Interstitial Deletions at 6q14.1-q15 Associated with Obesity, Developmental Delay and a Distinct Clinical Phenotype.

BACKGROUND: Interstitial deletions of the long arm of chromosome 6 have been described in several patients with obesity and a Prader-Willi-like phenotype. Haploinsufficiency of the SIM1 gene located at 6q16.3 is suggested as being responsible for the regulation of body weight. Here we report on 2 patients with interstitial deletions at 6q14.1-q15 presenting with obesity and symptoms strikingly similar to those reported for deletions involving the SIM1 gene despite not having a deletion of this gene. METHODS: Array comparative genomic hybridisation was used to diagnose 2 children with obesity and developmental delay, revealing 2 interstitial deletions at 6q14.1-q15 of 8.73 and 4.50 Mb, respectively, and a region of overlap of 4.2-Mb. RESULTS: The similar phenotype in the 2 patients was most likely due to a 4.2-Mb common microdeletion at 6q14.1-q15. Another patient has previously been described with an overlapping deletion. The 3 patients share several features, such as developmental delay, obesity, hernia, rounded face with full cheeks, epicanthal folds, short palpebral fissures, bulbous nose, large ears, and syndactyly between toes II and III. CONCLUSIONS: Together with a previously reported patient, our study suggests that the detected deletions may represent a novel clinically recognisable microdeletion syndrome caused by haploinsufficiency of dosage-sensitive genes in the 6q14.1-q15 region.

17q21.31 microdeletion syndrome: further expanding the clinical phenotype.

Microdeletions of the 17q21.31 region are associated with hypotonia, oromotor dyspraxia, an apparently characteristic face, moderate learning disability and have an estimated prevalence of approximately 1 in 16,000. Here we report 3 individuals who extend further the phenotypic spectrum observed with microdeletions of the 17q21.31 region. They all have learning disability, hypotonia, and craniofacial dysmorphism in keeping with previous reported cases. One case has iris-choroid coloboma and partial situs inversus, 2 features that are newly recorded phenotype abnormalities. These deletions were detected from a cohort of 600 individuals with learning disability and congenital anomalies, reflecting that 17q21.31 microdeletions are a common finding in such cases. FISH analysis demonstrated that each of the deletions occurred as de novo events. The deleted region in our cases encompasses the previously defined critical region for 17q21.31, and includes CRHR1 and MAPT, putative candidate genes for the 17q21.31 phenotype. The 17q21.31 microdeletion phenotype is perhaps more variable than previously described despite haploinsufficiency for the same genes in many cases.

The timing of histologic changes in liver lacerations.

Microscopic examination was performed on 55 cases of traumatic liver lacerations incurred from fatal motor vehicle accidents. None of the deaths was due to the liver injury. In 38 of 55 cases, the decedent was pronounced dead at the scene. Microscopic examination of the liver lacerations in these 38 cases revealed no histologic changes related to the trauma. In 17 of 55 cases, the decedent was transported to the emergency room (ER) with a "survival time" (from Emergency Medical Service arrival to the time of pronouncement) of 15 minutes to 7 hours and 10 minutes. Nine of these 17 had vital signs at the scene. Five of the 17 had neutrophilic infiltration and hepatocyte necrosis at the site of the laceration. Four of these had vitals signs at the scene. Survival time of the 5 patients with a vital reaction at their liver injury ranged from 51 minutes to 7 hours and 10 minutes.

FISH mapping of de novo apparently balanced chromosome rearrangements identifies characteristics associated with phenotypic abnormality.

