Endoscopic ultrasound guided fine needle aspiration of non-pancreatic lesions: an institutional experience

Background

Endoscopic ultrasound guided fine needle aspiration biopsy (EUS‐FNA) has proven to be an effective diagnostic modality for the detection and staging of pancreatic malignancies. In recent years EUS‐FNA has also been used to diagnose lesions of non‐pancreatic sites such as structures in close proximity to the gut wall within the mediastinum, abdomen, pelvis and retro‐peritoneum.

Aims

To evaluate experience with EUS‐FNA of non‐pancreatic sites at a large university medical centre.

Methods

The study cohort included 234 patients who underwent EUS‐FNA of 246 lesions in non‐pancreatic sites (122 peri‐pancreatic and coeliac lymph nodes; 9 peri‐pancreatic masses; other sites: mediastinum 12, gastric 25, liver 27, oesophagus 17, duodenum/colon/rectum 15, retro‐peritoneum 8, lung 7, miscellaneous 4).

Results

The cytology diagnoses were classified as non‐neoplastic/reactive in 82 (33%), atypical/suspicious for malignancy in 25 (10%), malignant in 86 (35%) and non‐diagnostic in 53 (22%) cases. Surgical pathology follow‐up was available in 75 (31%) cases. Excluding the non‐diagnostic cases there were 7 false negative and 3 false positive cases. The sensitivity, specificity and positive predictive value of EUS‐FNA in the diagnosis of lesions of non‐pancreatic sites was 92%, 98% and 97%, respectively.

Conclusions

EUS‐FNA can be effectively used as a diagnostic modality in the diagnosis of lesions from non‐pancreatic sites.     

Disruption of an exon splicing enhancer in exon 3 of MLH1 is the cause of HNPCC in a Quebec family

Background

A 3 bp deletion located at the 5′ end of exon 3 of MLH1, resulting in deletion of exon 3 from RNA, was recently identified.

Hypothesis

That this mutation disrupts an exon splicing enhancer (ESE) because it occurs in a purine‐rich sequence previously identified as an ESE in other genes, and ESEs are often found in exons with splice signals that deviate from the consensus signals, as does the 3′ splice signal in exon 3 of MLH1.

Design

The 3 bp deletion and several other mutations were created by polymerase chain reaction mutagenesis and tested using an in vitro splicing assay. Both mutant and wild type exon 3 sequences were cloned into an exon trapping vector and transiently expressed in Cos‐1 cells.

Results

Analysis of the RNA indicates that the 3 bp deletion c.213_215delAGA (gi:28559089, {"type":"entrez-nucleotide","attrs":{"text":"NM_000249.2","term_id":"28559089","term_text":"NM_000249.2"}}NM_000249.2), a silent mutation c.216T→C, a missense mutation c.214G→C, and a nonsense mutation c.214G→T all cause varying degrees of exon skipping, suggesting the presence of an ESE at the 5′ end of exon 3. These mutations are situated in a GAAGAT sequence 3 bp downstream from the start of exon 3.

Conclusions

The results of the splicing assay suggest that inclusion of exon 3 in the mRNA is ESE dependent. The exon 3 ESE is not recognised by all available motif scoring matrices, highlighting the importance of RNA analysis in the detection of ESE disrupting mutations.     

CRYM mutations cause deafness through thyroid hormone binding properties in the fibrocytes of the cochlea

Background

In a search for mutations of μ‐crystallin (CRYM), a taxion specific crystalline which is also known as an NADP regulated thyroid hormone binding protein, two mutations were found at the C‐terminus in patients with non‐syndromic deafness.

Objective

To investigate the mechanism of hearing loss caused by CRYM mutations

Methods

T3 binding activity of mutant μ‐crystallin was compared with that of wild‐type μ‐crystallin, because μ‐crystallin is known to be identical to T3 binding protein. To explore the sites within the cochlea where μ‐crystallin is functioning, its localisation in the mouse cochlea was investigated immunocytochemically using a specific antibody.

Results

One mutant was shown to have no binding capacity for T3, indicating that CRYM mutations cause auditory dysfunction through thyroid hormone binding properties. Immunocytochemical results indicated that μ‐crystallin was distributed within type II fibrocytes of the lateral wall, which are known to contain Na,K‐ATPase.

