Nachweis des Sentinel-Lymphknotens mittels präoperativer Lymphszintigraphie und intraoperativer Gammasondenmessung bei malignem Melanom

Ziel der vorliegenden Arbeit ist die Überprüfung der Wertigkeit nuklearmedizinischer Verfahren in der prä- und intraoperativen Diagnostik des Sentinel-Lymphknotens (SLN). Methoden: Bei 214 Patienten führten wir während der vergangenen vier Jahre die präoperative Lymphszintigraphie und bei 150 Patienten die intraoperative Gammasondenmessung zur Lokalisationsdiagnostik des SLN durch. Ergebnisse: Es fanden sich bei 214 Patienten 247 Abflußgebiete. Bei drei Patienten konnte kein Lymphabfluß nachgewiesen werden. Es handelte sich um Melanome der Wange, zwei dieser Patienten waren voroperiert. 14 Patienten zeigten Intervall-Lymphknoten. Bei 150 Patienten erfolgte eine operative Entfernung des SLN (Sentinel-Lymphonodektomie, SLNE) mit intraoperativer Gammasondenmessung. Bei zwei Patienten mit supraklavikulärem Primärtumor waren vier SLN präoperativ festgelegt worden, von denen intraoperativ nur zwei gefunden wurden. In allen anderen Fällen konnte der SLN intraoperativ entdeckt und entfernt werden. Bei 19 der 150 Patienten (12,7%) wurden Metastasen in einem SLN nachgewiesen. Die Häufigkeit der Metastasierung nahm von 0% im Stadium pT1 kontinuierlich bis 44% im Stadium pT4 zu. Schlußfolgerung: Die Lymphszintigraphie und Gammasondenmessung sind geeignete Verfahren für die Lokalisation des SLN. Die SLNE ist eine zuverlässige Methode, um eine Lymphknotenbeteiligung bei malignem Melanom nachzuweisen. Sie minimiert den operativen Eingriff.

Sentinel lymph node diagnostic in prostate carcinoma: Part II: Biokinetics and dosimetry of 99mTc-Nanocolloid after intraprostatic injection

Aim: To visualise the sentinel lymph nodes (SLNs) of the prostate we injected the radiotracer into the parenchyma of the prostate. The activity was deposited in liver, spleen, bone marrow, urinary bladder and regional lymphatic system. The aim of this work is to determine biokinetical data and to estimate radiation doses to the patient. Methods: The patients with prostate cancer received a sonographically controlled, transrectal administration of 99mTc-Nanocoll®, injected directly into both prostate lobes. In 10 randomly selected patients radionuclide distribution and its time course was determined via regions of interest (ROIs) over prostate, urinary bladder, liver, spleen and the lymph nodes. The uptake in the SLNs was estimated from gamma probe measurements at the surgically removed nodes. To compare tumour positive with tumour free lymph nodes according to SLN-uptake and SLNlocalisation we evaluated 108 lymph nodes out of 24 patients with tumour positive SLN. For calculating the effective dose according to ICRP 60 of the patients we used the MIRD-method and the Mirdose 3.1 software. Results: The average uptake of separate organs was: bladder content 24%, liver 25.5%, spleen 2%, sum of SLN 0.5%. An average of 9% of the applied activity remained in the prostate. The residual activity was mainly accumulated in bone marrow and blood. Occasionally a weak activity enrichment in intestinal tract and kidneys could be recognized. The effective dose to the patient was estimated to 7.6 μSv/MBq. The radioactivity uptake of the SLN varied in several orders of magnitude between 0.006% and 0.6%. The probability of SLN-metastasis was found to be independent from tracer uptake in the lymph node. The radioactivity uptake of the SLNs in distinct lymph node regions showed no significant differences. Conclusion: The radiotracer is transferred out of the prostate via blood flow, by direct transfer via the urethra into the bladder and by lymphatic transport. Injecting a total activity of 200 MBq leads to a mean effective dose of 1.5 mSv. It is not recommended to use the tracer uptake in lymph nodes as the only criterion to characterize SLNs.

Sentinel lymph node diagnostic in prostate carcinoma: Part I: Technique and clinical evaluation

Aim: Evaluation of the significance of lymphoscintigraphy and intraoperative probe measurement for the identification of the sentinel lymph node (SLN) in prostate cancer. Patients and method: In 117 patients with prostate cancer scintigrams in various projections were acquired till approximately 6 hours p.i. after ultrasound guided transrectal intraprostatic injection of 99mTc-Nanocoll ®. On the following day the SLNs were identified in the operation theatre with a gamma probe and removed. Pelvic standard lymph node dissection followed SLNE. Results: In three of 117 patients with preoperative lymphoscintigraphy no SLN was scintigraphically detectable. These three patients had antecedent transurethral resection of the prostate. In 113 of the residual 114 patients SLN could be intraoperatively localized. In the mean four SLNs per patient were removed. 28 of 117 patients had pelvic lymph node metastases. In 25 cases SLN were right-positive, in one false-negative and in one intraoperatively not detectable. In one patient we found macrometastasis of up to 4 cm diameter (one SLN was tumour positive). In 15 cases only the SLN was bearing tumour. Conclusion: The SLNE with preoperative lymphoscintigraphy and intraoperative gamma probe measurement is suitable for detecting lymph node metastasis in prostate cancer. SLNE is superior to the surgical techniques commonly used in pelvic lymphadenectomy.

