Management of young patients with lupus nephritis using tacrolimus administered as a single daily dose.

AIMS: Studies on immunosuppressive treatment with tacrolimus (Tac) in subjects with lupus nephritis (LN) are limited. Here, we report our experience with Tac administered daily as a single-dose for maintenance therapy in young patients with pediatric-onset, long-standing LN. METHODS: Eleven consecutive patients with long-standing biopsy-proven LN were recruited for at least 6 months or longer (6 - 24 months) as part of an open-label trial for the single-daily-dose administration of Tac (3 mg/day, 0.04 - 0.075 mg/kg) without dose increases of concomitantly administered prednisolone (PDN). Tac treatment was started at the time of the most recent flare. Data on clinical parameters and serologic lupus activity were collected prospectively. RESULTS: The baseline characteristics of the patients were as follows: mean age, 18 years; urinary protein/creatinine ratio (Up/cr), 0.74 +/- 1.49; serum C3 level, 69.5 +/- 26.5 mg/dl (normal 79 - 152 mg/dl); serum complement hemolytic activity (CH50), 23.0 +/- 8.9 U/ml (normal 23 - 46 U/ml); serum anti-dsDNA antibody titer, 58.9 +/- 54.2 IU/ml (normal < 12.0 IU/ml); serum creatinine, 0.54 +/- 0.13 mg/dl; and European Consensus Lupus Activity Measurement (ECLAM) index, 4.4 +/- 2.2. Despite the gradual tapering of the PDN dose, a marked improvement, compared with the baseline values was observed in the ECLAM index even at 1 month and in the serological parameters at 3 months after the start of treatment. These favorable results persisted until the end of the study. The Up/cre ratio gradually decreased and had dropped significantly at 24 months after the start of treatment. After a mean of 18 months of treatment, complete responses were achieved in 8 patients (73%) and a partial response was achieved in 2 patients. The remaining one patient showed no response. No serious adverse effects were observed. CONCLUSION: These data suggest that low-dose Tac treatment, administered once daily, is an effective and safe method for managing selected young patients with pediatric-onset, long-standing LN. However, further studies involving a larger number of patients are needed to confirm these results.

Retinoic acid signalling is a candidate regulator of the expression of pituitary-specific transcription factor Prop1 in the developing rodent pituitary.

Development of the anterior pituitary proceeds via spatiotemporal patterning of transcription factors and signalling molecules. Among them, retinoic acid (RA) functions as an important signalling molecule for vertebrate organogenesis in many tissues. However, little is known regarding the target genes in the developing pituitary. The present study aimed to clarify the relationship between endogenous RA signalling and mRNA expression of the pituitary-specific transcription factor Prop1 in the pituitary primordium of Rathke's pouch. Gene expression analysis and in situ hybridisation demonstrated that retinaldehyde dehydrogenases (Raldhs) and all types of RA receptors (Rars) are expressed at the level of transcription in the rat Rathke's pouch. Ex vivo organ culture using Rathke's pouch and an in vitro reporter assay demonstrated that RA signalling increases the expression level of Prop1 via RARα. Moreover, a reporter assay using serial truncated constructs of the 5'-upstream region of mouse Prop1 revealed a predicted cis-regulatory element of RARα. This is the first report of a relationship between RA signalling and Prop1-expression during early pituitary development.

Insulin-like growth factor-II (IGF-II)/Mannose-6-phosphate receptors are increased in primary human thyroid neoplasms.

Insulin-like growth factor (IGF)-II receptors were demonstrated in normal and neoplastic tissues of human thyroid. Specific binding of [125I]IGF-II to thyroid membranes was dependent on the time and temperature of incubation, and a steady state was achieved after 22 h of incubation at 4 degrees C. The binding of [125I]IGF-II was dose-dependently displaced by unlabelled IGF-II with 50% inhibition at an IGF-II concentration of 6 ng/ml. IGF-I had a relative potency of 1% compared to IGF-II, and insulin showed no inhibition at concentrations as high as 2000 ng/ml. Scatchard analysis of the binding data revealed a single class of IGF-II receptor with high affinity. Affinity crosslinking and autoradiography demonstrated the type II IGF receptors. Specific binding of [125I]IGF-II to thyroid papillary cancer tissues (mean [S.D.]13.2[1.3]% per 200 micrograms protein, n = 8) was significantly (P less than 0.01) higher than that to the surrounding normal tissues (4.8 [0.5]%). The binding in follicular cancer and follicular adenoma was also significantly higher than that in the corresponding normal tissues. The higher IGF-II binding to neoplastic tissues was due to an increase in the number of binding sites without any change of affinity. These results suggest that the increased IGF-II receptors may be involved in growth or functions of thyroid neoplasms.

