Abstract P4-06-11: Cryoablation of murine mammary tumors induce robust immune response

Background: Breast cancer is traditionally not considered as a highly immunogenic disease.

Triple-negative breast cancer (TNBC) is an aggressive form of breast cancer with reported high genomic instability and high mutation rate, indicating the possible presence of neoantigens. Cryoablation, the destruction of cells by ultra-low temperatures, can release these neoantigens and induce a tumor specific immune response.

We hypothesized these neoantigens might be sufficient to trigger a robust immune response to prevent and/or reduce spread and relapse of TNBC.

In this pilot study we cryoablated orthotopical 4T1 tumors in immune competent Balb/c mice and compared the results to surgery to evaluate 1) possible induction of immune responses and 2) effects on metastases formation.

Methods: We used 4T1 mammary carcinoma cells to initiate tumor growth in the mammary fatpad. Tumors were treated by cryoablation, cryoablation followed by surgery (cryo-surgery), or surgery alone. Tumor growth was followed and allowed to reach 3-4mm in largest dimension. Animals were euthanized 7 days post-treatment and tissues were collected to assess cytokine levels and presence of dissociated 4T1 cells. Single-cell suspensions of tumor, tumor-draining lymph node [TDLN], and spleen were tested for secretion of mouse Th1/Th2 cytokines using a bead array and measured by flow cytometery. Possible metastatic spread was assessed by a clonogenic assay using cells from venous blood, lung, and brain. Cell suspensions were seeded in growth medium supplemented with the selection agent 6-thioguanine, allowing only resistant 4T1 cells to form colonies.

Results: Cryoablation transformed tumors into a gelatinous mass surrounded by a fibrotic capsule, as typically seen in the clinic. Frozen sections of tumors revealed a necrotic core and infiltrating lymphocytes in the microenvironment. These animals displayed robust increases of Th1 and Th2 cytokines in both spleen and TDLN compared to animals with cryo-surgery treatment. TDLN of animals with surgically excised tumors secreted only IL-2. Circulating tumor cells were found in animals prior to treatment, while no 4T1 colonies formed from cell suspensions of lung and brain tissue [N=8]. At end-point, the surgery alone group had more 4T1 foci formed from lung and brain [mean foci /animal = 6.25 and 0.75, respectively; N=6] than the other two groups. Two animals in this group progressed and were euthanized early due to numerous lung metastases. The cryoablated group had the lowest number of foci formed in the lung and brain [2.25 and 0 respectively; N=8], and all animals were healthy at the predetermined end-point. Mean foci formation in the cryo-surgery group [N=7] was in-between the two other groups and one animal was euthanized early due to metastatic burden 5 days after surgery.

Conclusion: Cryoablation of TNBC can induce stimulatory immune responses in vivo. These immune responses might explain why animals treated with cryoablation, though having circulating tumor cells at the time of treatment, exhibited fewer micro metastatic growths compared to surgery alone and the cryo-surgery combination. On-going experiments aim to identify long-term effects of cryoablation on the formation of metastatic foci and growth.

Citation Format: Klein JD, Aukers Z, Kennedy J, Ciocca RM, Sabol JL, Carp NZ, Wallon UM. Cryoablation of murine mammary tumors induce robust immune response [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-06-11.

P4-09-21: A Novel Prognostic Marker for Triple-Negative Breast Cancers

BACKGROUND: Triple-negative breast cancers (TNBC) represent a highly aggressive form of this disease with few treatment options available. Currently, even the smallest node negative cancers are considered by many to warrant treatment with chemotherapy (CTX). While many recur early (within 2–3 years), there is a subset of long-term survivors illustrating the heterogeneity within this group. Here we report our ongoing effort to establish tissue inhibitor of metalloproteinase-4 (TIMP-4) as a prognostic marker in all early breast cancers a. While the canonical function of TIMPs is to inhibit tissue degradation, numerous reports have established that TIMPs exert tumor promoting activity. In our prospective study, we evaluated TIMP-4 as prognostic marker for TNBC and its role in disease progression.

METHODS: Specimens from our retrospective and prospective cohorts were assessed by immunohistochemical staining using standard techniques and a monoclonal antibody for TIMP-4b in accordance with the IRB approved protocol. Staining intensity was documented on a scale of 0–3. No data was released to the treating physicians at the time of collection. Outcome data from a total of 240 pts was obtained through tumor registry and clinician practices. Staining intensity was then correlated with outcome to calculate sensitivity and specificity of the marker. To determine the role of TIMP-4 in TNBC cell behavior we have performed microarray analyses. The effects of TIMP-4-induced signaling were tested using invasion and clonogenic survival assays under normal growth conditions and after exposure to gamma radiation.

