[Role of a health network dedicated to patient care for sleep disorders]. / Rôle d'un réseau de santé dans la prise en charge des troubles du sommeil.

The Réseau Morphée is a health network funded by the Regional Health Commission (Mission Régionale de Santé d'Ile-de-France). Its mission is to improve the management of sleep disorders via actions for the public, patients and health professionals. For patients suffering from sleep apnea, the network improves access to care and organises education and support groups for patients treated by Continuous Positive Airway Pressure (CPAP) in order to improve compliance. Health professionals can optimise patient care using an Internet based computerised consultation system which automatically incorporates sleep recording and CPAP reports. The expertise of the Morphée medical team is on hand at all times to help in the management of complex patients and expert advice from other members of the network is shared during regular patient management meetings. The réseau Morphée is certified as a continuing medical education (FMC) and clinical practice accreditation (EPP) organisation and so active members can validate both their FMC and EPP.

[3D Histology: a protocol of micrographic surgery well fitted for French dermatologists and pathologists]. / Histologie 3D: une technique de chirurgie micrographique adaptée aux dermatologues et pathologistes hospitaliers et libéraux.

We present 2 techniques of micrographic surgery (3D-histology) useful to control lateral and deep limits of cutaneous tumors. We have adapted the protocol created in Germany, at the University of Tuebingen, for French pathologists and dermatologists.

Splitting bone marrow trephines into frozen and fixed fragments allows parallel histological and molecular detection of B cell malignant infiltrates.

Clonality analysis of the immunoglobulin heavy chain (IgH) gene is helpful in identifying malignant B cell infiltrates in the bone marrow and is usually carried out on separate aspirates or on the same formalin-fixed decalcified bone marrow specimen. To determine whether the removal of the decalcification step would improve the molecular analysis, we first studied 12 bone marrow specimens with lymphoma infiltration split into a fixed and a small frozen fragment. Both the detection rate of IgH gene monoclonality and DNA quality were found to be superior in the frozen part than in the fixed part. Conversely, to evaluate whether the split would compromise histological analysis, we selected a series of 134 bone marrow specimens obtained from patients with small B cell lymphoma and showing IgH monoclonality on the frozen part. The histological detection rate of infiltrated or suspicious infiltrates (95%) on the fixed part was not altered by saving a frozen part.

Association of serum pepsinogen with atrophic body gastritis in Costa Rica.

Individuals with atrophic gastritis (AG), especially atrophic body gastritis (ABG), are at increased risk of developing gastric cancer. Serum concentrations of pepsinogens (PG) have been proposed as markers for ABG. The aim of this study was to determine the risk factors for AG and ABG and the potential of using serum PG concentrations to detect ABG in a dyspeptic population in Costa Rica, which is one of the countries with the highest incidence and mortality rates of gastric cancer in the world. Seven biopsy specimens, a fasting blood sample and a questionnaire concerning sociodemographic factors were obtained from 501 consecutive dyspeptic patients. The serum PGI level and the PGI/PGII ratios were significantly lower in patients with ABG than in other groups (P<0.000). A cut-off point of 3.4 led to a sensitivity of 91.2% in identifying ABG, a negative predictive value of 98.1%, but a positive predictive value of only 11.2%. Helicobacter pylori were present in 93% of the patients and all those with peptic ulcers were positive. AG was associated with increased age, lower body mass index, high alcohol intake and low fruit consumption. ABG was associated with age, alcohol consumption and PGI/PGII<3.4. In dyspeptic patients with a high prevalence of H. pylori infection, serum PG levels provide an assessment of ABG but it is necessary to introduce other serological and genetic markers in order to achieve a better specificity. Those markers could be serum antibodies to H. pylori-CagA, cytokine gene polymorphisms or others.

Follicular large-cell lymphoma treated with intensive chemotherapy: an analysis of 89 cases included in the LNH87 trial and comparison with the outcome of diffuse large B-cell lymphoma. Groupe d'Etude des Lymphomes de l'Adulte.