N-ras mutation: an independent prognostic factor for aggressiveness of papillary thyroid carcinoma.

BACKGROUND: The clinical importance of point mutations of ras oncogene in differentiated thyroid cancers has not been fully clarified. The purpose of this study is to determine the prognostic importance of ras mutation in papillary thyroid carcinoma. METHODS: Tumors of 91 patients with papillary carcinoma were studied; mean follow-up was 14.1 years (range, 1 to 40 years). Patients were grouped as follows: class I, intrathyroidal disease, n = 21; class II, cervical node metastases, n = 22; class III, extrathyroidal disease, n = 19; and class IV, distant metastases, n = 29. DNA was analyzed with polymerase chain reaction, oligonucleotide hybridization, and DNA sequence analysis techniques. RESULTS: Thirteen (14.3%) of 91 tumors showed an N-ras point mutation: 4.8% (1 of 21) patients in class I; 4.5% (1 of 22) patients in class II; 15.8% (3 of 19) patients in class III; and 27.8% (8 of 29) patients in class IV. Each mutation changed codon 61 from glutamine to arginine. Patients with distant metastases (8 of 29) had a significantly higher incidence of ras mutations than others (5 of 62, p = 0.01). Patients in classes III and IV also had a higher incidence of mutations (11 of 48) than patients in classes I and II (2 of 43, p = 0.01). The incidence of ras mutations was significantly higher in patients who died of papillary cancer (5 of 15, 33.3%) than in patients who are still alive (8 of 76, 10.5%) (p = 0.02). Kaplan-Meier survival curves also showed a greater mortality from tumor (p < 0.05) and a higher recurrence rate (p < 0.01) in ras-positive tumors than in the ras-negative group. Finally, in studies by multivariate analyses, positive ras mutation and age were shown to be two independent prognostic factors for prediction of death from papillary cancer and recurrence of cancer. CONCLUSIONS: Mutation of N-ras gene at codon 61 is an independent prognostic factor for aggressiveness of papillary thyroid carcinomas.

Aggressive surgical approach for locally invasive papillary carcinoma of the thyroid in patients over forty-five years of age.

Aggressive radical resection was performed on 18 of 21 elderly patients with locally invasive-papillary carcinoma of the thyroid. Diagnostic studies, including computed tomographic and endoscopic examinations, were useful in allowing accurate determination of tumor extent. Radical resection usually consisted of total or subtotal thyroidectomy and neck dissection combined with excision of the affected organs, which in one case included a laryngotracheoesophagectomy (reconstruction of the digestive tract with a forearm free flap), a sleeve, or a window resection of the trachea in nine cases (immediate end-to-end anastomosis in all but one), a partial esophagectomy in two cases, and resection of the outer layer of the trachea or esophagus in six cases. After these operations, one patient died of rupture of the carotid artery, one died of cancer in 4 years, and one other died of unrelated disease. The other 15 patients are alive and well 1 to 5 years postoperatively, although additional exploration for nodal metastases was required in three patients. Aggressive resection therefore appears to be justified for control of locally advanced, differentiated carcinoma of the thyroid.

Comparison of mutations of ras oncogene in human pancreatic exocrine and endocrine tumors.

BACKGROUND: Ras oncogene mutations have been found in many human cancers; however, pancreatic endocrine tumors have rarely been studied. The purpose of this study was to analyze ras mutations in pancreatic endocrine tumors and to compare these results with the incidence of ras mutations in pancreatic exocrine cancers studied in our laboratory. METHODS: Ras oncogene mutations were studied in 33 foregut endocrine tumors (pancreatic 31, duodenal submucosa 2). Eleven were insulinomas, 12 gastrinomas, 2 glucagonomas, and 11 others were nonfunctioning islet cell carcinomas. Thirteen were benign and 20 were malignant. These were compared with 65 pancreatic exocrine cancers. Tumors were microdissected from paraffin-embedded sections. DNA was extracted and amplified by polymerase chain reaction. Mutations were detected by a oligonucleotide hybridization method with sequence-specific phosphorus 32-radiolabeled probes. RESULTS: No ras mutations were identified among the 33 pancreatic endocrine tumors. In contrast, 51 of 65 (78.5%) pancreatic exocrine cancers exhibited a ras mutation. Fifty were K-ras mutations and one unusual tumor exhibited a N-61 ras mutation. CONCLUSIONS: Ras oncogene mutations do not play a role in the tumorigenesis of pancreatic endocrine tumors.

