Lumbar radiculopathy caused by extradural rheumatoid nodules. Case report

The authors report on a 51-year-old woman with a 9-year history of rheumatoid arthritis (RA) who presented with symptomatic rheumatoid nodules in the lumbar extradural region with compression on the L-5 nerve roots bilaterally. She had also suffered from dysesthesia in the right lower leg and intermittent claudication. Magnetic resonance imaging revealed masses compressing the dural sac, and on lumbar myelography and computed tomography myelography a filling defect at L4-5 was revealed, which was compressing the dural sac posterolaterally on both sides. The masses were surgically removed. On histological examination the typical characteristics of rheumatoid nodules were found. Soon after the operation all of the patient's symptoms disappeared. There have been few reports on extradural rheumatoid nodules. Patients with RA usually complain of articular symptoms, and in fact the patient in the present study had been referred to the authors' institution for total hip arthroplasty. However, various symptoms other than those arising from articular lesions were found clinically. The authors believe that if patients with RA are also examined for extraarticular lesions, it is likely that these will be more frequently detected.     

Limb salvage in soft tissue sarcomas involving neurovascular structures using combined surgical resection and brachytherapy

While there is debate in the literature concerning the tolerance of neurovascular structures to external beam radiation, the tolerance of these tissues to interstitial radiation has never been established. To evaluate the dose of radiation and its effect on early and late toxicity of neurovascular structures, a retrospective review of our experience was undertaken. Between 1975 and 1987, 299 patients with extremity sarcomas underwent limb-sparing surgery and tumor bed Iridium-192 interstitial implantation at Memorial Sloan-Kettering Cancer Center. Forty-five patients (15%) of this group were found to have locally advanced tumors involving major neurovascular structures. Of these patients, 64% had high grade lesions. Eleven percent had evidence of gross residual disease on these structures, and an additional 58% had microscopic residual disease at or close to the margins of resection. After loading catheters were placed directly upon the neurovascular structures in the exposed tumor bed and a median dose of 4400 cGy was delivered to the target volume. Eight patients had previous radiation to the treated field and 13 patients received postoperative radiation. With a median follow-up of 4 years, the 5-year actuarial disease-free survival was 69% and the 5-year actuarial freedom from in-field failure was 79%. The 5-year actuarial incidence of distant metastases was 30%. Eighty-four percent of the patients maintained long-term preservation of limb function without the need for amputation. Four patients (9%) ultimately developed evidence of radiation neuritis 6-20 months post therapy. All four patients had received additional radiation with cumulative doses exceeding 9000 cGy to the neurovascular bundle. We conclude that combined surgical resection and interstitial radiation for locally advanced sarcomas with neurovascular involvement can provide excellent local control with preservation of limb and neurovascular function without significant toxicity.     

Making dendritic cells from the inside out: lentiviral vector-mediated gene delivery of granulocyte-macrophage colony-stimulating factor and interleukin 4 into CD14+ monocytes generates dendritic cells in vitro

We have evaluated a one-hit lentiviral transduction approach to genetically modifying monocytes in order to promote autocrine and paracrine production of factors required for their differentiation into immature dendritic cells (DCs). High-titer third-generation self-inactivating lentiviral vectors expressing granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin 4 (IL-4) efficiently achieved simultaneous and persistent codelivery of the transgenes into purified human CD14+ monocytes. Coexpression of GM-CSF and IL-4 in CD14+ cells was sufficient to induce their differentiation into a DC-like phenotype, as evidenced by their morphology, immature immunophenotypic profile (CD14-, CD1a+, CD80+, CD86+, MHC-I+, MHC-II+), and their ability to further develop into a mature phenotype (CD83+) on further treatment with soluble CD40 ligand. Mixed lymphocyte reactions showed that the T cell-stimulating activity of lentivirus-modified DCs was superior to that of DCs grown by conventional methods. Lentivirus-modified DCs displayed efficient antigen-specific, MHC class I-restricted stimulation of autologous CD8+ T cells, as shown by IFN-gamma production and CTL assays. DCs coexpressing GM-CSF and IL-4 could be kept metabolically active and viable in culture for 14 days in the absence of exogenously added growth factors, unlike conventionally produced DCs. Coexpression of FLT3 ligand did not improve the viability, expansion, or immunologic performance of lentivirus-modified DCs. This article demonstrates the proof-of-concept to genetically convert monocytes to DC-type antigen-presenting cells with lentiviral vectors.     

