Quantitative biochemical analysis of microtubule content in normal and transformed 3T3 cells.

Microtubules in normal and transformed BALB 3T3 cells were preserved in a stabilizing medium and measured by a [3H]colchicine-binding tubulin assay, and compared to total cellular tubulin measured under nonstabilizing conditions. Essentially no change in tubulin or microtubule content was seen with changes in cell density or with changes in cellular morphology at various stages of growth of normal or transformed cells or induced by dibutyryl cAMP treatment of transformed cells. Of five cell lines transformed by a variety of agents, four had a significantly higher total tubulin content than untransformed 3T3 cells and all of them had an increased microtubule content. None of the transformed lines had a lower fraction of tubulin recoverable as sedimentable microtubules compared to untransformed cells, and in three of them this fraction was significantly higher. These results establish that microtubules are present in transformed cells to at least the extent (if not greater) than in normal cells but that there are variations in the total amount of tubulin and microtubules as well as the fraction of the total tubulin present as microtubules which are not strictly correlated with transformation or cell morphology.

Local anesthetic-induced inhibition of collagen secretion in cultured cells under conditions where microtubules are not depolymerized by these agents.

Tertiary amine local anesthetics previously have been shown to influence some microtubule-dependent cellular functions. Since several cell secretion processes, including secretion of collagen, have been shown to be inhibited by microtubule-disrupting drugs such as colchicine, we determined whether local anesthetics affect collagen secretion. Six local anesthetics inhibited collagen and non-collagen protein secretion (up to 98%) into the extracellular medium of 3T3 cells and human fibroblasts, an effect apparently independent of influences on proline transport and total protein synthesis. A combination of colchicine and cytochalasin B did not duplicate the effects of local anesthetics. The effects of subsaturating concentrations of colchicine and procaine on secretion were additive, suggesting that both drugs act on the secretory pathway at the level of microtubules, but other effects of the two types of drugs were strikingly different. In comparing the mechanisms of action of colchicine and local anesthetics, it was seen that, in contrast to colchicine, radioactive procaine and lidocaine were slowly transported into 3T3 cells, did not bind to the tubulin-containing TCA-insoluble fraction, and did not bind to purified tubulin in vitro. The fraction of cellular tubulin present as microtubules (47% in normal cells) was determined by measuring tubulin in stabilized, sedimentable microtubules compared to total tubulin, using a [3H]colchicine binding assay. Pretreatment of cells in the cold or with colchicine led to depolymerization of microtubules, but pretreatment with five local anesthetics tested did not. Therefore, in contrast to colchicine, local anesthetics in concentrations that inhibit secretion do not directly interact with or depolymerize microtubules. These drugs, however, do affect a microtubule-dependent process and may do so by detaching the microtubular system from the cell membrane.

Primary ovarian small cell carcinoma of pulmonary type. A clinicopathologic, immunohistologic, and flow cytometric analysis of 11 cases.

Eleven primary ovarian tumors that resembled small cell carcinoma of the lung are reported. They occurred in women 28-85 (mean 59) years of age, most of whom presented with abdominal swelling. Six of the tumors were unilateral and five bilateral; seven had spread beyond the ovary. The tumors ranged from 4.5 to 26 (mean 13.5) cm in greatest dimension and were mostly solid, with a variable minor cystic component. Microscopic examination showed small to medium-sized round to spindle-shaped cells with scanty cytoplasm, hyperchromatic nuclei, and inconspicuous nucleoli growing in sheets, closely packed nests, and occasionally islands and trabeculae. A component of endometrioid carcinoma was present in four tumors, another tumor showed squamous differentiation, another contained a cyst lined by atypical mucinous cells, and two others were associated with a Brenner tumor. Argyrophil granules were present focally in two of six tumors appropriately stained. Immunohistochemical staining was performed in nine cases: in six there was staining of the small cell component for keratin, in five for epithelial membrane antigen, in seven for neuron-specific enolase, in two for chromogranin, and in one for Leu-7. Vimentin staining was not observed. Flow cytometry was performed on eight tumors: five were aneuploid and three diploid. Five of seven patients with long-term follow-up died of, or with, disease at 1-13 (mean 8) months, one died after an unknown interval, and one was alive at 7.5 years. Two other patients had recurrent or residual disease at 6 and 8 months.

