Adenomyosis-associated recurrent acute cerebral infarction mimicking Trousseau's syndrome: A case study and review of literature.

Background: Adenomyosis is a common and benign uterine disease. Acute cerebral infarction (CI) associated with adenomyosis is rarely reported and difficult to treat. We experienced successful treatment for this disease. Case Description: A 50-year-old woman presented with a 2-day history of visual disturbance. Magnetic resonance imaging showed multiple tiny diffusion-weighted high-density spots on several lobes. No common risk factors for stroke were detected. Cancer antigen 125 level was 999 U/mL, along with massively expanded uterus and adnexa. Based on the diagnosis of benign adenomyosis, Xa inhibitor and GnRH agonists were administered for CI and adenomyosis, respectively. Acute CI recurred 7 days after admission. We suspected a relationship between infarction and adenomyosis and concluded hysterectomy as a proper treatment strategy based on the literature. Eighteen months after hysterectomy, no recurrence of CI without anti-thrombus medications has been detected. Conclusion: Hysterectomy is a radical therapy that is effective in preventing acute CI due to adenomyosis associated with ischemic symptoms.

Primary Sellar Neuroblastoma in an Elderly Patient: Case Report.

A 71-year-old male presented with an isolated well-enhanced sellar lesion accompanied by hypopituitarism, diagnosed preoperatively as a pituitary adenoma, meningioma, or metastatic brain tumor. However, histological examinations yielded a diagnosis of neuroblastoma. Primary sellar neuroblastoma in the elderly is very rare. We therefore describe this case of primary sellar neuroblastoma, mimicking common pituitary tumor, and review the literature. There have so far been only nine reported cases of primary sellar neuroblastoma in the English literature. All reports like the present case, demonstrated similar neuroimaging of a "dumbbell-shaped extension in the sellar region." Moreover, the tumors may exhibit characteristic features, such as rapid tumor growth, hypopituitarism, or oculomotor nerve palsy, and these findings may represent helpful signs for the diagnosis of primary sellar neuroblastoma.

Efficacy of ribavirin against malignant glioma cell lines.

Ribavirin (1-ß-D-ribofuranosy-1,2,4-triazole-3-carboxamide) has been widely administered as an antiviral agent against RNA and DNA viruses. Ribavirin, in combination with interferon, has predominantly been applied in the treatment of the hepatitis C virus infection and its potential antitumor efficacy has recently become a point of interest. The aim of the present study was to evaluate the effect of ribavirin on the growth of malignant glioma cells, to identify novel predictive genes in malignant glioma cells (by analyzing gene expression profiles) and to assess the influence of ribavirin on the cell cycle of malignant glioma cells. The present study evaluated the antitumor efficacy of ribavirin against various malignant glioma cell lines (A-172, AM-38, T98G, U-87MG, U-138MG, U-251MG and YH-13). After culturing the cells in ribavirin-containing culture medium (final concentration, 0-1,000 µM) for 72 h, the viable proliferated cells were harvested and counted. The half maximal inhibitory concentration of ribavirin, with regard to the growth of the malignant glioma cell lines, was determined from the concentration of ribavirin required for 50% growth inhibition in comparison to the untreated control cells. Furthermore, the current study identified the genes in which the gene expression levels correlated with the ribavirin sensitivity of the malignant glioma cells lines, using a high-density oligonucleotide array. Finally, cell cycle analysis was performed on the U-87MG cell line. It was identified that ribavirin inhibited the growth of all of the malignant glioma cell lines in a dose-dependent manner, although the ribavirin sensitivity varied between each cell line. Of the extracted genes, PDGFRA demonstrated the strongest positive correlation between gene expression level and ribavirin sensitivity. Cell cycle analysis of the U-87MG cell line demonstrated that ribavirin treatment induces G0/G1 arrest and thus may be an effective agent for inhibiting malignant glioma cell growth. Therefore, the results of the current study indicate that ribavirin may have potential as a therapeutic agent in the treatment of malignant gliomas.

Gene expression profiles predicting the response to IFN-ß and a combination of temozolomide and IFN-ß in malignant gliomas.