Influence of the injection technique on the false negative rate of SLNE in multifocal breast cancer

Aim: We investigated the influence of the injection technique on the false negative rate in identifying the sentinel lymph node in multifocal breast cancer. Patients, methods: 958 consecutive patients were divided into unifocal and multifocal breast cancer patients. The scintigrafic and intraoperative detection rate as well as the false negatives were calculated in relation to peritumoral or subareolar injection. Results: In all patients the scintigrafic and intraoperative detection rate exceeded 99%, except in patients with multifocal cancer, who were injected peritumorally. In this group the intraoperative detection rate declined to 96%. In patients with unifocal breast cancer the false negative rate was below 5%, independent of the injection technique. Multifocal breast cancer patients showed a significant dependence on the injection technique. The false negative rate was 26.3% in patients with peritumoral injection and 5.6% in those with subareolar injection. Conclusion: The results clearly demonstrate that in multifocal breast cancer a reliable detection of a SLN is impossible with the peritumoral injection technique. Subareolar injection seems to be a way to operate on multifocal breast cancer with SLNE, but the number of investigated patients is too low for statistic approval. So, prospective studies should be performed to validate these preliminary results before SLNE becomes routine in multifocal breast cancer.

Diagnostic value and therapeutic impact of 18F-FDG-PET/CT in differentiated thyroid cancer

The clinical significance of 18F-FDG-PET/CT in the follow-up of patients with differentiated thyroid carcinoma was evaluated and the results were compared with those of 18F-FDGPET, 131I-whole-body scintigraphy including SPECT/CT (WBS) and ultrasound. In addition, it was the aim to investigate the impact of 18F-FDG-PET/CT on the therapeutic management. Patients, methods: 327 patients (209 women, 118 men; mean age 53 ± 18 years) with differentiated thyroid cancer (242 papillary, 75 follicular, 6 mixed, 1 Hürthle cell and 3 poorly differentiated tumours) were analyzed retrospectively at four tertiary referral centres. 289 18F-FDG-PET/CT and 118 18F-FDG-PET studies were performed in these patients between 2007 and 2010. In addition, an overall clinical evaluation was performed, including cytology, histology, thyroglobulin level, ultrasound, WBS, and subsequent clinical course in order to compare the molecular imaging results. Finally, the change in therapeutic management due to findings of 18F-FDG-PET/CT was investigated. Results: The sensitivity of 18F-FDG-PET/CT was 92%, the specificity was 95%. Sensitivity and specificity of 18F-FDG-PET alone were 67% and 93%, respectively. WBS showed a sensitivity of 65% and a specificity of 94%. The corresponding values of ultrasound were 37% and 94%, respectively. The sensitivity of 18F-FDG-PET/CT in the group of patients with a negative WBS (n=194) amounted to 96%. When 18F-FDG-PET/CT and WBS were considered in combination, tumour tissue was missed in only 2 out of 133 patients; when 18F-FDG-PET and WBS were combined, tumour tissue was missed in 1 out of 24 patients. 18F-FDG-PET/CT resulted in management change in 43% (n=57/133) with a decision on surgical approach in 20% (n=27/133). Conclusions: 18F-FDG-PET/CT is superior to 18F-FDG-PET alone in patients with differentiated thyroid cancer and has a direct impact on the therapeutic management of patients with suspected local recurrence or metastases, particularly in those with negative WBS.

Validation of sentinel lymph node dissection in prostate cancer: experience in more than 2,000 patients

PURPOSE

Sentinel lymph node dissection (SLND) has replaced extended lymphadenectomy for nodal staging in several solid tumours. We present our results of SLND in prostate cancer in regard to detection and false-negative rate.

METHODS

In a 2-day protocol about 300 MBq (99m)Tc-nanocolloid are injected into the prostate. Two hours later static scans of the pelvis are performed to get information about the number and location of radioactive lymph nodes. During surgery the radioactive nodes are excised with the help of a gamma probe and sent separately to the pathologist. The histological procedure includes haematoxylin and eosin staining, serial sections and immunohistochemistry.

RESULTS

Since 1999, a total of 2,020 men underwent SLND alone or in combination with either standard or extended lymphadenectomy after radical retropubic prostatectomy. Lymph nodes positive for metastases were found in 16.7% of patients. The scintigraphic detection rate was 97.6% and the intraoperative detection rate 98%. For 187 lymph node-positive men who had either standard or extended lymphadenectomy in addition to SLND the false-negative rate could be calculated, resulting in false-negative findings in 11 of 187 patients (6%).

CONCLUSION

Our results demonstrate that SLND in prostate cancer is a reliable procedure for nodal staging.

[Influence of the injection technique on the false negative rate of SLNE in multifocal breast cancer]

AIM

We investigated the influence of the injection technique on the false negative rate in identifying the sentinel lymph node in multifocal breast cancer.

PATIENTS, METHODS

958 consecutive patients were divided into unifocal and multifocal breast cancer patients. The scintigrafic and intraoperative detection rate as well as the false negatives were calculated in relation to peritumoral or subareolar injection.

RESULTS

In all patients the scintigrafic and intraoperative detection rate exceeded 99%, except in patients with multifocal cancer, who were injected peritumorally. In this group the intraoperative detection rate declined to 96%. In patients with unifocal breast cancer the false negative rate was below 5%, independent of the injection technique. Multifocal breast cancer patients showed a significant dependence on the injection technique. The false negative rate was 26.3% in patients with peritumoral injection and 5.6% in those with subareolar injection.