Conclusions

CRYM mutations may cause auditory dysfunction through thyroid hormone binding effects on the fibrocytes of the cochlea. μ‐Crystallin may be involved in the potassium ion recycling system together with Na,K‐ATPase. Future animal experiments will be necessary to confirm a causal relation between Na,K‐ATPase, T3, and deafness.     

Echocardiographic evaluation during weaning from mechanical ventilation

INTRODUCTION:

Echocardiographic, electrocardiographic and other cardiorespiratory variables can change during weaning from mechanical ventilation.

OBJECTIVES:

To analyze changes in cardiac function, using Doppler echocardiogram, in critical patients during weaning from mechanical ventilation, using two different weaning methods: pressure support ventilation and T‐tube; and comparing patient subgroups: success vs. failure in weaning.

METHODS:

Randomized crossover clinical trial including patients under mechanical ventilation for more than 48 h and considered ready for weaning. Cardiorespiratory variables, oxygenation, electrocardiogram and Doppler echocardiogram findings were analyzed at baseline and after 30 min in pressure support ventilation and T‐tube. Pressure support ventilation vs. T‐tube and weaning success vs. failure were compared using ANOVA and Student''s t‐test. The level of significance was p<0.05.

RESULTS:

Twenty‐four adult patients were evaluated. Seven patients failed at the first weaning attempt. No echocardiographic or electrocardiographic differences were observed between pressure support ventilation and T‐tube. Weaning failure patients presented increases in left atrium, intraventricular septum thickness, posterior wall thickness and diameter of left ventricle and shorter isovolumetric relaxation time. Successfully weaned patients had higher levels of oxygenation.

CONCLUSION:

No differences were observed between Doppler echocardiographic variables and electrocardiographic and other cardiorespiratory variables during pressure support ventilation and T‐tube. However cardiac structures were smaller, isovolumetric relaxation time was larger, and oxygenation level was greater in successfully weaned patients.     

Type 1 diabetes and the OAS gene cluster: association with splicing polymorphism or haplotype?

Background

The 2′,5′‐oligoadenylate synthetase genes (OAS1, OAS2, and OAS3) map to human chromosome 12q24 and encode a family of enzymes pivotal to innate antiviral defence. Recently, the minor allele of an OAS1 single nucleotide polymorphism (SNP) that alters splicing (rs10774671) was found to be associated with increased enzymatic activity and, in a case‐sibling control study, with type 1 diabetes (T1D).

Methods

We have confirmed this T1D association in 784 nuclear families (two parents and at least one affected offspring) by the transmission disequilibrium test (TDT; G:A = 386:329, p = 0.033). However, because of linkage disequilibrium within OAS1 and with the other two OAS genes, functional attribution of the association to this SNP cannot be assumed. To help answer this question, we also genotyped two non‐synonymous SNPs in OAS1 exons 3 and 7.

Results

All three SNPs showed significant transmission distortion. Three of the eight possible haplotypes accounted for 98.4% of parental chromosomes and two of them carried the non‐predisposing A allele at rs10774671. Parents heterozygous for these two haplotypes showed significant transmission distortion (p = 0.009) despite being homozygous at rs10774671.

Conclusions

We confirm the T1D association with rs10774671, but we conclude that it cannot be attributed (solely) to the splicing variant rs10774671. A serine/glycine substitution in OAS1 exon 3 is more likely a functional variant.     

Analysis of mitochondrial DNA sequences in patients with isolated or combined oxidative phosphorylation system deficiency

Background

Enzyme deficiencies of the oxidative phosphorylation (OXPHOS) system may be caused by mutations in the mitochondrial DNA (mtDNA) or in the nuclear DNA.

Objective

To analyse the sequences of the mtDNA coding region in 25 patients with OXPHOS system deficiency to identify the underlying genetic defect.

Results

Three novel non‐synonymous substitutions in protein‐coding genes, 4681T→C in MT‐ND2, 9891T→C in MT‐CO3 and 14122A→G in MT‐ND5, and one novel substitution in the 12S rRNA gene, 686A→G, were found. The definitely pathogenic mutation 3460G→A was identified in an 18‐year‐old woman who had severe isolated complex I deficiency and progressive myopathy.

