January 2000: 12 year old boy with recent onset seizures.

A 12-year old boy presented with new onset of seizures and a CT scan showed a left frontal lobe tumor which was removed completely. Neuropathological examination showed a pleomorphic ganglion cell tumor with necrosi, and endothelial proliferation. The diagnosis was extraventricular atypical neurocytic neoplasm ("cystic ganglioneurocytoma").

Recognition and management of preoperative risk.

Internists are frequently asked to do preoperative consultations and to manage perioperative complications. Realistic goals are to identify patient factors that increase the risk of surgery, to quantify this risk in order to make decisions about the appropriateness of and timing of the surgery, to provide recommendations on how to minimize the risk, to identify and manage coexisting medical conditions and their associated medication requirements, to monitor the patient for perioperative problems, and to make recommendations to deal with these problems when they occur. With few exceptions, nonselective imaging and laboratory screening tests have repeatedly been shown to be of little value when the history and physical do not suggest a problem. The risk associated with the planned surgery can be estimated, with the most common serious complications being cardiac events. Updated versions of Goldman's risk indices are particularly helpful for this. Clinical variables are optimally combined with selective stress testing to discern which patients will benefit from preoperative revascularization. This has been studied best in the setting of vascular surgery. A critical guiding principle is that the value of revascularization must be judged in terms of long term gains rather than just immediate perioperative benefit. Other interventions include the selective use of beta blockers, adequate analgesia for all, control of hypertension, and appropriate volume management, especially in the settings of preexisting CHF or valvular disease. It must also be recognized that perioperative ischemia and CHF often present atypically. An approach that combines aspects of both the ACC/AHA and the ACP guidelines seems optimal. A variety of noncardiac issues must also be addressed. Postoperative pulmonary complications are common, especially with preexisting pulmonary disease, thoracic and upper abdominal surgery, and obesity. PFTs and ABGs are indicated in selected patients. Stopping smoking, incentive spirometry, and selective use of bronchodilators and antibiotics are helpful. Patients with rheumatologic diseases have specific concerns based on systemic manifestations of disease including anemia, thrombocytopenia, pulmonary fibrosis, pericarditis, and hypercoagulability; medication effects particularly from steroids and nonsteroidal anti-inflammatory drugs; and specific joint problems including contractures and atlantoaxial joint instability. Diabetes increases the risk of infection and cardiac complications. Prevention of ketoacidosis and glucose control are necessary and can be achieved through a variety of approaches, depending on whether the patient suffers from Type 1 or Type 2 diabetes. The threshold for transfusion has increased in recent years, as has the use of erythropoietin and autologous blood donation. There is no longer an absolute hemoglobin that requires transfusion, although most require transfusion for hemoglobins less than 8 mg/dL, especially in the setting of cardiac disease and bloody surgery. The elderly require surgery at an increased rate and often do not do as well as younger patients. The primary issues are, however, not their age but their increased frequency of underlying disease and diminished reserve. The latter makes them prone to postoperative delirium, sensitivity to medications, and cardiac and pulmonary problems. Despite the many diseases that patients often have and the stresses of surgery itself, modern anesthetic and surgical techniques allow almost all patients to undergo necessary procedures at acceptable risk. The internist plays a critical role in minimizing this risk even further.

Stimulation of rat hepatic amino acid transport by burn injury.

Burn injury accelerates hepatic amino acid metabolism, but the role of transmembrane substrate delivery in this response has not been investigated. We therefore studied the effects of cutaneous scald injury on the Na+-dependent transport of glutamine and alanine in isolated rat liver plasma membrane vesicles. Scald injury resulted in liver damage and a 1.4- to 2.3-fold and 1.5- to 2.8-fold stimulation of hepatic transport rates for glutamine and alanine, respectively, proportional to the total burned surface area (TBSA) after 24 hours. Enhanced uptake of glutamine and alanine was attributable to increases in the maximum velocity (Vmax) of system N and system A activities, respectively. Hepatic amino acid transport activity remained elevated in vesicles from burned animals after 72 hours, but the degree of stimulation (1.3- to 1.7-fold for glutamine and 1.3- to 1.6-fold for alanine) was less than that observed 24 hours after thermal injury. Liver function tests returned to control values after 72 hours as well, indicating rectification of hepatic damage. In contrast to the induction of hepatic system A and system N activity in catabolic states such as cancer and endotoxemia, further studies showed that tumor necrosis factor (TNF) failed to play a significant role in burn-stimulated amino acid transport rates. When combined with plasma liver enzyme profiles, early transient hepatic amino acid transporter stimulation may support amino acid-dependent pathways involved in the repair of burn-dependent hepatic damage.