CONCLUSION

The results clearly demonstrate that in multifocal breast cancer a reliable detection of a SLN is impossible with the peritumoral injection technique. Subareolar injection seems to be a way to operate on multifocal breast cancer with SLNE, but the number of investigated patients is too low for statistic approval. So, prospective studies should be performed to validate these preliminary results before SLNE becomes routine in multifocal breast cancer.

Characterization of the indigenous PAH-degrading bacteria of Spartina dominated salt marshes in the New York/New Jersey Harbor

The aerobic polyaromatic hydrocarbon (PAH) degrading microbial communities of two petroleum-impacted Spartina-dominated salt marshes in the New York/New Jersey Harbor were examined using a combination of microbiological, molecular and chemical techniques. Microbial isolation studies resulted in the identification of 48 aromatic hydrocarbon-degrading bacterial strains from both vegetated and non-vegetated marsh sediments. The majority of the isolates were from the genera Paenibacillus and Pseudomonas. Radiotracer studies using (14)C-phenanthrene and (14)C-pyrene were used to measure the PAH-mineralization activity in salt marsh sediments. The results suggested a trend towards increased PAH mineralization in vegetated sediments relative to non-vegetated sediments. This trend was supported by the enumeration of PAH-degrading bacteria in non-vegetated and vegetated sediment using a Most Probable Numbers (MPN) technique, which demonstrated that PAH-degrading bacteria existed in non-vegetated and vegetated sediments at levels ranging from 10(2 )to 10(5 )cells/g sediment respectively. No difference between microbial communities present in vegetated versus non-vegetated sediments was found using terminal restriction fragment length polymorphism (of the 16S rRNA gene) or phospholipid fatty acid analysis. These studies provide information on the specific members and activity of the PAH-degrading aerobic bacterial communities present in Spartina-dominated salt marshes in the New York/New Jersey Harbor estuary.

[Sentinel lymph node dissection in prostate cancer. Experience after more than 800 interventions]

There is no consensus on which prostate cancer patients should undergo lymph node removal and which lymph nodes should be included. Therefore, most clinicians rely on nomograms and dispense with lymph node dissection in patients with low-risk disease. Meanwhile, there are some studies which prove that there are also lymph node metastases in patients with low-risk prostate cancer and that lymph node metastases are predominantly localized outside the region of standard lymphadenectomy. In more than 800 men we could show that lymph node metastases were found more often than shown in the Partin tables. These lymph node metastases were detected by sentinel lymph node dissection outside the region of standard and extended lymphadenectomy. Because of insufficient preoperative diagnostics it is unclear which patients have positive lymph nodes. Therefore, it is useful to perform lymph node dissection in every patient. Men with positive nodes could have a better prognosis, when sentinel and extended lymph node dissection are performed.

Low dose mitomycin c, capecitabine & radiation for HIV patients with anal squamous cell carcinoma

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Background: Chemoradiotherapy has replaced radical surgery as the initial treatment of choice for anal squamous cell carcinoma (ASCC). Optimal chemotherapy regimen for ASCC in HIV positive patients is not yet defined. The addition of mitomycin C to 5-FU and radiotherapy in the past improves local control, colostomy-free, and even disease-free survival in large tumors. The concern is hematologic toxicity if use in HIV positive patients. We report 2 cases safely using low dose mitomycin C, capecitabine and concurrent XRT. One of these patients has ESRD, which the use of cisplatin is not an option. Methods: 2 HIV positive patients, (CD4 range 106–113, at diagnosis of ASCC) were treated with low dose of mitomycin C on day 1 for 2 cycles (5mg flat dose), day 1–7 capecitabine titrated up to 1.5 gm/m2 divided b.i.d, and concurrent XRT (total dose 5040 cGy). Prior to treatment, 1 patient was diagnosed with squamous cell carcinoma in-situ and the other with stage 1 squamous cell carcinoma. 1 patient has end stage renal disease with SCr between 10 and 12 mg/dl at the time of treatment. Results: Both patients completed treatment. No grade 3 or 4 hematologic or gastrointestinal toxicities were noted. No hand-foot syndrome was observed probably due to low dose of capecitabine. Both patients are still alive and remain in remission (16–18 months post treatment). Conclusions: Our 2 cases suggest that the use of low dose mitomycin C in addition to capecitabine and XRT is well tolerated and is efficacious in HIV-positive patients with ASCC.

No significant financial relationships to disclose.

Radioiodine therapy for combined disseminated and nodular thyroid autonomy

Ziel: Die kombinierte Schilddrüsenautonomie wird zurzeit mit unterschiedlichen Konzepten radioiodtherapiert. Der Unterschied liegt in der Berechnung des autonomen Volumens. In dieser retrospektiven Studie wird ein neues Verfahren der Volumenberechnung vorgestellt. Patienten und Methoden: Bei 398 Patienten mit kombinierter Autonomie, die eine gute Korrelation von heißen Knoten und sonographisch zirkumskripten Läsionen aufweisen, wird das Volumen der heißen Knoten anhand der sonographischen und szintigraphischen Messdaten ermittelt und das Volumen der disseminierten Autonomie mit einem Wichtungsfaktor (VF) bewertet. Dieser Faktor entspricht dem Quotienten der Impulsdichte von disseminiertem zu zircumskriptem Gewebe im Schilddrüsenszintigramm. Nach Messung des maximalen Iod-131-Uptakes und der effektiven Halbwertszeit (HWZ) in einem Radioiodtest wird die Aktivitätsmenge für eine Herddosis von 400 Gy ermittelt. Ergebnisse: Die Erfolgsquote beträgt mit und ohne Thyreostase 97% bei einer Hypothyreoserate von 18,6 % in der Bewertung des Therapieerfolges ab dem 4. Monat nach Radiojodtherapie. Schlussfolgerung: Die Radioiodtherapie bei kombinierter Autonomie unter Verwendung eines Wichtungsfaktors (Produkt aus VF und Volumen des perinodulären Gewebes) für die Berechnung der Therapieaktivität des disseminierten Autonomieanteils führt bei Patienten mit guter Korrelation von sonographischem und szintigraphischem Befund zu einer hervorragenden Erfolgsquote.

