Alternative lengthening of telomeres and survival in patients with glioblastoma multiforme.

Despite advances in the molecular pathogenesis of glioblastoma multiforme, no reliable prognostic markers have been identified. We analysed telomerase activity and telomere lengths in glioblastoma multiformes from 77 patients. 19 patients (25%) had tumours with the alternative-lengthening-of-telomere (ALT) phenotype. Median survival for patients with this phenotype was 542 days (95% CI 114-970) compared with 247 days (224-270) for glioblastoma multiformes with normal telomeres (p=0.0003). Cox's regression analysis showed that this association is independent of age. In patients with non-ALT tumours, telomerase activity did not affect survival (median 287 [199-375] vs 236 [230-242] days, p=0.275). We conclude that ALT is a prognostic indicator for patients with glioblastoma multiforme.

Non-Hodgkin's lymphoma presenting with spinal involvement: the Sheffield Lymphoma Group experience (1970-2000).

Spinal non-Hodgkin's lymphoma is rare. We retrospectively reviewed the clinical and histopathologic records of 39 consecutive patients referred to the Sheffield Lymphoma Group from 1970 to 2000 and analysed the prognostic differences between localised (stage IE and IIE) and secondary (stage III and IV) spinal non-Hodgkin's lymphoma (S-NHL) patients. Forty-five percent of all patients were over 60 years old. More patients were male (58%); presented with stage IE and IIE (63%), mostly of intermediate/high grade histology (74%); over a third had symptoms; nearly a third (11 patients) were paraplegic and 14 had sphincter dysfunction at diagnosis. The overall survival of all patients was 39% at 5 years (median 24.7 months), whilst that of localised S-NHL was 51% (median 89.7 months). Univariate analysis showed better survival for patients with good mobility status at presentation (p < 0.0l) and complete response to initial treatment (p < 0.00l). In primary S-NHL, histology (p < 0.05) significantly influenced overall survival. In conclusion, disease is frequently locally advanced at presentation with aggressive histologic grade: thorough staging should always be performed to exclude widespread disease. Good mobility status predicts for good survival outcome. Optimal treatment is still uncertain.

Mdm2 and the p53 pathway in human pituitary adenomas.

OBJECTIVE: Studies on pituitary tumours have failed to identify mutations in the tumour suppressor gene p53 suggesting that the protein identified is wild type. p21(WAF--1) is a downstream effector of p53 which promotes growth arrest. Mdm2 (mouse double minute) is a protein induced by wild type p53 and forms an autoregulatory feedback loop suppressing wild type p53 activity. The purpose of this study was to examine a group of pituitary tumours for expression of p53 and its two downstream effector proteins p21(WAF--1) and mdm2 and to compare this with their radiological invasive status and proliferative potential as assessed by Ki-67 expression. SUBJECTS AND METHODS: Sixty-nine tumours removed at transsphenoidal surgery were examined by immunocytochemistry using antibodies against p53, p21(WAF--1), mdm2 and Ki-67 (MIB-1). The invasive status of the tumours was determined from the preoperative CT/MRI scans. RESULTS: p53 was expressed in 42 of 69 (61%) pituitary adenomas but there was no relationship with either pituitary tumour invasive status (P = 0.71) or volume (P = 0.33). p53 expression correlated, however, with the proliferative state of the tumours as assessed by the MIB-1 labelling index (P = 0.0065). Invasive tumours had a higher growth fraction than non-invasive ones (P = 0.027). p21(WAF--1) was expressed in the nuclei of 58/69 (84%) pituitary adenomas and its expression correlated with that of p53 (r = 0.26, P = 0.03). Mdm2 was expressed in the cytoplasm of 46/69 (67%) tumours and this correlated with the nuclear staining for p53 (P = 0.022) while nuclear staining was seen in 32/69 (46%) tumours but this did not correlate significantly with nuclear p53 staining (P = 0.096). CONCLUSIONS: These results suggest that p53, p21(WAF--1) and mdm2 are all expressed in pituitary tumours suggesting that the p53 protein detected by immunocytochemistry is wild type. Expression of p53 is associated with tumours which have a higher proliferative status. The p53 activity is probably the result of upstream signals of local stresses mediated through either genetic change, cytokines, hypoxia or hormonal factors. Our results suggest, however, that the downstream pathway mediated through the activities of p21(WAF--1) and mdm2 may be dysfunctional in these tumours.

