Enzyme-linked immunosorbent assay method for human autophosphorylated insulin receptor. Applicability to insulin-resistant states.

The insulin receptors from erythrocytes of 50 patients with non-insulin-dependent diabetes mellitus were tested for their ability to autophosphorylate. The assay was performed by a new enzyme-linked immunosorbent assay system that used monoclonal anti-insulin receptor antibodies absorbed to microtiter plates as a first antibody and polyclonal antiphosphotyrosine antibody as a labeled second antibody. By this assay, 3 patients were identified with defects in their insulin receptor kinase, although their defects appeared heterogeneous. Patient 1 had 85% less maximal autophosphorylation with a normal ED50 (1.6 x 10(-9) M insulin). Patient 2, who had polycystic ovary disease, had a 49.2% decrease in maximal autophosphorylation of insulin receptors, and the ED50 was shifted to the right (5.6 x 10(-8) M). Patient 3 with acanthosis nigricans had a normal maximal autophosphorylation, but the ED50 shifted to the right (2.9 x 10(-8) M). The mechanisms for the diversity detected in this assay is not known, but this technique has sufficient specificity and sensitivity to be used to screen for insulin-resistant patients who have a lack of kinase activity.

Immunocytochemical localization of prorenin, renin, and cathepsins B, H, and L in juxtaglomerular cells of rat kidney.

To examine the correlation of localization of prorenin, renin, and cathepsins B, H, and L, immunocytochemistry was applied to rat renal tissue, using a sequence-specific anti-body (anti-prorenin) that recognizes the COOH terminus of the rat renin prosegment. In serial semi-thin sections, immunodeposits for prorenin, renin, and cathepsins B, H, and L were localized in the same juxtaglomerular (JG) cells. Immunodeposits for renin were detected throughout the cytoplasm of the cells, whereas those for prorenin were detected in the perinuclear region. Immunoreactivity for cathepsin B was stronger than that for cathepsins H and L. By electron microscopy, prorenin was localized in small (immature) granules but not in large mature granules, whereas renin was localized mainly in mature granules. In serial thin sections, prorenin, renin, and cathepsin B were colocalized in the same immature granules containing heterogeneously dense material (intermediate granules). By double immunostaining, co-localization of renin with cathepsins B, H, or L was demonstrated in mature granules. The results suggest the possibility that processing of prorenin to renin occurs in immature granules of rat JG cells, and cathepsin B detected in JG cells may be a major candidate for the maturation of renin.

Immunocytochemical localization of cathepsins B, H, L, and T4 in follicular cells of rat thyroid gland.

To localize cathepsins B, H, and L in follicular cells of rat thyroid gland, we applied immunocytochemistry to the thyroid tissue using their respective monospecific antibodies. On serial semi-thin sections, cathepsins B, H, and L were localized in granules of various sizes located throughout the cytoplasm, whereas T4 was detected in larger granules located in the apical and supranuclear regions. By electron microscopy, cathepsins B, H, and L were localized in large less-dense granules (so-called colloid droplets) and in dense bodies of various sizes, whereas T4 was localized more intensely in large less-dense granules than in smaller dense bodies. By double immunostaining using an immunogold method, cathepsins H and B or L were co-localized in the same cytoplasmic granules. Moreover, immunoblotting demonstrated that proteins similar to cathepsins B, H, and L in the liver are present in the thyroid gland. These results suggest that cathepsins B, H, and L participate not only in degradation of thyroglobulin but in maturation of thyroid hormones, although it remains unknown whether all of them participate in the maturation process.

Immunocytochemical localization of cathepsins B, H, and their endogenous inhibitor, cystatin beta, in islet endocrine cells of rat pancreas.