Radial scar without associated atypical epithelial proliferation on image-guided 14-gauge needle core biopsy: analysis of 49 cases from a single-centre and review of the literature

The purpose of this study was to evaluate the reliability of image-guided 14-gauge needle core biopsy in the diagnosis of radial scar without associated atypical epithelial proliferation, by comparison with definitive histological diagnosis on surgical excision. The records of 8792 consecutive image-guided 14-gauge needle core biopsy of the breast performed from January 1996 to December 2009 were reviewed. Forty-nine cases of radial scar without associated atypical epithelial proliferation were identified and compared with definitive histological diagnosis on surgical excision. The definitive histological diagnosis on surgical excision confirmed the results of image-guided 14-gauge needle core biopsy in 36 of 49 cases (73.5%), in 9 cases (18.3%) radial scar was associated with atypical epithelial proliferation, while 4 cases out of 49 cases were upgraded to carcinoma (3 cases of ductal carcinoma in situ and one case of invasive lobular carcinoma), with an underestimation rate of 8.2%. A diagnosis of radial scar without associated atypical epithelial proliferation on image-guided 14-gauge needle core biopsy does not exclude a malignancy on surgical excision; consequently during the multidisciplinary discussion further assessment by surgical excision or vacuum-assisted excision, as recently reported, needs to be considered to obtain a definitive histological diagnosis.     

Changes in very low density lipoproteins with cholesterol loading in man

We have studied the effects of cholesterol loading in man, seeking changes in VLDL that may define a population of particles that resemble the atherogenic β-VLDL in experimental animals. Comparisons were made in 6 men during two diets, containing either 200 mg or 1700 mg cholesterol daily. Although the total plasma cholesterol did not rise significantly over 4 wk of cholesterol loading (mean ± SD 178 ± 41 to 194 ± 48 mg/dl), distinct changes in lipoprotein composition occurred; (1) HDL cholesterol rose significantly (34 ± 4 to 41 ± 5) and plasma apoprotein Al rose from 118 ± 10 to 129 ± 9 mg/dl, (2) Within VLDL, the proportion of apoproteins E:C rose from 0.18 to 0.32 (p < 0.005), though the apoprotein E concentration did not change, (3) Within VLDL, the ratio of cholesteryl esters:triglyceride rose, (4) Within VLDL (Sf 20–400) a population of particles that bound to heparin on heparin-sepharose columns increased threefold; since these particles were richer in apoprotein E and in cholesteryl ester than were VLDL not bound to heparin, we conclude that cholesterol loading leads to an increase in smaller VLDL particles, possibly partly catabolized VLDL or independently secreted IDL, that resemble findings in cholesterol fed animals, and (5) Transport kinetics of apoprotein B in VLDL studied in four subjects did not show a rise in production but this does not rule out increased secretion of a cholesteryl ester, apoprotein E enriched subpopulation of VLDL.     

Role of magnetic resonance in the staging of endometrial carcinoma

Biopsy is the technique of choice for the definitive diagnosis of endometrial carcinoma. Since lymphatic tumor spread has been demonstrated to depend on the degree of myometrial involvement, the definition of the latter with imaging techniques may significantly affect both prognosis and therapy. We investigated, by means of MR imaging at 0.5 T, 14 patients with endometrial carcinoma, to assess both tumor stage and myometrial involvement. FIGO staging system was employed, and M parameter evaluated (M0 = no myometrial involvement; M1 = involvement confined to the inner third; M2 = involvement confined to the middle third; M3 = involvement of the whole myometrium). Another parameter was the characteristic high signal of the tumor on PD and T2W images. The patients were then operated and MR information was correlated with surgical findings. Overall diagnostic accuracy of MR imaging was 85.7% in tumor staging, and 92.2% in defining M parameter. Tumor spread into adnexa and into cervical canal was poorly demonstrated by MR imaging.