Risk factors for relapse in clinical stage I nonseminomatous testicular germ cell tumors: results of the German Testicular Cancer Study Group Trial.

PURPOSE: To prospectively assess potential risk factors for relapse in clinical stage I nonseminomatous germ cell tumors of the testis (CS I NSGCT). PATIENTS AND METHODS: From September 1996 to May 2002, 200 patients with CS I NSGCT were prospectively assigned to retroperitoneal lymph node dissection (RPLND), and risk factor assessment was performed within a multicenter protocol. One hundred sixty-five patients had an adequate minimum follow-up of 12 months (mean, 34.5 months) or had pathologic stage II. RESULTS: Pathologic stage II disease was found in 27.9% of patients. Only 0.6% of patients relapsed in the retroperitoneum after confirmation of pathologic stage I disease. With reference pathology, vascular invasion (VI) was most predictive of stage in multifactorial analysis (accuracy, 65.1%). However, the positive predictive value (PPV) of VI to predict patients who have metastatic disease or relapse during follow-up was only 52.7%. With absent VI, low-risk patients had a negative predictive value (NPV) of 76.9%. With a combination of several risk factors, the PPV increased to 63.6% and the negative predictive value increased to 86.5%. CONCLUSION: Even with an optimal combination of prognostic factors and reference pathology, more than one third of patients predicted to have pathologic stage II or relapse during follow-up will not harbor metastatic disease and, therefore, would be overtreated with adjuvant therapy. However, patients at low risk may be predicted at an 86.5% level, and thus, surveillance in highly compliant patients would be a valuable option. For high-risk patients, further reduction of adjuvant treatment is necessary.     

Chorea minor mit subklinischer Herzbeteiligung Welche Wertigkeit hat die Farbdopplerechokardiographie bei der Diagnose der rheumatischen Valvulitis?

Zusammenfassung Für die Diagnose einer rheumatischen Valvulitis wird nach den revidierten Jones-Kriterien von 1992 ein pathologischer Auskultationsbefund gefordert, der echokardiographische Befund einer Mitralklappeninsuffizienz wird nicht akzeptiert. Wir stellen eine Patientin mit akutem rheumatischem Fieber vor, bei der sich neben einer Chorea minor keine weiteren Major- oder Minorsymptome fanden. Allerdings konnte echokardiographisch neben einem Perikardergu? eine Mitralklappeninsuffizienz nachgewiesen werden. Diskussion: Bei Patienten mit akutem rheumatischem Fieber wird eine Mitralklappeninsuffizienz ohne auskultatorisches Korrelat weitaus h?ufiger als bei gesunden Kindern nachgewiesen und ist unter Anwendung strenger echokardiographischer Kriterien von physiologischen Mitralklappenregurgitationen abgrenzbar. Da sich auch bei Patienten ohne klinische Zeichen einer Valvulitis nach langer Latenz ein rheumatischer Herzfehler manifestieren kann, sollte – unter Anwendung strenger echokardiographischer Kriterien – der Nachweis einer pathologischen Mitralklappeninsuffizienz in den Jones-Kriterien berücksichtigt werden.      

Juvenile Parodontopathie bei Ehlers-Danlos-Syndrom Typ VIII

Zusammenfassung Wir berichten über eine 15j?hrige Patientin mit einer frühzeitig einsetzenden Parodontopathie, die auch bei weiteren Familienmitgliedern vorgelegen hat. Weiterhin waren eine erh?hte Vulnerabilit?t der Haut mit verz?gerter und atypischer Wundheilung sowie eine überstreckbarkeit der Gelenke vorhanden. Auff?llig war au?erdem eine Voralterung, v.a. im Gesicht. Anhand des klinischen Bilds sowie der Familienanamnese konnte ein Ehlers-Danlos-Syndrom Typ VIII diagnostiziert werden, welches autosomal-dominant vererbt wird. Die genetischen und biochemischen Grundlagen dieser Erkrankung sind bisher nicht bekannt. Diskussion: Eine Parodontopathie im Rahmen eines Ehlers-Danlos-Syndroms kann als charakteristisch für den Typ VIII angesehen werden, w?hrend sie nur selten ein Symptom des Typs VI darstellt. Die beim Ehlers-Danlos-Syndrom nur zum Teil auftretende Voralterung kann zur Fehldiagnose eines Progeriesyndroms führen. Aufgrund der Parodontopathie sollte eine frühzeitige zahn?rztliche Betreuung erfolgen, um das Auftreten von Zahnverlusten m?glichst zu verz?gern.      