Elevated p53 expression in benign meningiomas protects against recurrence and may be indicative of senescence.

Prediction of recurrence after resection of benign meningiomas represents a significant clinical problem. A prospective study commenced in 1984 aimed to elucidate the molecular mechanisms involved in the development of abnormal karyotype and tumour recurrence in meningiomas. Expression of key cell cycle regulators p53, p21, mdm2 and proliferating cell nuclear antigen (PCNA) were studied by immunohistochemistry in 85 tumours for which follow-up data was available. It was found that most tumours expressed p53, p21 and PCNA, with significant correlations between expression of p53 and both p21 and PCNA. As PCNA fulfils a multifunctional role its expression may be an unreliable indicator of proliferation in benign tumours. The degree of tumour excision remains the best prognostic indicator while p53 is the main predictor of abnormal karyotype. Karyotype is not however, related to prognosis. Incompletely excised tumours which expressed high levels of p53 and p21 did not recur. It is suggested that this is indicative of a fully functional p53-mediated DNA damage response mechanism. Rather than contributing to tumour progression, p53 is fulfilling its role as guardian of the genome in benign meningiomas. This study shows that induction of senescence may be an important tumour suppressor mechanism in benign tumours.

Ganglioneuroblastoma of the cauda equina.

A 39-year-old lady presented with low back pain and neurogenic claudication. Magnetic resonance imagining revealed an intradural neoplasm in the cauda equina region. The patient underwent lumbar laminectomy and total excision of the neoplasm. Biopsy showed it to be a ganglioneuroblastoma, which is rare in the spinal canal and so far does not appear to have been reported in the region of the cauda equina. Its management is discussed.

Long-term follow up of progesterone receptor status in benign meningioma: a prognostic indicator of recurrence?

OBJECT: A long-term prospective analysis of patients with benign meningioma was undertaken to determine whether progesterone receptor (PR) status of the excised tumor has any influence on recurrence. METHODS: Between 1983 and 1985, a total of 62 meningiomas in 53 patients (age range 19-79 years, mean age 55.6 years) were studied for clinical, histological, and pathological characteristics, including hormone receptor status and DNA features. Progesterone receptor status was quantified by cryostat section assay, and then factors affecting recurrence were analyzed. During 1997 all case records were reviewed to determine whether tumor had recurred in any patient, and PR status was correlated with tumor recurrence. Of the 62 tumors, 60 were benign, and of the benign tumors 29 (48%) were PR positive. Patients harboring 14 of the 60 benign tumors were lost to follow up. Of the 46 tumors included in the final analysis, 13 were recurrent (all within 5 years) and 33 were nonrecurrent. Of the 33 nonrecurrent tumors, 14 had not recurred 5 to 10 years postresection and 19 had not recurred after more than 10 years. Chi-square analysis of the results did not show an association between recurrence and patient's sex, extent of resection, histological subtype, or tumor site but did show an association between recurrence and PR negativity (p = 0.013). CONCLUSIONS: The results indicate that benign meningiomas that are PR positive are less likely to recur, a finding that has prognostic and therapeutic implications.

beta -amyloid precursor protein positive axonal bulbs may form in non-head-injured patients.

Since the early 1980s axonal bulbs staining positively for beta-amyloid precursor protein (betaAPP) have been used as a marker of diffuse axonal injury (DAI), bulb formation been attributed to shearing forces generated during rotational acceleration/deceleration head injury. This study draws attention to the observation that they may form in the absence of a head injury and, thus, axonal injury cannot be assumed to result from mechanical injury alone. Out of 20 cases with no history of head injury studied, which only showed evidence of neuronal hypoxic change, 11 (55%) showed variable positive staining for betaAPP in a similar anatomical distribution to that previously described for DAI. The role of hypoxia in the formation of axonal bulbs, as well as the possible role of betaAPP as an acute phase protein, are discussed. These observations further clarify the pattern and relationship between neuronal and axonal staining observed following a brain insult and emphasize the possible role of betaAPP as a neuroprotective protein.

Adult primitive neuroectodermal tumour. A case report and review of the literature.

A 19-year-old woman presented with left-sided sensorineural hearing loss. She was found to have a left cerebellopontine angle tumour, thought to be an acoustic neuroma on MRI, and was treated with radiosurgery. There was no evidence of tumour on MRI at 6 months. After 1 year, she was admitted with further neurological symptoms. Repeat MRI showed multiple craniospinal tumours. Biopsy of the cerebellar tumour revealed it to be a primitive neuroectodermal tumour (PNET). This is a rare tumour in this age group and its management is discussed.