Temozolomide (TMZ) is an alkylating agent that has yielded significant benefits and is a current standard agent in the treatment of malignant gliomas. However, its survival benefit remains unsatisfactory. Recently, a synergistic antitumor effect between TMZ and interferon-ß (IFN-ß) was reported in malignant glioma cells. The Japan Clinical Oncology Group (JCOG) brain tumor study group has recently began a randomized phase II study to evaluate the clinical effectiveness of combination therapy with TMZ and IFN-ß in glioblastomas. However, it is not sufficient just to evaluate the mechanisms and establish an experimental basis for rational clinical therapy with IFN-ß and TMZ. The precise mechanisms governing the direct effects of IFN-ß and a combination of IFN-ß and TMZ in gliomas are not yet fully understood. To gain insight into the mechanisms of sensitivity/resistance involving IFN-ß and combination therapy with IFN-ß and TMZ, and further to identify new marker(s) that could be used clinically to predict the response to such therapy and new target gene(s) for therapies related to malignant glioma patho-genesis, we evaluated the gene expression profiles of human malignant glioma cell lines employing a high-density oligo-nucleotide DNA array, GeneChip. We present a list of the most highly upregulated and downregulated genes which may be involved in conferring a response to IFN-ß and synergistic effect between IFN-ß and TMZ in malignant gliomas. Although the present study has several limitations, our reported candidate genes could represent not only potential molecular markers but also chemotherapy targets for improving the treatment outcome by devising strategies that are able to circumvent primary drug resistance in malignant gliomas.

Isolated intracranial Rosai-Dorfman disease without dural attachment--case report.

A 33-year-old female presented with an isolated well-enhanced intracerebral lesion with peritumoral edema in the frontal lobe, which was tentatively diagnosed preoperatively as either a primary intraparenchymal neoplasm or metastatic brain tumor. However, histological examinations yielded a diagnosis of Rosai-Dorfman disease. Isolated intracranial Rosai-Dorfman disease is very rare, and without dural attachment, as in our case, is exceptional. The present case mimicked intraparenchymal neoplasm. Rosai-Dorfman disease should be considered in the differential diagnosis of isolated intraparenchymal tumors. Magnetic resonance imaging including diffusion-weighted imaging may be helpful in the diagnosis of isolated intracranial Rosai-Dorfman disease.

Non-promoter hypermethylation of zygote arrest 1 (ZAR1) in human brain tumors.

Zygote arrest 1 (ZAR1) is a novel maternal-effect gene of crucial importance during the oocyte-to-embryo transition. Comprehensive methylation analysis of tumor-specific differently methylated regions in human malignant melanomas has recently led to the identification of non-promoter hypermethylation of the ZAR1 gene that had never been identified as an aberrant methylated region in any human tumor. Notably, ZAR1 hypermethylation was frequently observed in melanomas but was absent in benign nevi, and ZAR1 expression was found to be up-regulated in methylated tumors. These findings prompted us to screen for ZAR1 non-promoter methylation in various types of human brain tumors using MassARRAY EpiTYPER. Strikingly, hypermethylation of ZAR1 was observed frequently in diffuse astrocytomas (100%), anaplastic astrocytomas (94%), glioblastomas (93%), oligodendrogliomas (100%), anaplastic oligodendrogliomas (100%), and pituitary adenomas (90%), but not at all in pilocytic astrocytomas. For other tumor types ZAR1 hypermethylation was infrequent: 17% of vestibular schwannomas and 33% of meningothelial meningiomas. Detectable ZAR1 transcript was not found in any of hypermethylated glioma cell lines. Our results indicate that hypermethylation of the ZAR1 non-promoter is extremely frequent in diffuse gliomas and pituitary adenomas, although ZAR1 expression is unlikely to play a tumorigenic role.

Gene expression profiling predicts response to temozolomide in malignant gliomas.

Malignant gliomas are highly lethal neoplasms that cannot be cured with currently available therapies. Temozolomide (TMZ) is a recently introduced alkylating agent that has yielded significant benefits and become a key agent in the treatment of high-grade gliomas. However, its survival benefit remains unsatisfactory. Understanding the molecular basis of TMZ sensitivity/resistance is necessary for improving the treatment outcome by devising strategies that are able to circumvent primary drug resistance. We therefore combined the in vitro TMZ response with microarray gene expression data to identify genes that could potentially be used to predict the response of malignant gliomas to TMZ therapy. We first obtained the individual IC50 values for TMZ in seven malignant glioma cell lines (A-172, AM-38, T98G, U-87MG, U-138MG, U-251MG and YH-13) and then identified the genes whose expression correlated most highly with TMZ sensitivity employing a cDNA microarray. We present here a list of the most highly up-regulated and down-regulated genes which may be involved in conferring TMZ sensitivity/resistance in malignant gliomas, although most of the genes have not been implicated as a causal factor in the TMZ response except MGMT. We also demonstrated and confirmed the MGMT methylation status, quantitative MGMT mRNA levels, and MGMT protein expression levels in TMZ resistant glioma cells in vitro. Our results are thus consistent with previous studies and suggest that a dominant mechanism conferring sensitivity/resistance to TMZ exists in malignant glioma cells. Although the present study dose have several limitations, our reported candidate genes could represent not only potential molecular markers for TMZ sensitivity/resistance but also chemotherapy targets. Furthermore, the present study could provide a foundation for alternative therapeutic strategies including novel combination treatments that incorporate additional reagents directed at overcoming resistance to TMZ.