PURPOSE: The aims of this study were as follows: (1) to analyze clinical, histopathologic characteristics, treatment outcome, and prognostic factors of patients with follicular large-cell lymphoma (FLCL); and (2) to compare them with those of patients with diffuse large B-cell lymphoma (DLCL) treated in the same therapeutic trial. PATIENTS AND METHODS: Eighty-nine FLCL patients who were histologically reviewed and who received an intensive chemotherapy regimen according to the LNH 87 protocol were analyzed and compared with 1,096 B-cell DLCL patients included in the same protocol. RESULTS: After intensive induction treatment, 59 patients (67%) achieved a complete remission [CR]. Estimated 5-year survival was 59%, and estimated 5-year freedom from progression (FFP) was 39%. Prognostic factors associated with shorter FFP were age greater than 60 years (P = .02), advanced clinical stage (P = .01), abnormal lactic dehydrogenase (LDH) level (P = .02), abnormal beta-2 microglobulin (P = .02), B symptoms (P = .03), bone marrow involvement (P = .04), and high expression of bcl-2 protein (P = .05). When compared with B-cell DLCL patients, FLCL patients were younger (P = .02), had a better Eastern Cooperative Oncology Group (ECOG) status (P = .05), less bulky mass (P = .04), more advanced clinical stages (P < .001), and more bone marrow involvement (P = .02). No significant difference was observed between FLCL and DLCL patients for response to therapy (67% v 67% of CR), 5-year overall survival (58% v 51%), 5-year disease-free survival (53% v 57%), or FFP survival (39% v 43%). CONCLUSION: FLCL patients have a favorable response rate and survival when treated with intensive chemotherapy. Their outcome is similar to that of B-cell DLCL patients, and a long-term FFP is observed for a substantial number of patients. Some adverse prognostic factors (including those of the International Prognostic Index, bone marrow involvement, and beta-2 microglobulin) have been identified to define a subset of patients who require other therapeutic approach.

Bone loss in hypothyroidism with hormone replacement. A histomorphometric study.

To determine the influences of hormone replacement on bone tissue in primary hypothyroidism, a histomorphometric study on undecalcified transiliac bone specimens was performed before treatment in ten patients, during the first month of treatment in 16 patients, and after more than six months of treatment in 15 patients. There were no obvious clinical or biologic signs of excessive replacement therapy. Before treatment, trabecular resorption surfaces were lower and bone cortical thickness was increased. From as early as the first month of treatment, trabecular resorption surfaces and cortical porosity were higher than normal but cortical thickness was still increased. After more than six months of treatment there was a significant loss of trabecular (decreased trabecular bone volume) and cortical (normal mean cortical width; increased porosity) bone with hyperremodeling (increased trabecular resorption surfaces and trabecular osteoid surfaces). This osteoporosis is similar to that observed in hyperthyroidism.

The N-acetylglucosamine-specific receptor of the thyroid: purification, further characterization, and expression patterns on normal and pathological glands.

The N-acetylglucosamine receptor of the thyroid has been putatively described as both a prohormonal receptor that could play a role in the intrafollicular retention of immature thyroglobulin and a vectorial conveyor of these immature molecules to the iodination site. To further characterize this receptor, we have developed a purification procedure yielding nanomolar amounts of N-acetylglucosamine receptor. This thyroid lectin appeared to have an isoelectric point near 5.2 and to be composed of 51-kilodalton monomers with no Asn-linked glycoconjugates. Recognition of the receptor by antipeptide antibodies (Ab/ROV1) raised against a preselected sequence of cation-dependent lectins indicated immunological kinship with the Gal/GalNAc-specific hepatic lectin. Affinity-purified Ab/ROV1 and polyclonal antibodies against the purified receptor (TGRD-Ab) were used to study the location and expression pattern of the receptor on animal and human thyroid tissue. On porcine slices, positive labeling was observed in various intracellular vesicular compartments with both antibodies and was particularly intense in the apical membrane and subapical compartments. The same pattern was observed in normal human thyroid. In contrast, the receptor 1) could not be found on epithelial cells from thyroid papillary carcinoma; 2) was abundant, but concentrated in the subnuclear region of the thyrocytes in adenomatous goiter; and 3) was almost exclusively located at the basolateral membrane in follicular carcinoma as well as in thyrocytes from glands treated with antithyroid drug before surgery. These observations indicate that expression of the N-acetylglucosamine receptor is characteristic of the fully differentiated phenotype, and its potential function as a thyroglobulin conveyor back to the lumen would be either impaired or abolished in some disease processes.

