Identification of material with paternal HLA antigen immunoreactivity from purported circulating immune complexes in patients with gestational trophoblastic neoplasia.

Circulating immune complex(es) (CIC) have been shown to rise progressively only when patients with hydatidiform molar pregnancy enter gonadotropin-documented remission. The CIC in 3 patients with gestational trophoblastic neoplasia (GTN)--1 with hydatidiform mole and 2 with choriocarcinoma--were characterized. Their clinical course was monitored by serial antigen-nonspecific polyethylene glycol (PEG) 6000-CIC assay and simultaneous human chorionic gonadotropin (HCG) assay from presentation until sustained gonadotropin-documented remission. As serial HCG progressively decreased to normal following surgical or chemotherapeutic reduction in tumor burden, PEG-CIC concurrently rose. Serum obtained at or near peak PEG-CIC levels was precipitated by 3.75% PEG 6000 and fractionated by column chromatography on Sephadex G-200 (exclusion limit, greater than 600,000 mol wt) in glycine-HCl and 1 M NaCl buffer at pH 2.8. None of the 5 elution fractions obtained from the 3 patients contained HCG or anti-HCG activity. However, in the hydatidiform molar patient, fractions 1 through 3 (mol wt greater than 67,000--and containing immunoglobulin) were shown to competitively inhibit complement-dependent antibody lysis on 1 of 4 paternal HLA haplotype (AW32) targets. In 2 of the 3 patients studied, low-molecular-weight fractions (not containing immunoglobulin) significantly inhibited reference anti-HLA binding of antisera directed against only 1 of 4 paternal HLA haplotypes. The immunospecificity of this inhibition was confirmed by criss-cross control assays in which elution fractions obtained from both of these patients were tested for inhibition of lymphocytolysis of both sets of paternal lymphocytes. None of these fractions were immunoreactive to maternal HLA haplotypes. Further analysis of serum from the hydatidiform molar patient revealed that no free complement-fixing antibody against paternal antigens could be found by conventional screening assays in unfractionated patient sera. Three of 4 paternal HLA antigens or non-complement-fixing anti-HLA immunoglobulin was detected in unfractionated pretreatment, treatment, and remission sera of the hydatidiform molar patient. Only in this patient's remission sera was unbound AW32 antigen or non-complement-fixing anti-AW32 antibody detected. These data demonstrate the successful characterization of at least 1 specific antigen fractionated from a tumor-associated immune complex. The implication that some patients with GTN may recognize and react to immunogenic paternal HLA antigens as part of their successful response to therapy for trophoblastic tumor is discussed.

Serial circulating immune complex levels and mitogen responses during progressive tumor growth in WF rats.

Inbred male WF rats were given im injections of one of two antigenically and histologically distinct syngeneic tumor isografts, adenocarcinoma DMH-W 163 or spontaneous renal cell carcinoma SPK. Serum and peripheral blood lymphocytes were harvested from tumor-bearing and normal age-matched controls before and after isograft challenge at weekly intervals. Serial circulating immune complex (CIC) levels were quantitated by polyethylene glycol (PEG) insolubilization. T-cell mitogen responses to phytohemagglutinin (PHA) and concanavalin A (Con A) were followed serially. Tumor growth was measured at least weekly. PEG-CIC values rose early after tumor injection, increased with tumor growth, and declined in some animals just before death. Mitogen response to PHA was significantly decreased in isografted tumor-bearing rats, particularly at later stages of tumor development, compared to normal uninoculated controls. Responses to Con A were variable, and suppression was not always seen in tumor bearers. In animals that did not have progressive tumor growth after isograft injection, PEG-CIC levels did not change and responses to PHA were not suppressed. Patterns of CIC change and responses to PHA were not affected by differences in tumor histology or growth rates. Thus serial CIC levels measured by the PEG assay correlate with tumor growth and precede nonspecific suppression of T-cell mitogenic response in these animal tumor models.

Adult presentation of agenesis of the hemidiaphragm.

A 66-year-old woman presented with a 3-day history of classical features of large bowel obstruction. At emergency laparotomy, the transverse colon and splenic flexure were located in the left hemithorax. The entire left hemidiaphragm was absent, and there were no diaphragmatic remnants visible. This is the oldest reported case of an absent hemidiaphragm. Previous cases of "agenesis" of the hemidiaphragm in adults either reported diaphragmatic remnants intraoperatively or failed to rule them out radiologically when managed conservatively. We would suggest that this is the first reported case of an adult presenting with true agenesis of the hemidiaphragm.

Let the finger linger.

Retrorectal masses are rare and of insidious onset. We report a consecutive series of six such cases (males = 4, females = 2). The main presenting complaint was back pain and the most reliable physical sign was a palpable mass posteriorly on rectal examination (all cases). C T scan was the most radiologically informative investigation. Surgical intervention was undertaken using both anterior (trans-abdominal) and posterior (retrorectal) approaches. The majority of the masses excised were benign and all patients, to date, remain well.