Pleomorphic granular cell astrocytoma in the pineal gland: case report.

Pleomorphic granular cell astrocytoma in the pineal region is exceedingly rare, and its clinicopathological features are distinctive. A 67-year-old woman was admitted with a staggering gait. Magnetic resonance imaging revealed a mass lesion at the pineal gland accompanied by obstructive hydrocephalus. Following surgery, pathological examinations demonstrated a pleomorphic granular cell astrocytoma. The patient has been free from recurrence for 24 months after surgery without adjuvant therapy. The specimen exhibited nuclear and cytoplasmic pleomorphism. The nuclei varied in size, shape and coarseness. Variability was also observed in the eosinophilic granular bodies, Rosenthal fibers and spindle-shaped tumor cells. GFAP, S-100 and vimentin were immunohistochemically positive. Reticulin network was absent between the tumor cells, and granular cells with ballooned cytoplasm showing positive staining for PAS. Pleomorphic granular cell astrocytoma is believed to be a form of astrocytoma originating from the pineal gland. Its clinicopathological features resemble those of pleomorphic xanthoastrocytoma. However, it can be differentiated from the latter by the absence of reticulin fibers, absence of basement membrane between adjacent cells, and presence of large numbers of mitochondria.

Aberrant hypermethylation of non-promoter zygote arrest 1 (ZAR1) in human brain tumors.

Zygote arrest 1 (ZAR1) is a novel maternal-effect gene which is extremely important during the oocyte-to-embryo transition. Comprehensive methylation analysis of tumor-specific differentially methylated regions in human malignant melanoma has recently led to the identification of non-promoter hypermethylation of the ZAR1 gene that had never been previously linked to aberrant methylation. Strikingly, ZAR1 hypermethylation was frequently observed in melanomas but was absent in benign nevi, and ZAR1 expression was found to be up-regulated in methylated tumors. The present study searched for non-promoter ZAR1 hypermethylation in 90 primary human brain tumor samples, normal brain tissue from one autopsy case, and 7 glioma cell lines, employing Sequenom MassARRAY, in which bisulfite-treated fragments are quantitatively detected using time-of-flight mass spectroscopy. ZAR1 transcript expression levels were also evaluated by quantitative real-time reverse transcription-polymerase chain reaction in the 7 glioma cell lines. Hypermethylation of ZAR1 was frequently found in diffuse astrocytomas (7/7, 100%), anaplastic astrocytomas (16/17, 94%), glioblastomas (27/29, 93%), oligodendrogliomas (3/3, 100%), anaplastic oligodendrogliomas (3/3, 100%), and pituitary adenomas (9/10, 90%), but not in pilocytic astrocytomas (0/3). Other tumor types showed infrequent ZAR1 hypermethylation: 1 (17%) of 6 vestibular schwannomas and 4 (33%) of 12 meningothelial meningiomas. The normal brain tissue revealed no evidence of ZAR1 methylation. All 7 glioma cell lines displayed aberrant hypermethylation of ZAR1, but none had detectable ZAR1 transcript. Our findings indicate that non-promoter hypermethylation of ZAR1 is extremely frequent in diffuse gliomas and pituitary adenomas, but methylation-related aberrant ZAR1 expression is far less likely to be related to glioma tumorigenesis.

Effect of IFN-beta on human glioma cell lines with temozolomide resistance.