Continuing evolution in the operative management of primary hyperparathyroidism.

During the past several decades the operation for primary hyperparathyroidism at The University of Chicago, Ill, has changed from subtotal parathyroidectomy for all patients to removal of an adenoma with performance of biopsies of all other glands to bilateral neck exploration, resection of the adenoma, and performance of fewer biopsies of normal glands. During the 1980s, 308 operations were performed; 288 patients underwent first operations. Two hundred forty-five (85.1%) of these patients had an adenoma and forty-three (14.9%) had hyperplasia (multiglandular disease); none had a carcinoma. Resolution of hypercalcemia was achieved in 281 patients (97.5%); seven patients experienced failed explorations. The early cure was the same whether or not preoperative localization studies were performed. Nineteen patients underwent 20 reoperative parathyroidectomies during this period. Preoperative localization studies, done in 16 (80%) of 20 cases, were very helpful. Ninety percent of patients with abnormal parathyroid glands in their neck or mediastinum were cured with their initial reoperation.

Breast cancer shortly after the diagnosis of interstitial pneumonia associated with polymyositis.

Polymyositis is sometimes associated with pulmonary fibrosis or malignant diseases, however, rarely with both simultaneously. For such patients, no criterion for initial treatment and tapering of steroid has been reported. We describe a patient who had breast cancer and interstitial pneumonia associated with polymyositis. In this case, slow tapering of the steroid was an important aspect of the treatment, and close clinical follow-up was necessary to monitor for disease exacerbation.

Immunohistochemical classification of the localization of laminin in the thickened bronchial epithelial basement membrane of deceased bronchial asthma patients.

To ascertain histological changes in the basal lamina of the bronchial epithelial basement membrane in patients with severe bronchial asthma, an immunohistochemical study was conducted in 43 patients who died of bronchial asthma. Antibodies against laminin, a component of the lamina lucida, were utilized. The results revealed various patterns for immunoreactivity to laminin in the thickened basement membrane layer. We were able to classify these reactivities into four patterns. In Pattern A, laminin reactions branched vertically in relation to the thickened basement membrane layer. In Pattern B, laminin reactions formed lines along the lower margin of the thickened basement membrane layer. In Pattern C, laminin reactions formed lines along the upper margin of the thickened basement membrane layer. Finally, in Pattern D, no laminin reactions were observed. In addition, relationships between immunohistological characteristics of laminin and findings such as epithelial cell shedding, basal cell proliferation and basement membrane layer thickening were investigated. In many Pattern A patients, epithelial cell shedding was observed, but goblet cell hyperplasia and basal cell proliferation were barely detectable. Conversely, in numerous Pattern D patients, epithelial cell shedding was barely seen, but goblet cell hyperplasia and basal cell proliferation were marked. Hence, Patterns A and D were on opposite ends of the spectrum of morphological characteristics associated with severe bronchial asthma. In Patterns B and C, laminin reactions formed lines along the lower and upper margin of the thickened basement membrane layer, respectively. However, no marked differences existed in epithelial cell shedding and basement membrane layer thickening. The present study is thus the first to clarify that laminin reactions in the thickened basement membrane layer vary, and this feature is unique to the bronchi of patients with severe bronchial asthma.

Characterization of benzodiazepinooxazoles: crystal and molecular structure of trans and cis isomers of oxazolam.