Conclusions

Bioinformatic analyses suggest a pathogenic role for the novel 4681T→C substitution found in a boy with Leigh''s disease. These results show that the clinical phenotype caused by the primary Leber''s hereditary optic neuropathy mutation 3460G→A is more variable than has been thought. In the remaining 23 patients, the role of mtDNA mutations as a cause of the OXPHOS system deficiency could be excluded. The deficiency in these children probably originates from mutations in the nuclear genes coding for respiratory enzyme subunits or assembly factors.The oxidative phosphorylation (OXPHOS) system consists of five enzyme complexes composed of >70 subunits encoded by the nuclear genome and 13 subunits encoded by mitochondrial DNA (mtDNA). Both isolated and combined enzyme complex deficiencies have been reported in children with various clinical phenotypes. Defects in the OXPHOS system are common causes of inborn errors in energy metabolism, with an estimated incidence of 1 per 10 000 live births.¹ The inheritance pattern is autosomal recessive in most cases, but autosomal dominant and X‐chromosomal inheritance has also been described. Maternal inheritance points to a mutation in mtDNA as the cause of the disease.²More than 2000 human mtDNA‐coding region sequences have been reported since 2000, and about half of these sequences are from Europeans.^3,4,5,6,7,8 The total number of non‐synonymous mutations leading to an amino acid replacement in mtDNA of European origin has been estimated to be 1081, but as many as 18 100 sequences should be analysed to identify 95% of these substitutions.⁹ Sequencing of the complete mtDNA from patients with an OXPHOS system deficiency will evidently lead to the identification of novel pathogenic mutations. This approach has already yielded several novel mutations in MT‐ND genes so far, and some of them—for example, 10191T→C and 14487T→C—may not be uncommon causes of disease.^10,11

Key points

• Enzyme deficiencies of the oxidative phosphorylation (OXPHOS) system may be caused by mutations in the mitochondrial DNA (mtDNA) or in the nuclear DNA. The sequence of mtDNA‐coding region was analysed in 25 patients with OXPHOS system deficiency to identify the underlying genetic defect.
• 4681T→C, a novel substitution in MT‐ND2, was found in a patient with Leigh''s disease. Further analyses suggested a pathogenic role for this substitution.
• 3460G→A, one of the mutations causing Leber''s hereditary optic neuropathy, was identified in a patient with progressive myopathy. The finding suggests that the clinical phenotype caused by this mutation is more variable than what has been known.

There is a growing need to analyse complete mtDNA sequences with a high throughput and in a cost‐efficient manner. We analysed the entire coding region of mtDNA in 28 patients (consisting of children and young adults) with OXPHOS system deficiency using a protocol consisting of conformation‐sensitive gel electrophoresis (CSGE) of amplified mtDNA fragments and subsequent sequencing of those fragments that differed in mobility in CSGE. Obtained sequences were compared with previously reported mtDNA sequences to identify haplotype‐specific or novel variants, and to detect possible sequencing errors.¹² The quality of the sequences was confirmed by comparison of the sequences obtained using the CSGE protocol with those obtained using direct mtDNA sequencing, and by correct identification of three samples with a known pathogenic mutation. Three novel non‐synonymous substitutions and one novel rRNA substitution were detected, and their pathogenic potential was estimated on several criteria.     

Impact of MELD allocation policy on survival outcomes after liver transplantation: a single-center study in northeast Brazil

OBJECTIVE:

To analyze the impact of model for end‐stage liver disease (MELD) allocation policy on survival outcomes after liver transplantation (LT).

INTRODUCTION:

Considering that an ideal system of grafts allocation should also ensure improved survival after transplantation, changes in allocation policies need to be evaluated in different contexts as an evolutionary process.

METHODS:

A retrospective cohort study was carried out among patients who underwent LT at the University of Pernambuco. Two groups of patients transplanted before and after the MELD allocation policy implementation were identified and compared using early postoperative mortality and post‐LT survival as end‐points.

RESULTS:

Overall, early postoperative mortality did not significantly differ between cohorts (16.43% vs. 8.14%; p = 0.112). Although at 6 and 36‐months the difference between pre‐ vs. post‐MELD survival was only marginally significant (p = 0.066 and p = 0.063; respectively), better short, medium and long‐term post‐LT survival were observed in the post‐MELD period. Subgroups analysis showed special benefits to patients categorized as non‐hepatocellular carcinoma (non‐HCC) and moderate risk, as determined by MELD score (15‐20).