Cytogenetic changes in two cases of subependymal giant-cell astrocytoma.

Cytogenetic analysis of subependymal giant-cell astrocytomas (SEGAs) from two patients presenting the clinical symptoms of tuberous sclerosis complex (TSC) revealed clonal chromosomal changes, resulting in the partial loss of chromosome 22q in both tumors. Immunohistochemically, tumors exhibited features of glial differentiation, while ultrastructural studies identified the characteristic paracrystalline inclusions within the tumor cells. To our knowledge, it is the first cytogenetic description of SEGAs associated with TSC.

The activation by staphylokinase of human plasminogen.

The activation of human plasminogen by a highly purified staphylokinase was investigated using casein or an active site titrant (p-nitrophenyl-p-guanidinobenzoate, NPGB) as a substrate. The reaction rate was time dependent, showing a pronounced lag period with either substrate. Saturation curve estimated from the caseinolytic assay was sigmoid, but changed to quasi-hyperbolic in the presence of pre-formed human plasmin. With NPGB, the extent of plasminogen conversion into esterolytic plasmin was directly proportional to staphylokinase concentration, and the saturation point was reached when the molar concentration of staphylokinase equaled that of plasminogen. It is concluded that staphylokinase acts stoichiometrically, forms an equimolar complex with plasminogen, and thus is not an enzyme but a modifier. Staphylokinase-activated plasminogen exhibits properties of a hysteretic enzyme.

A versatile method for purification of diphtheria toxoid for immunization purposes.

Diphtheriae growth supernatant. The toxoid was quantitatively recovered from the immunosorbent in two fractions: the first in 0.005 M hydochloric acid and the second in 6' M urea containing 0.1 M HCL. Both fractions were soluble in aqueous solvents, and both had a similar specific activity: between 200 and 250 Lf/mg protein, and about 1.5 protective unit (ED50) per l Lf unit, as assayed in guinea pigs. Using the same procedure, the specific activity of a commerical toxoid preparation, purified and concentrated, was increrased two fold, from 130 Lf/mg to 260 Lf/mg protein.

Proton magnetic resonance spectroscopy of primary pediatric brain tumors: neuropathological correlation.

Forty-five children with primary brain tumors were evaluated by in vivo proton magnetic resonance spectroscopy (MRS) with the aim of detecting correlations between the obtained spectra and tumor malignancy and histology. All investigations were performed using a 1.5 T MR scanner (Picker) with point-resolved spectroscopic (PRESS) sequence (TR 1600 ms, TE 270 ms, NEX 256). Spectra were analyzed for N-acetylaspartate (NAA), choline containing-compounds (Cho), creatine and phosphocreatine (Cr) and lactate (Lac). The Cho/NAA ratio was the most useful parameter for differentiating between normal brain, benign and malignant tumors as well as discriminating the three main groups of pediatric brain tumors namely pilocytic astrocytoma, ependymoma and medulloblastoma. Proton MRS appears to be an important noninvasive technique in the differential diagnosis of pediatric brain tumors.

Dysembryoplastic neuroepithelial tumor (DNT): an ultrastructural study of six cases.

We report six cases od DNT with a detailed ultrastructural characteristics. The patient age ranged from 7 to 16 years (mean 12), the location was temporal in three cases and frontal, temporooccipital and parietooccipital in each of one remaining cases. The predominant clinical feature in each case was history of episodes of intractable seizures. Histopathologically, the neoplasms were multinodular, each nodule was well-circumscribed and was composed of glioneuronal elements embedded in the variable amount of myxoid matrix. The oligodendroglial-like cells (OLC) predominated in the nodules with some accompanying mature neurons. The nodules were frequently surrounded by small calcifications which could be found also within the tumors. OLCs were immunoreactive for S-100 protein and neurons had the expression of synaptophysin and neurofilament proteins. Ultrastructurally, each tumor consisted of three major elements: neoplastic cells (OLC), elongated processes forming neuropil-like structure and expanded "mucoid" extracellular space: the latter gave an impression of cellular elements floating within it. Neoplastic cells had round, oval or elongated nuclei, no discernible nucleoli and a relatively narrow rim of the cytoplasm. Some nuclei were irregular and invaginated and pseudoinclusions were observed; a part of cytoplasm sequestered within pseudoinclusions often appeared degenerated with large blabs and electron-lucent vesicles, some of these contained in turn semicircular profiles of unknown significance. The second element consisted of innumerable cellular processes. Some of these were elongated and formed stacks connected by symmetrical symmetric or asymmetric adhesive plaque junctions. The others had shorter "neck" containing microtubules, these extended into bullous extensions. Dense-cored vesicles were occasionally observed, in both cytoplasm of neoplastic cells and within processes. In one cell, cross-sectioned annulate lamellae were found. In cytoplasm of a few cells, unusual inclusions reminiscent ribosome-lamellae complexes were observed. These were cylindrical resembling "laboratory tubes" with a cone-like endings. At higher power, walls of the "tubes" resolved into layered structures composed of several laminae; between laminae, ribosome-like structures were visible.