RESULTS: Elevated TIMP-4 expression identified a high risk of relapse and short survival time with 75% sensitivity and 80% specificity. No discernable differences were noted between retrospective and prospective cohorts. Array analyses revealed activation of the PI3K/AKT pathway in the presence of TIMP-4. Furthermore, elevated TIMP-4 increased the invasive behavior of breast cancer cells in Matrigel™-coated invasion chambers and reduced sensitivity to gamma irradiation. These effects were reversible by addition of either a PI3K inhibitor or an anti-TIMP-4 antibody, suggesting their use as potential therapeutic strategies.

CONCLUSIONS: On the basis of these clinical data we suggest that TIMP-4 may offer a simple prognostic marker for TNBC patients at highest risk. The presence of TIMP-4 identifies a patient population likely to recur quickly despite standard CTX treatment. Our research suggests that targeted therapy of the PI3K/AKT pathway and/or a biological therapeutic approach directed against TIMP-4 may be of benefit in this subset of pts and should be explored. Therefore, TIMP-4 testing of TNBC patients could aid in the selection of a treatment regimen to improve survival outcome.

a Liss, M et.al. Am. J. Pathol. 2009

b Donover, P et.al. J. Cell. Biochem. 2010

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-09-21.

Breast cancer fear in girls: a major “side effect” of breast cancer in loved ones and a backlash of ubiquitous media coverage

Abstract #5078

Background: Breast cancer significantly impacts girls' lives: it affects 1:8 women and directly impacts those most influential in girls' lives (e.g. mothers, friends' mothers, teachers, coaches). Plus, girls are often exposed to powerful media messages meant to raise breast cancer awareness. Our hypothesis is that these factors could generate significant fear and misunderstanding in adolescent and pre-adolescent girls.
 Methods: To better understand the impact of breast cancer fear in girls, the nonprofit organization Breastcancer.org and the Taking Care of Your “Girls” book project, together with the Lankenau Hospital Health Education Center, conducted an in-school online survey in girls ages 8 to 18 years (median 15), prior to the delivery of a Breast Health Assembly in 7 Philadelphia and Atlanta areas schools. 2450 girls attended the assemblies, of which 1709 participated in the survey (about 70% question completion rate).
 Results: In total, 73% of girls had a relative or close acquaintance who had had breast cancer (most often: a friend's mother [49% n=580/1201]). Although only 3.34% (n=40/1196) of girls' mothers had had breast cancer, girls were most fearful of breast cancer affecting their mothers. While only 46% (n=768/1573) thought breast cancer was common in grandmothers, 76% (n=1192/1572) reported it was most common in mothers. Although only 3.35 % (n=53/1580) believed that breast cancer was common in teens, 26% (477/1554) said that they've already feared having breast cancer themselves. The most common triggers for this fear were a misinterpretation of a normal breast finding, a news report on breast cancer, or a new breast cancer diagnosis in someone they knew. Over 20% believed that infection, drug use, stress, and tanning could cause breast cancer; and 10-20% reported their belief that caffeine, getting bumped or bruised in the breast, and antiperspirants could cause it. In addition, 8.5% thought that breast-feeding increased breast cancer risk.
 Discussion: 73% of the girls in this study have one or more women close to them who've had breast cancer and all girls are sensitive to the media. These factors seem to contribute to their fear of the disease and their tendency to overestimate breast cancer risk (in themselves and their mothers). Furthermore, they were un- or misinformed about true breast cancer risk factors and effective breast health measures. The impact of a girl's unrealistic fear of breast cancer is unknown. We are concerned that it may deter rather than motivate healthy behaviors. Breast health programs are necessary to replace fear and inaccurate information with facts and reassurance. These results might be useful in the design of education and intervention strategies to improve psychological wellbeing and the achievement of long-term public health goals.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5078.