We report fluorescence in situ hybridization (FISH) mapping of 152, mostly de novo, apparently balanced chromosomal rearrangement (ABCR) breakpoints in 76 individuals, 30 of whom had no obvious phenotypic abnormality (control group) and 46 of whom had an associated disease (case group). The aim of this study was to identify breakpoint characteristics that could discriminate between these groups and which might be of predictive value in de novo ABCR (DN-ABCR) cases detected antenatally. We found no difference in the proportion of breakpoints that interrupted a gene, although in three cases, direct interruption or deletion of known autosomal-dominant or X-linked recessive Mendelian disease genes was diagnostic. The only significant predictor of phenotypic abnormality in the group as a whole was the localization of one or both breakpoints to an R-positive (G-negative) band with estimated predictive values of 0.69 (95% CL 0.54-0.81) and 0.90 (95% CL 0.60-0.98), respectively. R-positive bands are known to contain more genes and have a higher guanine-cytosine (GC) content than do G-positive (R-negative) bands; however, whether a gene was interrupted by the breakpoint or the GC content in the 200 kB around the breakpoint had no discriminant ability. Our results suggest that the large-scale genomic context of the breakpoint has prognostic utility and that the pathological mechanism of mapping to an R-band cannot be accounted for by direct gene inactivation.

Molecular and clinical characterization of de novo and familial cases with microduplication 3q29: guidelines for copy number variation case reporting.

Microdeletions of 3q29 have previously been reported, but the postulated reciprocal microduplication has only recently been observed. Here, cases from four families, two ascertained in Toronto (Canada) and one each from Edinburgh (UK) and Leiden (Netherlands), carrying microduplications of 3q29 are presented. These families have been characterized by cytogenetic and molecular techniques, and all individuals have been further characterized with genome-wide, high density single nucleotide polymorphism (SNP) arrays run at a single centre (The Centre for Applied Genomics, Toronto). In addition to polymorphic copy-number variants (CNV), all carry duplications of 3q29 ranging in size from 1.9 to 2.4 Mb, encompassing multiple genes and defining a minimum region of overlap of about 1.6 Mb bounded by clusters of segmental duplications that is remarkably similar in location to previously reported 3q29 microdeletions. Consistent with other reports, the phenotype is variable, although developmental delay and significant ophthalmological findings were recurrent, suggesting that dosage sensitivity of genes located within 3q29 is important for eye and CNS development. We also consider CNVs found elsewhere in the genome for their contribution to the phenotype. We conclude by providing preliminary guidelines for management and anticipatory care of families with this microduplication, thereby establishing a standard for CNV reporting.

Chromosome analysis: what and when to request.

Chromosome abnormalities have long been recognised as an important cause of learning disability and multiple malformation syndromes; 0.8% of live born infants have numerical or structural chromosomal anomalies resulting in an abnormal phenotype. The identification of such anomalies is important, both clinically and for accurate genetic counselling. Recently, the human genome sequence has enabled higher resolution screens for chromosome anomalies using both molecular cytogenetic and array based techniques. This review suggests a simple algorithm for the targeted use of diagnostic cytogenetic tools in specific patient groups commonly seen in paediatric practice.

Epididymal rhabdomyoma: report of a case, including histologic and immunohistochemical findings.

Genital rhabdomyoma is a rare tumor of skeletal muscle origin that is usually found in the vulvar area of young women. The English literature contains only 2 previous case reports involving men, both of whom were 19 years old. One of these lesions originated in the tunica vaginalis of the testis, and the other originated in the prostate gland. We present the clinical, histologic, and immunohistochemical findings of an epididymal rhabdomyoma in a 20-year-old man. To our knowledge, this is the first such case reported in this location.

Oral bropirimine immunotherapy of bladder carcinoma in situ after prior intravesical bacille Calmette-Guérin.