Ovarian serous borderline tumors with micropapillary and cribriform patterns: a study of 40 cases and comparison with 44 cases without these patterns.

A group of investigators have proposed that the presence of micropapillary or cribriform patterns within ovarian serous tumors diagnosed as borderline according to World Health Organization (WHO) criteria identifies a subset of these neoplasms that are apt to be associated with invasive peritoneal implants and therefore should be designated as "micropapillary carcinoma." The authors of the current article identified 40 serous borderline tumors that showed one or both of these patterns, using the earlier investigators' published criteria for so-called micropapillary carcinoma, and compared them with 44 tumors that lacked these patterns (controls). Twenty-six patients with micropapillary tumors were aged 21 to 76 years (mean 38); 11 with cribriform tumors were aged 34 to 79 years (mean 60); and 3 with tumors having both patterns were aged 21 to 58 years (mean 38); the control patients were aged 22 to 83 years (mean 54). An advanced stage, bilaterality, and ovarian surface growth were features of the "micropapillary" tumors more often than of the control tumors. Except for a postoperative death related to sepsis, all 11 patients with Stage I tumors with either or both patterns who were followed until their death, or for at least 5 years (mean 7.9 years), survived without evidence of disease; a twelfth patient had a recent removal of recurrent pelvic tumor at 2.8 years and was alive at 3.3 years. Six of the eight patients with Stage II or III tumors with either or both patterns who were followed for at least 5 years (mean 7.5 years) survived disease-free. No deaths from tumor or progressive recurrences occurred in 27 control cases with 5-14 (mean 7.9) years of follow-up data. The two tumor-related deaths in the entire series, one from a micropapillary tumor and one from a cribriform tumor, occurred in patients who had Stage III tumors with invasive peritoneal implants. No patient with "micropapillary" tumors and noninvasive implants had progressive disease. Two women with "micropapillary" tumors and two control subjects had stable recurrent tumor or a newly developed tumor in a contralateral ovary that had been spared during the initial operation. Our findings confirm those of previous investigators that noninvasive serous tumors with a micropapillary or cribriform pattern or both patterns may be accompanied by invasive peritoneal implants more often than tumors without such patterns and that in such cases the disease is likely to be progressive and fatal. Since so-called micropapillary carcinomas lack obvious stromal invasion within the ovary, and their prognosis when they spread to the peritoneum is much closer to that associated with typical Stage II and III serous borderline tumors than to that associated with similarly staged serous carcinomas, the authors believe that this newly described category of tumors should remain as a subset within the borderline category, with a notation that their prognosis is poor if they are associated with invasive peritoneal implants.

Sinonasal hemangiopericytoma. A reassessment with electron microscopy, immunohistochemistry, and long-term follow-up.

Sinonasal hemangiopericytomas are rare, occasionally misdiagnosed neoplasms that have often been considered distinct from hemangiopericytomas of other sites. Eleven cases were studied. Nine arose from the nasal cavity and two from the paranasal sinuses. The patients' mean age was 58 years. In nine cases there were no appreciable mitoses; in two, mitoses were frequent. Of 10 cases studied by immunostaining, all were positive for vimentin; two had faint focal staining for actin; one focally expressed S-100 protein; all were negative for cytokeratins, desmin, and Factor VIII-related antigen; and none bound Ulex europaeus agglutinin 1. Five cases were studied by electron microscopy. The most consistent features were basal lamina-like material partly surrounding tumor cells and completely separating them from endothelium, tapered cytoplasmic extensions, and orderly bundles of filaments. Intercellular junctions and pinocytotic vesicles were present in some tumors. Of nine cases with adequate follow-up, tumors recurred in four cases (44%) after a mean of 6.5 years, and none metastasized. A review of the literature showed that high local recurrence rates, late recurrences, and low rates of metastasis were features of tumors in this location. This might be a reflection of early presentation, small tumor bulk, and difficulty of complete resection, rather than evidence for a biologically distinct neoplasm.