The stereochemistry of the trans and cis isomers of 2(S)- and 2(R)-oxazolam is described. A total of four molecular structures of the 11b(R) and 11b(S) diastereomers of 2(S)- and 2(R)-oxazolam have been revealed by X-ray diffraction techniques. 2(S)-Oxazolam crystallizes in space group P2(1)/c, with cell dimensions a = 16.180(2) A, b = 8.791(2) A, c = 13.574(2) A, and beta = 102.07(1) degrees. The molecule in an asymmetric unit exhibited disorder at the 2-carbon (C2) atom, and the structures for trans and cis isomers have been resolved crystallographically. 2(S)-Oxazolam forms polymeric chains with intermediation of ethanol through hydrogen bonding. 2(R)-Oxazolam crystallizes in space group P1, with cell dimensions a = 7.754(1) A, b = 8.654(1) A, c = 15.795(2) A, alpha = 104.09(1) degrees, beta = 91.19(1) degrees, and gamma = 114.00(1) degrees. A similar disorder at the C2 position has been elucidated by a mixture of trans- and cis-2(R)-oxazolams. The two 2(R)-oxazolam molecules form a dimer with a hydrogen bond net. The structural details, focusing on the conformation and molecular complex formation of both oxazolams, have been discussed in connection with the oxazolidine ring stability and the crystal polymorph.

Granulated 'marginal cell layer' in the rat anterior pituitary gland.

A granulated 'marginal layer cell' was observed in the lining of Rathke's residual pouch of 5 and 10 day-old rat anterior pituitary glands. Immunohistochemistry was not employed to identify the precise function of these cells. However, the cytological characteristics of nearly all of the cells indicated that they resembled GH-secreting cells, with a few displaying morphological features of corticotrophs. In pituitary glands of 5-20 day-old rats, both ends of Rathke's residual pouch extended into the pars distalis at the site of transitional zone of this lobe and of the pars intermedia. The cells within the 'invading' residual pouch contained numerous microvilli. In the middle portion of the residual pouch, cavities lined by 'marginal layer cells' had numerous microvilli and were adjoined by junctional complexes. In the adult rat pituitary gland, there were no granulated cells in the 'marginal cell layer' and no invasion of the residual pouch into the anterior lobe. From these data the possible source of the follicle and of the folliculo-stellate cells in the anterior pituitary of the rat is proposed.

Cytochemistry of Ca(++)-dependent adenosine triphosphatase (Ca-ATPase) in rat anterior pituitary cells.

In the present study, we demonstrate the localization of Ca(++)-ATPase in the anterior pituitary of the male rat. Ca(++)-ATPase was mainly distributed on the membrane system of the granular cells, which included the plasma membrane, the outer mitochondrial membrane, the enveloping membrane of secretory granules, the smooth endoplasmic reticulum and some components of the Golgi complex. No reaction product was detected on the membrane of the rough endoplasmic reticulum or that surrounding the lysosomes. A positive reaction was clearly observed on the membranes surrounding 'large' secretory granules, while that present on the membranes of the 'small' granules was comparatively weak. The cells which contained the 'large' granules were interpreted as growth hormone-secreting cells and those in which the 'small' granules were located as gonadotrophs. There were either no reaction or one that was barely detectable on the plasma membrane of the folliculo-stellate cells. These data along with our previous findings (Soji, 1982, 1984) suggest that the membranous enzymes are not uniformly distributed over all pituitary cells but rather are specific for a given cell population(s).

Immunohistochemical study of the post-natal development of the folliculo-stellate cells in the rat anterior pituitary gland.

We investigated the post-natal development of cell-to-cell communication within the rat anterior pituitary gland cells using immunohistochemistry of the S-100 protein. Tissues of animals from 10 to 60 days of age were analyzed. At 10 days of age, S-100 protein-containing cells were rarely observed. With age, the population of S-100 immunostained cells increased until day 40 when they were found to be quite numerous. No further changes were noted from day 40 through day 60. From our previous studies, we conclude that the cells which reacted with the S-100 antiserum were folliculo-stellate cells and their developmental pattern parallels that of the hypophyseal-gonadal axis.

Sealing of the follicular lumen of the anterior pituitary gland of the male rat.

It is commonly accepted that follicular lumina of the adult rat anterior pituitary gland are tightly sealed by junctional complexes, especially tight junctions. In this report, we describe the presence of follicular lumina that are unsealed. Peroxidase (HRP) was used to study such structures and when injected through the femoral vein, was observed in association with a few follicular lumina, on their microvilli and around the cilia of folliculo-stellate cells. The existence of peroxidase-positive follicles clearly shows that follicles of the hypophysis are not always firmly sealed by tight junctions. The folliculo-stellate cells which faced the peroxidase-positive follicles displayed HRP deposits which were membrane bound within their cytoplasm. These findings suggest an absorptive function for the folliculo-stellate cells.