To determine the characteristics of lysosomes in rat islet endocrine cells, we examined the precise localization of cathepsins B, H, and L and their specific inhibitors, cystatins alpha and beta, using immunocytochemical techniques. By use of serial semi-thin sections, we detected immunoreactivity for cathepsin B in insulin-, glucagon-, somatostatin-, and pancreatic polypeptide-positive (PP) cells. Strong immunoreactivity for cathepsin H was seen in A-cells and weak immunoreactivity in PP cells, but none in others. Immunodeposits for cystatin beta were demonstrated in B-cells. Brief dipping of thin sections in 1% sodium methoxide before the following immunocytochemical reaction enhanced specific deposits of immunogold particles on the target organelles. Use of a double-immunostaining technique showed co-localization of insulin with cystatin beta in many secretory granules. This suggests that cystatin beta may regulate converting enzymes participating in the maturation process of insulin. By use of an immunogold technique, heterogeneous localization of cathepsins B and H in lysosomes was also found among islet cells at the light microscopic level. This may be due to the difference in peptides degraded in lysosomes among the cells.

An immunocytochemical study on co-localization of cathepsin B and atrial natriuretic peptides in secretory granules of atrial myoendocrine cells of rat heart.

To examine localization of cathepsin B, a representative lysosomal cysteine protease, in atrial myoendocrine cells of the rat heart, immunohistochemistry at the light and electron microscopic level was applied to the atrial tissue, using a monospecific antibody for rat liver cathepsin B. In serial semi-thin sections, immunoreactivity for cathepsin B and atrial natriuretic peptides (ANP) was detected in the para-nuclear region of atrial myoendocrine cells. Several large granules and many fine granules in the region of the cells were positively stained by the cathepsin B antibody. Gold particles indicating cathepsin B antigenicity labeled secretory granules in the cells, which were also labeled by those indicating ANP, using thin sections of the Lowicryl K4M-embedded material. Moreover, some granules labeled densely by immunogold particles for cathepsin B seemed to be lysosomes. By double immunostaining using thin sections of the Epon-embedded material, gold particles indicating cathepsin B and ANP antigenicities were co-localized in secretory granules of the cells. By enzyme assay, activity of cathepsin B was three times higher in atrial tissue than ventricular tissue. The results suggest that co-localization of cathepsin B and ANP in secretory granules is compatible with the possibility that cathepsin B participates in the maturation process of ANP.

Internal jugular phlebectasia.

Internal jugular phlebectasia or abnormal fusiform dilatation of the jugular venous system usually presents as a neck mass that increases in size with maneuvers, which increase intrathoracic pressure. We present a case of internal jugular phlebectasia in which, due to an atypical presentation, the diagnosis was confirmed only by surgical exploration. The pathophysiology and radiologic evaluation are discussed to determine the role reserved for surgery in the management of this entity.

Adenoid cystic salivary gland carcinoma: a clinicopathologic correlation.

Between 1960 and 1980, 71 cases of adenoid cystic carcinoma (ACC) were reviewed according to treatment modality and clinical course. Histologic review of pathologic slides was performed to classify the tumors into their predominant histologic pattern (tubular, cribriform, solid). The predominant histologic patterns of the tumors were equally divided between tubular and cribriform. Very few were classified as a solid pattern. In the patients receiving the same type of therapy (surgery and irradiation), the cribriform and tubular variants of ACC demonstrated no difference in the rate of distant metastases and overall survival. The cribriform variant demonstrated a significantly worse prognosis in terms of local recurrence rate. The patients who had a solid histologic pattern of ACC appeared to have an overall worse prognosis in terms of distant metastases and long-term survival. The long-term survival of patients with ACC may be related to the development of distant metastases despite local control.

Improved treatment of salivary adenocarcinomas: planned combined surgery and irradiation.