Ovarian involvement by the intra-abdominal desmoplastic small round cell tumor with divergent differentiation: a report of three cases.

Three girls, one 14 and two 15 years of age, with the recently described neoplasm that has been designated "intra-abdominal desmoplastic small round cell tumor with divergent differentiation," and ovarian involvement at presentation are described. In two cases the ovarian tumor was initially thought to be the primary neoplasm. In all cases there was extensive extraovarian tumor at the time of presentation. The ovarian involvement was bilateral in two cases and unilateral in the third. Microscopic examination showed prominent nodular growth within the ovaries. The tumors were characterized predominantly by nests of small cells with hyperchromatic nuclei and scant cytoplasm separated by a prominent desmoplastic stroma. A few tubules containing mucinous secretion were present in one case. On immunohistochemical staining many of the tumor cells stained positively for cytokeratin, epithelial membrane antigen, desmin, and vimentin. Staining for neuron-specific enolase was present in two cases but was conspicuous in only one of them. Leu-7 was expressed by the tumor cells in two cases, and S-100 protein by one, giving further support to the possibility of neuroectodermal differentiation within some of these neoplasms. The two cases studied by electron microscopy both showed frequent intercellular junctions, basal lamina, cytoplasmic filaments, and sparse, small dense granules of either neuroendocrine or lysosomal type. Paranuclear aggregates of filaments were found in one case and cellular processes were prominent in the other case. The differential diagnosis in these cases was extensive and included a number of small cell tumors that may involve the ovary, either primarily or secondarily, in young females. The desmoplastic small round cell tumor should be considered in such cases when the appearances on routine examination are consistent with the diagnosis, and appropriate immunohistochemical stains should be performed to confirm the diagnosis.

Inter-instrument comparison of blood gas analyzers and assessment of tonometry using fresh heparinized whole human blood.

Because of limitations associated with commercial blood gas quality controls and tonometry of stored blood, fresh heparinized blood was used to compare PO2 and PCO2 performance of ten blood gas analyzers. Function of nine gas mixer/tonometer systems was evaluated. These were used to create blood samples with target values for PO2 and PCO2. All ten analyzers had high precision; this magnified small differences between observed results and target values. Grand mean results from all ten analyzers were within 0.8 mm Hg of the target for PO2 of 40.0 and 100.0 and for PCO2 of 20.0 and 70.0 mm Hg. Eight automated blood gas analyzers gave clinically indistinguishable results for PO2 and PCO2 that were sufficiently accurate for clinical purposes. Also reported is the practicality of using tonometry of fresh heparinized blood in a per shift quality control program for PO2 and PCO2.

Neuroendocrine tumors of the genital tract.

Neuroendocrine tumors are more common in the female than male genital tract; most are uterine small cell carcinomas or ovarian carcinoids. Primary ovarian carcinoids are divided into insular, trabecular, strumal, and mucinous types; most are benign. Carcinoids metastatic to the ovary are more aggressive; most arise in the gastrointestinal tract. Scattered neuroendocrine cells are seen in a variety of ovarian surface epithelial tumors; sporadic mucinous cystic tumors with neuroendocrine cells have been associated with Zollinger-Ellison syndrome. Frank neuroendocrine carcinomas in the ovary include small cell carcinoma and large cell neuroendocrine carcinoma, each with a poor prognosis and often associated with a conventional surface epithelial tumor Such carcinomas also occur in the endometrium and cervix. Uterine carcinoids are rare if strict criteria are applied. Small cell neuroendocrine carcinomas also occur rarely in the vagina and vulva. Most male genital tract neuroendocrine tumors are prostatic small cell carcinomas or testicular carcinoids. Extragonadal carcinoids of the male genital tract are rare. Testicular carcinoids should be distinguishedfrom metastatic tumors. It is important to distinguish prostatic small cell carcinoma from poorly differentiated adenocarcinoma with small cells. Small cell neuroendocrine carcinomas also occur rarely in the scrotum, penis, and penile urethra.