Small B-cell lymphoproliferative disorders: an overview of diagnostic approach.

Despite their common origin from the B-cell mature lymphoid system, small B-cell lymphomas/leukaemias represent in fact an heterogeneous group of diseases. Recent advances in immunohistochemistry and molecular techniques have improved our knowledge of the immune system and lymphoid neoplasms. An international consensus has been recently reached among pathologists and clinicians, that recognises clinico-pathological entities which are defined by a combination of morphological, immunophenotypical, genetic and clinical features. In each entity, a range of histological grade and clinical aggressiveness can be encountered. Recognition of these entities, combined with clinical prognostic factors has clinical implications in terms of response to treatment and prognosis. The purpose of this paper is to focus on a practical approach, either clinical or pathological, of the diagnosis of small B-cell lymphoma/leukaemia.

Detection of circulating cells expressing chromogranin A gene transcripts in patients with lung neuroendocrine carcinoma.

High grade lung neuroendocrine carcinomas, like small and large cell neuroendocrine carcinomas, pose therapeutic problems. Most initially respond to chemotherapeutic agents, but early relapses are frequent and are resistant to the presently available treatments. Our study reports for the first time the development and evaluation of a test for detecting the presence of circulating tumour cells by measuring chromogranin A gene transcripts with reverse transcriptase-polymerase chain reaction (RT-PCR) and Southern blotting. The test is specific and sensitive (detection of 10 cancer cells/ml blood), and only minimally invasive. Positivity is statistically correlated to high grade neuroendocrine carcinomas and to a poor prognosis with a 3-fold higher lethal risk. The test now needs to be assessed for its usefulness as a tool in the initial staging procedures and follow-up by comparison with the recent immunoradiometric assay (RIA) for detection of chromogranin A in the serum.

Primary extramedullary plasmacytoma of the liver. A case report.

We report the first case of primary extramedullary plasmacytoma of the liver. The tumor was situated in segment VIII of the liver without extrahepatic extension. Histologically, the tumor was composed of sheets of mature plasma cells with slight atypia in association with proplasmacytes invading the hepatic parenchyma. Neither plasmoblasts nor lymphoplasmacytes were present. Immunohistochemistry demonstrated monoclonal IgG and kappa light-chain expression. In situ hybridization confirmed the monotypic expression of kappa light-chain mRNA. Bone marrow examination revealed no abnormality. After surgery, the IgG kappa spike detected in preoperative plasma samples decreased. The patient is disease free 31 months postoperatively.

Immunohistochemical study of 100 pancreatic tumors in 28 patients with multiple endocrine neoplasia, type I.

One hundred pancreatic tumors ranging in size from 0.3 to 7 cm were studied in 28 patients (17 male and 11 female patients; mean age 35 years) with multiple endocrine neoplasia, type I. An immunohistochemical study was performed on deparaffinized sections using the following antibodies: neuron-specific enolase, chromogranin A or synaptophysin, insulin, glucagon, somatostatin, pancreatic polypeptide (PP), vasoactive intestinal peptide (VIP), gastrin, adrenocorticotropic hormone, alpha-subunit of human chorionic gonadotropin, gonadotropin-releasing factor, serotonin, and calcitonin. Among the 100 tumors (all multiple), seven were unclassified, 10 were plurihormonal, and 83 produced a predominant hormonal secretion (with 50-90% of the same cell type), including 37 "A-cell tumors" (glucagon), 27 "B-cell tumors" (insulin), 11 PP-cell tumors, one G-cell tumor (gastrin) and one vasoactive intestinal peptide (VIP)-cell tumor. These multiple tumors had a different predominant hormonal secretion in the same patient in 23 of the 28 cases. There was a preferential association of A-cell tumor and B-cell tumor. Hyperplasia of the islets of Langerhans was not detected in adjacent pancreas. Nesidioblastosis was observed in 30% of cases.

