Mirror-image asymmetry in monozygotic twins with kabuki syndrome.

Kabuki syndrome (OMIM 147920) is a rare disorder characterised by moderate intellectual disability, growth retardation, microcephaly and characteristic facial dysmorphic features which comprise long palpebral fissures, eversion of the lateral third of the eyelids and arched eyebrows with lateral sparseness. Mutations in MLL2 are the most frequent cause of this disorder. More than 100 MLL2 point mutations have been reported, but large intragenic deletions comprising one or more exons have not yet been identified. We report on a pair of monozygotic twin brothers in whom a deletion of 2 neighbouring exons was detected. The twins had the characteristic facial features of Kabuki syndrome, and they suffered from microcephaly, cleft lip and palate and congenital heart disease. Cleft lip and palate were left-sided in the first twin and right-sided in the second twin, i.e. they represented a mirror-image asymmetry. The intragenic deletion in these brothers broadens the spectrum of MLL2 mutations, and they provide a rare example of mirror-image asymmetry of congenital malformations in monozygotic twins.

Association of polymorphisms and haplotypes in the human growth hormone 1 (GH1) gene with breast cancer.

The growth hormone 1 (GH1)/insulin-like growth factor I (IGF-I) axis plays an important role in the development of breast cancer. By binding to its receptor, GH1 stimulates the production of IGF-I and its binding protein IGFBP3, resulting in the regulation of cell proliferation, differentiation and apoptosis. The GH1 gene expression is regulated by a highly polymorphic proximal promoter and a distal locus control region (LCR) 14.5 kb upstream of the gene. We investigated the effect of single nucleotide polymorphisms (SNPs) in the LCR and in the promoter region and an intron 4 SNP (IVS4+90 T/A) on breast cancer risk in a large cohort of Polish and German familial breast cancer cases and controls. SNPs in the LCR did not show an influence on breast cancer risk, either alone or in haplotypes. Three SNPs in the promoter region (G-340T, A-68G/C and A-63T/C) showed an increased and four SNPs (A-137G, G-119T, G-93delG and T-4G) a decreased allele frequency in the cases compared with the controls. Two of the SNPs (A-137G and G-93delG) lead to a decreased breast cancer risk among the minor allele carriers in the joint analysis of the two populations (odds ratio (OR) 0.62, 95% confidence interval (95% CI) 0.44-0.89, P = 0.01 and OR 0.65, 95% CI 0.47-0.90, P = 0.01, respectively). Haplotype analysis with these seven promoter SNPs revealed a protective association (OR 0.61, 95% CI 0.37-1.00, P = 0.04) for the haplotype GAGdAAT, containing the G-93delG variant allele, which in the single analysis already showed a protective effect. The effect was marginally stronger in combination with the LCR GC haplotype (OR 0.49, 95% CI 0.23-1.01, P = 0.04).

[Status of the human DNA papillomavirus in cervical tumors]. / Status DNK virusa papillom cheloveka v opukholiakh sheiki matki.

Cervical carcinoma is etiologically associated with the human papilloma virus (HPV), HPV 16 and HPV 18 being the most common. Viral DNA is thought to persist mostly in the episomal form in early tumor development, and in the integrated form in carcinomas. This assumption was checked with a new method that discriminated between RNAs transcribed from episomal and integrated HPV DNAs. Both forms were detected in carcinomas of Russian patients regardless of the disease stage. The data were verified by two other methods. RNA with sequences of the HPV transforming gene E7 proved to be transcribed from either DNA form. The results suggest that HPV integration is not crucial for carcinoma progression.

Prospective clinical study comparing DNA flow cytometry and HPV typing as predictive tests for persistence and progression of CIN I/II.