The Localio approach: a technical note for a large sacral chordoma.

Whenvever possible, radical resection of retrorectal tumours should be performed.(1) We describe the Localio technique (abdominosacral approach) in a case of a large malignant sacral chordoma. We emphasise the necessity to perform such an approach to achieve a radical resection for these tumours which have little chemosensitivity and minimal radiosensitivity. We highlight clinical features which suggest the presence of a spinal tumour and reiterate the absolute importance of rectal examination.

Thrombomodulin expression in colorectal carcinoma is protective and correlates with survival.

Thrombomodulin (TM) is an endothelial receptor that exhibits anticoagulant, antifibrinolytic and anti-inflammatory activity by inhibiting thrombin and cellular adhesion. In this study, the expression and significance of TM was examined in primary colorectal cancer and its prognostic implications explored. TM immunostaining was performed on formalin-fixed, paraffin-embedded tissue sections, from primary lesions of 200 patients with colorectal carcinoma. Institutional Ethical approval was granted and clinical data retrieved from patients' records. All normal colonic tissue expressed TM on endothelial cells. TM tumour cell expression was demonstrated in 53 (26.5%) cases and 147 (73.5%) showed no neoplastic cell staining. On univariate and multivariate analysis TM expression on tumour cells correlated significantly with tumour stage, differentiation, Jass score and 5 year survival. TM expression decreases as overall stage and tumour size increase (P=0.03). In all, 91% TM positive tumours were well differentiated and 85% of TM negative tumours were poorly differentiated (P<0.01). Five year survival rates of patients with positive and negative TM expression were 71 and 41%, respectively. Survival rate was poorer in those patients who were TM negative compared with those who were positive (P<0.01). A total of 101 (50.5%) of the cases were node negative. In this group, 5 year survival rates of patients with positive and negative TM expression were 87.5 and 37.8%, respectively, demonstrating a poorer survival rate for those who are node negative and TM negative at the time of surgery (P<0.001). This study demonstrates that loss of TM is a key indicator in tumour biology and prognosis.

Quality-of-life assessment of patients after ileal pouch-anal anastomosis for slow-transit constipation with rectal inertia.

PURPOSE: Severe idiopathic constipation with rectal inertia represents a challenging medical problem that, in extremis, might warrant surgery. We studied a group of patients who have undergone proctocolectomy and ileal pouch-anal anastomosis for this problem. The purpose was to assess the functional success of this procedure and its impact on the social function of the patients. METHODS: Patients with functional, intractable constipation have one motion or less per week and are laxative-dependent. The indication for surgery was based on failure of long-term medical therapy. The selection criteria were normal colonoscopy, normal anal manometry and pudendal nerve latency test, and abnormal transit study and abnormal video proctography. The functional outcome after surgery was assessed by anal manometry and stool frequency. Quality of life was analyzed using the Rand health survey 1.0 consisting of a comprehensive questionnaire used preoperatively and postoperatively with emphasis on physical function, role limitation because of functional/emotional problems, social function, pain, and general health. RESULTS: Fifteen patients (14 females) underwent ileal pouch-anal anastomosis over a seven-year period (1993-1999). The mean age was 41 (range, 25-47) years. All had a temporary defunctioning loop ileostomy fashioned, and there were no anastomotic leaks. Two patients required pouch excision within 18 months because of intractable pelvic pain. The mean stool frequency was eight (range, 3-12) per day at the first follow-up. At the second follow-up, this had improved to five (range, 2-6) per day. The mean resting and squeeze anal pressures preoperatively were 82 cm H2O and 104 mmHg, respectively, and were unchanged after surgery. Significant improvement in lifestyle scores were recorded in the categories of physical function, social function, and pain at the first follow-up and in all categories at the second follow-up (P < 0.05). CONCLUSION: Restorative proctocolectomy is an option in selected patients and leads to progressive improvement in quality of life.

Safety of double-stapled anastomosis in low anterior resection.

Clinical leakage of the anastomosis follows low anterior resection for rectal carcinoma in 5-10 per cent of patients despite standard stapling techniques. A modification of this method has obviated the need for a distal purse string. A flexible transverse stapling instrument (Roticulator 55) is applied across the rectum below the tumour, and a double-staggered row of staples is inserted as a substitute for the distal purse string. End-to-end stapled anastomosis is then performed with peranal insertion of a Premium CEEA stapling instrument. In 111 patients the indications for operation were colorectal carcinoma (96 patients), diverticulosis (ten), megarectum (four) and ulcerative proctocolitis (one). Three patients had clinical evidence of anastomotic leakage; all survived. The incidence of radiological leakage on Gastrografin enema 10-12 days after operation was 9 per cent. The perioperative mortality rate was 2 per cent; all deaths were from cardiovascular causes. Local recurrence of tumour occurred in eight patients (7 per cent) after a mean follow-up of 40 months. In conclusion, double-stapled end-to-end anastomosis has made low anterior resection for rectal carcinoma a safe procedure with a low mortality rate, an acceptable local recurrence rate and minimal (clinical) anastomotic leakage.

