Abdominal malignancies in patients with Wilson's disease.

BACKGROUND: Wilson's disease is associated with heavy copper overload, primarily in the liver. Copper is a toxic metal, and might be expected to be associated with cancer induction, as iron is in haemochromatosis. However, liver cancer is currently believed to be extremely rare in this disease, and other intra-abdominal malignancies have not been reported. AIM: To assess the frequency of abdominal malignant disease in patients with Wilson's disease on long-term follow-up. DESIGN: Retrospective study in two specialist Wilson's disease clinics: Cambridge/London and Uppsala. METHODS: We reviewed the case records of 363 patients seen at three centres: Addenbrooke's Hospital, Cambridge, 1955-1987; the Middlesex Hospital, London, 1987-2000; and the University Hospital, Uppsala, Sweden, 1966-2002. Patients were grouped by length of follow-up: 10-19 years; 20-29 years; 30-39 years; and 40 years or more. RESULTS: No cancers were seen in patients followed for <10 years. For patients in the 10-19 years group, the frequency was 4.2%; at 20-29 years, it was 5.3%; and at 30-39 years, 15%. No cancers were seen in the 40+ years follow-up group. The cancers consisted of hepatomas, cholangiocarcinomas, and poorly differentiated adenocarcinomas of undetermined primary site. DISCUSSION: Patients with Wilson's disease appear to be vulnerable to the formation of aggressive malignant intra-abdominal tumours during long-term follow-up, irrespective of treatment. Ultrasound scanning of the abdomen seems to be a useful screening procedure.

Metronidazol as a probable cause of severe liver injury.

Metronidazol, a commonly used antibiotic drug, has been very rarely associated with hepatotoxicity. In particular, no reports have appeared in the literature about cases of metronidazol-associated severe hepatotoxicity, leading to liver transplantation or death. We report on a case of acute fulminant liver failure in a young woman, who had, two years previously, developed jaundice after intake of metronidazol. During the current hospitalization, metronidazol treatment had been undertaken two weeks previously and also this time the patient developed severe hepatocellular injury and cholestasis. A viral etiology was ruled out as well as vascular, metabolic and malignant etiology. Although, the cause of the liver injury in this case is not proven, the relationship between this drug and two occasions of severe liver damage, suggests a positive challenge as well as rechallenge. An International algorithm was used for the assessment of the causality of a drug in this case of acute liver injury and a "probable" classification was obtained.

Risk factors for epithelial borderline ovarian tumors: results of a Swedish case-control study.

OBJECTIVE: Borderline ovarian tumors have a favorable prognosis. Previous epidemiological studies indicate common risk factors for invasive epithelial ovarian cancers and borderline tumors, but it remains unresolved whether these tumors are precursors of invasive cancers or a separate disease entity. The objective of this population-based case-control study conducted in 1993-1995 was to examine reproductive and other factors in relation to the risk of borderline ovarian tumors. METHODS: Subjects were 193 histologically verified incident epithelial borderline tumor cases and 3899 randomly selected controls aged 50-74 years, whose data were collected through mailed questionnaires. Risk estimates were calculated by unconditional logistic regression. RESULTS: Ever parous women were at reduced risk, with odds ratios of 0.44 (95% confidence interval (CI) 0.26-0.75) for serous and 0.63 (95% CI 0.34-1.19) for mucinous tumors. No clear trends emerged for age at first birth, at menarche, and at menopause. Lactation reduced tumor risk. Oral contraceptive ever use conferred no protection, with odds ratios of 1.40 (95% CI 0.87-2.26) for serous and 1.04 (95% CI 0.61-1.79) for mucinous tumors. The odds ratio for serous tumors following unopposed estrogen ever use was 2.07 (95% CI 1.08-3.95), whereas no risk increase appeared with estrogens supplemented by cyclic or continuous progestins. Mucinous tumors were not associated with hormone replacement therapy. The odds ratio for serous tumors in the highest category of body mass index was 6.47 (95% CI 3.09-13.5). CONCLUSIONS: Increasing parity and lactation reduce the risk of borderline ovarian tumors in women aged 50-74, while no protection follows oral contraceptive use. Hormonal situations such as unopposed estrogen use and obesity, where estrogens are not counteracted by progestins, may increase the risk of serous tumors.