OBJECTIVES: Bropirimine is an oral immunomodulator that has demonstrated anticancer activity in transitional cell carcinoma in situ (CIS) in both the bladder and upper urinary tract. Activity also has been documented in patients after prior therapy with bacille Calmette-Guérin (BCG). To more accurately estimate bropirimine's efficacy in BCG-resistant bladder CIS, a Phase II trial was performed. A separate analysis was performed in additional patients intolerant of BCG toxicity. METHODS: Patients received bropirimine 3.0 g/day by mouth for 3 consecutive days, weekly, for up to 1 year. Bladder biopsies and cytologic examination were performed quarterly. Complete response (CR) required negative biopsy and cytology results. RESULTS: Twenty-one of 86 patients entered were not evaluable. CR was seen in 21 (32%; 95th percentile confidence interval [CI], 21% to 44%) of 65 evaluable patients, including 14 (30%, CI 17% to 43%) of 47 BCG-resistant, and 7 (39%, CI 16% to 61%) of 18 BCG-intolerant patients. Overall, by intent-to-treat analysis, CR was thus seen in 21 (24%) of 86 subjects. Most BCG-resistant patients were failures to BCG without relapse, and had received 12 to 36 (median 12) BCG treatments; intolerant patients had received 4 to 11 treatments (median 6). Response duration ranged from 65 to 810 days, with median not yet reached (but greater than 12 months). Thirteen (15%) of 86 stopped bropirimine due to toxicity. Progression to invasive or metastatic disease during or immediately after therapy was documented in only 4 patients (6%), all nonresponders. CONCLUSIONS: Bropirimine may be an alternative to cystectomy for some patients with bladder CIS who have failed or have not tolerated BCG. Further evaluation to improve responses and durability is warranted.

Terminal nerve distribution to the urethra and bladder neck: considerations in the management of stress urinary incontinence.

PURPOSE: Recent reports have suggested an increased incidence of intrinsic sphincter dysfunction, most of which seems to appear following the failure of a previous, usually vaginal, surgical repair. Our studies attempt to define more precisely the neuroanatomical relationships that exist in the region of the bladder neck and proximal urethra, and between the urethra and anterior vaginal wall. MATERIALS AND METHODS: We dissected the pelves of adult female cadavers and step sectioned them at 4 mm. intervals. Several staining methods were used on each section to identify and document the position of the nerves and vascular structures between the vaginal wall and urethra. RESULTS: A rich plexus of blood vessels and nerves with ganglia is located between the vaginal wall, and the proximal urethra and bladder neck. The greatest concentrations of nerves are in the 4 o'clock and 8 o'clock positions but nerve fibers are identified throughout the loose areolar tissue planes through which vaginal surgery for stress urinary incontinence is often performed. CONCLUSIONS: When performing surgical procedures for the correction of stress urinary incontinence, the possibility that denervation and devascularization of the terminal urethra and bladder neck secondary to surgical dissection could contribute to the subsequent development of intrinsic sphincter dysfunction should be considered.

The significance of central pathology review in clinical studies of transitional cell carcinoma in situ.

PURPOSE: The causes of interobserver variation in the pathological diagnosis of urothelial neoplasia were studied. MATERIALS AND METHODS: A central review was performed on pathological specimens in a multi-institutional clinical study of patients with in situ transitional cell carcinoma of the bladder. RESULTS: A significant discrepancy in pathological diagnosis was noted between the original report and the central review in 60 of 159 biopsies (38%) and in 73 of 217 cytology specimens (34%). Biopsy discrepancies were almost equally divided between upgrades and downgrades, whereas 89% of cytology discrepancies involved an upgrade in diagnosis by the central reviewer. The most significant factor causing variability in biopsy diagnoses was the multiplicity of classifications used by the originating pathologists. Other factors included fixation and biopsy artifacts. Cell degeneration secondary to treatment was the most important factor resulting in cytology under grading. At originating institutions the correlation of diagnoses between concurrent biopsy and cytology specimens was poor. CONCLUSIONS: The lack of a well accepted standard for the histopathological diagnosis of transitional cell carcinoma in situ poses a major problem for multi-institutional studies of this disease. Organizers must include a histopathological standard in the study plan and publicize it to all participants, particularly pathologists. Central review of pathological specimens is essential to maintain data integrity.

