflicting results. Our monocentric study assessed the impact of socioeconomic deprivation using the validated EPICES (Evaluation of Deprivation and Inequalities in Health Examination Centers) score in a prospective cohort of intensively treated AML patients.

METHODS

EPICES questionnaires were given to patients receiving intensive chemotherapy for newly diagnosed AML at the Paoli Calmettes Institute between July 2012 and December 2014. Study participants were categorized as non-deprived (score <30.17), deprived (score 30.17-48.51), or very-deprived (score ≥ 48.52). The primary endpoint was Overall Survival (OS). The independence of EPICES score effects was analyzed via Cox regression with adjustment for confounding factors.

RESULTS

209 AML patients received the questionnaire, 149 (71.3 %) patients responded. The median EPICES score was 23.6; 26.8 % and 10.1 % of patients were deprived and very deprived, respectively. OS was 23.16 months (95 %CI [17.15-33.31]). According to multivariate analysis, a very-deprived EPICES score, European Leukemia Net categories, age, smoking, and the absence of allogeneic stem cell transplantation were independent factors associated with decreased OS.

CONCLUSION

Our results underscore the importance of integrating nonbiological factors in the prognostic stratification of AML patients. The very deprived population exhibited worse OS, confirming that socioeconomic parameters play a role in patient outcomes in AML. Very deprived patients with AML should receive specific attention and adapted clinical management.

Clinical Decisions for Psychiatric Inpatients and Their Evaluation by a Trained Neural Network

Ninety-two consecutive treatment decisions regarding psychotic and depressed inpatients were evaluated by a trained neural network. Simultaneous evaluations according to the Brief Psychiatric Rating Scale (BPRS), the Hamilton scale, and the neural network were performed. A 15-point decrease in the BPRS for psychotic patients or a 10-point decrease in the Hamilton scale for depressed patients was the cut-off point for treatment success. The neural network performed similarly to the clinicians. The combined clinician-network success rate reached 79% and was significantly higher than that for each alone. Clinicians and neural network disagreed on 62% of decisions made for depressed patients and on 55% of decisions made for psychotic patients. The proportion of agreement was lower in both diagnostic groups than expected by chance. However, the high success of the combined clinician and neural network decisions and the high rate of mutual disagreement may imply that a combined decision is fruitful.

Extent of cervical involvement in endometrial cancer as a predictor of outcome

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Background: Endometrial cancer will affect 40,000 women this year. Extent of myometrial invasion and presence of cervical stromal disease are risk-factors for metastasis and recurrence. Uterine cervical involvement is often not known in advance of surgery, and superficial involvement may not be seen at frozen section. The objective of this study was to determine if the extent of cervical invasion is a predictor of outcome. Methods: The institutional cancer registry was searched for cases of stage II uterine cancer from 1996–2006. Inclusion criteria were endometrioid histology and clinical data and pathology available for evaluation. Demographics, extent of surgery, tumor grade, depth of myometrial invasion, presence of lymph-vascular space invasion (LVSI), and last follow up were collected. In addition, a gynecologic pathologist evaluated all slides to determine depth of cervical stromal invasion. Statistical analysis to compare predictors of outcome was performed. Results: There were 800 cases of endometrial cancer diagnosed from 1996–2006, 75 (9%) were stage II. Fifty two cases met all inclusion criteria. Mean age at diagnosis was 63.4 years. Mean BMI was 31.6. Ninety four percent were white, 4% black, and 2% Asian. All patients had a hysterectomy, 6 (11.5%) had a radical hysterectomy and 36 (69%) had lymphadenectomy performed. Eighteen (34.6%) were stage IIA and 32 (61.5%) were IIB. LVSI was seen in 15 (28.8%) cases. On pathologic review, 37.5% had no cervical stromal invasion, 42.5% had invasion of less than half and 20% had invasion of more than half of the cervical stroma. Forty patients (77%) received adjuvant radiation. There were 8 recurrences and 6 disease-related deaths. The mean follow up period was 30 months. Extent of cervical invasion did not correlate with recurrence or survival. Factors associated with increased risk of recurrence were: LVSI (p = 0.017), lack of lymph node sampling (p = 0.035), and age >55 years (p = 0.027). Women with and without recurrence were compared and did not significantly differ. Conclusions: In this study with pathologic review, extent of cervical involvement in stage II endometrial cancer was not associated with increased risk of recurrence or death. Age >55 years, lack of node sampling and presence of LVSI were predictors of recurrent disease.