Physiologie der Megakaryopoiese und des Thrombozyten

Zusammenfassung Thrombozyten werden aus dem Zytoplasma von Megakaryozyten freigesetzt und haben eine entscheidende Funktion bei der Blutgerinnung. Sie sind auch in entzündliche Prozesse und die Wundheilung involviert. Die Proliferation und Differenzierung von Megakaryozyten wird durch die Bindung des Wachstumsfaktors Thrombopoietin (Tpo) an seinen Rezeptor c-Mpl stimuliert und reguliert. Glykoproteine der Thrombozytenmembran vermitteln bei Gefäßverletzung die Bindung von Thrombozyten an das subendotheliale Gewebe und die Aggregation zu hämostatischen Gerinnseln. Störungen der Megakaryopoiese, Thrombozytopoiese und Thrombozytenfunktion verursachen mit oder ohne Thrombozytopenie eine Gerinnungsstörung. Mit der molekularbiologischen Analyse ist es in jüngster Zeit gelungen, die Regulationskaskaden für die Plättchenfunktion, Thrombopoiese und Megakaryopoiese zunehmend besser zu verstehen und auf Krankheiten zu beziehen. Damit verknüpft sich die Hoffnung, gezielter in pathologische Prozesse eingreifen zu können.     

Antecedents of respiratory pauses in extremely low birth weight infants supported by proportional assist ventilation.

OBJECTIVE: To determine characteristics of breathing patterns prior to respiratory pauses in extremely low birth weight (ELBW) infants breathing spontaneously under proportional assist ventilation (PAV). METHODS: Thirteen infants (mean +/- SD: gestational age 25 +/- 1 weeks; birth weight 753 +/- 149 g; age 4 +/- 3 days) were studied. Recordings were obtained under PAV over two-hour periods on two consecutive days. The last 10 breaths preceding respiratory pauses were analyzed. RESULTS: Tidal volume, inspiratory and expiratory peak flow, and mean inspiratory flow decreased in the last breaths prior to respiratory pauses compared to all other breaths (p < 0.001). Of all apneas 89% were preceded by a decrease in tidal volume of at least 33% (435/487; p < 0.001). The positive predictive value of a decrease in tidal volume to predict an apnea was 26% (435/1640; p < 0.001). CONCLUSIONS: Decreases in tidal volume of at least 33% and in airflow are the predominant changes in the breathing pattern prior to respiratory pauses in ELBW infants, preceding 89% of all respiratory pauses. Their low positive predictive value of 26% however, indicates that further variables of breathing need to be implemented to predict cessation of breathing with higher precision.     

Diaphysäre Femurpseudarthrosen – nur ein technisches Problem?