Gamma probe guided biopsy of the sentinel node in malignant melanoma: a multicentre study

Sentinel lymph node biopsy was attempted in 336 patients with clinically node-negative cutaneous melanoma. All patients were injected with technetium-99m labelled radiocolloid, with 108 patients simultaneously receiving vital blue dye for sentinel node identification. Sentinel lymph nodes were identified in 329 patients, giving a technical success rate of 97.9%. Metastatic disease was identified in 39 (11.9%) of the patients in whom sentinel nodes were found. Patients with negative sentinel nodes were observed and patients with positive sentinel nodes underwent comprehensive lymph node dissection. The presence of metastatic disease in the sentinel nodes and primary tumour depth by Breslow or Clark levels were joint predictors of survival based on Cox proportional hazards modelling. Disease recurrences occurred in 26 (8.8%) patients with negative sentinel lymph nodes, with isolated regional recurrences as the first site in 10 (3.4%). No patients with Clark level II primary tumours were found to have positive sentinel nodes or disease recurrences. One patient with a thin (<0.75 mm) Clark level III primary had metastatic disease in a sentinel node. Patients with metastases confined to the sentinel nodes had similar survival rates regardless of the number of nodes involved.

Increased tight junctional permeability is associated with the development of colon cancer

Epithelial tissues act as barriers between two fluid compartments, and the epithelial barrier function is provided by the epithelial cells and the tight junctions (TJs) that connect them. We have shown previously that chronic treatment of a cultured epithelial monolayer with phorbol ester tumor promoters induces an increase in transepithelial paracellular permeability and produces tumor-like polyps, suggesting an association between TJ permeability and tumor formation. In this study, we analyzed the association between TJ permeability and formation of tumors in vivo. The permeability of the TJs was assessed in normal human and rat colon epithelia and in colon tumors by measuring the transepithelial electrical resistance, the paracellular flux rate of D-[(14)C]mannitol and the electron microscopic evaluation of the penetration of the electron dense dye ruthenium red across the TJs. By these criteria, the TJs of human colon tumors, including carcinomas and adenomatous polyps, and the TJs of 1,2-dimethylhydrazine (DMH)-induced rat colon tumors were leakier than the TJs of normal colon. Treatment of rats with the carcinogen DMH induced a progressive increase in the number of aberrant colonic crypts, considered the putative pre-neoplastic colonic phenotype while increasing TJ permeability of the colon epithelium prior to the development of tumors. These results showed that increased TJ permeability of the colon epithelium and consequently a decrease in epithelial barrier function precede the development of colon tumors.

Paget's disease of the male breast

A histopathologically proven case of Paget's disease of the breast in a 47-year-old male induced a review of the 32 cases in the world's literature. Paget's disease usually presents in the 5th and 6th decades of life without any obvious racial predilections. The most frequent presenting signs include ulceration, eczema, nipple discharge, bleeding, and crust formation. At the time of presentation, 50 per cent of the patients have a palpable breast mass, positive lymph nodes, or both. When entertaining the diagnosis of Paget's disease of the breast using morphologic characteristics of the cells, the diagnosis of malignant melanoma and Bowen's disease (intraepithelial squamous cell carcinoma) must be included in the differential diagnosis. Certain differences will be seen between these three entities based on specific cell staining and the uptake of certain tumor markers. There is no evidence that this disease behaves differently in males versus females, but the 5-year survival for males is worse: 20 to 30 per cent in males versus 30 to 50 per cent in females. The treatment of this disease must focus on the pathology of the underlying tumor. Current treatment involves modified radical mastectomy or radical mastectomy for Stage I and II tumors. Adjuvant chemotherapy, radiation, and tamoxifen are also used depending on the nodal and receptor status of the tumor.

The effect of Fe3+ ion on benzylpenicillin in micellar and nonmicellar aqueous solutions

The effect of Fe3+ ions on the hydrolysis of benzylpenicillin in aqueous solution below and above the critical micellar concentration (c.m.c. = 0.26 M) has been studied. The catalytic effect of Fe3+ ions on hydrolysis of this drug has been demonstrated; the reaction rate constant, calculated from UV absorption data of non-micellar solutions, decreases with concentration. It is likely that Fe3+ ions form complexes with the products of degradation. The bright brown slightly soluble product formed in micellar solutions was analyzed by UV - Vis reflection, IR and mass spectroscopy and, in agreement with the results of elemental analysis, is postulated to be an octahedral binuclear complex, Fe2BP4(OH)2. This study has been linked with the clinical observation that prolonged treatment with penicillin leads to anemia.