Expression of cellular retinol- and retinoic acid-binding proteins in normal and pathologic human parathyroid glands.

We have previously reported data establishing the human parathyroid gland as a target organ for vitamin A. In the present study, we identified Ito-like cells in parathyroid glands, suggesting local stores of vitamin A. Furthermore, we used immunohistochemistry to investigate the expression of the cellular retinol-binding protein type 1 and the cellular retinoic acid-binding protein type 1 (CRABP I) in histologically normal glands, in remnants of "normal" glandular tissue adjacent to adenoma, in adenomas, and in hyperplastic glands of chief cell type. All normal and abnormal glands displayed immunoreactivity to the two antibodies. CRABP I appeared in the cytoplasm, cell membranes, and nuclear membranes in normal glands, but only exceptionally in the nuclear membranes in abnormal glands. Since retinoic acid inhibits the secretion of parathyroid hormone and CRABP I is thought to play a key role in regulating the amount of retinoic acid available to interact with specific nuclear receptors, these data may suggest impaired transport of retinoic acid to cell nuclei, thus contributing to the development of hyperparathyroidism.

Disrupted IGF2 promoter control by silencing of promoter P1 in human hepatocellular carcinoma.

Previous investigations have supported or indicated a stimulatory role of the insulin-like growth factor II gene (IGF2) in hepatocarcinogenesis. We have studied the transcript levels, promoter usage, and imprinting status of the ICF2 gene and its relationship to H19 in human hepatocellular carcinomas (HCCs) and liver tumor cell lines. The activity of the IGF2 promoter P1 was lost in about 70% of the cases (18 of 25). This is the most prominent abnormality regarding the IGF2 regulation in this study. Total IGF2 as well as promoter P3 transcription were up-regulated in a small group of the tumors. Twenty genetically informative cases were obtained from 26 cases, thus excluding the probability of loss of heterozygosity of the IGF2 gene. Among these, nine showed abnormal monoallelic expression of IGF2. One HCC and one HCC cell line proved loss of functional imprinting of IGF2. H19 and IGF2 were regulated in parallel, and expression levels were variable. Taken together, the disruption of the IGF2 promoter regulation, particularly the loss of P1 activity, is a common feature of human HCCs. The loss of P1 activity explains the frequent loss of biallelic IGF2 expression and may potentially be used as a diagnostic or monitoring marker for human HCC.

Biosynthesis and function of all-trans- and 9-cis-retinoic acid in parathyroid cells.

We demonstrate that cultured human and bovine parathyroid cells incubated with all-trans-[11,12-3H]-retinol convert this tracer into all-trans- and 9-cis-retinoic acid. By using RT-PCR, cellular retinol-binding protein type I (CRBP I), cellular retinoic acid binding protein I and II (CRABP I and II), retinoic acid receptors (RARs) alpha, beta and gamma, and 9-cis-retinoic acid receptor (RXR) alpha transcripts were detected in human parathyroid cDNA. CRBP I and CRABP I expression was confirmed by immunohistochemistry. Both 9-cis- and all-trans-RA were found to suppress parathyroid hormone (PTH) secretion from dispersed human adenomatous parathyroid cells, which was augmented by combined treatment with 1mM RA and 100 nM 1,25 (OH)2D3. The present data establish parathyroid gland as a target for retinoids and as a site of synthesis of the hormonal forms of vitamin A (retinol), all-trans- and 9-cis-retinoic acid.

Expression levels of the insulin-like growth factor-II gene (IGF2) in the human liver: developmental relationships of the four promoters.