DNA content and proliferative activity in ovarian small cell carcinomas of the hypercalcemic type. Implications for diagnosis, prognosis, and histogenesis.

Ovarian small cell carcinoma of the hypercalcemic type is a rare cancer of young women of nuclear histogenesis. Although usually lethal, a subset of patients with stage I tumors have survived. Twenty-five cases of small cell carcinoma (17 stage I, 1 stage II, and 7 stage III) were evaluated by flow cytometric analysis performed on paraffin-embedded tissue. Forty classifiable histograms from 23 cases were DNA diploid; histograms from two cases could not be interpreted. The mean S-phase fraction was 10.5% (4.7% to 18.4%), and the mean G2/M fraction was 5% (1.5% to 19.5%) in 22 cases. Mean values of mitotic rate, S-phase fraction, G2/M fraction, and proliferation index (%S + %G2/M) were not associated with stage or outcome, nor did any proliferation variable correlate with interval to death. A comparative review of flow cytometric findings in other types of ovarian cancer that may be confused with small cell carcinoma indicates that flow cytometry is an objective diagnostic aid to distinguish small cell carcinoma of the hypercalcemic type from other forms of small cell carcinoma, malignant germ cell tumors, and sex-cord tumors, and that small cell carcinoma probably does not belong in either the surface epithelial or germ cell categories of ovarian cancer. Finally, the flow cytometric findings in this report exemplify the rare phenomenon of a diploid DNA content in a very lethal tumor and indicate that an accurate diagnosis of tumor type is essential before a prognosis on the basis of flow cytometric data can be made.

Prognostic importance of intraoperative rupture of malignant ovarian epithelial neoplasms.

OBJECTIVE: To determine whether rupture of malignant ovarian epithelial tumors at the time of operation influences the patient's overall prognosis. METHODS: Between 1975 and 1990, 79 patients with stage I invasive epithelial ovarian cancer were treated at Massachusetts General Hospital. Patients were identified from the tumor registry, and charts were reviewed retrospectively. In 71 of the 79 cases, pathologic slides were evaluated. Of the 79 patients, 36 had stage Ia tumors, 20 stage Ic secondary to intraoperative rupture (Ic-rupture), and 17 stage Ic secondary to capsular invasion-serosal disease or positive ascites or washings (stage Ic-other). Survival analysis was performed to compare the three groups of patients. RESULTS: There were four recurrences and deaths among the 20 women with stage Ic-rupture tumors (20%), compared to one (3%) among the 36 women with stage Ia. The recurrence-free survival at the median follow-up time for the two groups was 97 +/- 3 and 78 +/- 10 months, respectively (P = .03); overall survival was 97 +/- 3 and 73 +/- 12 months (P = .04). There were two recurrences (12%) and one death (6%) among the 17 women with stage Ic-other, giving recurrence-free and overall survivals of 88 +/- 8 and 94 +/- 6 months, respectively. The survival experience of this last group was not significantly different from that in the Ic-rupture group (P = .2). The hazard ratios for overall survival associated with stage Ic-rupture and each potential confounder, except for bloating, exceeded 6.5, with P < or = .10. All deaths occurred in the 28 patients with grade 2 or 3 tumors. Even in this smaller group, the hazard ratio for stage Ic-rupture was 6.8 (P = .09). CONCLUSION: Intraoperative rupture of malignant epithelial ovarian neoplasms may worsen the prognosis of patients with stage I ovarian cancer.

Intravascular papillary endothelial hyperplasia involving the synovium.

To our knowledge, this is the first reported case of intravascular papillary endothelial hyperplasia occurring in the synovium. The patient, a 16-year-old boy, presented with pain and hemarthrosis of the knee in the absence of known trauma. The lesion arose within a subsynovial varix and episodically bled with the intra-articular hemorrhage and reactive synovial changes producing the patient's symptomatology. The clinical, pathologic, and ultrastructural features of the lesion are summarized from a review of the literature, and the differential diagnosis of hemarthrosis with a hemosiderotic synovitis is discussed.