Cerebral hydatid cyst in children. Experience of 27 cases

The authors present 27 cases of cerebral hydatid cyst (CHCy) treated between 1980 and 1992. These cases of CHCy represent 2.8% of all cases of expansive nontraumatic lesions in children. Most of the patients were between 6 and 10 years of age. There was a substantial prevalence of male patients-18 cases (66.6%). Most of the children with CHCy were from rural areas. The cysts were all located in the cerebral hemispheres (none in the posterior fossa). Usually two or three lobes were affected and the cysts were most often retrorolandic. Only 8 patients (29.6%) also had pulmonary or hepatic infestation. All patients were operated on immediately the diagnosis was established. Operative mortality was very low (1 patient died immediately after surgery). There have been 11 cases of recurrence; all these patients have been reoperated on. Neurological sequelae were mainly partial and general seizures. Epilepsy developed postoperatively in five patients. Paresis, which usually disappears in time, was the most common motor disturbance. Two other important postoperative complications were subdural effusion and ventricular dilatation (six cases). There have been five cases of multiple recurrences (four of these patients have since died). Treatment with albendazole was used in three cases without significant results.

Chronic post thoracotomy pain

Chronic post-thoracotomy pain (CPP) is a vexing clinical problem whose management has received scant attention. In order to identify the risk factors associated with CPP and determine the optimal treatment, the records of 238 consecutive patients who underwent thoracotomy were reviewed. CPP was defined as discomfort requiring the regular administration of analgesics that continued more than three months following surgery. CPP was present in 25 (11%) patients: 10/20 (50%) chest wall resections, 5/25 (20%) pleurectomies, 10/193 (5%) pulmonary resections. Among the 23 patients who required preoperative narcotics, 12 (52%) developed CPP. Improved pain control and decreased narcotic use was achieved via the administration of nonsteroidal anti-inflammatory medication and tricyclic anti-depressants. In addition, 10/25 patients required 11 pain procedures: trigger-point injection, intercostal blocks, injections of epidural steroids, stellate ganglion block. Recurrent pain occurred in 20 patients following initial control. All were found to have tumor regrowth. We conclude that CPP occurs more commonly following chest-wall resection and pleurectomy, and that preoperative narcotic use is a predictor of CPP. Worsening pain following initial relief should prompt a vigorous search for recurrent cancer.

Morbidity after intraperitoneal insertion of saline-filled tissue expanders for small bowel exclusion from radiotherapy treatment fields: a prospective four year experience with 34 patients

When prolonged small bowel exclusion (SBE) from external radiotherapy (RT) fields or immediate exclusion of bowel from brachytherapy sources is required for a patient without adequate omentum, there are no simple proven methods available for accomplishing these goals. We report a prospective study of SBE by intraperitoneal, saline-filled tissue expanders (TE). Thirty-four patients had exclusion of small bowel from either external radiotherapy (RT) ports (20), afterloading catheter treatment fields (5), both (5), or from intracavitary implants (4). Twenty-seven TEs were placed in the pelvis and 7 in the iliolumbar fossa. TE volume ranged from 400-1500 cc (median 550 cc). Patients had rectal (n = 15), colon (6), endometrial (4), anal (3), and vaginal (1) cancers and sarcomas (5). Fifteen patients had recurrent neoplasms, 13 of which were in previously irradiated fields. Nine patients had colorectostomies directly behind the TE, and 12 had other bowel (6) or ureteral (3) anastomoses or bladder repairs (3) adjacent to the TE.

RESULTS

TEs remained in the patients from 6 to 173 days (median 95). Morbidity included three early TE withdrawals before RT was begun, one for a prolonged ileus, one for a perineal wound dehiscence, and one for an unrelated small bowel obstruction. Two patients (5.9%) early in the series had post-withdrawal complications (non-lethal small bowel fistulas requiring reoperation), although in a recent cohort of patients no post-withdrawal complications occurred using a different placement technique (0/17 vs. 2/14, P = 0.2). The patient injury complication rate was 4/34 (11.8%). None of these limited or delayed RT, but RT was limited to less than that planned in one other by TE deflation (total complication rate 14.7%). There were no clinical infections involving the prostheses, even though one patient had an abdominal wound dehiscence, 3 had pelvic abscesses, and 2 had exposure of the TE through the vagina (1 planned, 1 at dehisced vaginal cuff) after TE placement. We noted no acute and one possible late RT complication in these patients (18 months median follow-up, range 3-43 months). Small bowel was displaced from > 95 per cent of the RT treatment volume in 70 per cent and from > 75 per cent of the treatment volume in 89 per cent of 27 evaluable patients treated with external RT.

CONCLUSION

Intraperitoneal placement of a saline-filled tissue expander is a simple, safe and effective means of small bowel exclusion from RT portals.