No significant financial relationships to disclose.

Attenuation of lung reperfusion injury after transplantation using an inhibitor of nuclear factor-kappaB

A central role for nuclear factor-kappaB (NF-kappaB) in the induction of lung inflammatory injury is emerging. We hypothesized that NF-kappaB is a critical early regulator of the inflammatory response in lung ischemia-reperfusion injury, and inhibition of NF-kappaB activation reduces this injury and improves pulmonary graft function. With use of a porcine transplantation model, left lungs were harvested and stored in cold Euro-Collins preservation solution for 6 h before transplantation. Activation of NF-kappaB occurred 30 min and 1 h after transplant and declined to near baseline levels after 4 h. Pyrrolidine dithiocarbamate (PDTC), a potent inhibitor of NF-kappaB, given to the lung graft during organ preservation (40 mmol/l) effectively inhibited NF-kappaB activation and significantly improved lung function. Compared with control lungs 4 h after transplant, PDTC-treated lungs displayed significantly higher oxygenation, lower PCO(2), reduced mean pulmonary arterial pressure, and reduced edema and cellular infiltration. These results demonstrate that NF-kappaB is rapidly activated and is associated with poor pulmonary graft function in transplant reperfusion injury, and targeting of NF-kappaB may be a promising therapy to reduce this injury and improve lung function.

A human papillomavirus related to human papillomavirus MM7/LVX82 produces distinct histological abnormalities in human foreskin implants grown as athymic mouse xenografts

Studies of human papillomaviruses (HPVs) are hampered by the lack of a conventional culture system because HPV completes its life cycle only in fully differentiated human tissue. To overcome this obstacle, the athymic mouse xenograft system has been used to study the pathogenesis of HPV 11 and to develop neutralizing assays for vaccine development. Recently, HPV 40 has been produced in this system, and HPV 16 has been produced using mice with severe combined immune deficiency. To identify and characterize additional genital HPV types for similar studies, condylomata acuminata lesions containing a high copy number of HPV and detectable L1 major capsid protein were used to prepare infectious virus stocks. Human foreskin fragments were infected with the virus preparations and implanted under the renal capsules of athymic mice. After 5 months of growth, implant tissue was removed and processed for studies to detect HPV infection. Evidence of HPV infection was noted in some of the implants, but in contrast to HPV 11-infected epithelium, the implants derived from the new virus preparations contained a lesser degree of acanthosis, less developed koilocytosis, and a reduced number of preserved nuclei in the hyperkeratotic material within the cyst lining. The L1 consensus region was amplified by polymerase chain reaction from implant DNA and sequenced. Alignment of the amplified sequences with those in the HPV sequence database showed that the 452-bp amplimer was closely related but not identical to HPV LVX82 and HPV MM7 (also called Pap 291). The entire 7.9-kb genome was amplified by polymerase chain reaction and cloned. The presence of virions of the new isolate (named HPV IU) in the implants was verified by immunohistochemical detection of L1 major capsid protein and by demonstration of virion particles by electron microscopy. A second extract was made from one of the new implants and used to successfully propagate HPV IU. These experiments demonstrate that experimental infection of human epithelium with the new isolate, HPV IU, is associated with histological abnormalities that differ in potentially important ways from the changes observed in experimental HPV 11 infection.

ASCUS and AGUS criteria. International Academy of Cytology Task Force summary. Diagnostic Cytology Towards the 21st Century: An International Expert Conference and Tutorial

ISSUES

The conference participants addressed the following issues: (1) reporting of equivocal diagnoses, (2) strategies to minimize the use of such diagnoses, (3) morphologic criteria, and (4) management of women with equivocal diagnoses.