We have studied the insulin-like growth factor-II gene (IGF2) promoter usage in normal human liver from fetal to late adult life by quantifying the specific transcripts by RNase protection assays using exon-specific probes. While the fetal liver uses only three promoters (P2, P3, P4) for the transcription of IGF2, all four promoters can be used from the age of 2 months after birth. The levels of the individual promoter transcripts vary substantially during development and the P3 promoter, which is a highly active fetal promoter, was not used by all the investigated adult patients but was detected in 30% of the adult group as a whole. The P1 promoter, which has previously been considered as the only one responsible for IGF2 transcription in the postnatal/adult liver, displayed a trend of increasing relative and absolute activity throughout life, but in some adult cases it was found to be less active than the P4 promoter. The P4 promoter displayed an age-related trend of decreasing activity from a very high fetal level, but individual exceptions were apparent. The P2 promoter transcript, peaking at the age of 2 months, showed a relatively even absolute amount from 18 months onwards. Thus, while P2 and P3 were both found to reach their highest activity after birth, the P4 promoter displayed its highest transcription at the fetal stage. The total IGF2 transcription, primarily from P2, P3 and P4, was found to peak shortly after birth. After this age, the P3 promoter transcript declined most rapidly and a low or zero amount was detected in adulthood. From the age of 18 months to old adulthood the total IGF2 mRNA, derived primarily from P1, P2 and P4, displayed a relatively even amount (approximately one tenth) of that seen at the peak at 2 months. This data may be important in relation to translatability of the various IGF2 transcripts.

Long-term treatment of Wilson's disease with triethylene tetramine dihydrochloride (trientine).

Long-term treatment with triethylene tetramine dihydrochloride, (trientine, TETA) was evaluated in 19 patients with Wilson's disease (WD). Two were given the drug as first choice and 17 after treatment with penicillamine. The change was made because of side-effects, lack of improvement or worsening of neurological symptoms. All penicillamine-induced side-effects reverted. Thirteen patients still receive trientine, and the mean total observation time on this treatment is 8.5 years/patient. Seven of the 13 are free from symptoms related to WD, five have mild to moderate neurological symptoms, mainly dysarthria. One patient with neurological symptoms who received trientine from the start of treatment deteriorated rapidly and is now severely dystonic. The symptoms initially worsened and later improved in one patient. All other patients improved during trientine treatment. Three patients died: two from a multifocal cancer including the liver and one non-complier from a ruptured spleen. Two patients underwent liver transplantation for progressive liver failure: one non-complier and one with liver cirrhosis whose liver function deteriorated despite treatment; both are now free from symptoms. Unexpectedly, two patients developed a serious colitis, one with duodenitis as well, that improved after withdrawal of the drug. No other unfavourable effects of trientine were recorded.

Ultrasound monitored laser-induced local hyperthermia in the liver. An experimental study on pigs.

Ultrasound (US) was used to monitor the size of tissue necrosis generated by Nd-YAG laser-induced local interstitial hyperthermia and tissue coagulation in 8 normal pig livers. Four treatments were done in each liver with 4 different energy settings. The size of the tissue necrosis measured on specimens was compared to the size measured on US. The laser energy caused a round tissue necrosis with some charring in the centre surrounded by a zone of white necrosis and a thin border of hyperaemia. A good correlation was found between the true and US-measured size of the necrosis diameters. It therefore seems possible to safely guide and monitor local laser hyperthermia in the liver with real-time US. The water-cooled quartz fibre used in this study has, however, some limitations.

Expression of cellular retinoid-binding proteins during normal and abnormal epidermal differentiation.

Retinoids have important roles in growth and differentiation of epidermal cells. We have analyzed the expression of two intracellular retinoid-binding proteins, the cellular retinol-binding protein type I and the cellular retinoic acid-binding protein type I, during normal and abnormal epidermal differentiation. Both proteins were found to be expressed in normal epidermis with increasing expression from basal layer towards superficial layers. In psoriatic lesions, a hyperproliferative condition of the skin, the epidermal expression of cellular retinol-binding protein I was induced, whereas expression of cellular retinoic acid-binding protein I was sharply down-regulated. This and other features of psoriatic lesions indicate that down-regulation of cellular retinoic acid-binding protein I expression might cause aberrant retinoid-regulated gene expression in skin. In basal and squamous cell carcinomas, cellular retinoic acid-binding protein I expression was down-regulated, whereas cellular retinol-binding protein I was expressed. Apart from epidermal cells, a mesenchymal, dendritic cell-type, strongly expressing cellular retinoic acid-binding protein I, was identified in the dermis. In several hyperproliferative conditions of the skin, including psoriasis, and squamous and basal cell carcinomas, this cell type was abundant. These results have implications for the role of retinoids in normal and abnormal epidermal differentiation and suggest that part of the phenotype of psoriasis is due to inappropriate metabolism of retinoic acid in skin.