Effects of preoperative chemotherapy on the morphology of resectable breast carcinoma.

We examined pathologic specimens from 43 patients with Stage T1-T3 lesions who were treated preoperatively with four cycles of doxorubicin/cyclophosphamide, followed by segmentectomy/mastectomy and axillary node dissection (the National Surgical Adjuvant Breast and Bowel Project B-18 protocol). Specimens from 46 patients treated post-operatively with the same regimen served as histologic controls. The initial diagnosis was made by core needle biopsy (28%) or by fine-needle aspiration (72%). Six changes were noted in 36 patients (84%), with complete regression in 10, but histologic evidence of regression and characteristic cytologic changes occurred in only one-half of the 43 patients, and there was poor correlation between histologic regression and clinical response; (2) an increased nuclear grade occurred in 32% of the cases; (3) unusually prominent intraductal and/or intralymphatic tumor was observed in 40%; (4) histologic evidence of tumor regression in axillary lymph nodes was noted in nine cases; (5) regressive changes also occurred in non-neoplastic breast tissue and in lymphoid populations of lymph nodes; and (6) difficulty was noted in evaluating residual atypical intraductal proliferations. These findings add a quantitative dimension to previously published descriptions and emphasize the need for pathologic staging in these patients. In addition, they provide histopathologic evidence of downstaging in axillary lymph nodes and of relative treatment resistance by intraductal and intralymphatic tumor.

Recruitment of a pathology course director.

The process of choosing a course director rarely involves a rigorous examination of the duties to be assumed, primarily because the selection is from among existing faculty rather than as a result of formal recruitment. The selectee tends to be surprised (and often disheartened) by the amount of time the job requires. This report was developed from workshops conducted at recent meetings of both the Group for Research in Pathology Education and the Association of Pathology Chairmen. It describes the overall scope of a course director's activities, including the percentage of time devoted to various functions, and identifies issues to be addressed at the time of the course director's selection. Although the appointment may still be from within the department, the recruitment process does allow for a more full and open discussion of the job to be accomplished.

p53 is mutated in a subset of advanced-stage prostate cancers.

Inactivation of p53, a tumor suppressor gene, contributes to the genesis and/or progression of a substantial fraction of all human cancers, including > or = 50% of breast, lung, and colon carcinomas. Mutated p53 alleles typically contain missense single-base substitutions within exons 5-8 and encode abnormally stable p53 proteins that accumulate to high levels in tumor cell nuclei. To evaluate the frequency, type, and clinical significance of p53 mutation in human prostate cancer, archival tumor material from 150 prostate cancer patients was examined by immunohistochemistry (IHC) with anti-p53 antibodies. Abnormal nuclear p53 accumulation (IHC) was observed in 19 tumors (12.7%) and was strongly related to disease stage (23% of 69 stage III or IV tumors were IHC+ versus 4% of 74 stage 0-II tumors; P < 0.001, Fisher's exact test). The methods of polymerase chain reaction, single-strand conformational polymorphism, and direct sequencing were used to identify mutations, predominantly missense single-base substitutions in exons 5, 7, or 8 in 9 of 14 IHC+ cases but in none of 20 IHC- cases; 5 of these mutations were G:C-->A:T transitions at CpG dinucleotides. These data indicate that mutated p53 alleles are quite uncommon in early prostate cancers but are found in 20-25% of advanced cancers, suggesting a role for p53 mutation in the progression of at least a subset of prostate cancers.

Morphology of the uvula in obstructive sleep apnea.