CONSENSUS POSITION

Equivocal diagnoses should be minimized, to the extent possible, by emphasizing cytologist education and training, improved specimen collection and quality assurance monitoring of individual and laboratory diagnosis rates. Cases fulfilling criteria for other diagnostic entities should not be included in the equivocal category. Regardless of the term utilized, an equivocal diagnosis should be qualified in some manner to indicate that the diagnosis defines a patient at increased risk of a lesion, particularly for those cases which raise concern about a possible high grade lesion. Qualification of an equivocal diagnosis can also be accomplished by appending laboratory statistics of the likelihood of various clinical outcomes or recommendations for patient follow-up. In contrast to favoring a reactive process versus squamous intraepithelial lesion (SIL), a more rationale approach to qualification of atypical squamous cells of undetermined significance may be to separate cases equivocal for low grade SIL from those suspicious for high grade SIL. With regard to glandular lesions, the conference participants expressed unanimous support for the separation of adenocarcinoma in situ (AIS) from atypical endocervical cells of undetermined significance when sufficient criteria are present. However, the diagnosis of a precursor lesion to AIS, endocervical glandular dysplasia, was controversial. The majority of conference participants discourage the use of such terms as mild glandular dysplasia and low grade glandular dysplasia for cytologic diagnoses.

ONGOING ISSUES

Conference participants agreed that a term reflecting diagnostic uncertainty is necessary to communicate findings that are equivocal. However, participants could not agree on the wording of such a term. Opinions differed as to: (1) use of atypical, abnormal or morphologic changes to describe cell changes, (2) whether the diagnosis should indicate a squamous or glandular origin of the cells in question when this determination can be made, and (3) the value of defining morphologic criteria for such a diagnosis. The debate over terminology, as well as morphologic criteria, is ongoing, and the readership is invited to communicate opinions to Acta Cytologica. Management of women with equivocal diagnoses varies widely from locale to locale and may differ based on how the equivocal diagnosis is qualified. Findings insufficient for the diagnosis of a high grade lesion may warrant more aggressive follow-up than cases equivocal for a low grade lesion. Where sensitivity of detection of lesions is of paramount importance, follow-up will generally consist of more frequent cytology screening or colposcopy and biopsy. However, in some countries it is considered unethical to have a high percentage of false positive diagnoses, which result in overtreatment and an unnecessary burden for women participating in cervical screening. Future studies may provide a morphologic, or perhaps molecular, basis for distinguishing true precursors of neoplasia from minor lesions of no significant clinical import; this would allow a more coherent and rational approach to diagnosis and management of women with equivocal cytologic findings.

Evaluation of PAPNET testing as an ancillary tool to clarify the status of the "atypical" cervical smear

To assess the utility of the PAPNET system (Neuromedical Systems Inc., Suffern, NY) in clarifying the status of cervical smears showing borderline abnormalities, we analyzed the results of five cytotechnologists who reclassified 200 "atypical" smears by evaluating PAPNET images only. The interobserver agreement (reliability) of the PAPNET reviewers was computed, and their readings were compared with three standards: the consensus diagnosis of five pathologists who used light microscopy, the detection of cancer-associated human papillomavirus DNA by Southern analysis, and the correlation with diagnoses of biopsy specimens obtained during passive follow-up. The PAPNET reviewers classified 18 to 65% of cases as normal, 25 to 42% as equivocal, and 10 to 55% as abnormal. Unanimous interobserver agreement was achieved in only 24 (13%) cases. Four of the five PAPNET reviewers agreed moderately well with the results of the pathology reference panel. In four of the five PAPNET reviews, classification of cases as abnormal was strongly correlated with the detection of cancer-associated types of human papillomavirus. Consensus PAPNET results of abnormal were predictive of abnormal histologic findings at follow-up. Theoretically, if colposcopy had been performed on all of the women with equivocal or abnormal PAPNET results (based on the consensus of the panel), as much as 95% of biopsy-confirmed lesions could have been detected, but 79% of women would have been referred. Restriction of colposcopy referral to women with definitely abnormal PAPNET readings would have reduced referrals to 31%, but the sensitivity of the triage would have dropped to 51% of biopsy-confirmed lesions.