Gut-associated lymphoid tissue and dimethylhydrazine-induced colorectal carcinoma in the Wistar/Furth rat.

Although gut-associated lymphoid tissue in the form of discrete lymphoid patches (LP-GALT) in mammalian intestine in most prominent in the distal ileum, appendix, and, in some species, the cecal appendage, LP-GALT can be found throughout the intestinal tract. LP-GALT appears as single or multiple subepithelial lymphoid follicles covered by a specialized, structurally unique epithelium. In the colon of the Wistar/Furth (W/Fu) rat, LP-GALT appears as aggregates of follicles, or lymphoid patches, that can be detected macroscopically. We studied the relationship between 1,2-dimethylhydrazine- (DMH) induced colon carcinomas and the lymphoid patch associated epithelium in these animals. In addition, we defined the normal distribution of colonic lymphoid patches in both DMH-treated and control rats. Patches were found macroscopically and confirmed by histologic examination at five constant sites: lower pole of cecum, proximal ascending colon, the major colonic flexure, mid descending colon, and the rectosigmoid. There are also the predominant sites of DMH induced carcinomas in W/Fu rats. In 120 DMH-treated animals, 109 colon carcinomas were found. Eight percent were in the lower pole of the cecum, 56% in the proximal ascending colon, 16% at the major flexure, 15% in the mid descending colon, and 5% in the rectosigmoid. Lymphoid patches could often be detected histologically in association with DMH-induced tumors. The depth of tumor invasion was found to correlate inversely with our ability to identify tumor-associated lymphoid patches suggesting that tumors arising at the anatomical sites were lymphoid patches occur progressively destroyed them. Of colon tumors confirmed histologically to be associated with lymphoid patches, 88% were superficial lesions confined to the submucosa and 12% were more extensive but confined to the bowel wall. No lymphoid patches could be found associated with tumors that extended through the bowel wall. Thus, DMH-induced colon carcinomas in W/Fu rats arise at sites containing preexisting LP-GALT with associated specialized epithelium.

The effect of 1,2-dimethylhydrazine (DMH) carcinogenesis on peripheral T cell subsets in the Wistar Furth rat.

1,2-dimethylhydrazine (DMH)-induced colon cancer in Wistar/Furth (W/Fu) rats is analogous in many ways to human colorectal cancer. As part of our attempt to understand the immunobiology of these tumors, we have utilized the recently available monoclonal antibodies W3/25 and OX8 to monitor helper (Th) and suppressor (Ts) lymphocyte subpopulations. Normal untreated male W/Fu rats of less than 1 year of age were phenotyped (n = 43). The mean percentage of Th and Ts was 42 +/- 1 (mean +/- SEM) and 33 +/- 1, respectively. The mean Th/Ts ratio was 1.3 +/- 0.1. A Th/Ts equal to or greater than 1 is considered "normal" in the W/Fu rat. The DMH-treated rats (20 mg/kg/wk) were evaluated in initial experiments at various intervals after treatment. Rats studied 24 hours after a single DMH injection had no alterations in T cell subsets. Rats studied 28, 32, and 65 weeks after the start of 16 weekly DMH injections were found to have a decrease in the percentage of Th and a relative increase in Ts, with Th/Ts ratios of 0.6 +/- 0.2, 0.7 +/- 0.1, and 0.7 +/- 0.1, respectively (each P less than 0.01). In a separate experiment in which rats were studied after 4, 8, and 16 weeks of DMH injections, no alterations in T cell subsets were noted. Rats (n = 5) studied at 20 weeks after the start of DMH were found to have 41 +/- 3% Th and 36 +/- 2% Ts and a Th/Ts ratio of 1.2 +/- 0.1. Three of five rats were found to have adenocarcinomas. Four of five rats had Th/Ts less than 1. One rat with Th/Ts equal to 0.9 had metastatic disease. Rats studied at 25 weeks (n = 8) were found to have more advanced carcinomas (4/8) that were causing obstruction or bleeding in the animal. There was a significant decrease in Th and Ts in this group, with 24 +/- 3% and 26 +/- 3% respectively (P less than 0.001). The Th/Ts ratio for this group was 0.9 +/- 0.1 (P less than 0.01). In other experiments, rats were treated with DMH or placebo over a 16-week period and serially bled during and after treatment. No effect of DMH treatment on T cell subsets was noted. Repeated bleeding alone was noted to cause persistent alterations of T cell subpopulation.(ABSTRACT TRUNCATED AT 400 WORDS)