The possible role of hypoxia in the formation of axonal bulbs.

AIMS: To assess the possible role of hypoxia in the formation of axonal bulbs. METHODS: Study material comprised sections from 28 brains showing evidence of cerebral hypoxia with no history of head injury, four with a history of head trauma but no evidence of hypoxic change, eight with a history of head trauma and hypoxic change, and four from control brains originally described as "diffuse axonal injury." These were subjected to microwave antigen retrieval and immunohistochemistry using monoclonal antibodies to beta amyloid precursor protein (beta APP), glial fibrillary acid protein (GFAP), and CD68-PGM1. RESULTS: Positive staining for beta APP was seen in all four controls, all four cases of head injury only, seven of eight cases of head injury and hypoxic changes, and 12 of 28 cases of hypoxia without history of head injury; 22 of 25 cases who had been ventilated showed positive staining. The majority of cases showed evidence of cerebral swelling. CONCLUSIONS: Axonal bulbs staining positively for beta APP may occur in the presence of hypoxia and in the absence of head injury. The role of hypoxia, raised intracranial pressure, oedema, shift effects, and ventilatory support in the formation of axonal bulbs is discussed. The presence of axonal bulbs cannot necessarily be attributed to shearing forces alone.

Meningiomas, dicentric chromosomes, gliomas, and telomerase activity.

Lack of telomere maintenance during cell replication leads to telomere erosion and loss of function. This can result in telomere associations which probably cause the dicentric chromosomes seen in some tumour cells. One mechanism of telomere maintenance in dividing cells is the action of telomerase, a ribonucleoprotein enzyme that adds TTAGGG repeats onto telomeres and compensates for their shortening during cell division. Over 90 per cent of extracranial malignant neoplasms have been found to have telomerase activity. This study sought to determine if there was a relationship between absence of telomerase activity and presence of dicentric chromosomes in meningiomas and to what extent the other main group of central nervous system tumours, the gliomas, expressed telomerase activity. Telomerase activity was measured on 25 meningiomas and 29 gliomas. Four of the meningiomas were atypical variants and 11 were positive for dicentric chromosomes. Twenty-five of 29 gliomas were glioblastoma multiforme tumours. Measures were taken to ensure absence of false positives due to primer-dimer interaction and false negatives due to protein degradation or the presence of Taq polymerase inhibitors. All 25 meningiomas and the four low-grade gliomas (WHO grade II) were telomerase activity-negative. Seven (28 per cent) of the 25 glioblastoma multiforme tumours showed telomerase activity. The absence of telomerase activity in meningiomas and the high frequency of telomere associations support the hypothesis that these tumours are benign, transformed but pre-crisis. The relatively low frequency of telomerase activity in the malignant glioblastoma multiforme suggests that most of these tumours may have other mechanisms of telomere maintenance and that the potentially therapeutic telomerase inhibitors will not be of great value in the future management of the majority of patients suffering from these tumours.

IL-8 mRNA expression by in situ hybridisation in human pituitary adenomas.

Several cytokines have been shown to be expressed in normal and adenomatous pituitary tissue. Recently, interleukin-8 (IL-8) mRNA was identified by reverse transcription (RT)-PCR in each of a series of 17 pituitary tumours examined. We have investigated further the presence of IL-8 mRNA, using in situ hybridisation in two normal human anterior pituitary specimens and 25 human pituitary adenomas. IL-8 mRNA was not identified in either of the two normal pituitary specimens. Only three of the 25 adenomas were positive for IL-8 mRNA. In these three tumours, which included two null cell adenomas and one gonadotrophinoma, the majority of tumour cells (>90%) were positive for IL-8 mRNA. The remaining 22 adenomas were completely negative. There was no difference in tumour size or type between the IL-8 positive and the IL-8 negative tumours, and immunocytochemistry for von Willebrandt factor showed that the two groups were also similar in their degree of vascularisation. In conclusion, IL-8 mRNA was found in 12% of pituitary adenomas studied and was histologically identified within the tumour cells. In situ hybridisation is a more appropriate technique for assessing cytokine mRNA production by human pituitary tumours because RT-PCR may be too sensitive, identifying very small, possibly pathologically insignificant, quantities of mRNA that could be produced by supporting cells such as fibroblasts, endothelial cells or macrophages.