Toward objective quality assurance in cervical cytopathology. Correlation of cytopathologic diagnoses with detection of high-risk human papillomavirus types

Using The Bethesda System, five pathologists independently diagnosed 200 smears that originally had been classified as "atypical," and the results were correlated with concurrent detection of human papillomavirus (HPV) DNA by Southern analysis and by polymerase chain reaction amplification. The smears were reclassified as benign reactive changes (negative), atypical squamous cells of undetermined significance, or squamous intraepithelial lesion (SIL). Exact five-way cytologic agreement was achieved in only 29% of smears, and no slide was diagnosed as atypical squamous cells of undetermined significance by all reviewers. The detection of high-risk types of HPV correlated strongly with the likelihood of a diagnosis of squamous intraepithelial lesion. High-risk HPV types were detected in approximately 60% of smears reclassified as squamous intraepithelial lesion compared with 30% of those reclassified as atypical squamous cells of undetermined significance and 10% of negative smears (P < .001). Every smear unanimously diagnosed by the panel as squamous intraepithelial lesion was associated with detectable HPV DNA, mainly of high-risk types. Low-risk HPV DNA types were found with similar frequency in all diagnostic categories assigned by the reviewers. Based on the consistent relation between high-risk HPV detection and diagnoses according to the Bethesda System, the authors conclude that HPV testing may have an important role in quality assurance in cervical cytopathology.

Chemokine expression in trinitrochlorobenzene-mediated contact hypersensitivity

The expression of the murine IP-10 and MCP-1 genes has been examined in the skin of mice during contact hypersensitivity reactions to the hapten trinitrochlorobenezene (TNCB). In both naive and passively sensitized animals, challenge with TNCB resulted in elevated expression of both genes as early as 4 h as detected by Northern hybridization analysis. Twenty-four hours after challenge, expression was markedly reduced in naive animals but remained elevated in sensitized animals. This prolonged expression of chemokine gene products correlates with the tissue swelling response generally used as a measure of delayed-type hypersensitivity (DTH) in this model and suggests that the continued expression of these genes results from the stimulation of hapten-specific T helper cells. Examination of cell type expression patterns by in situ hybridization using 3H-radiolabeled riboprobes confirmed the results of Northern hybridization experiments. Both genes were expressed predominantly in cells exhibiting the morphology of connective tissue fibroblasts, although the distribution of cells positive for IP-10 mRNA expression differed from that of cells expressing MCP-1 mRNA. IP-10 expression was localized almost exclusively to a population of connective tissue cells surrounding the fur follicle. MCP-1 expression was rarely found associated with fur follicles but instead was distributed throughout the dermis in cells embedded in the collagenous extracellular matrix. Surprisingly, neither endothelial cells lining the small vessels located deep within the dermis nor epidermal keratinocytes were positive under any of the conditions utilized in the present study. Expression of both IP-10 and MCP-1 has been previously reported in a variety of distinct cell types in vitro. The present results indicate that only a subset of the cell types with such potential are stimulated to express these chemokine genes in vivo during hapten-mediated DTH responses, implying the presence of subtle cell type- and tissue-specific control mechanisms.

Clinical decisions for psychiatric inpatients and their evaluation by a trained neural network

Ninety-two consecutive treatment decisions regarding psychotic and depressed inpatients were evaluated by a trained neural network. Simultaneous evaluations according to the Brief Psychiatric Rating Scale (BPRS), the Hamilton scale, and the neural network were performed. A 15-point decrease in the BPRS for psychotic patients or a 10-point decrease in the Hamilton scale for depressed patients was the cut-off point for treatment success. The neural network performed similarly to the clinicians. The combined clinician-network success rate reached 79% and was significantly higher than that for each alone. Clinicians and neural network disagreed on 62% of decisions made for depressed patients and on 55% of decisions made for psychotic patients. The proportion of agreement was lower in both diagnostic groups than expected by chance. However, the high success of the combined clinician and neural network decisions and the high rate of mutual disagreement may imply that a combined decision is fruitful.