Alterations in pharyngeal structure and function are considered fundamental in the pathogenesis of obstructive sleep apnea (OSA). However, little is known about morphologic features of the pharynx in patients with OSA. We therefore studied the tissue composition of the uvula (midsagittal section) in patients with OSA, using a quantitative, morphometric point-counting technique. Uvula tissue was obtained by uvulopalatopharyngoplasty (UPPP) in 33 patients (mean number of apneas per hour of sleep = 32.7 +/- 5.2) and by autopsy in 22 normal subjects not known to have OSA. All statistical comparisons were controlled for differences caused by age and body mass index. Patients with OSA had a significantly greater percentage of muscle in the uvula (18.1 +/- 1.9% versus 9.3 +/- 2.1%, p = 0.02) than did normal subjects. A significant difference in fat content was also found (9.5 +/- 1.4% in patients versus 4.0 +/- 1.0% in normal subjects, p less than 0.02). These differences between patients with OSA and control subjects could not be accounted for by anthropometric or sex differences. The percentage of uvula fat tissue was significantly related to the frequency of apneas and hypopneas in sleep (r = 0.43, p less than 0.01). Uvula morphology in 6 nonapneic snorers undergoing UPPP was similar to that of patients with OSA. We conclude that the uvula in patients with OSA contains more muscle and fat than the uvula in control subjects, possibly contributing to pharyngeal narrowing in OSA.

Correlation of aromatase activity with histological differentiation of breast cancer--a morphometric analysis.

Differentiation is a term that indicates the degree to which a tumor resembles histologically the tissue or cell of origin. A system to quantitate the proportion of breast cancer cells participating in glandular differentiation or remaining within ducts was employed. The degree of tumor differentiation of 58 primary breast cancers was correlated with estrogen (ER) and progesterone receptors (PR) and tumor aromatase activity. There was a significant association between tumor differentiation (greater than or equal to 2% cancer cells exhibiting glandular differentiation) and the presence of ER or PR in tumors. Conversely, there was no correlation between tumor differentiation and measurable tumor aromatase activity.

Tumor-associated antigens in breast carcinomas. Prognostic significance.

In an attempt to identify biologic markers that might predict prognosis in breast cancer patients, the presence or absence of seven tumor-associated antigens in 54 infiltrating breast carcinomas was correlated with tumor recurrence rates (minimum five-year follow-up), axillary lymph node metastases and tumor volume. Immunohistochemical kappa-casein was present in 30 (56%) tumors, alpha-lactalbumin in 39 (72%) tumors, secretory component of IgA in 26 (48%) tumors, carcinoembryonic antigen in 34 (63%) tumors, pregnancy-specific beta-1-glycoprotein in 7 (13%) tumors, beta subunit of human chorionic gonadotrophin in 1 (2%) tumor and human placental lactogen in 0 (0%) tumors. There was no significant correlation between the presence or absence in tumor of any of the antigens, and prognosis as assessed either by 5-year recurrence rates (P greater than 0.18) or by the presence of axillary lymph node metastases (P greater than 0.20). No significant difference was noted in mean tumor volume (cm3) +/- SEM, between tumors with or without antigen immunoreactivity (P greater than 0.05).

Synovial sarcoma of the jaw in a dog.

A case of synovial sarcoma of the jaw with pulmonary metastasis is described in a dog. It appears to be a rare or underdiagnosed neoplasm in animals and not previously reported in the jaw. Its diagnostic microscopic features are the biphasic cellular pattern and cleft formations. It may otherwise resemble haemangiopericytoma, malignant fibrous histiocytoma, reticulum cell sarcoma, fibrosarcoma, or giant-cell tumour of soft tissue.

Purkinje cell inclusions and 'atelencephaly' in 13q-chromosomal syndrome.

Severe microcephaly was present from birth in a child with a 13q-chromosomal syndrome [46,XY,del(13)(q22q31)]. He died at 20 months of age. Neuropathologic findings included atelencephaly and eosinophilic cytoplasmic inclusions in cerebellar Purkinje cells. Ultrastructurally, the inclusions consisted of stacks of parallel cisternae separated by electron-dense granular material. The relationship between these inclusions and the smaller cytoplasmic inclusions known as "lamellar bodies" is discussed, and the central nervous system malformations in this syndrome are reviewed.