Chromosome aberrations in an alpha-fetoprotein-producing hepatoblastoma.

The cytogenetic findings of an alpha-fetoprotein (AFP)-producing hepatoblastoma in a 14-month-old girl are reported. Ten of 36 tumor cells were chromosomally abnormal, yielding the composite karyotype 47,XX,2q +, t(3;5)(p25;q31),dup(4)(q12q26), +20. Three of the chromosomal abnormalities (2q+, break at 4q12, +20) have been reported previously and might be of pathogenetic significance.

Differential expression of platelet-derived growth factor alpha- and beta- receptors on fat-storing cells and endothelial cells of rat liver.

Fat-storing cells and endothelial cells of the liver sinusoids play important roles in the biosynthesis and degradation of hyaluronan (HYA). These cells were isolated from rat liver by a simple and rapid procedure involving: (1) cell separation by centrifugation on a Nycodenz gradient, after dispersion of the liver cells by collagenase perfusion; (2) further purification of the cells by centrifugation on a discontinuous Percoll gradient; and (3) culturing of the cells, taking advantage of the different time that seeded cells need for attachment to plastic surfaces. We have determined the effects of two isoforms of platelet-derived growth factor (PDGF), PDGF-BB and PDGF-AA, on HYA production by the original fat-storing cells, as well as by fat-storing cells which had changed in vitro to myofibroblast-like cells. PDGF-BB was found to stimulate HYA synthesis in both types of cells with a maximal response equal to that obtained with 10% fetal calf serum. PDGF-AA had no stimulatory effect on HYA production. Fat-storing cells and their modified myofibroblast-like phenotype bound specifically to 125I-PDGF-BB, but not to 125I-PDGF-AA, indicating that they had PDGF beta-receptors, but not alpha-receptors. In contrast, liver endothelial cells were found to have PDGF alpha-receptors, but not beta-receptors.

Isolation of the perisinusoidal vitamin A-storing cells from rat liver on Ca2(+)-immobilized glass surfaces.

Calcium was immobilized on glass slides employing covalently coupled iminodiacetic acid. The calcium-coated glass surfaces were then used for purification and culturing of perisinusoidal vitamin A-storing cells from rat liver. The cells were isolated in a yield of 0.9 x 10(6) cells/g rat liver without cross-contamination by other hepatic cell types. The cells were characterized by morphology, vitamin A fluorescence, and immunohistochemistry to detect expression of cellular retinol-binding protein.

Isolation and characterization of a cDNA clone corresponding to bovine cellular retinoic-acid-binding protein and chromosomal localization of the corresponding human gene.

A bovine adrenal cDNA library was constructed and a clone corresponding to cellular retinoic-acid-binding protein (CRABP) mRNA was isolated and sequenced. The insert of the clone corresponds to 75 bp of the 5' untranslated portion, the whole translated and the complete 3' untranslated portion of the bovine CRABP mRNA. A genomic Southern blot, probed with CRABP cDNA, indicated that only one copy of the gene is present in the human genome. Hybridizing bands in restricted chicken and fish DNA were also observed. Using the CRABP cDNA as probe we have located the human CRABP gene to chromosome 3 in hybridizations to mouse-human, hamster-human and rat-human cell hybrids. In situ hybridizations on rat testis cells probed with CRABP and cellular retinol-binding protein antisense mRNA indicate that both proteins are expressed in tubuli cells.

Impaired release of vitamin A from liver in primary biliary cirrhosis.