Human interferon-beta (IFN-beta) is known to exhibit pleiotropic biological activities including antitumor effects. On the other hand, temozolomide (TMZ), an oral bioavailable alkylating agent with excellent tolerability, has demonstrated efficacy and has become a key therapeutic agent in patients with malignant gliomas; however, its survival benefit remains unsatisfactory. More recent studies have indicated that there might be favorable therapeutic interactions between IFN-beta and TMZ, although the therapeutic advantages of such a combination have not yet been fully explored. The main aim of the present study was to determine whether an antitumor effect could be potentiated by a combination of IFN-beta and TMZ. The antitumor effect of and cell sensitivity to IFN-beta and TMZ and the synergistic potential of IFN-beta and TMZ in combination were evaluated in six malignant glioma cell lines. Correlations among the MGMT methylation status, quantitative level of MGMT mRNA, MGMT protein expression and the antitumor effect of these agents were also evaluated, since one of the most prominent resistance mechanisms to TMZ involves the DNA repair protein MGMT. The cell growth inhibitory effects of IFN-beta and TMZ on all tumor cell lines were observed in a dose-dependent manner, and the human malignant glioma-derived cell lines differed in their sensitivity to TMZ. The MGMT status, including promoter hypermethylation, quantitative mRNA expression and protein expression, was strongly correlated with TMZ sensitivity. A synergistic cell growth inhibitory effect and down-regulated MGMT mRNA levels were significantly observed when a clinically achievable CNS dose of IFN-beta was combined with TMZ, as compared to treatment with IFN-beta or TMZ alone in TMZ-resistant T98G cells. Furthermore, significant amounts of endogenous IFN-beta protein were detected in TMZ-treated T98G cells by ELISA. These results suggest that the clinical therapeutic efficacy of TMZ might be improved by a combination with IFN-beta in malignant gliomas unmethylated at the MGMT gene. The data provide an experimental basis for future strategies in TMZ chemotherapy, although further studies are needed to determine the detailed role of combined IFN-beta and TMZ chemotherapy in increasing tumor sensitivity.

Relevance of MSP assay for the detection of MGMT promoter hypermethylation in glioblastomas.

O6-Methylguanine-DNA methyltransferase (MGMT) promoter hypermethylation has recently emerged as a powerful determinant of chemotherapy sensitivity in glioblastomas. To adapt such an important epigenetic biomarker to routine application in the clinical setting, we validated the conventionally used methylation-specific polymerase chain reaction (MSP) assay for its relevance in the determination of MGMT methylation status. MGMT promoter hypermethylation analysis employing MSP was performed on 25 primary glioblastoma samples and 7 cell lines, and compared with the more robust direct promoter sequencing that profiled the methylation status of 27 CpG sites within the MGMT promoter. In addition, the MGMT expression at the protein level was evaluated in the primary tumor samples using immunohistochemistry and in the cell lines using Western blotting analysis. Our MSP analyses yielded reproducible results, which were identical to the bisulfite sequencing data in all except one primary tumor that was negative on MSP. A poor correlation existed between the immunohistochemical staining results and the methylation status of the MGMT promoter in primary glioblastoma samples. Neither MSP-MGMT methylation nor immunohistochemical MGMT expression had prognostic implications in this small and non-uniform group of patients. In all of the cell lines with loss of MGMT expression, signals of methylated DNA were detected by MSP. Our data support the feasibility and reliability of MSP analysis, which could be routinely implemented in the diagnostic setting.

Aberrant hypermethylation of p14ARF and O6-methylguanine-DNA methyltransferase genes in astrocytoma progression.

The aim of the present study was to elucidate genetic alterations that are critically involved in astrocytoma progression. We characterized 27 World Health Organization grade II fibrillary astrocytomas which later underwent recurrence or progression, paying specific attention to the CpG island methylation status of critical growth regulatory genes. p14(ARF) and O(6)-methylguanine-DNA methyltransferase (MGMT) hypermethylation represented frequent events (26% and 63%, respectively), which were mutually exclusive except in one case, with alternate or simultaneous methylation of these two genes occurring in 85% of our tumor series. Seventeen tumors (63%) contained TP53 mutations, which were closely related to the presence of MGMT methylation. Methylation of the p21(Waf1/Cip1), p27(Kip1) and p73 genes and homozygous deletion of the p16(INK4a), p15(INK4b) and p14(ARF) genes were not detected in any of the primary low-grade tumors. The presence of p14(ARF) methylation at first biopsy was associated with shorter patient survival, whereas the presence of MGMT methylation carried a better clinical outcome after salvage therapy. Examination of 20 cases whose histological data for recurrent tumors were available revealed that malignant progression occurred in all of the tumors with p14(ARF) methylation but less frequently (50%) in the lesions with MGMT methylation. On analysis of their respective recurrent tumors, five of six patients whose primary low-grade tumors carried p14(ARF) methylation exhibited homozygous co-deletions of the p14(ARF), p15(INK4b) and p16(INK4a) genes, which were restricted to glioblastoma as the most malignant end point. Our findings suggest that p14(ARF) hypermethylation and MGMT hypermethylation constitute distinct molecular pathways of astrocytoma progression, which could differ in biological behavior and clinical outcome.