DISCUSSION:

This study ensured a more robust estimate of how the MELD policy affected post‐LT survival outcomes in Brazil and was the first to show significantly better survival after this new policy was implemented. Additionally, we explored some potential reasons for our divergent survival outcomes.

CONCLUSION:

Better survival outcomes were observed in this study after implementation of the MELD criterion, particularly amongst patients categorized as non‐HCC and moderate risk by MELD scoring. Governmental involvement in organ transplantation was possibly the main reason for improved survival.     

Markers of autoimmune liver diseases in postmenopausal women with osteoporosis

INTRODUCTION:

Osteoporosis is a common complication of chronic liver diseases. However, there is limited information about autoimmune liver diseases as a factor of secondary osteoporosis. Therefore, we aimed to investigate the autoantibodies of autoimmune liver diseases in patients with osteoporosis.

METHODS:

One hundred fifty female patients with postmenopausal osteoporosis were included. Bone mineral density was measured by dual energy X‐ray absorptiometry. We analysized autoantibodies including antinuclear antibodies, liver membrane antibodies, anti‐liver/kidney microsomal autoantibodies1, liver‐specific protein, anti‐smooth muscle antibodies, and anti‐mitochondrial antibodies by indirect immunofluorescence. Serum was assayed for the levels of aminotransferases.

RESULTS:

The mean age of the patients was 63,13±8,6 years. The mean values of L1‐L4 T‐scores and femur total T‐scores were ‐3,08±0,58 and ‐1,53±0,81, respectively. Among the 150 patients with osteoporosis, 14 (9.3%) were antinuclear antibodies, four (2.7%) were liver membrane antibodies, three (2.0%) were anti‐liver/kidney microsomal autoantibodies1, and two (1.3%) were liver‐specific protein positive. None of the patients had anti‐mitochondrial antibodies or smooth muscle antibodies positivity. The mean values of levels of aminotransferases were within normal range.

CONCLUSIONS:

The presence of liver membrane antibodies, liver‐specific protein, and anti‐liver/kidney microsomal autoantibodies1 has permitted us to see that there may be some suspicious clues of autoimmune liver diseases in patients with osteoporosis as a secondary risk factor. On the other hand, there is a need for comprehensive studies with a larger sample size and studies designed to compare the results with a normal population to understand the clinical importance of our findings.     

Penetrance of adrenocortical tumours associated with the germline TP53 R337H mutation

Background

An inherited germline P53 mutation has been identified in cases of childhood adrenocortical carcinoma (ACT), a neoplasm with a high incidence in southern Brazil. The penetrance of ACT in carriers of the point mutation, which encodes an arginine‐to‐histidine substitution at codon 337 of TP53 (R337H), has not been determined.

Objective

To investigate the penetrance of childhood ACT in carriers of the R337H TP53 mutation.

Methods

The family histories of 30 kindreds of 41 southern Brazilian children with ACT were obtained. A PCR based assay was used to detect this P53 mutation in a large number of relatives of children with ACT. In all, 927 individuals were tested for the mutation, 232 from the non‐carrier and 695 (including the 40 probands) from the carrier parental lines.

Results

40 children with ACT carried the TP53 R337H mutation; the remaining child with ACT was not tested. There was no evidence of Li‐Fraumeni syndrome in any of the kindreds; however, seven met the criteria for Li‐Fraumeni‐like syndrome. The carrier parental line was identified in each kindred. Of the 695 individuals tested in the carrier parental line, 240 (34.5%) were positive for the mutation, while none of the 232 individuals in the other parental line carried the mutation. The penetrance of ACT was 9.9% (95% confidence interval, 8.7% to 11.1%).

Conclusions

The TP53 R337H mutation dramatically increases predisposition to childhood ACT but not to other cancers, and explains the increased frequency of ACT observed in this geographic region.     

Pediatric lymphomas in Brazil

OBJECTIVE:

This study provides the clinical pathological characteristics of 1301 cases of pediatric/adolescent lymphomas in patients from different geographic regions of Brazil.