The treatment outcome of 47 patients with adenocarcinoma of major and minor salivary gland origin treated at the Washington University Medical Center between 1960 and 1980 was retrospectively reviewed by site, histologic grade, and treatment modality. Planned irradiation with surgery was the initial treatment for 21 patients, irradiation alone for 14 patients, surgery alone for 11 patients, and chemotherapy for 1. Four patients presented with distant metastases at diagnosis and were not treated definitively. Twenty-seven patients had tumors histologically graded at the time of original treatment; one-third of these were low-grade, and two-thirds were high grade. Treatment results were analyzed in terms of local control as well as overall survival. Median survival for the entire group was 4.1 years. Local-regional disease control was significantly improved in the combination therapy group (81%) compared with the groups treated with irradiation alone (29%) and surgery alone (8%). Disease free survival was also significantly improved with combination therapy. Patients with low-grade adenocarcinoma had better local control and survived longer than those with high-grade. However, one-third of the patients with high-grade tumors survived 5 years. We conclude that both local disease control and survival of patients with adenocarcinoma of salivary gland origin were improved with the planned combination of irradiation and surgery.

The temporal fossa in head and neck reconstruction: twenty-two flaps of scalp, fascia, and full-thickness cranial bone.

We reviewed 22 consecutive flaps based on the blood supply of the temporal fossa. Our purpose was to demonstrate reliability of the vascular supply and to illustrate the versatility of these tissues for reconstruction of specialized structures, including eyelids, eyebrow, ear, lips, oral lining, orbit, and mandible. For these complex problems, all but one patient required multiple-stage surgery to obtain their final aesthetic and functional results. All flaps proved reliable and versatile. Their advantages include proximity to the reconstructive site, ease of bilateral reconstructions, and well-camouflaged donor deficit. In particular, the ability to transfer vascularized full-thickness cranial bone for total or bilateral mandibular reconstructions presents an additional possibility for this difficult problem. We conclude that the reconstructive potential of these flaps is limited only by the surgeon's ingenuity.

Laryngeal epidermoid carcinoma associated with juvenile laryngeal papillomatosis.

The speculation whether juvenile laryngeal papillomatosis may transform into or be associated with epidermoid carcinoma is explored. We document a case of invasive laryngeal carcinoma arising in preexisting juvenile laryngeal papillomatosis. After multiple childhood laryngoscopies and a tracheotomy, a 54-year-old, 30-pack per year smoker, who had never received radiation therapy, developed a florid exophytic transglottic squamous cell carcinoma. Histologically, the invasive epidermoid carcinoma was surrounded by a field of papillomata with varying degrees of atypical changes. After total laryngectomy, isolated papillomata were found in the lower trachea. There were no cervical lymph node metastases. No postoperative radiation therapy was given. Persistent squamous papillomata in the tracheostomy site, the lower trachea, and the posterior pharynx were treated with the CO2 laser. We emphasize the need to maintain a high index of suspicion for malignancy. In addition, we review the problem of benign papillomata in the aerodigestive tract following laryngectomy.

High-grade malignancies of the parotid gland: effective use of planned combined surgery and irradiation.

The trend toward treatment of parotid gland malignancies with planned combined surgery and postoperative radiation therapy is currently being followed by many centers, although prospective studies confirming the efficacy of this treatment regimen have only recently begun. We have reviewed only our "high-grade" histologic types: adenocarcinomas, malignant mixed tumors, high-grade mucoepidermoid carcinomas, squamous cell carcinomas, and undifferentiated carcinomas. Acinic cell carcinomas, adenoid cystic carcinomas, and low-grade mucoepidermoid carcinomas were excluded from study because of their different biologic behavior. Since 1974, we have employed the approach of surgical extirpation with preservation of the facial nerve when possible for all parotid tumors, combined with planned postoperative radiation therapy (50-70 Gy). We reviewed the 37 cases of "high-grade" parotid gland malignancies and compared the patients treated with the combined modality approach with our historical patients treated initially with surgery alone. Despite an apparent higher stage at presentation, our combined treatment group ultimately had significantly better local control (70% vs. 20%), and an equivalent survival rate at five years. Tumor was present at the margin of resection in 14 (74%) cases treated with combined surgery and irradiation. The facial nerve was preserved in six of these patients with positive margins, and only one of these patients developed a local or regional treatment failure. In conclusion, our data confirms the efficacy of surgical exploration to determine the extent of disease and surgical resection, preserving facial nerve function if possible, followed by postoperative radiation therapy at adequate doses. Control of local-regional disease was much improved by combined modality therapy as opposed to surgical resection alone, despite the prevalence of residual microscopic disease in the resection margins. Facial nerve function is optimally preserved by this approach of conservative surgery combined with postoperative radiation therapy.