Promoter hypermethylation profile of cell cycle regulator genes in pituitary adenomas.

Aberrant hypermethylation of CpG islands in the promoter region plays a causal role in the inactivation of various key genes involved in the cell cycle regulatory cascade, which could result in a loss of cell cycle control. The aim of the present study was to examine in more detail the prevalence and role of the promoter methylation of genes with a proven involvement in the cell cycle regulation of pituitary adenomas, since their tumorigenesis has not yet been clearly defined. We profiled the CpG island methylation status of a series of well-characterized cell cycle regulation genes: the RB1, p14(ARF), p15(INK4b), p16(INK4a), p21(Waf1/Cip1), p27(Kip1), and p73 genes, in 34 pituitary adenomas as determined by a methylation-specific polymerase chain reaction assay. Promoter hypermethylation of the RB1, p14(ARF), p15(INK4b), p16(INK4a), p21(Waf1/Cip1), p27(Kip1), and p73 genes was detected in 12 (35%), 2 (6%), 11 (32%), 20 (59%), 1 (3%), 0 (0%), and 4 (12%) of the adenomas, respectively. In total, 88% (30 of 34) of the adenomas displayed methylation of at least one of such cell cycle regulatory genes, especially methylation of the member genes of the RB1 pathway (29 of 34; 85%). Promoter hypermethylation of p15(INK4b) coincided with RB1 and/or p16(INK4a) methylation, whereas RB1 and p16(INK4a) methylations tended to be mutually exclusive (p = 0.0048). Furthermore, promoter hypermethylations of p14(ARF), p21(Waf1/Cip1), and p73 (not belonging to the member genes of the RB1 pathway) were also coincident with RB1 and/or p16(INK4a) methylation except in one p73 methylated case. In contrast, none of the clinicopathological features, including the cell proliferation index, was significantly correlated with any particular methylation status. Our results suggested that aberrant hypermethylation of the key cell cycle regulatory genes occurs at a relatively high frequency in pituitary adenomas, especially in RB1 pathway genes with promoter hypermethylation of the p16(INK4a) gene being the most common deregulation. We further obtained evidence to indicate that RB1 and p16(INK4a) methylations tended to be mutually exclusive, but did occasionally coincide with other cell cycle regulation gene methylations.

Aberrant promoter hypermethylation profile of cell cycle regulatory genes in malignant astrocytomas.

Aberrant hypermethylation of the CpG islands in the promoter region plays a casual role in the inactivation of various key genes involved in the cell cycle regulatory cascade, which could result in loss of cell cycle control. The aim of the present study was to investigate the role of promoter methylation of genes with a proven involvement in the cell cycle regulation of malignant astrocytomas. We profiled the CpG island methylation status of the RB1, p14ARF, p15INK4b, p16INK4a, p21Waf1/Cip1, p27Kip1, and p73 genes by methylation-specific polymerase chain reaction assay in a homogeneous cohort of patients with malignant astrocytomas, and assessed their relationships with clinical behavior. Promoter hypermethylation of the RB1, p14ARF, p15INK4b, p16INK4a, p21Waf1/Cip1, p27Kip1, and p73 genes was detected in 3 (6%), 7 (13%), 4 (7%), 2 (4%), 1 (2%), 3 (6%), and 12 samples (22%) among 54 newly diagnosed malignant astrocytomas, respectively. A total of 50% of the cases carried methylation of at least one gene, and only 9% of the cases displayed concordant hypermethylation of two genes. None of the tumors disclosed three or more methylated loci. The presence of methylation of these genes or a group of genes was not associated with any distinct clinicopathological characteristics including tumor grade, proliferation activity, responsiveness to adjuvant therapy, or patient survival. p73 protein accumulation was demonstrated by immunohistochemical staining in 6 (15%) of the 40 samples examined, with no significant association with the methylation status of p73 and any of the clinicopathological parameters tested. Our results demonstrated that a significant fraction of malignant astrocytomas displayed at least one methylated locus of the key cell cycle-related genes, although the genes were rarely hypermethylated, independent of the clinicopathological parameters. Thus, this epigenetic change is unlikely to play an important role in the evolution and development of malignant astrocytomas.