[Radioiodine therapy for combined disseminated and nodular thyroid autonomy. Results after using a correction term for the disseminated part]

AIM

In combined focal and disseminated thyroid autonomy a variety of concepts in the treatment with radioiodine are used. The difference lies mainly in the calculation of the autonomous volume. This retrospective study shows a new method of calculating the autonomous volume.

PATIENTS AND METHODS

In 398 patients with combined thyroid autonomy and good correlation of scintigraphically hot nodules and lesions defined by ultrasound the volume of the nodules is ascertained from scintigraphic and ultrasound parameters and the volume of the disseminated autonomous tissue is assessed with a weighting factor (VF). This factor is the ratio of impulse density in a ROI over the disseminated volume divided by the corresponding impulse density over the nodular volume of the thyroid scintigraphy. The sum of nodular volume and weighted perinodular volume gives the total autonomous volume. A standard radioiodine test gives the maximum iodine-131-uptake and effective half-life to calculate the activity to obtain a treatment dose of 400 Gy.

RESULTS

The rate of success with and without thyrostatic medication was 97% with an 18.6% rate of hypothyroidism observed from 4 months post therapy onwards.

CONCLUSION

The use of the weighting factor VF in the treatment of combined autonomy leads to an excellent rate of success in patients with good correlation of functional imaging and ultrasound findings.

Sharper focus for a radially polarized light beam

We experimentally demonstrate for the first time that a radially polarized field can be focused to a spot size significantly smaller [0.16(1)lambda(2)] than for linear polarization (0.26lambda(2)). The effect of the vector properties of light is shown by a comparison of the focal intensity distribution for radially and azimuthally polarized input fields. For strong focusing, a radially polarized field leads to a longitudinal electric field component at the focus which is sharp and centered at the optical axis. The relative contribution of this component is enhanced by using an annular aperture.

Long-term ST database: a reference for the development and evaluation of automated ischaemia detectors and for the study of the dynamics of myocardial ischaemia

The long-term ST database is the result of a multinational research effort. The goal was to develop a challenging and realistic research resource for development and evaluation of automated systems to detect transient ST segment changes in electrocardiograms and for supporting basic research into the mechanisms and dynamics of transient myocardial ischaemia. Twenty-four hour ambulatory ECG records were selected from routine clinical practice settings in the USA and Europe, between 1994 and 2000, on the basis of occurrence of ischaemic and non-ischaemic ST segment changes. Human expert annotators used newly developed annotation protocols and a specially developed interactive graphic editor tool (SEMIA) that supported paperless editing of annotations and facilitated international co-operation via the Internet. The database contains 86 two- and three-channel 24 h annotated ambulatory records from 80 patients and is stored on DVD-ROMs. The database annotation files contain ST segment annotations of transient ischaemic (1155) and heart-rate related ST episodes and annotations of non-ischaemic ST segment events related to postural changes and conduction abnormalities. The database is intended to complement the European Society of Cardiology ST-T database and the MIT-BIH and AHA arrhythmia databases. It provides a comprehensive representation of 'real-world' data, with numerous examples of transient ischaemic and non-ischaemic ST segment changes, arrhythmias, conduction abnormalities, axis shifts, noise and artifacts.

[Sentinel lymph node diagnosis in prostatic carcinoma: I: Method and clinical evaluation]

AIM

Evaluation of the significance of lymphoscintigraphy and intraoperative probe measurement for the identification of the sentinel lymph node (SLN) in prostate cancer.

PATIENTS AND METHOD

In 117 patients with prostate cancer scintigrams in various projections were acquired till approximately 6 hours p.i. after ultrasound guided transrectal intraprostatic injection of 99mTc-Nanocoll. On the following day the SLNs were identified in the operation theatre with a gamma probe and removed. Pelvic standard lymph node dissection followed SLNE.

RESULTS

In three of 117 patients with preoperative lymphoscintigraphy no SLN was scintigraphically detectable. These three patients had antecedent transurethral resection of the prostate. In 113 of the residual 114 patients SLN could be intraoperatively localized. In the mean four SLNs per patient were removed. 28 of 117 patients had pelvic lymph node metastases. In 25 cases SLN were right-positive, in one false-negative and in one intraoperatively not detectable. In one patient we found macrometastasis of up to 4 cm diameter (one SLN was tumour positive). In 15 cases only the SLN was bearing tumour.

CONCLUSION

The SLNE with preoperative lymphoscintigraphy and intraoperative gamma probe measurement is suitable for detecting lymph node metastasis in prostate cancer. SLNE is superior to the surgical techniques commonly used in pelvic lymphadenectomy.

[Sentinel lymph node diagnosis in prostatic carcinoma: II. Biokinetics and dosimetry of 99mTc-Nanocolloid after intraprostatic injection]

AIM

To visualise the sentinel lymph nodes (SLNs) of the prostate we injected the radiotracer into the parenchyma of the prostate. The activity was deposited in liver, spleen, bone marrow, urinary bladder and regional lymphatic system. The aim of this work is to determine biokinetical data and to estimate radiation doses to the patient.