Tumor necrosis factor-alpha induces cell type and tissue-specific expression of chemoattractant cytokines in vivo

Recombinant murine tumor necrosis factor-alpha (TNF-alpha) was shown to be a strong, systemic stimulus in vivo for members of the chemoattractant cytokine gene families (JE, KC, IP-10). The three genes showed differential sensitivity to TNF-alpha, and their expression demonstrated differential tissue specificity. IP-10 was the most strongly induced messenger RNA and was seen in the liver, kidney, and spleen but very poorly in the lung or skin. JE exhibited a similar pattern, though the magnitude of expression was markedly lower. KC expression was seen only in the liver of TNF-alpha-treated mice. The time course of expression for IP-10 was rapid and transient and showed strong dose dependence. In mice treated with TNF-alpha intravenously, messenger RNA was localized in the splenic stroma but not in adherent macrophages or nonadherent lymphocytes. In situ hybridization found the majority of intercrime expression in the splenic red pulp with little or no expression seen in the white pulp. In vitro, TNF-alpha was a potent stimulus of chemoattractant messenger RNA expression in fibroblasts but not in inflammatory peritoneal macrophages. These results indicate that TNF-alpha may be an important stimulus for chemoattractant cytokine gene expression in vivo, and the primary cell types responsible may be either stromal fibroblasts, microvascular endothelium, and/or a subset of anchored mononuclear phagocytes.

Cytolytic (TIA-1+) tumor infiltrating lymphocytes in B cell non-Hodgkin's lymphomas. SWOG Central Repository Members

TIA-1 is a monoclonal antibody (mAb) that identifies cytolytic cells. We studied eleven B cell non-Hodgkin's lymphomas (NHL) of low grade, eleven B cell NHL of intermediate-high grade, and 10 benign lymphoid hyperplasias (BLH) to investigate potential differences in the number of host cytolytic tumor infiltrating lymphocytes (TILs). Frozen sections were immunostained with TIA-1 mAb and the number of immunoreactive cells (TIA-1+) per mm2 of tissue was quantitated within reactive or neoplastic lymphoid follicles or random areas of diffuse NHL. The number of TIA-1+ cells/mm2 was significantly higher in intermediate and high grade B cell NHL than in low grade NHL or BLH with means +/- se of 1377.8 +/- 173, 866.2 +/- 92.3 and 774.1 +/- 76.2, respectively (p < 0.0183 and p < 0.0125). There was no significant difference between BLH and low grade NHL. The increased number of TIA-1+ TILs in B cell NHL of intermediate and high grade suggests the possibility of a host cytolytic immune response versus the tumor. Paradoxically, B cell tumors of worst biological outcome contained more cytolytic TILs. Functional defects of host cytolytic TILs in NHL patients should be investigated in future studies.