A cohort of 70 consecutive women at a university hospital colposcopy clinic with untreated CIN I and CIN II (CIN I/II) confirmed by cytology and histology was followed for 1 year in the setting of a prospective trial. In the lesions, the presence of DNA from HPV types was examined by restriction fragment length polymorphism (RFLP) analysis. Aneuploid cell lines were demonstrated by aneuploid histograms generated by high-resolution DNA flow cytometry. HPV type 16 infection and the existence of aneuploid cell lines proved to be significant risk factors for CIN I/II lesions to persist or progress to CIN III in the 1-year follow-up period in the same cohort of patients. The relative risks and 95% confidence intervals (CI) were 1.81 (1.44-2.76) for aneuploid cell lines and 1.74 (1.10-2.76) for HPV type 16 infection in CIN I/II lesions. As a predictive diagnostic test for CIN I/II lesions to persist or progress, the specificity and positive predictive value (PPV) for aneuploid histograms were 100% (CI, 73.5-100%) and 100% (CI, 86.8-100%), respectively. The low sensitivity of 27.3% (CI, 14.9-42.8%) restricted the clinical application of the test, leaving 32 of 44 women with persisting or progressing CINI/II with diploid histograms. HPV type 16 positivity by FRLP had a PPV of 68.4% (CI, 43.5-87.4%) as a prognostic test. Six of 19 HPV 16 infected women showed complete remission of their CIN lesion. A combination of the two tests did not provide any additional information.

Detection of integrated papillomavirus sequences by ligation-mediated PCR (DIPS-PCR) and molecular characterization in cervical cancer cells.

Human papillomavirus (HPV) genomes usually persist as episomal molecules in HPV associated preneoplastic lesions whereas they are frequently integrated into the host cell genome in HPV-related cancers cells. This suggests that malignant conversion of HPV-infected epithelia is linked to recombination of cellular and viral sequences. Due to technical limitations, precise sequence information on viral-cellular junctions were obtained only for few cell lines and primary lesions. In order to facilitate the molecular analysis of genomic HPV integration, we established a ligation-mediated PCR assay for the detection of integrated papillomavirus sequences (DIPS-PCR). DIPS-PCR was initially used to amplify genomic viral-cellular junctions from HPV-associated cervical cancer cell lines (C4-I, C4-II, SW756, and HeLa) and HPV-immortalized keratinocyte lines (HPKIA, HPKII). In addition to junctions already reported in public data bases, various new fusion fragments were identified. Subsequently, 22 different viral-cellular junctions were amplified from 17 cervical carcinomas and 1 vulval intraepithelial neoplasia (VIN III). Sequence analysis of each junction revealed that the viral E1 open reading frame (ORF) was fused to cellular sequences in 20 of 22 (91%) cases. Chromosomal integration loci mapped to chromosomes 1 (2n), 2 (3n), 7 (2n), 8 (3n), 10 (1n), 14 (5n), 16 (1n), 17 (2n), and mitochondrial DNA (1n), suggesting random distribution of chromosomal integration sites. Precise sequence information obtained by DIPS-PCR was further used to monitor the monoclonal origin of 4 cervical cancers, 1 case of recurrent premalignant lesions and 1 lymph node metastasis. Therefore, DIPS-PCR might allow efficient therapy control and prediction of relapse in patients with HPV-associated anogenital cancers.

Overexpression of p16(INK4A) as a specific marker for dysplastic and neoplastic epithelial cells of the cervix uteri.

Cytological screening for cervical cancer or its precursors using Papanicolaou's smear test (Pap test) has been highly efficient to reduce the morbidity and mortality of cervical cancer. However, evaluation of the Pap test relies on subjective diagnostic parameters and is affected by a high rate of false-positive and false-negative results. More objective diagnostic parameters to identify truly dysplastic or neoplastic cells in cervical smears as well as in cervical biopsy samples would therefore avoid insecurity for many patients and the high screening costs associated with repeated testing. Cervical dysplasia is induced by persistent infections through high-risk types of human papillomaviruses (HPVs). Outgrowth of dysplastic lesions is triggered by increasing expression of two viral oncogenes, E6 and E7, which both interact with various cell cycle-regulating proteins. Among these is the retinoblastoma gene product pRB, which is inactivated by E7. pRB inhibits transcription of the cyclin-dependent kinase inhibitor gene p16(INK4a). Increasing expression of the viral oncogenes in dysplastic cervical cells might thus be reflected by increased expression of p16(INK4a). In line with this hypothesis, we observed marked overexpression of p16(INK4a) in all cervical intraepithelial neoplasm (CIN) I lesions (n = 47) except those associated with low-risk HPV types (n = 7), all CIN II lesions (n = 32), all CIN III lesions (n = 60) and 58 of 60 invasive cervical cancers. In contrast, no detectable expression of p16(INK4a) was observed in normal cervical epithelium (n = 42), inflammatory lesions (n = 48) and low-grade cervical lesions (CIN I) associated with low-risk HPV types (n = 7). Dysplastic cells could also be identified in cervical smears using a specific p16(INK4a) monoclonal antibody. These data demonstrate that p16(INK4a) is a specific biomarker to identify dysplastic cervical epithelia in sections of cervical biopsy samples or cervical smears.