The ultrastructural study of primary intracranial germ tumors.

We describe here ultrastructural and clinicopathological features of five primary intracranial germinomas. By electron microscopy, two major tumor components were defined as large, well differentiated tumor cells and non-neoplastic cells such as macrophages, astrocytes and lymphocytes. Nuclei of tumor cells were round to oval, often presented irregularly contoured nuclear membranes with oval indentations and, occasionally, cytoplasmic invagination. Some of them constituted unusual conformational changes of nuclear membranes rarely described as intranuclear pockets. Desmosome-like intercellular junctions were observed in several neoplastic cells. The nucleoli were composed of a loose, fragmented nucleolonema, whereas elongated, anastomosing and rope-like nucleolonemas, described previously as characteristic for germinomas were not seen. Most tumor cells had villous cytoplasmic projections sometimes intermingled with similar projections of macrophages. Cytoplasm contained a moderate number of mitochondria, a few lysosomes, annulate lamellae, centrioles and glycogen particles. The other distinct components of tumor were lymphocytes, macrophages and astrocytes. Scattered astrocytes typically contained abundant glial filaments adjacent to primary tumor cell. A filopodia-like processes of macrophages often interspersed between other cells, were very prominent features of germinomas. Small lymphocytes were found scattered between the tumor cells, single or in clusters.

Desmoplastic cerebral astrocytoma of infancy: a case report.

We report a case of desmoplastic cerebral astrocytoma of infancy (DCAI), in a 7-month-old boy. DCAI belongs to a group of recently described central nervous system (CNS) tumors, which also includes desmoplastic infantile ganglioglioma (DIG), pleomorphic xanthoastrocytoma (PXA) and dysembryoplastic neuroepithelial tumor (DNT), all characterized by relatively favorable prognosis and occurring mostly in children and young adults. DCAI is a rare neoplasm arising in the cerebral hemispheres within the first two years of life, and histologically is characterized by dense fibrous desmoplasia. In our case, CT scan presents a massive partially cystic tumor of the left cerebral hemisphere with an enlargement of the ventricular system. Histologically, the tumor was composed of cells arranged in fascicles and whorls forming storiform pattern. Immunohistochemical stainings for glial fibrillary acidic protein proved glial histogenesis of this tumor, while no cells were unequivocally immunopositive for neuron specific enolase, neurofilament proteins and synaptophysin what excludes a diagnosis of DIG--a similar entity but containing also a neuronal elements. Our studies, comprising a complete clinical, radiological, histopathological and immunohistochemical data, correspond to a cases of DCAI published before and it is the first one described in Poland.

Clinicopathological analysis of pilocytic astrocytomas and gangliogliomas in children.

We present here a clinico-pathological analysis of 58 pilocytic astrocytomas (PA) and 11 gangliogliomas (GG) based on an analysis of neuronal markers (GFAP, SYN, NFP) in these two groups of neoplasms. During the retrospective review of 58 cases recognized primarily as PA, 11 verified neoplasms demonstrated strong reaction for SYN or NFP or for both antibodies. These cases were reclassified as gangliogliomas. None of 11 tumors recognized as GG were further reclassified as PA. The overall 5-year survival was 88.89% in PA and 70.00% in GG group.

Clinical, radiological and histological presentations of dysembryoplastic neuroepithelial tumors (DNT). Report of two cases.