Isolated locally recurrent rectal cancer: a review of incidence, presentation, and management

Locoregional recurrence after treatment for rectal cancer may be largely prevented by wide pelvic surgical margins, adjuvant radiotherapy, and chemotherapy. Approximately half of these recurrences will present with recurrence only at the surgical site; one third to one half will be resectable with conventional surgical procedures, but the rest will require extended resections, including sacrum and hypogastric vessels, to achieve clean margins. Only a small fraction of those treated will be cured. There is no proof that radiotherapy or chemotherapy added to surgical excision afford better results, since no trials have been or are likely to occur, given the rarity of the situation. However, best results seem to follow multimodality therapy using complete surgical resection and radiotherapy (IORT or brachytherapy with or without teletherapy) with chemopotentiation. Yet, there is no multimodality series with a sufficient number of patients and follow-up period to be able to distinguish the actual value of the treatment and which patients are most likely to benefit. It is important to note that there will be some patients with second LRR who can be further aided by aggressive locoregional therapy.

Primary leiomyosarcoma of the greater omentum: case report and review of the literature

Omental leiomyosarcomas are rare intra-abdominal tumors. This report describes a case of primary leiomyosarcoma of the greater omentum discovered on abdominal CT scan. The mass was removed via laparotomy and an omentectomy performed. At 2 years postoperatively there is no sign of tumor recurrence or metastasis.

Heterotopic mucinous cystadenoma of the pancreas

A 46-year-old female who had been experiencing severe diarrhea and marked weight loss underwent exploratory laparotomy because of a mass near the tail of the pancreas noted on CT scan. Pathologic examination revealed a mucinous cystadenoma of the pancreas occurring in heterotopic pancreatic tissue. This is the second reported case of mucinous cystadenoma occurring in heterotopic pancreatic tissue.

DNA content in correlation with postsurgical stage in non-small cell lung cancer

The relationship between DNA content, TNM stage, tumor size, grade, histology, and disease-free survival was assessed in a retrospective study of patients with non-small cell lung cancer who had undergone resection and complete mediastinal lymph node dissection. Flow cytometric analysis was performed on paraffin-embedded tissue of 90 consecutive patients. The patients were analyzed both as a group and by individual stage. Median follow-up was 11 months (range, 1 to 35 months). Aneuploid tumors were not significantly different from diploid tumors with regard to pathologic TNM stage (p = 0.34), size (p = 0.5), grade (p = 0.5), or histology (p = 0.34). Disease-free survival of patients with aneuploid tumors was not significantly different than that of patients whose tumors had normal DNA content (p = 0.69). DNA content did not correlate with established prognostic factors in patients with non-small cell lung cancer who underwent resection and complete mediastinal lymph node dissection.

Rapid resolution of duck hepatitis B virus infections occurs after massive hepatocellular involvement

A study was carried out to determine some of the factors that might distinguish transient from chronic hepadnavirus infection. First, to better characterize chronic infection, Pekin ducks, congenitally infected with the duck hepatitis B virus (DHBV), were used to assess age-dependent variations in viremia, percentage of DHBV-infected hepatocytes, and average levels of DNA replication intermediates in the cytoplasm and of covalently closed circular DNA in the nuclei of infected hepatocytes. Levels of viremia and viral DNA were found to peak at about the time of hatching but persisted at relatively constant levels in chronically infected birds up to 2 years of age. The percentage of infected hepatocytes was also constant, with DHBV replication in virtually 100% of hepatocytes in all birds. Next, we found that adolescent ducks inoculated intravenously with a large dose of DHBV also developed massive infection of hepatocytes with an early but low-level viremia, followed by rapid development of a neutralizing antibody response. No obvious quantitative or qualitative differences between transiently and chronically infected liver tissue were detected in the intracellular markers of viral replication examined. However, in the adolescent duck experiment, DHBV infection was rapidly cleared from the liver even when up to 80% of hepatocytes were initially infected. In all of these ducks, clearance of infection was accompanied by only a mild hepatitis, with no evidence that massive cell death contributed to the clearance. This finding suggested that mechanisms in addition to immune-mediated destruction of hepatocytes might make major contributions to clearance of infections, including physiological turnover of hepatocytes in the presence of a neutralizing antibody response and/or spontaneous loss of the capacity of hepatocytes to support virus replication.