Transvenous embolization of a dural arteriovenous fistula of the anterior cranial fossa: preliminary results.

We report two cases of a dural arteriovenous fistula of the anterior cranial fossa, one causing subarachnoid hemorrhage and one detected accidentally. The first case was incompletely treated by neurosurgery, and the second one was referred for endovascular therapy. Both fistulas were successfully occluded by transvenous embolization by using electrolytically detachable coils.

Detection of isolated disseminated tumor cells in bone marrow and blood samples of patients with hepatocellular carcinoma.

BACKGROUND: Patients with hepatocellular carcinoma (HCC) often develop recurrences after curative resection or liver transplantation. Therefore, tumor cell dissemination must have occurred preoperatively or intraoperatively. Current staging methods cannot reliably detect micrometastasis. Reverse transcription-polymerase chain reaction (RT-PCR) for alpha-fetoprotein (AFP) has been used to detect circulating liver cancer cells, but results in blood samples have been contradictory. HYPOTHESIS: AFP-RT-PCR is a specific and sensitive assay for the detection of disseminated tumor cells in central venous blood and bone marrow samples of patients with HCC and has prognostic relevance. DESIGN: Prospective consecutive series. SETTING: University hospital. PATIENTS AND METHODS: We performed preoperative, intraoperative, and postoperative analyses of central venous blood samples and preoperative analysis of bone marrow samples of patients with HCC and patients without malignant disease, using a modified AFP-RT-PCR method. Preoperative serum AFP levels were measured. Clinical follow-up ranged from 4 to 20 months. MAIN OUTCOME MEASURES: Sensitivity and specificity of AFP-RT-PCR, correlation of AFP-RT-PCR results to tumor stage and tumor recurrence. RESULTS: In serial dilution experiments, 50 AFP-expressing HepG2 cells were detected in 10 mL of blood. Peripheral blood samples of 20 healthy volunteers and bone marrow samples of 21 patients with benign diseases consistently tested negative for AFP, whereas 4 of 24 patients with HCC showed AFP expression in bone marrow samples. All these patients had advanced disease; however, correlation of positive RT-PCR results to tumor stage was not significant (P = .07). One of the 4 AFP-positive patients developed an intrahepatic recurrence soon after liver transplantation. Central venous blood of patients with HCC (n = 24) and patients with benign liver diseases (n = 13) equally demonstrated AFP-expressing cells. There was no correlation of RT-PCR results to serum AFP levels. CONCLUSIONS: Perioperative screening for micrometastasis in bone marrow of patients with HCC is sensitive and specific with AFP-RT-PCR and may have prognostic relevance. Alpha-fetoprotein is not a suitable marker for the detection of tumor cells in central venous blood samples.

Significant increase of a specific variant TSG101 transcript during the progression of cervical neoplasia.

The human tumour susceptibility gene TSG101 has recently been identified on chromosomal locus 11p15.1-15.2 which is frequently affected by genetic alterations in neoplastic lesions of the uterine cervix. Aberrant transcripts of the TSG101 gene have been reported in various tumour entities, including breast, ovarian and prostate cancers, but also in several non-neoplastic tissues. We analysed TSG101 transcription by reverse transcription-polymerase chain reaction (RT-PCR) in a total of 139 clinical samples of cervical tissues and in cervical carcinoma cell lines. Variant transcripts were observed in all cell lines, in 69 of 122 (57%) cervical dysplasia and carcinoma samples and in five of 17 (29%) normal cervical tissues. One specific variant TSG101 transcript (delta 154-1054) was detected with a significantly increased frequency in advanced preneoplastic cervical lesions. However, the relative abundance of variant TSG101 transcripts appeared to be generally low, as only wild-type, but no variant transcripts were detectable in Northern blot analyses of cervical carcinoma cell lines. These data point to a progressive loss of stringent splice control functions or to extended alternative splicing in advanced dysplasia and neoplasia. The relative amounts of variant transcripts do not support a major functional role of TSG101 variants in cervical carcinogenesis.

Occipital pain in osteoid osteoma of the atlas. A report of two cases.