METHODS

The patients with prostate cancer received a sonographically controlled, transrectal administration of 99mTc-Nanocoll, injected directly into both prostate lobes. In 10 randomly selected patients radionuclide distribution and its time course was determined via regions of interest (ROIs) over prostate, urinary bladder, liver, spleen and the lymph nodes. The uptake in the SLNs was estimated from gamma probe measurements at the surgically removed nodes. To compare tumour positive with tumour free lymph nodes according to SLN-uptake and SLN-localisation we evaluated 108 lymph nodes out of 24 patients with tumour positive SLN. For calculating the effective dose according to ICRP 60 of the patients we used the MIRD-method and the Mirdose 3.1 software.

RESULTS

The average uptake of separate organs was: bladder content 24%, liver 25.5%, spleen 2%, sum of SLN 0.5%. An average of 9% of the applied activity remained in the prostate. The residual activity was mainly accumulated in bone marrow and blood. Occasionally a weak activity enrichment in intestinal tract and kidneys could be recognized. The effective dose to the patient was estimated to 7.6 microSv/MBq. The radioactivity uptake of the SLN varied in several orders of magnitude between 0.006% and 0.6%. The probability of SLN-metastasis was found to be independent from tracer uptake in the lymph node. The radioactivity uptake of the SLNs in distinct lymph node regions showed no significant differences.

CONCLUSION

The radiotracer is transferred out of the prostate via blood flow, by direct transfer via the urethra into the bladder and by lymphatic transport. Injecting a total activity of 200 MBq leads to a mean effective dose of 1.5 mSv. It is not recommended to use the tracer uptake in lymph nodes as the only criterion to characterize SLNs.

Transgene analysis proves mRNA trans-splicing at the complex mod(mdg4) locus in Drosophila

The Drosophila BTB domain containing gene mod(mdg4) produces a large number of protein isoforms combining a common N-terminal region of 402 aa with different C termini. We have deduced the genomic structure of this complex locus and found that at least seven of the mod(mdg4) isoforms are encoded on both of its antiparallel DNA strands, suggesting the generation of mature mRNAs by trans-splicing. In transgenic assays, we demonstrate the ability of Drosophila to produce mod(mdg4) mRNAs by trans-splicing of pre-mRNAs generated from transgenes inserted at distant chromosomal positions. Furthermore, evidence is presented for occurring of trans-splicing of mod(mdg4)-specific exons encoded by the parallel DNA strand. The mod(mdg4) locus represents a new type of complex gene structure in which genetic complexity is resolved by extensive trans-splicing, giving important implications for genome sequencing projects. Demonstration of naturally occurring trans-splicing in the model organism Drosophila opens new experimental approaches toward an analysis of the underlying mechanisms.

Extensive sterile abscess in an invasive fibrous thyroiditis (Riedel's thyroiditis) caused by an occlusive vasculitis

Riedel's thyroiditis is a rare disease determined by an invasive fibrosclerotic transformation of the thyroid gland. It may be one manifestation of multifocal fibrosis with still unknown etiology. Because it mimics carcinoma, a biopsy must be performed to get the correct diagnosis. The condition is self-limiting when confined to the neck. Prognosis depends on the extent of extracervical fibrosclerosis. We present a patient with a huge cervical and mediastinal, unilateral thyroid mass expanding to the aortic curve, which led to tracheal deviation and compression with symptoms of stridor and dyspnea. These symptoms continued under a course of high-dose steroids; thus an operation was necessary to relieve the airway obstruction and limit inflammation. Intraoperative and pathological findings showed an inflammatory infiltration of the adjacent neck muscles and a sterile abscess caused by an occlusive vasculitis. Therefore, hemithyroidectomy had to be performed instead of a local limited resection.

Genetic and molecular complexity of the position effect variegation modifier mod(mdg4) in Drosophila

mod(mdg4), also known as E(var)3-93D, is involved in a variety of processes, such as gene silencing in position effect variegation (PEV), the control of gypsy insulator sequences, regulation of homeotic gene expression, and programmed cell death. We have isolated a large number of mod(mdg4) cDNAs, representing 21 different isoforms generated by alternative splicing. The deduced proteins are characterized by a common N terminus of 402 amino acids, including the BTB/POZ-domain. Most of the variable C termini contain a new consensus sequence, including four positioned hydrophobic amino acids and a Cys(2)His(2) motif. Using specific antibodies for two protein isoforms, we demonstrate different distributions of the corresponding proteins on polytene chromosomes. Mutations in the genomic region encoding exons 1-4 show enhancement of PEV and homeotic transformation and affect viability and fertility. Homeotic and PEV phenotypes are enhanced by mutations in other trx-group genes. A transgene containing the common 5' region of mod(mdg4) that is present in all splice variants known so far partially rescues the recessive lethality of mod(mdg4) mutant alleles. Our data provide evidence that the molecular and genetic complexity of mod(mdg4) is caused by a large set of individual protein isoforms with specific functions in regulating the chromatin structure of different sets of genes throughout development.

[Sentinel lymph node detection by preoperative lymphoscintigraphy and intraoperative gamma probe guidance in malignant melanoma]

AIM

The purpose of this work was to prove the clinical significance of nuclear medical procedures in pre- and intraoperative detection of the SLN.

METHODS

In the past 4 years, we did preoperative lymphoscintigraphy in 214 patients (pts.). Intraoperative localisation of the SLN with a hand-held gamma probe followed in 150 pts.