Interventricular methotrexate therapy for carcinomatous meningitis due to breast cancer: a case with leukoencephalopathy.

A 46-year-old woman presented with paraplegia and severe lumbago. She had had a radical mastectomy for left breast cancer 10 years earlier, and 6 months prior to presentation she completed CMF chemotherapy for treatment of retroperitoneal metastasis. CT and MRI to identify potential causes of the paraplegia and lumbago showed leptomeningeal carcinomatosis due to dissemination from invasive recurrence of the retroperitoneal tumor. An Ommaya reservoir was inserted, and infusion of intrathecal methotrexate (MTX; 5 mg twice weekly) began. Her clinical symptoms improved after receiving 53 mg MTX. However, after receiving 83 mg MTX, the patient became dizzy from leukoencephalopathy. Although administration of prednisolone mostly resolved her symptom, the patient died 9 months after the diagnosis of carcinomatous meningitis.

Non-invasive lobular carcinoma within a fibroadenoma, a preoperatively diagnosed case.

Breast cancer within a fibroadenoma is rare and usually diagnosed postoperatively from pathological specimens. This paper reports a 54-year-old female with non-invasive carcinoma within a fibroadenoma, diagnosed preoperatively. She underwent a medical examination and mastopathy was suspected. On physical examination a mass 2 cm in diameter was palpated in the left breast. Ultrasonography showed a mass with smooth margins and uniform internal echoes, but cytology showed malignancy. Mammography showed a round mass with distinct margins and no calcification. As fibroadenoma, diagnosed by ultrasonography and mammography, and breast cancer, diagnosed by cytology, were not consistent results several core biopsies were performed. Needle biopsy showed proliferation of atypical epithelial cells; breast cancer within a fibroadenoma was diagnosed. MRI showed a circular mass with distinct, smooth margins and in a dynamic study, the mass showed irregular staining and the presence of early staining. Left lumpectomy and dissection of the left axillary lymph nodes was performed. Histological examination showed non-invasive lobular carcinoma occurring within a fibroadenoma.

Human amniotic epithelial cells are morphologically homogeneous: enzymehistochemical, tracer, and freeze-substitution fixation study.

We examined the fine subcellular morphology of human amniotic epithelial cells and attempted to answer the question as to whether amniotic epithelial cells consist of heterogeneous or homogeneous cells, which has long been controversial. Study subjects were fetal membranes from pregnant women (n=18) who abdominally gave birth to healthy infants at term (37.9+/-0.7 weeks of gestation, mean+/-sd). The methods employed were transmission electron microscopy, enzymehistochemistry, tracer permeability analysis, and freeze-substitution fixation. The labelings for acid phosphatase, cytochrome c oxidase, and CA++ATPase were seen in the lysosomes, mitochondria, and lateral plasma membranes, respectively. The staining distribution pattern of these three enzymes and the morphology of the organelle highlighted by these enzymehistochemistry did not differ among cells. Freeze-substitution fixation revealed that intercellular spaces in the amniotic epithelial cells were narrower than previously thought, but the tracers (horse radish peroxidase and lanthanum nitrate) fully entered these spaces. There were no variations in the tracer permeability among cells. All cells from freeze-substitution fixation exhibited the same morphological features. From these morphological viewpoints, we conclude that human term amniotic epithelial cells consist of a homogeneous cell population.

Gallium-67 imaging in the evaluation of thyroid malignancy.

One hundred thirty-six patients with suspected thyroid malignancy were studied prospectively with Ga-67 imaging of the thyroid and whole body. All patients subsequently had diagnoses proven by biopsy or surgical resection. Patients with malignant tumors (anaplastic carcinoma, malignant lymphoma, adenocarcinoma, medullary carcinoma, adenocarcinoma with squamous cell transformation, and metastases to the thyroid from other tumors) were examined serially after appropriate therapy. The authors draw on their own experience and a literature review to propose the following indications for Ga-67 imaging in patients with thyroid disease: 1) suspected anaplastic carcinoma or malignant lymphoma of the thyroid gland, 2) detection of distant metastases of anaplastic thyroid carcinoma and malignant lymphoma, 3) evaluation of efficacy of therapy, 4) suspected metastases to the thyroid gland from other malignancies, and 5) differentiation of malignant lymphoma from chronic thyroiditis. The strengths, limitations, and potential pit-falls of the technique are discussed.