Between 1981 and 1994 at the Bergmannsheil Ruhr University Hospital in Bochum, Germany, we treated 145 patients with femoral diaphyseal nonunions following initial operative treatment. Of these patients, 138 received this initial operative treatment at an outside institution. The primary reconstructions for the fractures utilized plates in 112 cases, reamed nails in 24 cases and external fixators in 9 cases. The average age of the patients was 35 years and the mean time from the initial operative treatment was 2 years. Twenty-seven patients (19%) presented with a hypertrophic nonunion and 118 (81%) with an atrophic nonunion. There was a significant correlation between primary "classic" plating and development of an atrophic nonunion (chi 2-test: P < 0.01). We observed 34 wound infections (23%) with no significant correlation to the type of primary osteosynthesis. We determined that 73 of the pseudarthroses were due to improper osteosynthesis techniques. Of these cases, 41% involved the use of plates, 83% involved the use of reamed nails, and 78% involved the use of external fixators. Fracture location near the diaphyseal-metaphyseal junctions was common in this problematic group. Ninety-two percent of all plates led to atrophic nonunions. There were 21 open fractures and of these 90% (n = 19) developed an atrophic pseudarthrosis and 29% (n = 6) developed a wound infection. Fifty-seven (39%) of all patients had additional injuries, but we found that did not increase the risk of disturbed bone healing. Our revision operations focused on the elimination of wound infections, refreshment of bone healing, and improvement in fragment stability. Only 28% of all "classic" plates and 11% of all external fixators were changed to an intramedullary implant at the time of the first revision surgery. Hypertrophic nonunions required a mean of 1.3 revision operations to achieve bone healing whereas a mean of 2 revision operations were necessary to fuse atrophic bone ends (P < 0.05). In cases of diaphyseal pseudarthrosis healing time was not affected by the type of osteosynthesis used for primary reconstructions. Since lack of fracture healing can often already be observed directly from postoperative X-rays, we recommend that revision procedures be performed early. The prolonged length of time to care for femoral nonunions underlines the importance of appropriate primary fracture treatment. That takes into consideration both the biomechanical and the biological aspects of bone healing.     

Expression, localization, and function of the carnitine transporter octn2 (slc22a5) in human placenta.

L-carnitine is assumed to play an important role in fetal development, and there is evidence that carnitine is transported across the placenta. The protein involved in this transfer, however, has not been identified on a molecular level. We therefore characterized localization and function of the carnitine transporter OCTN2 in human placenta. Significant expression of OCTN2 mRNA was detected in human placenta applying real-time polymerase chain reaction technology. Confocal immunofluorescence microscopy using an antibody directed against the carboxy terminus of OCTN2 protein revealed that it is predominantly expressed in the apical membrane of syncytiotrophoblasts. This was confirmed by the costaining of organic anion-transporting polypeptide B and MRP2, which are known to be expressed mainly in the basal and apical syncytiotrophoblasts membrane, respectively. To further support this finding, we performed transport studies using basal and apical placenta membrane vesicles. We could demonstrate that the carnitine uptake into the apical vesicles was about eight times higher compared with the basal ones. Moreover, this uptake was sodium- and pH-dependent with an apparent K(m) value of 21 muM and inhibited by verapamil, which is in line with published data for recombinant OCTN2. Finally, experiments using trophoblasts in cell culture revealed that expression of OCTN2 paralleled human choriogonadotropin production and thus is modulated by cellular differentiation. In summary, we show expression and function of OCTN2 in human placenta. Moreover, several lines of evidence indicate that OCTN2 is localized in the apical membrane of syncytiotrophoblasts, thereby suggesting a major role in the uptake of carnitine during fetal development.     

A novel metalloprotease from Vipera lebetina venom induces human endothelial cell apoptosis.

A novel endothelial cell apoptosis inducing metalloprotease (VLAIP) was found in the snake venom of Vipera lebetina. This metalloprotease is a heterodimeric glycoprotein with molecular mass of about 106 kDa. The protease hydrolyzes azocasein, fibrinogen and oxidized insulin B-chain. The enzyme readily hydrolyzes the Aalpha-chain and more slowly Bbeta-chain of fibrinogen. VLAIP does not cleave fibrin. The complete amino acid sequences of the two different monomers of VLAIP are deduced from the nucleotide sequences of cDNAs encoding these proteins. The full-length cDNA sequences of the VLAIP-A and VLAIP-B encode open reading frames of 616 and 614 amino acids that include signal peptide, propeptide and mature metalloproteinase with disintegrin-like and cysteine-rich domains. VLAIP belongs to the metalloprotease/disintegrin family of reprolysins and has high identity with the proteins that induce apoptosis of endothelial cells. Treatment of HUVEC cells with VLAIP induces changes in the attachment of cells to the substrate and causes cell death. We demonstrated that VLAIP inhibits endothelial cell adhesion to extracellular matrix proteins: fibrinogen, fibronectin, vitronectin, collagen I, and collagen IV. The induction of apoptosis by VLAIP was shown by means of a typical DNA fragmentation pattern of apoptotic cells as well as by monitoring phosphatidylserine externalization using annexin V-FITC staining and flow cytometric analysis.     