Contribution of patient history to the glutathione S-transferase activity of human lung, breast and colon tissue

Overexpression of the glutathione S-transferases (GSTs) and their involvement in the detoxification of anticancer agents has prompted numerous investigations of the enzyme activity of human tumor tissue. This study represents an in-depth evaluation of the contribution of patient history and pathological status to the GST activity of various human tissues. GST activity was elevated significantly in tumors of the lung, breast and colon as compared to unmatched and matched normal tissue from the same organ. The GST activity of primary breast tumors varied significantly with the stage of the tumor. Breast tumors previously treated with both radiation and chemotherapy had significantly lower levels of GST activity than untreated tumors. Neither progesterone nor estrogen receptor content was associated with the GST activity in primary breast tumors. Colon metastases possessed higher levels of GST activity than primary colon tumors but enzyme activity was independent of the Duke's classification of the tumor. Only tumors of the left colon had levels of GST activity that were higher than those of adjacent normal mucosa. No relationship was evident between either age or sex and the GST activity of any of the tissues examined. GST activity levels may reflect the site-specific ability of tissues to provide cellular protection against xenobiotics.

A technique for liver biopsy performed in Pekin ducks using anesthesia with Telazol

Infection of Pekin ducks with duck hepatitis B virus is a useful model for studying the hepadenoviruses, of which human hepatitis B virus is the prototype. The utility of this model has been limited, however, by the difficulties associated with anesthetizing and obtaining liver biopsies from ducks. We developed a technique using Telazol (13 mg/kg) to anesthetize ducks before surgical biopsy of the liver in ducks infected with duck hepatitis B virus. Eight Pekin ducks infected with duck hepatitis B virus underwent serial biopsies at 4- to 5-week intervals. There was one perioperative death in 34 surgical procedures with no evidence on intra-abdominal sepsis or wound complications. Telazol can be used safely and humanely to anesthetized ducks without the need for general endotracheal anesthesia.

Lymphokine-activated killer cell suppressor factor in malignant effusions

We examined the possibility that tumor-released products inhibit lymphokine-activated killer cell activation. Lymphokine-activated killer cells from human peripheral blood lymphocytes were activated with recombinant interleukin 2 for 4 days in the presence of malignant effusions or conditioned media from cultured cell lines (10% vol/vol). Eight of 10 malignant effusions/media suppressed the induction of lymphokine-activated killer cell cytotoxicity, as measured in a 4-hour sodium chromate release assay. Seven of 10 effusions/media inhibited lymphokine-activated killer cell proliferation. Suppression was both dose and time dependent. A representative suppressive effusion was fractionated by agarose gel chromatography, treated with detergents disruptive of ionic bonds and lipids, and refractionated using polyacrylamide gel chromatography. Seven suppressive fractions ranging in molecular weight from 1 x 10(5) to 3 x 10(5) d were isolated. It is speculated that this suppressor factor may represent a large multimeric structure with ionic-bonded individual suppressive components.

Malignant mesothelioma of the tunica vaginalis testis

Malignant mesothelioma of the tunica vaginalis is an extremely rare tumor. Appropriate treatment consists of inquinal orchiectomy with close followup. Treatment of locally recurrent malignant mesothelioma of the tunica vaginalis has not been standardized. We recommend radical resection for the initial presentation of locally recurrent disease rather than saving surgical resection as salvage therapy after other treatment modalities have failed. We report case 37 of malignant mesothelioma of the tunica vaginalis and review the literature.

Successful heart transplantation in recipients with recent preoperative pulmonary emboli

Acute pulmonary embolus (less than 6 weeks old) has been considered an absolute contraindication to heart transplantation for fear of the potential problems of lung abscess, empyema, bronchopleural fistula, and systemic sepsis in an immunosuppressed patient. It is difficult to adhere to this principle because 30% to 50% of patients with dilated cardiomyopathy may have an acute pulmonary embolus and would be excluded from transplantation. Several centers have considered such patients for heart transplantation if they are young, on maximal medical therapy, and in extremis. The surgical management of the postoperative pulmonary problems can include bronchoscopy, antibiotics, surgical drainage, decortication, and pulmonary resection with or without muscle flaps. We describe our approach to two such patients who were managed successfully with lobectomies and latissimus dorsi muscle flaps to seal the bronchus and fill the pleural space.

Dermoid tumour of the fourth ventricle with hyperdense aspect demonstrated on CT scan. Case report

The authors describe the case of a 37-year-old patient, who, after a minor craniocerebral trauma suffered in 1970, was admitted to hospital because of progressive headache, unsteady gait and balance disturbances, deglutition disorders and diplopia. Computed tomography (CT) scan showed a large median hyperdense tumour of posterior fossa with the fourth ventricle involvement. Operation under microscope was performed to remove a considerably large cystic tumour, occupying the fourth ventricle and cisterna magna, displacing the cerebellar lobes and pushing the vermis upward. The tumour was waxy and grey, whereas the cystic liquid had the colour and consistency of oily fluid. The capsule was occluded with the CO2 laser. Postoperative course was good.