Statistical evaluation of diagnostic and prognostic features of CD30+ cutaneous lymphoproliferative disorders: a clinicopathologic study of 65 cases.

Several clinical and histopathologic features of 65 CD30+ cutaneous lymphoproliferations were evaluated for their diagnostic value between CD30+ primary versus secondary cutaneous lymphomas and for their prognostic significance. Primary cutaneous disease, spontaneous regression, and absence of extracutaneous spreading (but not age < or =60 years) were associated with a better prognosis. Epithelial membrane antigen, BNH9, CD15 or CBF.78 antigen were expressed in all types of cutaneous lymphoproliferations. However, epithelial membrane antigen immunoreactivity was more frequently expressed in CD30+ secondary cutaneous large-cell lymphoma. Among CD30+ primary cutaneous large-cell lymphoma, CD15 expression was only seen in localized skin lesions. P53 expression was not associated with spontaneous regression, extracutaneous spreading, or survival. Nested reverse transcriptase-polymerase chain reaction allowed the detection of NPM-ALK transcripts in 10 of 26 CD30+ primary and in 3 of 11 secondary cutaneous large-cell lymphomas. The ALK protein was detected in only 1 of 50 primary and in 4 of 15 secondary cutaneous CD30+ lymphoproliferations. In CD30+ primary cutaneous lymphoproliferation, NPM-ALK transcripts might be expressed by very rare normal or tumoral cells that are undetectable by immunohistochemistry. However, the expression of either NPM-ALK transcripts or ALK-protein was not correlated with prognosis or age in CD30+ cutaneous lymphoproliferations.

The Spectrum of Cutaneous Lymphomas in HIV infection: a study of 21 cases.

We studied 21 HIV-associated lymphomas with cutaneous presentation to determine whether they showed features of primary cutaneous lymphoma arising fortuitously or whether they represented the cutaneous involvement of AIDS systemic lymphoma. Besides rare mycosis fungoides (n = 3), which shared typical clinicopathologic lesions, nonepidermotropic large-cell lymphomas (n = 18) were predominant. They frequently presented as a solitary nodule or tumor. Seven of the eight large T-cell lymphomas had a CD30-positive (CD30+) phenotype but did not express ALK protein. Overexpression of p53 protein was observed in six cases. Although EBV-EBER transcripts were detected in two of them, LMP1 protein was absent. Except for their original prevalence, the features of these T-cell CD30+ cutaneous lymphomas were the same as in immunocompetent patients. The 10 B-cell cutaneous lymphoma were immunoblastic or centroblastic lymphomas, with a differential expression of BCL-6 and Syndecan. Four of them expressed CD30, EBER-EBV transcripts, and LMP1 and p53 proteins. This B-cell CD30+ EBV+ phenotype contrasts with cutaneous lymphoma in immunocompetent patients. Human herpesvirus 8 was not involved in lymphomagenesis since its sequences were detected in a single patient with Kaposi's sarcoma and Castleman's disease. These lymphomas occurred in severely immunocompromised patients with a low CD4 count. Death was due to immunodepression rather than to lymphoma spread, suggesting avoiding aggressive immunosuppressive treatment in such patients.

Distribution of NGF receptors in normal and pathologic human lymphoid tissues.

To identify nerve growth factor (NGF) target cells in normal and pathologic human lymphoid tissues, we have studied the expression of the low-affinity NGF receptor (p75LNGFR) and the high-affinity tropomyosin-related kinase NGF receptor (TrkA). A RNAse protection assay revealed the expression of trk transcripts in thymus, spleen, palatine tonsils and lymph nodes. TrkA immunoreactivity was shown in thymic epithelial cells, cryptic tonsillar epithelium and several monocyte-derived cells including epithelioid and multinucleated Langhans' cells, follicular dendritic cells and interdigitated reticular cells. TrkA immunoreactivity was rarely observed in normal T- and B-lymphocytes, but was intense in lymphoma cells of several B-cell lymphoma subtypes, anaplastic large cell lymphomas and Reed-Sternberg cells. Western blot analysis revealed the presence of p75LNGFR and of p80Trk and glycosylated Trk isoforms (gp110, gp140). p75LNGFR immunoreactivity was detected in epithelial Hassal's bodies, follicular dendritic cells, interdigitated reticular cells, periarteriolar macrophages, endothelial sinusal cells and nerve endings. The broad expression of NGF receptors may be an indicator of neurotrophin activity in lymphoid tissues and suggests their implication in inflammatory or lymphoproliferative disorders.