RESULTS

In 214 pts. 247 lymphatic draining regions were found by preoperative scintigraphy. In 3 pts. with melanoma of the cheek no lymphatics/lymph nodes could be detected. 14 pts. showed interval lymph nodes. In 150 pts. gamma probe guided SLNE was done. In 2 pts. with supraclavicular primary tumor 4 SLN had been defined by preoperative scintigraphy but only 2 could be found intraoperatively. In all other cases (98.7%) the sentinel node was detected correctly by the gamma probe and then removed. In 19 of 150 pts. (12.7%) metastases were detected in the pathologic specimen. The incidence of lymph node metastases showed a continuous increase from 0% at tumor stage pT1 to 44% at stage pT4.

CONCLUSION

SLNE is an accurate method to determine nodal involvement in melanoma and minimizes operative invasiveness in melanoma surgery.

Functional mammalian homologues of the Drosophila PEV-modifier Su(var)3-9 encode centromere-associated proteins which complex with the heterochromatin component M31

The chromo and SET domains are conserved sequence motifs present in chromosomal proteins that function in epigenetic control of gene expression, presumably by modulating higher order chromatin. Based on sequence information from the SET domain, we have isolated human (SUV39H1) and mouse (Suv39h1) homologues of the dominant Drosophila modifier of position-effect-variegation (PEV) Su(var)3-9. Mammalian homologues contain, in addition to the SET domain, the characteristic chromo domain, a combination that is also preserved in the Schizosaccharyomyces pombe silencing factor clr4. Chromatin-dependent gene regulation is demonstrated by the potential of human SUV39H1 to increase repression of the pericentromeric white marker gene in transgenic flies. Immunodetection of endogenous Suv39h1/SUV39H1 proteins in a variety of mammalian cell lines reveals enriched distribution at heterochromatic foci during interphase and centromere-specific localization during metaphase. In addition, Suv39h1/SUV39H1 proteins associate with M31, currently the only other characterized mammalian SU(VAR) homologue. These data indicate the existence of a mammalian SU(VAR) complex and define Suv39h1/SUV39H1 as novel components of mammalian higher order chromatin.

SET domain proteins modulate chromatin domains in eu- and heterochromatin

The SET domain is a 130-amino acid, evolutionarily conserved sequence motif present in chromosomal proteins that function in modulating gene activities from yeast to mammals. Initially identified as members of the Polycomb- and trithorax-group (Pc-G and trx-G) gene families, which are required to maintain expression boundaries of homeotic selector (HOM-C) genes, SET domain proteins are also involved in position-effect-variegation (PEV), telomeric and centromeric gene silencing, and possibly in determining chromosome architecture. These observations implicate SET domain proteins as multifunctional chromatin regulators with activities in both eu- and heterochromatin--a role consistent with their modular structure, which combines the SET domain with additional sequence motifs of either a cysteine-rich region/zinc-finger type or the chromo domain. Multiple functions for chromatin regulators are not restricted to the SET protein family, since many trx-G (but only very few Pc-G) genes are also modifiers of PEV. Together, these data establish a model in which the modulation of chromatin domains is mechanistically linked with the regulation of key developmental loci (e.g. HOM-C).

Mammalian homologues of the Polycomb-group gene Enhancer of zeste mediate gene silencing in Drosophila heterochromatin and at S. cerevisiae telomeres

Gene silencing is required to stably maintain distinct patterns of gene expression during eukaryotic development and has been correlated with the induction of chromatin domains that restrict gene activity. We describe the isolation of human (EZH2) and mouse (Ezh1) homologues of the Drosophila Polycomb-group (Pc-G) gene Enhancer of zeste [E(z)], a crucial regulator of homeotic gene expression implicated in the assembly of repressive protein complexes in chromatin. Mammalian homologues of E(z) are encoded by two distinct loci in mouse and man, and the two murine Ezh genes display complementary expression profiles during mouse development. The E(z) gene family reveals a striking functional conservation in mediating gene repression in eukaryotic chromatin: extra gene copies of human EZH2 or Drosophila E(z) in transgenic flies enhance position effect variegation of the heterochromatin-associated white gene, and expression of either human EZH2 or murine Ezh1 restores gene repression in Saccharomyces cerevisiae mutants that are impaired in telomeric silencing. Together, these data provide a functional link between Pc-G-dependent gene repression and inactive chromatin domains, and indicate that silencing mechanism(s) may be broadly conserved in eukaryotes.

High-dose fractionated total-body irradiation, etoposide and cyclophosphamide for treatment of malignant lymphoma: comparison of autologous bone marrow and peripheral blood stem cells