Host tumor infiltrating lymphocytes in B cell non-Hodgkin's lymphomas

Tumor-infiltrating T lymphocytes (TIL-T) were quantitated by three color flow cytometry in cell suspensions from excisional biopsy specimens of 43 B cell non-Hodgkin's lymphomas (NHL) and 8 benign lymphoid hyperplasias (BLH) to identify potential differences in host T cell responses. We quantitated three TIL-T subsets: CD3+CD4+CD8- (helper-inducer), CD3+CD4-CD8+ (suppressor-cytotoxic) and CD3+CD25-HLADr+ (long term activated TIL-T) and compared them in three diagnostic groups: BLH, low grade B cell NHL (LG NHL) and intermediate-high grade B cell NHL (IG-HG NHL). The following results were obtained: Mean percentage +/- s.e. of activated TIL-T for BLH, LG-NHL and IG-HG NHL: 10.3 +/- 1.9, 23.2 +/- 4.6 and 38.8 +/- 9.5, respectively. Mean percentage +/- s.e. of suppressor-cytotoxic TIL-T for same groups: 13.9 +/- 1.5, 14.9 +/- 1.9 and 34.4 +/- 4.5, respectively. Mean percentage +/- s.e. of helper-inducer TIL-T cells for the same groups was 38.2 +/- 12.7, 32.1 +/- 7.2 and 22.5 +/- 4.6, respectively. Helper/suppressor ratio +/- s.e. for same groups was 3.0 +/- 1.1, 2.4 +/- 0.6 and 1.3 +/- 0.4, respectively. Activated and suppressor-cytotoxic TIL-T percentage progressively increased from BLH toward IG-HG NHL. The percentage of these two TIL-T subsets were significantly higher in IG-HG NHL than in BLH and LG-NHL (P < 0.0007, 0.0002, 0.0001 and 0.0260 for the comparisons TIL-T in BLH vs IG-HG NHL and LG-NHL vs IG-HG respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Determination of T cell monoclonality in non-Hodgkin's lymphoma by frozen section immunohistology. The SWOG Central Repository Members

Monoclonal antibodies (mAb) reactive with seven distinct T cell receptor (TcR) alpha/beta variable region (V) families have become available. We investigated the potential utility of these mAb to establish T cell clonality (restrictive expression of one single V region family type) by frozen section immunohistology. We studied 40 non-Hodgkin's lymphomas (NHL) previously classified, immunophenotypically and genotypically by the South Western Oncology Group (SWOG) as 20 B and 20 T cell NHL. Frozen sections of each neoplasm were immunostained with the following mAb: beta-V5a, beta-V5b, beta-V6a, beta-V8a, beta-V12a, alpha/beta-Va and alpha-V2a. The large atypical lymphocytes of 18 of 20 T cell NHL showed no reactivity with the seven V region family mAb and only two showed exclusive immunoreactivity (one with anti-alpha V2a and the other with anti-beta V6a). All large atypical B cells in the 20 B cell NHL were non-reactive with the V region family mAb and each of the 40 neoplasms disclosed no or a trace reactivity in small host T cells. The results show that clonality can be determined in only a small percentage of T cell NHL (Sensitivity 10%, specificity 100%). Therefore, until new mAb become available, genotypic analysis remains the most sensitive and reliable method to establish T cell clonality.

Localization of basic fibroblast growth factor mRNA in melanocytic lesions by in situ hybridization

Basic fibroblast growth factor (bFGF) is a mitogen for normal human melanocytes and keratinocytes in culture. Experiments in vitro suggest that keratinocytes supply bFGF to melanocytes through a paracrine mechanism and that the aberrant expression of bFGF in melanomas confers growth independence from bFGF-producing cells. To determine whether bFGF is expressed in vivo, we examined a series of benign and malignant melanocytic lesions in situ using bFGF riboprobes on tissue sections, and correlated bFGF expression with histologic phenotype. Seventeen melanocytic neoplasms were studied, including four common acquired nevi, four dysplastic nevi, four primary malignant melanomas, and five metastatic melanomas. Nevic cells in benign intradermal nevi showed low signal intensity (1+), whereas compound and dysplastic nevi showed 2+ to 3+ expression in the junctional nevic cell population and 1+ expression in the dermal nevic cell population. Melanocytes in primary melanomas had intermediate (2+) and those in metastatic melanomas had low (1+) levels of bFGF gene transcripts. Fibroblasts expressed high levels (3+) and epidermal and adnexal keratinocytes moderate (2+) levels of bFGF in all cases studied. Basic FGF expression in endothelial cells, known to produce and respond to this growth factor in vitro, was lower than that in the fibroblast and keratinocyte cell population and, in 10 of 17 cases, no bFGF mRNA was detectable. This study shows that bFGF is expressed in nevomelanocytes in vivo in all melanocytic lesions studied and thus cannot be used as a marker for transformation. The presence of bFGF gene transcripts in the various dermal cell types and in keratinocytes suggests that it may act as an autocrine and paracrine growth factor in regulating cellular proliferation in the skin.