The prognostic value of ventricular rupture in cerebral hemorrhage

Analysis of 41 cerebral hemorrhage cases associated or not with intraparenchymatous hematoma and ventricular rupture shows the role played by these associated phenomena in the evaluation and prognosis of these patients. The death rate was 56.25% in simple cerebral hemorrhage, 100% in hemorrhage associated with hematoma, 30.76% in hemorrhage associated with ventricular rupture and 80% in hemorrhage associated with hematoma and ventricular rupture. The authors point out that the mere presence of ventricular rupture is not a really aggravating factor. A particular severity resulting from association of hemorrhage with hematoma seems to be due to the extension of the cerebral lesion produced by the two conditions associated.

Ectopic pinealoma in the region of the optic chiasma

The authors report the case of a 31-year-old female patient who 10 years earlier had displayed diabetes insipidus and hyperglycemia and for 4 years galactorrhea and amenorrhea. Since one year her visual acuity had gradually declined to blindness. CT-scan revealed the presence of a tumoural formation in the optic chiasma and hypothalamic region. The histological examination of the operative-removed tumour showed that it was a type B pinealoma. The postoperative course was good for 42 hrs after which the patient died suddenly. Necropsy disclosed the presence of a myocardial infarct. The authors distinguish three categories of ectopic pinealoma: 1. tumours of the pineal gland with an aberrant development at the level of the 3rd ventricle, 2. metastatic pinealoma, and 3. ectopic pinealomas with an independent development in patients with normal pineal gland. The case reported below is of the 3rd category which is also the most veridical.

Bran-induced small-intestinal obstruction in a patient with no history of abdominal operation

An infrequently reported cause of small-bowel obstruction, but one with increasingly important implications in today's diet-conscious society, is bran. This report describes a patient with no history of abdominal operation who developed complete obstruction of the small bowel after the ingestion of two bowls of bran cereal. The obstructing mass of bran was removed by enterotomy and found to be an inspissated, toothpastelike plug. The patient recovered fully.

Strongyloidiasis. An unusual cause of colonic pseudopolyposis and gastrointestinal bleeding

This report describes a recent case in which colonoscopy of a patient with the presenting complaint of rectal bleeding revealed the right colon to be carpeted with 50-100 pseudopolyps, each 3-4 mm in diameter. Biopsy specimens taken during colonoscopy revealed the presence of Strongyloides stercoralis in the bowel wall. This diagnosis should be considered in any patient with gastrointestinal complaints and a history of travel to an endemic area.

Orbital, sphenoidal ridge and spinal meningiomas occurring in one patient

From the more than 1500 intracranial meningiomas, 600 spinal meningiomas and 400 orbital tumours operated on in our clinic between 1935-1980 we are reporting the case of a patient with multiple meningiomas which gradually developed in three different regions - right orbital, the left sphenoidal ridge and the upper thoracic region. We have not found any comparable case with these features in the medical literature. From the clinical, radiological and scintigraphic findings we established the coexistence and the gradual development of these multiple meningiomas in three different regions. The correlation of the clinical and paraclinical findings offered us the presumptive diagnosis of multiple orbito-cranial and spinal meningiomas before the last two operations.

Investigations on the presence of antibodies to papova viruses in patients with different forms of cancer and in other categories of patients or apparently healthy subjects. Note I. Neutralizing antibodies to SV-40 in the cerebrospinal fluid of patients with brain tumors and chronic neurological diseases

Neutralizing antibodies to SV-40 were detected in cerebrospinal fluid samples from 16 out of 43 patients with brain tumors and in 6 out of 20 patients with different nonmalignant chronic neurological diseases. The patients' age excluded the correlation with a vaccine-associated or occupational contact with SV-40. The results ascertain the occurrence of SV-40 or of an antigenically related virus in the population of Romania.