METHODS:

A retrospective analyses of diagnosed pediatric lymphoma cases in a 10‐year period was performed. We believe that it represents the largest series of pediatric lymphomas presented from Brazil.

RESULTS:

Non‐Hodgkin lymphomas represented 68% of the cases, including those of precursor (36%) and mature (64%) cell origin. Mature cell lymphomas comprised 81% of the B‐cell phenotype and 19% of the T‐cell phenotype. Hodgkin lymphomas represented 32% of all cases, including 87% of the classical type and 13% of nodular lymphocyte predominant type. The geographic distribution showed 38.4% of the cases in the Southeast region, 28.7% in the Northeast, 16.1% in the South, 8.8% in the North, and 8% in the Central‐west region. The distribution by age groups was 15–18 years old, 33%; 11–14 years old, 26%; 6–10 years old, 24%; and 6 years old or younger, 17%. Among mature B‐cell lymphomas, most of the cases were Burkitt lymphomas (65%), followed by diffuse large B‐cell lymphomas (24%). In the mature T‐cell group, anaplastic large cell lymphoma, ALK‐positive was the most prevalent (57%), followed by peripheral T‐cell lymphoma, then not otherwise specified (25%). In the group of classic Hodgkin lymphomas, the main histological subtype was nodular sclerosis (76%). Nodular lymphocyte predominance occurred more frequently than in other series.

CONCLUSION:

Some of the results found in this study may reflect the heterogeneous socioeconomical status and environmental factors of the Brazilian population in different regions.     

Entrapped victims in motor vehicle collisions: characteristics and prehospital care in the city of São Paulo, Brazil

OBJECTIVE:

To examine the severity of trauma in entrapped victims and to identify risk factors for mortality and morbidity.

INTRODUCTION:

Triage and rapid assessment of trauma severity is essential to provide the needed resources during prehospital and hospital phases and for outcome prediction. It is expected that entrapped victims will have greater severity of trauma and mortality than non‐entrapped subjects.

METHODS:

A transverse, case–control, retrospective study of 1203 victims of motor vehicle collisions treated during 1 year by the prehospital service in São Paulo, Brazil was carried out. All patients were drivers, comprising 401 entrapped victims (33.3%) and 802 non‐entrapped consecutive controls (66.7%). Sex, age, mortality rates, Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), corporal segments, timing of the prehospital care and resource use were compared between the groups. The results were analysed by χ², Zres, analysis of variance and Bonferroni tests.

RESULTS:

Entrapped victims were predominantly men (84.8%), aged 32±13.1 years, with immediate mortality of 10.2% and overall mortality of 11.7%. They had a probability of death at the scene 8.2 times greater than that of non‐entrapped victims. The main cause of death was hemorrhage for entrapped victims (45.2%) and trauma for non‐entrapped victims. Of the entrapped victims who survived, 18.7% had a severe GCS (OR = 10.62), 12% a severe RTS (OR = 9.78) and 23.7% were in shock (OR = 3.38). Entrapped victims were more commonly transported to advanced life support units and to tertiary hospitals.

CONCLUSION:

Entrapped victims had greater trauma severity, more blood loss and a greater mortality than respective, non‐entrapped controls.     

Probable role of Beta 2-adrenergic receptor gene haplotype in toluene diisocyanate-induced asthma

Purpose

A genetic polymorphism of the beta 2-adrenergic receptor is a major factor associated with the asthmatic phenotype. The association of this polymorphism with toluene diisocyanate (TDI)-induced asthma has not been investigated. We examined 103 TDI-induced asthma patients (TDI-OA), 60 asymptomatic exposed controls (AEC), and 263 unexposed healthy controls (NC) in order to identify beta 2-adrenergic receptor gene (ADRB2) polymorphisms and the possible association with TDI-induced asthma.

Methods

Single nucleotide polymorphisms (SNPs) of ADRB2 were genotyped by direct sequencing. Serum-specific IgE and IgG levels were measured using an enzyme-linked immunosorbent assay. Phenotypes and clinical patient parameters were compared.