Rapid dysplastic transformation of human genital cells by human papillomavirus type 18

This study delineates differences in biologic activity between human papillomavirus (HPV) types 16 and 18. Human cervical and foreskin epithelial cells were cultured and transfected with recombinant HPV-16 and -18 DNA, resulting in immortalized cell lines. Normal epithelial cells as well as HPV-16 and -18 immortalized cells of both early passages (less than 40 population doublings) and late passages (greater than 180 population doublings) were transplanted in athymic mice. Normal squamous cells formed well-stratified epithelium, while HPV immortalized cells developed either normal-appearing epithelium or typical dysplastic changes. Dysplastic changes were seen in none of the 13 grafts with early-passage HPV-16 cell lines, while 9 of 14 grafts with early-passage HPV-18 cell lines developed dysplasias (P less than 0.0004). These results support previous clinical observations suggesting that HPV-18 may be associated with a more aggressive and rapidly progressive form of cervical neoplasia.

Superficial laser vulvectomy. IV. Extended laser vaporization and adjunctive 5-fluorouracil therapy of human papillomavirus-associated vulvar disease

Although most human papillomavirus infections can be managed satisfactorily by office methods, extensive, refractory, and dysplastic vulvar disease poses frustrating problems. This observational cohort study evaluated the efficacy of extended laser ablation (vaporization of both clinically apparent and adjacent subclinical changes) among 160 women drawn from 1000 referrals between 1982-1987. During the final 2 years, the protocol incorporated two different 5-fluorouracil (5-FU) regimens: routine once-weekly applications as prophylaxis against postoperative recurrence, and twice-weekly dosing to avoid further laser surgery among patients with early but diffuse failures. One hundred seven patients (66.9%) were controlled by a single operation. Subsequent therapy for the remaining 53 women involved 44 additional superficial photovaporizations, 38 courses of therapeutic 5-FU, four deep laser destructions with skin grafting, and six trials of systemic alpha-interferon. Eventually, 158 patients (98.7%) entered stable clinical remission. Adjuvant 5-FU improved success rates among the 76 women with two or more adverse prognostic factors (87.5 versus 55.8%; P less than .01) but had no prophylactic value in the other 84 women. In contrast, the therapeutic 5-FU regimen was generally effective, avoiding the need for further surgery in 22 (57.9%) of 38 inevitable failures, compared with only four successes (10.3%) among 39 historic controls managed with caustic agents (chi 2 = 19.5; P less than .001). Improvements in laser technology had no impact upon outcome, but more sophisticated heat containment strategies reduced postoperative pain, healing time, and morbidity. Given adequate technique and an appropriate indication, we find extended laser ablation to be an excellent primary control method. However, the availability of an effective adjuvant regimen would be a valuable complement.

Spindle cell reaction to nontuberculous mycobacteriosis in AIDS mimicking a spindle cell neoplasm. Evidence for dual histiocytic and fibroblast-like characteristics of spindle cells

We report 5 patients with AIDS who had an unusual spindle cell proliferation in the lymph nodes and skin caused by nontuberculous mycobacteriosis. The spindle cell proliferation in these tissues may mimic a spindle cell neoplasm and pose a diagnostic problem if an infectious aetiology is not suspected. The fibroblast-like spindle cells contained numerous acid fast bacilli. They were strongly positive for antibody markers of monocyte/macrophage and leukocyte derivation: Leu M3, Mo-9, T-200, and HLA-DR, and variably positive for alpha-1 anti-chymotrypsin and lysozyme. Ultrastructurally these spindle cells were predominantly fibroblast-like with poorly developed features of macrophages. These results reveal the dual macrophage and fibroblastic character of the spindle cells and probably imply a functional differentiation rather than a histogenetic one.