Consecutive patients with non-Hodgkin's lymphoma (NHL, n = 133) or Hodgkin's disease (HD, n = 20) were treated with 12.0 Gy of fractionated total body irradiation, etoposide 60 mg/kg, and CY 100 mg/kg followed by infusion of autologous hematopoietic stem cells. Seventy-nine patients received purged (n = 62) or unpurged BM (n = 17), and 74 received unpurged PBSCs alone (n = 56) or with BM (n = 18). The median day for achieving a sustained granulocyte count of 0.5 x 10(9)/I was 14 range (7-66) for BM recipients and 10 (7-30) for PBSC +/- BM recipients (P = 0.03). A platelet count of 20 x 10(9)/I was achieved at a median of day 24 (6-145) in BM recipients and day 11 (range, 7-56) in PBSC +/- BM recipients (P = 0.007). The median number of platelet units transfused was 86 (0-1432) for BM recipients and 30 (6-786) for PBSC +/- BM recipients (P = 0.001). The median number of hospital days was 36 (10-88) for BM recipients and 27 (14-76) for PBSC +/- BM recipients (P = 0.0001). The unadjusted Kaplan-Meier (KM) estimates of survival, event-free survival (EFS) and relapse at 2 years were 0.57, 0.45 and 0.43 for patients receiving BM and 0.55, 0.36 and 0.59 for patients receiving PBSC +/- BM. After adjusting for confounding variables, the estimated relative risk (RR) of death from any cause was 0.92 (P = 0.75), of relapse was 1.25 (P = 0.39), of non-relapse mortality was 0.71 (P = 0.42) and of mortality and/or relapse was 1.17 (P = 0.48) for patients receiving PBSC +/- BM as compared to BM. For 46 patients with NHL receiving unpurged PBSC alone, the unadjusted KM estimate of relapse was 0.61 compared with 0.48 for 52 comparable patients receiving purged BM, while the RR for relapse for patients receiving unpurged PBSCs was 1.37 (P = 0.33) after adjusting for other significant covariates. These data confirm previous observations that patients who receive PBSC +/- BM have faster engraftment, fewer transfusions and shorter hospital stays than patients who receive only BM. There were no statistically significant differences between the two groups in survival, relapse, death from causes other than relapse and event-free survival.

Effects of 12 months quinapril therapy in asymptomatic patients with chronic aortic regurgitation

This study was performed to assess the effects of one year of ACE inhibition with quinapril on left ventricular performance and morphology in asymptomatic patients with chronic aortic regurgitation. Pre- and afterload reduction is known to have beneficial effects in patients with chronic aortic regurgitation. To date, no controlled study has been reported analyzing long term influence of ACE inhibitor treatment on asymptomatic patients with chronic aortic regurgitation. Twelve asymptomatic patients with isolated moderate to severe chronic aortic regurgitation, no coronary disease on coronary angiography and no previous vasodilator treatment were studied under control conditions and after three and 12 months of quinapril therapy (10-20 mg/day) using echocardiography and simultaneous right heart catheterization and radionuclide ventriculography at rest and during supine bicycle exercise. After one year quinapril therapy regurgitant fraction fell by 17% compared to control before therapy (p = 0.001), left ventricular enddiastolic volume at rest was reduced from 150 +/- 33 to 128 +/- 30 ml/m2 (p = 0.0003) and endsystolic volume decreased from 55 +/- 27 to 44 +/- 28 ml/m2 (p = 0.0005). Left ventricular ejection fraction at rest averaged 0.64 +/- 0.11 at control and increased after one year therapy to 0.67 +/- 0.11 (p = 0.05). With maximum exercise (100 W), ejection fraction failed to rise at control; after one year therapy with quinapril it increased to 0.70 +/- 0.15 (p = 0.019). Moreover, after one year quinapril therapy there was a significant reduction of 35% in left ventricular mass compared to control.(ABSTRACT TRUNCATED AT 250 WORDS)

The protein encoded by the Drosophila position-effect variegation suppressor gene Su(var)3-9 combines domains of antagonistic regulators of homeotic gene complexes

Modifier mutations of position-effect variegation (PEV) represent a useful tool for a genetic and molecular dissection of genes connected with chromatin regulation in Drosophila. The Su(var)3-9 gene belongs to the group of haplo suppressor loci which manifest a triplo enhancer effect. Mutations show a strong suppressor effect even in the presence of PEV enhancer mutations, indicating a central role of this gene in the regulation of PEV. By molecular analysis, Su(var)3-9 could be correlated with a 2.4 kb transcript which encodes a putative protein of 635 amino acids containing a chromo domain and a region of homology to Enhancer of zeste and trithorax, two antagonistic regulators of the Antennapedia and Bithorax gene complexes, as well as to the human protein ALL-1/Hrx which is implicated in acute leukemias. This region of homology is found in all four proteins at the C-terminus. The homology of Su(var)3-9 to both negative (Polycomb and Enhancer of zeste) and positive (trithorax) regulators of the Antennapedia and Bithorax complexes also suggests similarities in the molecular processes connected with stable transmission of a determined state and the clonal propagation of heterochromatinization.

The enhancer of position-effect variegation of Drosophila, E(var)3-93D, codes for a chromatin protein containing a conserved domain common to several transcriptional regulators

In Drosophila modifying mutations of position-effect variegation have been successfully used to genetically dissect chromatin components. The enhancer of position-effect variegation E(var)3-93D [formerly E-var(3)3] encodes proteins containing a domain common to the transcriptional regulators tramtrack and the products of the Broad complex. It interacts with a number of chromatin genes that suppress position-effect variegation. Mutations in E(var)3-93D exhibit an imprinting-like effect on the Y chromosome. This effect is transmitted paternally over several generations. Homeotic transformations in E(var)3-93D mutants indicate an involvement of the gene products in regulation of homeotic gene complexes. An antiserum raised against E(var)3-93D protein detects this chromosomal protein in a large subset of sites in polytene chromosomes. Our genetic and molecular data suggest that the proteins of E(var)3-93D are generally involved in establishing and/or maintaining an open chromatin conformation.