Dysembryoplastic neuroepithelial tumor (DNT) is a recently described rare brain neoplasm with characteristic clinical and morphological features and favorable prognosis. We report here two cases of DNT. The first concerned a 12 years old girl who presented complex seizures preceded by acoustic aura (melodies). Computed tomography revealed a hypodense tumor measuring 2 x 2.5 cm in diameter, located paracortically in the left temporal lobe. The second tumor was removed from a 21-year-old man with partial complex seizures. Nine years earlier patient underwent neurosurgery with partial removal of the tumor The tumor's histopathologic diagnosis is unfortunately lacking. Computed and magnetic resonance imaging showed a mass occupying the cortex and paracortical areas of the anterior pole of the temporal lobe. Histologically, both tumors consisted of small, S-100 protein immunopositive oligodendrocyte-like cells (OLCs) arranged between synaptophysin- and, to a lesser degree, NFP-immunopositive axons (glioneuronal element). In the second case, an area of pilocytic astrocytoma-like appearance was also found, these cells were immunopositive for GFAP. The present study provides clinical, radiological and histological data, which may be helpful in differential diagnosis of this newly recognised brain tumor.

Microsatellite instability and expression of DNA mismatch repair genes in malignant astrocytic tumors from adult and pediatric patients.

Microsatellite instability (MSI) is used as a molecular marker for defective DNA mismatch repair (MMR) genes. We report here alterations of MSI in 15 malignant astrocytomas (WHO grade III) and glioblastomas (GBM; WHO grade IV) of pediatric patients (2 - 21 years) and 12 GBM from adults (44 - 68 years) by comparative analysis of BAT25/BAT26 loci and 10 other microsatellite markers. High-level microsatellite instability (MSI-H) occurred in 4 of the 15 pediatric cases (26.7%) and in 1 of the 12 adult GBM cases (8.3%). Low-level microsatellite instability (MSI-L) was observed in 6 pediatric cases (40%) and 8 adult GBM (66.7%). Unstable BAT-25 locus was found in 1 of the MSI-H pediatric cases. Thus, 2 unstable cases showed no instability of this marker. For BAT-26, such a discordance was even more profound: in 1 of MSI-H cases, we obtained no PCR product and the remaining 3 showed no alterations of this marker. MSH2 (Human MutS, Homologue2) protein was detected in all but 3 pediatric cases (1 highly unstable and 2 low-level unstable) and in all adult cases. MLH1 (Human MutL, Homologue 1) protein was detected in all but 2 pediatric cases (1 highly unstable and 1 low-level unstable). Thus, 2 highly unstable pediatric cases showed no detectable MLH1/MSH2 proteins. Our data support earlier observations that MSI occurs predominantly in malignant astrocytic tumors of young patients, which lends support to the hypothesis of different molecular mechanisms of pediatric brain tumors. Surprisingly, we found no significant correlation between the status of 10 microsatellite markers and that of either BAT25 or BAT26 loci or with the expression of MMR genes.

Molecular abnormalities in pediatric embryonal brain tumors--analysis of loss of heterozygosity on chromosomes 1, 5, 9, 10, 11, 16, 17 and 22.

Embryonal tumors, the most common group of malignant brain tumors in childhood, are heterogeneous and have been associated with a large number of genetic abnormalities. The aim of this study was to comprehensively analyze loss of heterozygosity (LOH) on regions harboring suppressor genes (PTCH2, PTCH1, APC, PTEN, DMBT1, SUFU, AXIN1, hSNF5/INI1) and to study chromosomal regions in which deletions have been described most frequently (1p, 1q, 11p, 16p, 17p). Twenty-nine children (17 male and 12 female), aged from 1 year 13 years were included in this study. There were 24 medulloblastomas (MB) and 5 supratentorial primitive neuroectodermal tumors (sPNET). Tissue samples from 29 primary and 11 recurrent tumors were analyzed according to the LOH standard procedures, which were extended to include fluorescence in situ hybridization for detection of isochromosome 17q (i(17q)) and direct sequencing ofTP53 exon 4. LOH on 17p was found in 15 out of 29 tumors. FISH analysis identified the presence of i(17q) in 16 tumors. Comparison of LOH analysis and the FISH data indicated that alterations of 17p were related to be the introduction of an i(17q) formation. LOH on 10q and 9q was observed in 4 and 2 cases, respectively, and was associated with alterations of chromosome 17. These results indicated a connection between alterations of PTCH/SHH genes and abnormalities of chromosome 17. A deleted region on 22q, covering the hSNF5/INI1 locus, was observed in 3 tumors. Progression of the molecular changes occurred in 1 case of recurrent medulloblastoma. LOH on 10q and 17p was found in both primary and recurrent tumor, while losses on 11p, 16p, and 16q occurred only in the recurrent tumor. No evidence of alteration in TP53 exon 4 was identified.