An acquired G-CSF receptor mutation results in increased proliferation of CMML cells from a patient with severe congenital neutropenia.

Severe congenital neutropenia (CN) is characterized by a maturation arrest of myelopoiesis at the promyelocyte stage. Treatment with pharmacological doses of recombinant human granulocyte colony-stimulating factor (rh-G-CSF) stimulates neutrophil production and decreases the risk of major infectious complications. However, approximately 15% of CN patients develop myeloid malignancies that have been associated with somatic mutations in the G-CSF receptor (G-CSFR) and RAS genes as well as with acquired monosomy 7. We report a CN patient with chronic myelomonocytic leukemia (CMML) who never received rh-G-CSF. Molecular analysis demonstrated a somatic G-CSFR mutation (C2390T), which led to expression of a truncated G-CSFR protein in the CMML. Normal G-CSFR expression was unexpectedly absent in primary and cultured CMML. In addition, CMML cells showed monosomy 7 and an oncogenic NRAS mutation. In vitro culture revealed a G-CSF-dependent proliferation of CMML cells, which subsequently differentiated along the monocytic/macrophage lineage. Our results provide direct evidence for the in vivo expression of a truncated G-CSFR in leukemic cells, which emerged in the absence of rh-G-CSF treatment and transduces proliferative signals.     

Inhibition of glioblastoma angiogenesis and invasion by combined treatments directed against vascular endothelial growth factor receptor-2, epidermal growth factor receptor, and vascular endothelial-cadherin.

PURPOSE: Inhibition of angiogenesis can influence tumor cell invasion and metastasis. We previously showed that blockade of vascular endothelial growth factor receptor-2 (VEGFR-2) with the monoclonal antibody DC101 inhibited intracerebral glioblastoma growth but caused increased tumor cell invasion along the preexistent vasculature. In the present study, we attempted to inhibit glioma cell invasion using a monoclonal antibody against the epidermal growth factor receptor (EGFR), which in the context of human glioblastomas, has been implicated in tumor cell invasion. In addition, we analyzed whether blockade of vascular endothelial (VE)-cadherin as a different antiangiogenic target could also inhibit glioblastoma angiogenesis and growth. EXPERIMENTAL DESIGNS: Nude mice who received intracerebral glioblastoma xenografts were treated using monoclonal antibodies against VEGFR-2 (DC101), EGFR (C225), and VE-cadherin (E4G10) either alone or in different combinations. RESULTS: Increased tumor cell invasion provoked by DC101 monotherapy was inhibited by 50% to 66% by combined treatment with C225 and DC101. C225 inhibited glioblastoma cell migration in vitro, but had no effect on the volume of the main tumor mass or on tumor cell proliferation or apoptosis in vivo, either alone or in combination with DC101. The anti-VE-cadherin monoclonal antibody E4G10 was a weaker inhibitor of tumor angiogenesis and growth than DC101, and also caused a weaker increase in tumor cell invasion. CONCLUSIONS: Inhibition of angiogenesis achieved by blocking either VEGFR-2 or VE-cadherin can cause increased glioma cell invasion in an orthotopic model. Increased tumor cell invasion induced by potent inhibition of angiogenesis with DC101 could be inhibited by simultaneous blockade of EGFR.