Results

SNPs were identified (-47 T>C, -20 T>C, Arg16Gly A>G, Gln27Glu C>G, Leu134Leu G>A, Arg175Arg C>A) during ADRB2 screening (from -231 to 793 bp). No significant differences in allelic and genotypic frequencies were noted for any of the six ADRB2 SNPs. The Arg16Gly A>G, Leu134Leu G>A, and Arg175Arg C>A SNPs and haplotype 1 [TTACGC] were significantly associated with specific IgE antibodies to the TDI-human serum albumin (HSA) conjugate in TDI-exposed subjects (P<0.05). Exposed workers with the ADRB2 ht1/ht1 homozygote had a significantly higher TDI-HSA conjugate-specific IgE sensitization rate than did those with the null ht1 haplotype (odds ratio, 15.40; 95% confidence interval, 1.81-131.06).

Conclusions

ADRB2 polymorphisms may affect IgE-specific sensitization to TDI-HSA conjugate in TDI-exposed workers.     

Failure of carnitine in improving hepatic nitrogen content in alcoholic and non-alcoholic malnourished rats

AIMS:

To investigate the effect of carnitine supplementation on alcoholic malnourished rats'' hepatic nitrogen content.

METHODS:

Malnourished rats, on 50% protein‐calorie restriction with free access to water (malnutrition group) and malnourished rats under the same conditions with free access to a 20% alcohol/water solution (alcohol group) were studied. After the undernourishment period (4 weeks with or without alcohol), both groups were randomly divided into two subgroups, one of them nutritionally recovered for 28 days with free access to a normal diet and water (recovery groups) and the other re‐fed with free access to diet and water plus carnitine (0.1 g/g body weight/day by gavage) (carnitine groups). No alcohol intake was allowed during the recovery period.

RESULTS:

The results showed: i) no difference between the alcohol/no alcohol groups, with or without carnitine, regarding body weight gain, diet consumption, urinary nitrogen excretion, plasma free fatty acids, lysine, methionine, and glycine. ii) Liver nitrogen content was highest in the carnitine recovery non‐alcoholic group (from 1.7 to 3.3 g/100 g, P<0^.05) and lowest in alcoholic animals (about 1.5 g/100g). iii) Hepatic fat content (∼10 g/100 g, P>^.05) was highest in the alcoholic animals.

CONCLUSION:

Carnitine supplementation did not induce better nutritional recovery.     

Direct contact in inviting high-risk members of hereditary colon cancer families to genetic counselling and DNA testing

Background

Identification of hereditary predisposition to cancer has limited significance if not followed by efficient cancer prevention in the family. Probands are traditionally left to inform their relatives about the increased risk, but distant relatives may remain uninformed. An approach to contacting directly at‐risk persons assumed to be unaware of their increased cancer risk was taken. With cancer prevention as the ultimate goal, the study was aimed at investigating attitudes towards and psychosocial consequences of this novel strategy.

Methods

In families with hereditary non‐polyposis colorectal cancer (Lynch syndrome), 286 healthy adult relatives with a 50% risk of a predisposing mutation were contacted by letter. Of these, 112 participated in counselling and predictive testing. Baseline information and information obtained 1 month after the test for 73 respondents were compared with 299 corresponding subjects, approached via the proband (family‐mediated approach in our previous study) in these families.

Results

After the contact letter, 51% consented to the study. Of these, 92% approved of the direct contact and 33% had tried to seek information. In 34% of the mutation carriers, neoplasia was identified in the first post‐test colonoscopy. Although post‐test fear of cancer increased among the mutation carriers and decreased among noncarriers, almost all participants were satisfied with their decision to participate, independently of their test results, parallel to the family‐mediated approach.

Conclusion

In this large‐scale study, relatives in cancer families were actively contacted to inform them of the condition and genetic counselling. Their attitudes were encouraging, and the psychosocial consequences were similar to the family‐mediated approach. Our results suggest the appropriateness of direct contact as an alternative method of contact in cases of life‐threatening treatable disease.     

Identification of novel deletion breakpoints bordered by segmental duplications in the NF1 locus using high resolution array-CGH

Background

Segmental duplications flanking the neurofibromatosis type 1 (NF1) gene locus on 17q11 mediate most gene deletions in NF1 patients. However, the large size of the gene and the complexity of the locus architecture pose difficulties in deletion analysis. We report the construction and application of the first NF1 locus specific microarray, covering 2.24 Mb of 17q11, using a non‐redundant approach for array design. The average resolution of analysis for the array is ∼12 kb per measurement point with an increased average resolution of 6.4 kb for the NF1 gene.