STUDY DESIGN: Two cases of occipital pain caused by an osteoid osteoma of the atlas are presented. OBJECTIVES: To describe the management of occipital pain in two young patients. SUMMARY OF BACKGROUND DATA: Osteoid osteoma is a benign lesion mostly affecting the long bones. A spinal location is uncommon. To the authors' knowledge, there are only five other reports of an osteoid osteoma located in the atlas. METHODS: Occipital headache, which was relieved by salicylates, was the major symptom reported by the two adolescents. In the first patient, a lesion of C1 was seen on plain radiographs. In the second patient, the diagnosis of osteoid osteoma was suggested by scintigraphic imaging and subsequently by computed tomography. RESULTS: Pain disappeared in both cases after surgical excision of the lesion. Histologic examination disclosed characteristic features of osteoid osteoma. CONCLUSIONS: Occipital pain in adolescents, which is relieved by aspirin, should raise suspicion about the possibility of an osteoid osteoma of the atlas. If standard cervical spine radiographs are negative, isotope scanning and computed tomography can help to establish the diagnosis. Complete excision eliminates the lesion and produces immediate relief for the patient.

No evidence of p53 allele-specific predisposition in human papillomavirus-associated cervical cancer.

The potential association of distinct polymorphisms of the tumor suppressor gene p53 with an increased susceptibility to malignant transformation has been reported for various cancer entities. Most recently, p53 protein containing an arginine residue in codon 72 was shown to be more effectively degraded by the E6 oncoprotein of human papillomavirus (HPV) than the corresponding proline isoform in cervical carcinoma cells. Additionally, a seven times higher risk of cervical cancer for Arg homozygotes was suggested. We set out to confirm this allele-specific predisposition on a larger population, comprising 87 cervical cancer and 151 normal control samples. However, there was no significant difference in the observed frequencies of homozygous Arg genotypes in cervical cancer patients (52.8%) and normal controls (55.7%). Furthermore, the prevalence of the Arg/Arg allelotype did not vary between HPV+ (n = 75) and HPV- (n = 12) carcinoma samples. Thus, our investigation of a larger set of clinical samples does not support the proposed association of any polymorphic status of p53 at codon 72 with an elevated risk for cervical cancer.

Detection of high-risk cervical intraepithelial neoplasia and cervical cancer by amplification of transcripts derived from integrated papillomavirus oncogenes.

Cervical cancer emerges from cervical intraepithelial neoplasia (CIN) induced by high-risk HPV (HR-HPV) infections. However, the vast majority of CIN lesions regresses spontaneously, and only a few lesions persist or progress to invasive carcinoma. On the basis of morphological criteria, it is not possible to differentiate high-grade lesions that will regress or persist from those that inevitably will progress to invasive cancers. In most cervical carcinomas, human papillomavirus (HPV) genomes are integrated into host cell chromosomes and transcribed into mRNAs encompassing viral and cellular sequences. In contrast, in early preneoplastic lesions, HPV genomes persist as episomes, and derived transcripts contain exclusively viral sequences. Thus, detection of HPV transcripts derived from integrated HPV genomes may specifically indicate both CIN lesions at high risk for progression as well as invasive cervical cancers. Here, we established a protocol for the amplification of papillomavirus oncogene transcripts (APOT) from cervical specimens that allows us to distinguish episome- from integrate-derived HPV mRNAs. Cervical swab and biopsy samples from 549 patients attending outpatient clinics for cervical dysplasia were screened for the presence of HPV DNA, and 155 samples that were positive for either HPV type 16 (n = 143) or 18 (n = 12) were subjected to the APOT assay. In samples derived from normal cervical epithelia (n = 19) or low-grade cervical lesions (CIN I, n = 10), no integrate-derived HPV transcripts were found. In contrast, in 1 (5%) of 22 samples derived from CIN II lesions, in 10 (16%) of 64 samples from patients with CIN III lesions, and in 35 (88%) of 40 samples from patients with cervical cancer, integrate-derived HPV transcripts were detected. Thus, detection of integrate-derived HPV transcripts in cervical swabs or biopsy specimens by the APOT assay points to advanced dysplasia or invasive cervical cancer.

Identical variant TSG101 transcripts in soft tissue sarcomas and various non-neoplastic tissues.