Variations on the temporoparietal fascial flap.

An improved understanding of the vascular supply of the layers of the temporal fossa has increased the potential of this region for new and ingenious reconstructive techniques. Separate and independently vascularized layers of this region include hair-bearing scalp, glabrous skin, tempororoparietal fascia (and galea aponeurotica), temporalis muscle and fascia, and pericranium. Island flaps of glabrous skin and scalp provided esthetically appropriate tissue to cover a variety of defects. The malleable bulk of the subcutaneous fascial layers were combined with skin grafts to restore thin lining, and used as a vascularized bed for cartilage grafts in otherwise unsatisfactory recipient sites. Illustrative cases from our 5-year clinical experience are presented to demonstrate various combinations of the temporoparietal fascial pedicle with tissues from the temporal region to reconstruct the eyebrows, eyelids, orbits, cheeks, and lips.

Adenocarcinomas of major and minor salivary gland origin: a histopathologic review of treatment failure patterns.

Fifty-four cases of adenocarcinoma of major and minor salivary gland origin were seen between 1960 and 1980. Fifty of these were treated definitively. Planned surgery combined with radiation was the initial treatment for 22 patients (44%), surgery alone for 15 (30%), and radiation alone for 13 (26%). Of the patients receiving surgery with curative intent, 82% underwent complete resections (i.e., negative margins). Cervical lymph node involvement was present in 23% of cases, and 73% of these patients died of their disease within 3 years. Distant metastases developed in 37% of patients, with a median time of 1 year; 93% of these patients died within 3 years. Histologic grading was performed using objective criteria. Thirty-four percent of tumors were well-differentiated, 27% moderately differentiated, and 39% poorly differentiated. Patients with well-differentiated adenocarcinomas tended to survive disease-free longer and developed fewer distant metastases than those patients with moderately or poorly differentiated tumors.

Adenoid cystic carcinoma of major and minor salivary gland origin.

The records of 76 patients with adenoid cystic carcinoma of major and minor salivary gland origin seen at the Washington University Medical Center from 1963-1980 were reviewed to determine factors involved in local control, development of distant metastasis, and survival. Twenty-four (32%) patients were initially treated with surgery alone, 36 (47%) with combined surgery and irradiation, and 16 (21%) with irradiation alone. Local control after treatment was determined for all patients and was analyzed with respect to extent of surgery and dose of irradiation. Of 75 patients evaluable for local control, 30 (40%) failed with a median time of less than 5 years. There was no significant difference for patients treated vigorously for local recurrences after surgery. Patients who had a complete surgical resection (i.e., negative margins) survived significantly longer than patients treated by incomplete resection or biopsy alone followed by irradiation. Distant metastases developed in 50% of patients regardless of local control. Median survival after development of distant metastases was 40 months. There was no difference between major and minor gland sources for development of metastases. Lymph node involvement was rare. Our data indicate that complete and radical surgery results in the best survival. Combined modality therapy with surgery and irradiation optimizes the control of local disease. However, since distant metastases develop in spite of local control, in most instances we cannot recommend mutilating surgery for this disease entity.

Fascial pulley: cross-commissure lip reanimation for inferior division facial nerve paralysis.

The risks of causing further harm to the facial nerve are greater in surgery for partial facial paralysis. We present a new active and passive reconstruction technique for paralysis of the buccal-mandibular divisions of the facial nerve. Our fascial pulley technique of reanimation and suspension of the oral commissure produces no further injury to the facial nerve and the eyelids. In addition, it adds a better technique to the armamentarium of the reconstructive surgeon dealing with partial lower facial nerve paralyses.

MR imaging of primary leiomyosarcoma of the thyroid gland.