Management of anesthetic complications and emergencies in the obstetric patient.

The importance of cooperation and understanding between the obstetrician and anesthesiologist in the management of obstetric emergencies cannot be overemphasized. Indications for cesarean section and choice of anesthetic are significant considerations. Algorithms for the management of special treatment problems such as malignant hyperthermia, postdural headache, and epidural abscess and hematoma are presented. Posting of protocols for the management of particular crises in both delivery and postanesthesia care units is strongly recommended.

Multiple hyperbaric oxygenation (HBO) expands the therapeutic window in acute spinal cord injury in rats.

Hyperbaric oxygenation (HBO) therapy has been reported to improve neurological recovery following spinal cord injury (SCI). In the present study, we examined whether multiple HBO expands the therapeutic window for acute SCI. Single HBO (2.8 ATA, 1 hour) treatment was used at 30 minutes, 3 hours, and 6 hours following SCI, and serial HBO treatment (once daily for 1 week) at 6 hours and 24 hours post-injury. Mild SCI was induced by adjusting the height for a weight drop insult (10 g) to 6.25 mm above the exposed spinal cord. The group of animals receiving a single HBO intervention beginning at 30 minutes and 3 hours, or serial HBO treatment starting at 6 hours following the injury had a significantly better neurological recovery than animals with SCI only. The results of this study demonstrate that multiple HBO expands the therapeutic window for acute SCI to 6 hours after injury, further that serial HBO administration is superior to single HBO therapy.

Mucinous adenocarcinoma of the parotid gland. Report of a case with fine needle aspiration findings and histologic correlation.

BACKGROUND: Mucinous adenocarcinoma rarely arises as a primary tumor within the parotid gland, and only the histologic features of this tumor have been described. CASE: A 4-cm, firm mass arose in the right parotid gland of a 72-year-old male over a six-week period. Cystic on computed tomography, the mass, on fine needle aspiration biopsy, yielded monomorphic, moderately atypical cells, both single and clustered, associated with abundant mucoid material and focal necrosis. Tumor cells had eccentric nuclei, prominent nucleoli and occasional cytoplasmic vacuolization. A few binucleated and multinucleated tumor cells were present. Histologic sections of the resected gland showed mucinous adenocarcinoma. A metastatic workup was negative. The differential diagnoses on cytology included other primary tumors of the parotid gland producing mucin or a mucoid matrix and metastatic mucinous adenocarcinomas. CONCLUSION: To our knowledge, this is the first cytologic description of mucinous adenocarcinoma, primary in the parotid gland.

Interaction of an implanted pacemaker with a transesophageal atrial pacemaker: report of a case.

We report an interaction of a transesophageal atrial pacemaker (TAP) with a permanently implanted pacemaker in a cardiac patient who had undergone ablative therapy for atrial tachyarrhythmia 5 years earlier. The patient's permanent A-V pacemaker was completely inhibited by the TAP, and there was loss of ventricular contractions and blood pressure. The patient required epicardial A-V pacing to overcome the programmed heart rate of 76 bpm. We describe alternative methods to epicardial pacing. We also recommend close inspection of the chest radiograph, which often can reveal the serial numbers of the implanted pacemaker, as a means of identifying the device's functions and programming.

Administrative guidelines for response to an adverse anesthesia event. The Risk Management Committee of the Harvard Medical School's Department of Anaesthesia.

The Risk Management Committee of the Harvard Medical School's Department of Anaesthesia developed a set of guidelines recommending administrative actions that should be taken immediately following an adverse anesthesia event. The guidelines are intended to limit patient injury from a specific event associated with anesthesia and to ensure that the causes of the event are identified to prevent recurrence. The guidelines direct the primary anesthetist to concentrate on continuing care but quickly notify someone in a leadership position, who would become the "incident supervisor." The incident supervisor would be knowledgeable of the details of the protocol and direct activities for ensuring appropriate medical care, sequestration of equipment, documentation of information, and contact of other appropriate administrative personnel. Experience with the guidelines has shown that they can be effective if applied but that it is difficult to do that consistently in our large medical centers.