Hormonal evidence for the dissemination through the cerebrospinal fluid, of secreting cells from invasive pituitary adenomas

In 13 patients with invasive pituitary adenomas submitted to pituitary surgery (5 HGH-secreting adenomas, 6 prolactin-secreting adenomas, 2 non-secreting adenomas), the concentrations of HGH and prolactin (PRL) constantly decreased after operation both in the cerebrospinal fluid (CSF) and serum, and the CSF/serum ratio remained under one, with few exceptions. These last cases (2 with acromegaly, 2 with invasive prolactinomas), showed an increase of HGH or PRL concentrations in CSF when serum levels decreased; the CSF/serum ratio rose above one within 2 weeks post surgery in 2 patients, and within 2 years post surgery in another two. The circulation of CSF was not obstructed. This indicated the appearance of a new, extrapituitary source for secreting HGH or PRL directly into the CSF, a source which most probably developed through the dissemination, via CSF, of secreting cells from malignant pituitary adenomas.

Persistent vegetative state after multiple trauma. A clinicopathologic study

The clinico-pathological findings are reported in a case with persistent vegetative state after multiple cerebral lesions. The lesions are small in size, and are situated at different levels of the CNS, some of them being important in the maintenance of wakefulness and motor initiative. The differential diagnosis and the isolation of such a syndrome are discussed.

Induction of neovascularization by mitogen-activated spleen cells and their supernatants

The first objective of the experiment was to demonstrate that murine spleen cells treated with the T cell mitogen phytohemagglutinin induced neovascularization when adoptively transferred to the chorioallantoic membrane of chicken eggs. The second objective was to show that neovascularization could be induced by the supernatants from these cultures. The assay for neovascularization was based on the well established observation that angiogenesis can be induced on the chorioallantoic membrane by tumors and other substances. The supernatants were incorporated into a slow release polymer of hydroxyethylmethacrylate so as to produce a sustained release of the angiogenic material. The results showed that phytohemagglutinin activated spleen cells and their culture supernatants induced neovascularization on the chorioallantoic membrane. The significance of these observations are discussed as they relate to the hypothesis of lymphoid-induced neovascularization during tumor growth and other types of immunological inflammatory reactions.

Spinal dermoid tumours

The present work is a detailed analysis of 12 cases of spinal dermoid tumours operated on between 1935 and 1976. Of these 11 were medullary (3 intramedullary and 8 subdural extramedullary), representing an incidence of 0-80% of medullary tumours, and 1 was an extraspinal coccygeal tumour. Most of the tumours were located in the spinal canal and conus. Good results were obtained following total ablation in 7 cases and partial removal of the tumour in 5 cases.

Spinal dissemination following operation on cerebral oligodendroglioma

This paper concerns two cases of cerebral oligodendroglioma (intraventricular in one case, right temporal in the other), with spinal dissemination (cervical and upper thoracic respectively), manifested clinically 2 years and 14 months respectively after removal of the cerebral tumour. Anatomical examination confirmed the diagnosis of disseminated oligodendroglioma in the leptomeninges in both cases and also in the parenchyma in the second case.

Cerebral dermoid tumours

Four cases of cerebral dermoid tumour with an intraventricular, occipital and sellar location are reported, representing 0.04% of the verified cerebral tumours in the authors' statistics. A recurrence occurred after one year in the first case of intraventricular dermoid tumour; after the second operation aseptic meningitis developed and the patient died. In the second case microscopic examination revealed aspects of malignant transformation of the tumour. The symptoms did not differ from those of other cerebral tumours. Operations should be radical whenever possible, avoiding dispersion of the tumour contents in order to prevent a recurrence or aseptic meningitis.

Intrasellar abscess

A case of intrasellar abscess in a 31-year-old male, with pituitary insufficiency, visual field and acuity disturbances, is reported. In the pus extracted at surgery E. coli and Staphylococcus haemolyticus were identified. The patient died 20 days after the operation. Necropsy revealed the fibrous capsule of an abscess in the hypophyseal region and putriform tissue at the level of the hypothalamus, with three small tumours one of which proved to be a craniopharyngioma.

Intracranial ganglioneuromas in children

Two cases of tumours of the sellar and suprasellar region in children, manifested clinically by visual and endocrine disturbances, are reported. In both cases surgical removal of the intracranial tumour was performed. The histological diagnosis was central ganglioneuroma, an extremely rare tumour in children. Also worthy of note was the altogether exceptional location in these children of central ganglioneuromas in the sellar and suprasellar region.

Giant cell tumors of the calvaria

The authors report and discuss four rare cases of primary, giant cell tumor of the cranial vault, a usually benign tumor that develops in young patients and has an extremely low rate of latent malignancy. The authors believe the preferred treatment to be total surgical removal of the tumor; only in rare cases of malignancy when the tumor is impossible to remove totally should this be combined with radiotherapy. Associated minor trauma played only a tumor-revealing role and was not involved in the etiology.