Human papillomavirus type 6 in grade I transitional cell carcinoma of the urethra

Of 4 patients who underwent cystourethroscopy, biopsy and laser excision of suspected urethral condylomata acuminata 3 had coexistent grade I papillary transitional cell carcinoma of the urethra. Human papillomavirus type 6 messenger ribonucleic acid was demonstrated within biopsy specimens using tritium-labeled single-stranded antisense ribonucleic acid probes. Compared to condylomata the papillary transitional epithelium expressed less viral message, which might be expected in an epithelium that does not show full squamous epithelial or koilocytotic differentiation. Among these patients there was 1 papillary transitional lesion in the bladder that, although histologically similar, did not express human papillomavirus message, suggesting differential susceptibility of epithelium between the bladder and urethra. The finding of active human papillomavirus transcription within the urethral papillary transitional lesions raises the possibility of an active role for the virus in the pathogenesis of these lesions. These findings broaden the spectrum of epithelial types reported to support human papillomaviruses and provides impetus for a wider search for these viruses in other transitional cell neoplasms.

Major depression with psychotic features associated with acyclovir therapy

Psychiatric side-effects associated with acyclovir therapy are very rare in the medical literature. We present a case of depression with paranoid delusions in a patient with chronic lymphocytic leukemia that appeared after intravenous acyclovir treatment for herpes simplex infection. The clinical picture resolved following discontinuation of acyclovir and treatment with haloperidol and maprotiline. The patient's status was intact at an eight-month follow-up check. The few reports of psychiatric disorders due to acyclovir are reviewed and discussed.

Persistence and expression of human papillomavirus during interferon therapy

Alpha interferon did not prevent the persistence or expression of human papillomavirus (HPV) types 6 or 11 in respiratory tract papillomas. Seventeen patients receiving interferon therapy for a minimum of six months and a maximum of 39 months still had one to ten copies per cell genome of HPV DNA in their laryngeal tissues, seen by Southern blot hybridization. In papillomas that recurred during treatment, HPV RNA could be detected by in situ hybridization, and capsid protein could be detected by immunoperoxidase staining. Persistence of the HPV DNA, and recurrences that occurred during therapy, are attributed to the failure of interferon therapy to eliminate latent virus.

Schizophreniform episode following measles infection

A case of schizophreniform episode following measles infection in a 27-year-old woman is presented. The possibility that the clinical picture is a first description in the literature of an association between a schizophreniform episode and possible measles-induced allergic encephalitis is discussed. Other possible connections between measles infection and schizophreniform episode are also mentioned.

Disparities in estimates of IgG bound to normal platelets

Estimates of the number of IgG molecules bound to normal platelets have ranged from several hundred to several tens of thousands. The lower estimates were generated from direct binding assays and stoichiometric assumptions. The higher values derive from competitive binding assays, in which platelet-associated IgG (PAIgG) is calculated from a standard curve using soluble IgG standards. Using a kinetic-ELISA (enzyme-linked immunosorbent assay) antiglobulin assay, we measured normal platelet IgG to be 21,200 +/- 9,400 molecules per platelet when a competitive assay and soluble IgG standards were used. Direct measurement of bound antiglobulin by kinetic-ELISA and stoichiometric assumptions yielded a measurement of 259 +/- 117 IgG molecules per platelet. Soluble IgG and PAIgG are not comparable in their ability to bind anti-IgG. Disparities in estimates of normal PAIgG are probably due to methodological differences. The estimate most likely to be correct is several hundred IgG or less per normal platelet.

Hypophyseal metastatic renal cell carcinoma and pituitary adenoma. Case report and review of the literature

A patient with a remote history of nephrectomy for renal cell carcinoma presented with a visual field defect. At surgery, a metastasis from the hypernephroma and an adenoma were found coexisting in the anterior pituitary gland. Although hypernephromas are known to act as "recipient" tumors in cases in which two primary neoplasms coexist, it is unusual for a renal cell carcinoma to metastasize into another tumor.