P transposon-induced dominant enhancer mutations of position-effect variegation in Drosophila melanogaster

P transposon induced modifier mutations of position-effect variegation (PEV) were isolated with the help of hybrid dysgenic crosses (pi 2 strain) and after transposition of the mutator elements pUChsneory+ and P[lArB]. Enhancer mutations were found with a ten times higher frequency than suppressors. The 19 pUChsneory(+)- and 15 P[lArB]-induced enhancer mutations can be used for cloning of genomic sequences at the insertion sites of the mutator elements via plasmid rescue. Together with a large sample of X-ray-induced (48) and spontaneous (93) enhancer mutations a basic genetic analysis of this group of modifier genes was performed. On the basis of complementation and mapping data we estimate the number of enhancer genes at about 30 in the third chromosome and between 50 and 60 for the whole autosome complement. Therefore, enhancer of PEV loci are found in the Drosophila genome as frequently as suppressor genes. Many of the enhancer mutations display paternal effects consistent with the hypothesis that some of these mutations can induce genomic imprinting. First studies on the developmentally regulated gene expression of PEV enhancer genes were performed by beta-galactosidase staining in P[lArB] induced mutations.

Identification of an essential Drosophila gene that is homologous to the translation initiation factor eIF-4A of yeast and mouse

A gene encoding a protein homologous to the translation initiation factor eIF-4A in mouse has been identified in Drosophila melanogaster. The predicted amino acid sequence shows 73% identity with the mouse gene and 67% identity with a homologous protein from yeast. The single-copy Drosophila gene is located on chromosome arm 2L at 26A7-9. Several recessive lethal mutations have been isolated and genetically characterized. Northern blot hybridization shows two abundant transcripts of 1.75 kb and 1.9 kb throughout all developmental stages. Both transcripts are maternally provided to the oocyte.

[A registry of medullary thyroid cancer in West Germany]

A register for medullary thyroid carcinoma (MTC) in FRG has been set up by the "German Medullary Thyroid Carcinoma Study Group" in 1988. The aim is to provide a basis for collaborative work on MTC especially in the hereditary forms (i.e. multiple endocrine neoplasia [MEN] type IIa, IIb). For these hereditary varieties reliable screening tests exist and, if the disease is detected by family screening in an early stage, curative surgery is possible. Until now 408 patients (234 female, 174 male) with MTC have been reported by 17 cooperative centers. The mean age at diagnosis was 45.5 years. 25% (n = 104) are hereditary forms, most of them MEN IIa (n = 86), 13 are MEN IIb and 18 belong to the familial variety without other endocrinopathy. The mean age at diagnosis for MEN IIa was 36.5 years, MEN IIb 26.9 and for the pure familial form 27.5 years. As 33 patients per year have been diagnosed since 1982, nearly 25% of all expected cases of MTC in FRG have been registered.

[Decrease in immunoreactivity in melanoma. Analysis of DNCB tests in the literature]

It is generally accepted that cell mediated immunity is impaired in melanoma patients. Several studies, however, could not confirm this thesis, especially in early malignancy. Therefore, it was the aim of our study to evaluate the results of the DNCB skin tests in melanoma patients of the literature. DNCB sensitization lineally decreased with increasing tumor progression. The difference of the sensitization rates between controls and stage I patients and between melanoma stage I and stage II was significant (p less than 0.001). The difference between stage II patients and stage III melanoma was apparent; statistical analysis, however, could not be done, because the results of three out of six evaluated studies where contradictory. The results confirm the thesis of impaired delayed type immunity in the course of tumor progression and support the therapeutic approaches of immune modulation in tumor patients: BCG vaccination, DNCB sensitization, interferon application.

Alveolar echinococcosis of the femur

A case of alveolar echinococcosis with involvement of the femur is described. Bone involvement is extremely rare in alveolar echinococcosis. Attention is drawn to the difficulty of diagnosis, and the therapeutic possibilities are discussed.

Butyrate sensitive suppressor of position-effect variegation mutations in Drosophila melanogaster

Mutations at a locus on chromosome II of D. melanogaster suppressing position-effect variegation mutations have been identified which display recessive butyrate sensitivity. Survival of homozygous mutant flies is significantly reduced on medium containing sodium n-butyrate. The butyrate sensitive suppressor mutations are further characterized by recessive female sterility and reduced survival of homozygotes. Complementation analysis showed their allelism. The locus of these mutations, Su-var (2) 1, has been localized to 40.5 +/- 0.2 and, by using interstitial duplications, to region 31CD on the cytogenetic map. Moreover, the mutant alleles of the Su-var (2) 1 locus display a lethal interaction with the heterochromatic Y chromosome. The presence or absence of a Y chromosome in males or females has a strong influence on the viability of homozygous or transheterozygous suppressor flies. All the genetic properties of Su-var (2) 1 mutants suggest strongly that this locus affects chromosome condensation.

Nosocomial Salmonella epidemic

A patient admitted to the hospital with diarrhea due to Salmonella heidelberg subsequently developed fatal disseminated salmonellosis, despite vigorous antimicrobial treatment. Beginning five weeks after the initial patient's death, nine patients developed hospital-acquired S heidelberg infections characterized by diarrhea (in seven) and bacteremia (in two). A careful search for salmonellosis among patients and hospital staff revealed two asymptomatic excretors. Extensive culturing of samples from the environment did not show any contaminated objects or reservoirs. The epidemic ended after initiation of an energetic handwashing campaign and isolation procedures. The strain of S heidelberg isolated was resistant to chloramphenicol, ampicillin, and gentamicin. Especially interesting in the epidemic were the prolonged time between death of the index case and the appearance of nosocomial cases, the high fatality rate, and the marked antibiotic resistance.