Methods

We performed a comprehensive array‐CGH analysis of 161 NF1 derived samples and identified heterozygous deletions of various sizes in 39 cases. The typical deletion was identified in 26 cases, whereas 13 samples showed atypical deletion profiles.

Results

The size of the atypical deletions, contained within the segment covered by the array, ranged from 6 kb to 1.6 Mb and their breakpoints could be accurately determined. Moreover, 10 atypical deletions were observed to share a common breakpoint either on the proximal or distal end of the deletion. The deletions identified by array‐CGH were independently confirmed using multiplex ligation‐dependent probe amplification. Bioinformatic analysis of the entire locus identified 33 segmental duplications.

Conclusions

We show that at least one of these segmental duplications, which borders the proximal breakpoint located within the NF1 intron 1 in five atypical deletions, might represent a novel hot spot for deletions. Our array constitutes a novel and reliable tool offering significantly improved diagnostics for this common disorder.     

Prognostic factors of a good response to initial therapy in children and adolescents with differentiated thyroid cancer

BACKGROUND:

Therapeutic approaches in pediatric populations are based on adult data because there is a lack of appropriate data for children. Consequently, there are many controversies regarding the proper treatment of pediatric patients.

OBJECTIVE:

The present study was designed to evaluate patients with differentiated thyroid carcinoma diagnosed before 20 years of age and to determine the factors associated with the response to the initial therapy.

METHODS:

Sixty‐five patients, treated in two tertiary‐care referral centers in Rio de Janeiro between 1980 and 2005 were evaluated. Information about clinical presentation and the response to initial treatment was analyzed and patients had their risk stratified in Tumor‐Node‐ Metastasis; Age‐Metastasis‐Extracapsular‐Size; distant Metastasis‐Age‐Completeness of primary tumor resection‐local Invasion‐Size and American‐Thyroid‐Association classification

RESULTS:

Patients ages ranged from 4 to 20 years (median 14). The mean follow‐up was 12,6 years. Lymph node metastasis was found in 61.5% and indicated a poor response to initial therapy, with a significant impact on time for achieving disease free status (p = 0.014 for response to initial therapy and p<0,0001 for disease‐free status in follow‐up). Distant metastasis was a predictor of a poor response to initial therapy in these patients (p = 0.014). The risk stratification systems we analyzed were useful for high-risk patients because they had a high sensitivity and negative predictive value in determining the response to initial therapy.

CONCLUSIONS:

Metastases, both lymph nodal and distant, are important predictors of the persistence of disease after initial therapy in children and adolescents with differentiated thyroid cancer.     

Cowden syndrome and Bannayan Riley Ruvalcaba syndrome represent one condition with variable expression and age-related penetrance: results of a clinical study of PTEN mutation carriers

Background

The most commonly reported phenotypes described in patients with PTEN mutations are Bannayan–Riley–Ruvalcaba syndrome (BRRS), with childhood onset, macrocephaly, lipomas and developmental delay, and Cowden Syndrome (CS), an adult‐onset condition recognised by mucocutaneous signs, with a risk of cancers, in particular those of the thyroid and breast. It has been suggested that BRRS and CS are the same condition, but the literature continues to separate them and seek a genotype–phenotype correlation.

Objective

To study the clinical features of patients with known PTEN mutations and observe any genotype–phenotype correlation.

Methods

In total, 42 people (25 probands and 17 non‐probands) from 26 families of all ages with PTEN mutations were recruited through the UK clinical genetics services. A full clinical history and examination were undertaken.

Results

We were unable to demonstrate a genotype–phenotype correlation. Furthermore, our findings in a 31‐year‐old woman with CS and an exon 1 deletion refutes previous reports that whole exon deletions are only found in patients with a BRRS phenotype.

Conclusion

Careful phenotyping gives further support for the suggestion that BRRS and CS are actually one condition, presenting variably at different ages, as in other tumour‐suppressor disorders such as neurofibromatosis type 1. This has important counselling implications, such as advice about cancer surveillance, for children diagnosed with BRRS.