Guidelines for sedation by nonanesthesiologists during diagnostic and therapeutic procedures. The Risk Management Committee of the Department of Anaesthesia of Harvard Medical School.

The increasing use of sedation to enhance patient comfort during diagnostic and therapeutic procedures has been noted by the Joint Commission of Accredited Healthcare Organizations, specialty societies, and the public. Although anesthesiologists, by virtue of training and experience, possess unique qualifications to provide such sedation services, their availability remains somewhat limited by primary commitments to the operating room, intensive care unit, or pain service. The Risk Management Committee of the Department of Anaesthesia of Harvard Medical School has made specific recommendations to the Harvard-affiliated hospitals for anesthesiologists who participate in institutional-level committees in setting guidelines for such services when they are provided by nonanesthesiologists. Specific consideration is given to facilities, backup emergency services, equipment, education and training, issues of informed consent, documentation, and release of patients from medical care. These recommendations emphasize the collaboration of the department of anesthesia and other departments that provide sedation services in formulating policies and procedures that reflect values intrinsic to the practice of anesthesiology.

In vitro effects of hyperbaric oxygen on sickle cell morphology.

STUDY OBJECTIVE: To determine in vitro whether hyperbaric oxygen has any effect on the morphology of sickle cells. DESIGN: Prospective, in vitro, study, with each patient sample serving as its own control. SETTING: University medical center. PATIENTS: 10 children known to be homozygous for hemoglobin S. INTERVENTIONS: Blood samples were obtained from 10 children during routine visits to the University sickle cell clinic. Blood samples were exposed to room air to achieve maximal sickling. Each sample was divided into control and study aliquots, and the study portions placed in a research hyperbaric chamber with 100% oxygen at 3 atmospheres absolute pressure for 15 min. Then smears were prepared from all samples at regular intervals and examined by technicians in the sickle cell clinic who were blinded as to the details of this study. MEASUREMENTS: Percentages of normal cells, sickle cells and sickle forms were reported. Data were interpreted using t-tests. MAIN RESULTS: Hyperbaric oxygen appeared to have no effect on sickle cell morphology. Percentages of each cell type were unaffected by hyperbaric oxygen exposure. CONCLUSIONS: Hyperbaric oxygen appears to have no effect on the morphology of sickle cells in vitro. Other mechanisms may account for the beneficial clinical effects of hyperbaric oxygen in sickle cell crisis, although in vivo studies are warranted.

Preoperative exposure to calcium channel blockers suggests increased blood product use following cardiac surgery.

PURPOSE: In this study the authors reviewed the medical records of a random sample of patients undergoing coronary artery bypass grafting (CABG) during the preceding ten years at University Medical Center. The purpose of this study was to evaluate the impact of exposure to calcium channel blockers (CCB's) on blood product use following cardiopulmonary bypass (CPB). DESIGN: Retrospective medical record review. SETTING: University hospital. PARTICIPANTS: 527 patients undergoing CABG or re-do CABG. INTERVENTIONS: The medical records of approximately 50% of patients undergoing CABG or re-do CABG at University Medical Center between 1988 and 1998 were randomly selected by the medical records librarian for review. Preoperative medications, bypass time and temperature, and blood product use were recorded. RESULTS: Of the 527 patients studied, 309 (59%) had no exposure to CCB's. 218 (41%) were on CCB's at the time of admission. Patients who were on CCB's had an average 12.5 (+/- 1.0) blood product units transfused following bypass whereas those not on CCB's had an average 8.7 (+/- 0.6) units transfused (p < 0.001). Use of packed red blood cells (p < 0.001), fresh frozen plasma (p = 0.018) and platelets (p = 0.023) were each individually significantly increased. CONCLUSIONS: In this study, it appeared that patients exposed to CCB's before cardiac revascularization received significantly more blood products than those who were not exposed to CCB's. Because of the limitations imposed by retrospective studies, further prospective studies are warranted to define the clinical significance of CCB use in the perioperative period.