The endocrine pancreas in brain-dead donors. A prospective study in 25 patients.

To determine whether hyperglycemia in brain-dead donors is a sign of endocrine pancreas insufficiency, we studied pancreatic function in 25 consecutive brain dead patients. Blood samples were drawn at 2-hr intervals from donor referral until organ procurement to analyze glucose, insulin, and C-peptide levels. After donor retrieval, two specimens were taken from the pancreas for a subsequent immunohistochemical examination. At referral mean glycemia was 13.60 +/- 1.49 mmol/L, and there was a large range of plasma glucose levels (4.6-31.6). Of 25 patients, 16 had glycemia above 10 mmol/L. At organ procurement a mean of 20 hr later, mean glycemia as 8.61 +/- 0.58 mmol/L (P < 0.005 with paired t test), and only 5 patients had glycemia above 10 mmol/L. Hyperglycemia was associated with elevated insulin and C-peptide levels during donor management. An elevated C-peptide/glucose molar ratio might be considered a sign of peripheral insulin resistance. Hyperglycemia above 25 mmol/L could not be related to the amount of glucose administered during donor maintenance. Severe hyperglycemia had a natural tendency to be partly corrected. Histologic and immunohistochemical examinations were available in 17 cases and can be considered normal. It is concluded that endocrine pancreatic function can be considered effective after brain death. The mechanism of the relative insulin resistance of these patients requires further study. Blood glucose levels, in the range observed in this study, are not a good donor criterion of endocrine pancreatic function before pancreas transplantation.

Expression of NGF receptors in normal and pathological human thymus.

The expression of NGF receptors was investigated in normal human thymus and in thymic hyperplasias, thymomas and thymic carcinomas. By RT-PCR, we detected TrkAI transcripts encoding for the high-affinity NGF receptor. Western blot analysis showed the presence of both TrkA and p75NGFR proteins. In normal thymuses, epithelial subcapsular and medullar cells were TrkA immunoreactive. Interdigitated medullar cells were stained for both TrkA and p75NGFR. While epithelial cells of normal thymuses or benign thymomas exhibited a TrkA positive-p75NGFR negative phenotype, a switch to a TrkA negative-p75NGFR positive phenotype was observed in malignant epithelial cell tumours and was associated with cell proliferation-associated MIB1 expression. Our results argue for a local role of NGF and its receptors on thymic stromal cells both in normal and neoplastic conditions.

Double vs. single dose of pantoprazole in combination with clarithromycin and amoxycillin for 7 days, in eradication of Helicobacter pylori in patients with non-ulcer dyspepsia.

BACKGROUND: The necessity of increasing intragastric pH during eradication treatment in Helicobacter pylori infected patients is well established. However, the optimal dose of the proton pump inhibitors used in eradication regimen is still a subject of debate. AIMS: To compare the efficacy and tolerability of a double vs. a single daily dose of pantoprazole in a 7-day triple therapy in eradicating H. pylori. METHODS: In this regional, multicentre, comparative, randomized and double-blind study, H. pylori-positive patients with non-ulcer dyspepsia were treated for 7 days with clarithromycin 500 mg b.d. and amoxycillin 1000 mg b.d. and either a double (2 x 40 mg, Group 2PCA) or a single (40 mg, Group 1PCA) daily dose of pantoprazole. H. pylori infection was assessed at entry and at the end (day 38) of the study by histology and culture, or in some cases by 13C-urea breath test. RESULTS: From 203 patients recruited, 192 patients (96 in Group 2PCA and 96 in Group 1PCA) formed the intention-to-treat population. Twenty-six of them judged as major protocol violators were excluded from the per protocol analysis. H. pylori eradication rate was 75% in Group 2PCA and 56% in Group 1PCA in intention-to-treat analysis, and 80% in Group 2PCA and 59% in Group 1PCA in per protocol analysis (P < 0.05). The primary resistance to clarithromycin was 10.5%. The eradication rates for the clarithromycin susceptible strains were 86% for Group 2PCA and 71% for Group 1PCA in per protocol analysis (P < 0.05). Both regimens led to similar improvement of clinical symptoms and were equally well tolerated. CONCLUSION: A double (2 x 40 mg) daily dose of pantoprazole in a 7-day triple therapy is more effective than a single (40 mg) dose of this drug in eradication of H. pylori.