The ultrastructural study of primary intracranial germ cell tumours.

We describe here ultrastructural and clinicopathological features of five primary intracranial germinomas. By electron microscopy, two major tumour components were defined as large, well differentiated tumour cells and non-neoplastic cells such as macrophages, astrocytes and lymphocytes. Nuclei of the tumour cells often presented irregularly contoured nuclear membranes with oval indentations and, occasionally, cytoplasmic invagination. Some of them constituted unusual conformational changes of nuclear membranes rarely described as intranuclear pockets. Desmosome-like intercellular junctions were observed in several neoplastic cells. Nucleoli were composed of a loose, fragmented nucleolonema whereas elongated, anastomosing and rope-like nucleolonemas, described previously as characteristic for germinomas were not seen. Typically, the cytoplasm contained glycogen particles. Most tumour cells had villous cytoplasmic projections sometimes intermingled with similar projections of macrophages. Scattered astrocytes typically containing abundant glial filaments were adjacent to primary tumour cells.

Analysis of 200 consecutive neuropathologically verified brain tumors of childhood.

Brain tumors are the most frequent solid neoplasms of childhood. We present here a series of 200 consecutive cases of neuropathologically verified brain tumors in children under 18, operated on between 1990-1996 at the Polish Mother Memorial Hospital in Lódz. The respective diagnoses were established on the basis of light microscopy, ultrastructure and immunohistochemistry. The criteria of the World Health Organization (WHO) classification of central nervous system (CNS) tumors were used in all but one (superficial desmoplastic cerebral astrocytoma of infancy) case. The location of tumors, age and sex of children and tumors' histology in our material were compared with those of previously published series of pediatric brain tumors.

Ultrastructure of the primitive neuroectodermal tumors (PNET).

We report a prospective series of consecutive cases of primitive neuroectodermal tumor (PNET) studied by electron microscopy. Virtually all specimens showed a differentiation along neuroblastic lines as evidenced by the presence of neurites, dense-cored vesicles, microtubules and adhesive plaque junctions. We observed also numerous intracytoplasmic cilia and autophagic vacuoles. Synaptic specializations were only rarely seen. We conclude that PNET is a tumor category which is not undifferentiated ("primitive") and clearly exhibits features of neuroblastic differentiation.

Expression of synaptophysin and neurofilament protein confirms predominantly neuroblastic differentiation of primitive neuroectodermal tumors (PNET).

We report here that neuronal and glial differentiation is easily detected using synaptophysin (SF) and neurofilament protein (NFP) immunohistochemistry in primitive neuroectodermal tumors (PNET). Thus, for all practical reasons, every PNET should be regarded as PNET with "hidden" multipotential or bipotential differentiation.

Clinico-pathological analysis of pilocytic astrocytomas and gangliogliomas.

A pathological analysis of 58 pilocytic astrocytomas (PA) and 11 gangliogliomas (GG) was performed using immunohistochemistry. Antibodies against neuronal and glial markers (GFAP, SYN, NFP) were used. An analysis of survivors using the Kaplan Meier curve was also performed and compared with the literature reports. During the retrospective review of 58 cases recognized primarily as PA, 11 verified neoplasms demonstrated strong, immunopositive reaction for SYN or NFP or both antibodies. These cases were reclassified as gangliogliomas (GG). None of the 11 tumors recognized as GG was reclassified as PA. The overall 5-year survival was 88.89% in the PA and 70% in GG groups.

Ultrastructural study of subependymal giant cell astrocytoma: unusual paracrystalloid inclusions in tumour cells.

Subependymal giant cell astrocytoma (SEGA) is a tumour with a broad range of morphological, immunohistochemical and ultrastructural neoplastic cellular features. We report here the presence of this tumor in two 7-year-old-boys presented with a lateral intraventricular mass. Further clinical investigation confirmed the diagnosis of tuberous sclerosis. Ultrastructural and immunohistochemical investigation revealed that glial differentiation was more pronounced in these cases. Interestingly, tumour cells containing unusual paracrystalline inclusions, infrequently described in SEGA, were identified ultrastructurally. These inclusions are probably not related to other cellular organelles.