Inactivation of the TSG101 gene was recently shown to induce malignant transformation of NIH/3T3 fibroblasts. Abnormal TSG101 transcription profiles were observed in various human cancers, and large intragenic deletions of the TSG101 gene were reported for a series of human breast cancer specimens, pointing to a potential tumor-suppressive activity of TSG101. However, subsequent more detailed studies on a large panel of breast carcinoma samples did not confirm the tumor-associated genomic deletions. Here we analyzed the transcription patterns of the TSG101 gene in soft-tissue sarcomas and non-neoplastic human tissues. Forty-five of 71 soft tissue sarcoma samples (63%) displayed variant transcripts; however, identical aberrant transcripts were also detected in seven of 15 non-neoplastic control tissues. Restriction fragment length polymorphism analysis of the TSG101 gene excluded major genomic rearrangements in the soft tissue sarcoma samples. Northern blot analysis revealed a very low abundance of variant transcripts as compared with the wild-type TSG101 transcript. These data point to aberrant splicing of the TSG101 mRNA in normal and transformed human mesenchymal tissues rather than tumor specific alterations of the TSG101 gene. In summary, this analyses does not support a pathogenic role for altered TSG101 expression in human soft tissue sarcomas.

High cervical pain and impairment of skull mobility as the only symptoms of an occipital condyle fracture. Case report.

Occipital condyle fractures are rarely reported in survivors of trauma. Most cases involve patients with a major head trauma, lower cranial nerve palsy, and/or suspected lesions demonstrated on plain x-ray films of the skull or cervical spine. The authors describe a traffic-accident victim in whom an atlanto-occipital joint lesion was suspected based only on mobility investigation of the skull. Axial high-resolution computerized tomography of the atlanto-occipital joint showed a fracture of the right occipital condyle.

A cauda equina syndrome in a patient treated with oral anticoagulants. Case report.

The authors report a patient who was on oral anticoagulants because of mitral valve disease and who developed paraplegia from subarachnoid bleeding involving the cauda equina. The differential diagnosis, investigations and treatment of the cauda equina syndrome are described.

Occipital condyle fracture must be considered in the pediatric population: case report.

To our knowledge, no case of occipital condyle fracture after minor head trauma in the pediatric population has been published. We report the case of a 12-year-old girl with a Jefferson's fracture detected on x-ray films. Axial high resolution computed tomography and coronal reconstruction images demonstrated the additional occipital condyle fracture.

Extensive cervical intradural and intramedullary lipoma and spina bifida occulta of C1: a case report.

A 17-year-old boy presented with a 1-year history of progressive gait difficulties and slowing of fine hand movements. On neurological examination there was tetraspasticity, bilateral pes equinovarus and a decreased position sense in the feet. CT and MRI scan of the cervical spine demonstrated a spina bifida occulta of C1, an extensive intradural lipoma from the foramen magnum to C4 with a small intramedullary portion at C3, and a distal syringomyelia reaching down to D12. After excision of the extramedullary portion of the lipoma, there was a marked improvement of the gait and a reduction of the spasticity.

Failure of total hypophysectomy to remove intrasellar microadenoma in cushing's disease.

The pathological findings are described of a female patient with persistent Cushing's disease after two unsuccessful transsphenoidal operations: a left transsphenoidal hemihypophysectomy followed by a total hypophysectomy 1 month later. The patient was finally cured by bilateral adrenalectomy but suddenly died of heart failure 4 months later. Postmortem examination did not show invasive ACTH-secreting tissue in the pituitary region or an ectopic ACTH-secreting tumor, as initially presumed. Instead, a very small corticotroph adenoma was located immediately under the diaphragm sellae at the left side. The reasons for surgical failure in Cushing's disease are discussed. As in our patient, a missed small intrasellar adenoma must not be excluded when "total" hypophysectomy fails to cure Cushing's disease.

Cushing's disease and hyperprolactinemia due to a mixed ACTH- and prolactin-secreting pituitary macroadenoma.

A 36-year-old man with depression, Cushingoid features and hypogonadism was found to have simultaneous pituitary-dependent Cushing's disease and marked elevation of serum prolactin (PRL). CT-scan revealed a macroadenoma with suprasellar extension. Transphenoidal surgery cured the patient's Cushing's disease, but failed to correct his hyperprolactinemia, which was controlled by subsequent bromocriptine therapy. Immunostaining of the pituitary tumor was positive for PRL as well as for ACTH, and ACTH-related peptides beta-lipotropin and beta-endorphin in two distinct tumor cell lines. This pituitary tumor is one of the few mixed PRL- and ACTH-secreting tumors documented by immunostaining. It is the second reported in a macroadenoma, in which PRL-secreting tumoral cells are much more abundant than ACTH-secreting cells.