The potential role of myofibroblasts in the obliteration of arteriovenous malformations after radiosurgery.

OBJECTIVES: To examine the structural changes in arteriovenous malformations (AVMs) after stereotactic radiosurgery and to identify the cytoskeletal antigen phenotype of the proliferating cells to gain information about the possible mechanism of obliteration. METHODS: We conducted immunohistochemical and electromicroscopic investigations of surgical material that was removed from seven patients. The patients were harboring cerebral AVMs that had been previously treated with gamma knife irradiation, and they experienced subsequent bleeding 10 to 52 months after treatment. RESULTS: Light microscopy revealed spindle-shaped cell proliferation in the connective tissue stroma and in the subendothelial region of the vessels. The ultrastructural and immunohistochemical characteristics of these spindle cells were identical to those designated as myofibroblasts in wound healing processes and pathological fibromatoses. Whereas in nonirradiated specimens of AVMs, similar cells expressed vimentin and desmin positivity, in irradiated cases, alpha-smooth muscle actin activity was also observed. CONCLUSION: In view of the contractile activity of myofibroblasts, the proliferation generated by irradiation and the transformation of the resting cells into an activated form could be relevant to the shrinking process and eventual occlusion of AVMs after radiosurgery.

Effect of interleukin-1 and dexamethasone on interleukin-6 production and growth in human meningiomas.

Interleukin-6 (IL-6) has been shown to be released by cultured human meningioma cells and may be a positive or negative regulator of tumour growth. IL-6 protein and mRNA levels have been examined in a series of meningiomas. In 14 cases, the results are compared with the effects of IL-6 and dexamethasone on growth and IL-6 secretion in vitro. Tumours with the highest in vivo IL-6 mRNA expression also showed maximum induction of IL-6 and increased cellular proliferation on IL-1 stimulation in vitro. Dexamethasone decreased the IL-1-stimulated IL-6 release in all cases. Meningiomas which had little or no IL-6 message were refractory to IL-1 control of IL-6. Remarkably, these formed the group of meningiomas that increased their growth rate in response to dexamethasone.

Primary intracerebral lymphoma: a clinicopathological analysis of 14 patients presenting over a 10-year period in Sheffield.

Intracerebral disease was diagnosed in 14 out of 450 patients who presented with non-Hodgkin's lymphoma between January 1976 and January 1987. Twelve of the 14 presented after June 1980. Age ranged from 31 to 73 years and eight patients were male. Two patients had other tumours, and three had relevant associated immunosuppressive disorders. Radiological assessment of one further patient showed a cavitating bronchial carcinoma. Five patients were untreated, and one died before radiotherapy was complete. Eight patients completed courses of whole-brain irradiation; four of these received higher doses. All entered remission. Three patients are alive, between eight months and seven years after treatment. Of the remaining five, one never recovered intellectual function and died of bronchopneumonia; three died between eight and 30 months after treatment and autopsy showed severe radionecrosis of the brain with no residual tumour. All three had received higher doses of radiation and had undergone burrhole aspiration before treatment. Autopsy was refused on one patient who also appeared to have died from radionecrosis of the brain. Immunohistological examination in eight cases confirms that cerebral non-Hodgkin's lymphoma is a B-cell tumour. As other groups have found, its incidence appears to be rising. Survival rate is poor, and at least some deaths are related to both radiation necrosis and the bulk of residual tumour after diagnostic surgery.

The clinical, pathological and genetic aspects of sporadic late onset cerebellar ataxia: observations on a series of ten patients.

Ten patients with sporadic late onset cerebellar ataxia (LOCA) are described. The mean age of onset was 50.4 +/- 7.13 years. The important clinical features were gait ataxia, poor coordination of hands, intention tremors, exaggerated deep tendon reflexes, extrapyramidal symptoms and extensor plantar responses. Computerised tomography (CT) scanning in one patient showed a low density mid-line lesion, suggesting early cerebellar atrophy. Histopathological examination in one patient, clinically diagnosed as multiple sclerosis, revealed complete loss of Purkinje cells from the cerebellar folia with gliosis in the molecular layer and loss of small granular neurones. A marked loss of the neurones from the olivary nuclei with astrocytic proliferation was also seen. The disorder is probably genetically determined although a single Mendelian inheritance is unlikely in the absence of recurrence in the first degree relatives. Recurrence risks for gentic counselling are suggested.