Primary leiomyosarcoma of the thyroid gland is extremely rare and radiological information on this tumor is scant. We presented radiological findings on primary thyroid leiomyosarcoma in a 66-year-old woman in which anaplastic carcinoma was suspected based on clinical and cytological features and discussed the radiological clues to distinguish between the two diseases. Ultrasonography showed an ill-defined hypoechoic mass without halo in the left lobe and the isthmus of the thyroid gland. Computed tomography depicted a low-density mass with calcification and necrosis, which invaded the thyroid cartilage. No lymphadenopathy was seen. The tumor was demonstrated as an isointense mass on T1-weighted MR images and a mass of intermediate signal on T2-weighted images. The tumor showed a fair enhancement on gadolinium-enhanced T1-weighted images. Although the radiological picture was nonspecific, primary thyroid leiomyosarcoma appeared less invasive and far less frequent in developing nodal metastasis than anaplastic carcinoma in light of the literature.

Delayed primary reconstruction of subtotal nail bed loss using a split-thickness nail bed graft on decorticated bone.

Split-thickness nail bed grafting is the accepted method of treatment for injuries involving loss of nail bed tissue. The nail bed of the great toe may be used without donor-site morbidity, and nail bed grafting may be combined with other procedures for fingertip reconstruction. A case of fingertip avulsion injury with loss of the nail plate, nail bed, and periosteum over the exposed distal phalanx of the thumb was reconstructed by a split-thickness nail bed graft placed directly on granulating decorticated bone. The length, appearance, and function of the injured dominant thumb were preserved.

The medial periareolar approach to submuscular augmentation mammaplasty under local anesthesia.

The medial approach to submuscular augmentation mammaplasty under local anesthesia begins with a medial periareolar incision around one-half or more of the areola. A subcutaneous tunnel is made toward the medial breast border, avoiding mammary ducts and sensory nerves to the nipple. The breast is reflected laterally, exposing a patch of pectoralis major muscle. A submuscular pocket is then created beneath portions of the pectoralis major, rectus abdominis, external oblique abdominis, and serratus anterior muscles, after which the implant is inserted and the muscle, dermis, and skin are closed sequentially. The periareolar incision allows for favorable scars without compromising the access or exposure necessary for accurate implant placement. Complete muscle coverage of the implant should contribute to a lower rate of capsular contracture. With a medial submuscular approach, nipple sensation is rarely altered, and revisions, if necessary, can be done through the same incision, still under local anesthesia, for increased safety, economy, and convenience. The medial approach to breast augmentation is a highly versatile, safe, and consistent method of achieving excellent results in breast augmentation in terms of scar, symmetry, and softness.

Methyl prednisolone in double-lumen gel-saline submuscular mammary prostheses: a double-blind, prospective, controlled clinical trial.

At the time of immediate breast reconstruction with submuscular implants, 76 consecutive patients (89 breasts) were randomized into two groups. One received a gel-saline, double-lumen implant with 40 cc of saline added to the outer lumen, while the other received the same implant plus 40 cc of saline and 16 mg methyl prednisolone (40 mg%). Patients were followed for a minimum of 3 years. The groups, which were matched for patient age and implant size, were evaluated at 3, 12, 24, and 36 months for capsular contracture, steroid atrophy, and other complications. With completion of the double-blind study, the patients with submuscular gel-saline implants with only saline added had an overall capsular contracture rate of 38 percent at 3 months, 38 percent at 12 months, and 44 percent at 24 and 36 months. Those with methyl prednisolone had an overall capsular contracture rate of 14 percent at 3 months, and this remained unchanged through the end of the study. The rates of all other complications were comparable. Methyl prednisolone in a dose of 16 mg in 40 cc saline (concentration 40 mg%), when used in the outer lumen of a double-lumen gel-saline implant in a submuscular pocket, is both safe and efficacious in reducing the risk of capsular contracture for a minimum of 3 years in patients undergoing immediate breast reconstruction with submuscular mammary implants.