In 44 patients with primary biliary cirrhosis serum levels of vitamin A, retinol-binding protein and transthyretin (prealbumin) were found to be significantly lower than in 25 sex- and age-matched controls. Liver biopsies were available for chemical analyses in 28 of the patients. Their mean liver vitamin A concentration (2.8 +/- 2.0 mumoles per gm wet weight) did not differ significantly from that in 22 cases of sudden death which served as controls (2.0 +/- 1.5 mumoles per gm wet weight). Immunohistochemical investigation showed a normal distribution of serum retinol-binding protein in the patients' livers, whereas the staining pattern of cellular retinol-binding protein, believed to be involved in the intrahepatic transport of vitamin A, was abnormal. Thus, the number size and cellular retinol-binding protein staining intensity of fat-storing (Ito) cells were clearly higher in the patients as compared with controls. The results suggest that the low serum vitamin A levels in primary biliary cirrhosis are not a consequence of vitamin A deficiency but instead reflect a defective mobilization of vitamin A from the liver.

Quantitation and tissue localization of the cellular retinoic acid-binding protein.

The distribution of the cellular retinoic acid-binding protein (CRABP) in some rat tissues has been determined, and the protein has been localized by immunocytochemical techniques in sections from rat testis. In the testis CRABP was found in the seminiferous tubuli with Sertoli cells and the spermatogonia most intensely stained. All other cells of the germinal epithelium appeared largely devoid of CRABP. By use of an enzyme-linked immunosorbent assay CRABP was quantitatively estimated in several tissues and the highest levels were found in testis and eye. Comparisons of the tissue levels of CRABP and of the cellular retinol-binding protein (CRBP) did not reveal any apparent correlation.

Blood group isoantigen and involucrin expression in cervical intraepithelial neoplasia.

258 patients with dysplastic cervical lesions reclassified as CIN 1-3 and AIM 1-3 and with up to ten years of follow-up were immunostained with monoclonal antibodies against blood group isoantigens and involucrin for expression in normal and dysplastic squamous epithelium. The results show a varied staining pattern with a majority of unchanged staining properties in normal and dysplastic epithelium, the same frequency of increase as decrease in dysplasia and no correlation to progression or recurrence, in variance with previous reports.

Reliability of endometrial cancer diagnoses in a Swedish Cancer Registry--with special reference to classification bias related to exogenous estrogens.

In this study, various qualitative aspects of endometrial cancer diagnoses were critically evaluated regarding cases included in the Swedish Cancer Registry from the Uppsala Health Care Region. By comparing the number of such cases in the registry with cases reported directly from the departments of pathology and of gynecological oncology in the same region, it was found that approximately 5% of all incident cases had not been notified to the registry. An independent histopathological review of the original specimens showed that almost 9% of the cases did not represent an endometrial neoplastic lesion, the majority of these being reclassified as uterine sarcoma. The review also revealed the problem of a diagnostic bias that might arise in connection with estrogen exposure, in that a significantly higher proportion of the cases observed in a cohort of women who had received estrogen prescriptions were reclassified as a premalignant endometrial lesion than of the cases from the background population without estrogen exposure (33% versus 10%). Additional independent reviews of cases showing discordant diagnoses in the primary review indicated variability in diagnostic criteria among pathologists. It is concluded that when cancer registry data are employed in epidemiological studies of endometrial cancer, the use of additional sources of case recruitment is desirable in order to obtain a complete material; also that an independent histopathological review is necessary to standardize diagnostic criteria and thereby to avoid a classification bias.

Leiomyomatosis peritonealis disseminata.

Leiomyomatosis peritonealis disseminata (LPD) is a rare condition characterized by multiple subperitoneal spread of nodules, giving the clinical impression of a widespread malignant tumor. The histopathology of LPD is that of a benign leiomyoma, probably originating from the multipotent subcoelomic mesenchymal cells. Two new case reports are presented here, suggesting that some cases of LPD are wrongly classified as metastasizing leiomyosarcoma. As the prognosis in LPD is favorable, it is of great importance to establish the correct diagnosis. When both the pathologist and the clinician become aware of the multipotentiality of the mesothelium and the adjacent stroma and thereby the multifocal character of the lesions, some of the diagnostic problems might be overcome.