Low prevalence of monoclonal B cells in Helicobacter pylori gastritis patients with duodenal ulcer.

We have studied the prevalence of B-cell clonality among a large group of 320 patients with Helicobacter pylori gastritis and duodenal ulcer. These patients underwent endoscopic examination with multiple gastric biopsies at diagnosis and were followed 2 and 12 months after therapy. Histopathologic examination of 809 sets of biopsy specimens showed lymphoid gastritis with lymphoid aggregates or follicles, but without lymphoepithelial lesion, in 302 samples corresponding to initial biopsy specimens (n=130) or to posttreatment biopsy specimens (n=172). DNA extracted from fresh antral specimens allowed the amplification of Helicobacter pylori DNA in all cases before therapy. The arrangement of the immunoglobulin heavy chain gene was studied by polymerase chain reaction (PCR) in the 302 selected lymphoid gastritis samples. Single or dominant bands were seen only in four specimens from three patients (1.3%), whereas a polyclonal pattern was seen in the other 298 samples. The detection threshold of our PCR technique was approximately 3% of clonal B cells diluted in a polyclonal population. This threshold appeared to be a reliable cutoff between polyclonal gastritis and clonal MALT lymphoma. In our experience, Helicobacter pylori lymphoid gastritis appeared mainly as a benign polyclonal condition.

Benign lymphocytic angiitis and granulomatosis: a T-cell lymphoma?

Benign lymphocytic angiitis and granulomatosis is a T-cell lymphoproliferative disorder confined to the lung and corresponding to a low-grade angiocentric immunoproliferative lesion. Controversy remains as to whether these lesions are lymphomas. We report such a case in an 8-year-old patient with Burkitt's lymphoma in remission who presented with persistent bronchopneumopathy and bilateral pulmonary infiltrates on tomodensitometry. Surgical resection revealed the histologic changes of benign lymphocytic angiitis and granulomatosis. Immunohistochemistry showed no aberrant pan T-cell marker loss. Genetic analysis of frozen tissue by Southern blot DNA hybridization with probes to T-cell receptor beta- and gamma-chain genes and to the immunoglobulin heavy chain joining region gene (JH) identified no clonal rearrangement. Search for Epstein-Barr virus-DNA sequences by in situ hybridization and Southern blot analysis provided negative results. Our data imply that lowgrade angiocentric immunoproliferative lesions are not exclusively lymphomas but might represent a borderline lymphoproliferative disease (seen in the course of many diseases), perhaps corresponding to host immune response.

Gastric large cell lymphoma expressing cytokeratin but no leukocyte common antigen. A diagnostic dilemma.

A case of undifferentiated malignant tumor of the stomach is reported. The immunohistochemistry of biopsy specimens pointed to a diagnosis of carcinoma, the tumor cells being cytokeratin positive and leukocyte common antigen (LCA) negative. After resection, however, histopathologic results showed that the tumor was a large cell lymphoma with plasmablastic differentiation. A new immunohistologic study confirmed, on the one hand, the diagnosis of lymphoma with its monotypic character IgA kappa and, on the other, positivity with three different cytokeratins of the lymphoma cells and their negativity with LCA. The aberrant immunophenotyping of this lymphoma is exceptional and must not undermine the recognized usefulness of LCA and cytokeratin, which both are basic antibody markers of immunohistochemistry in undifferentiated malignant neoplasms.