Mixed epithelial polyps in association with hereditary non-polyposis colorectal cancer providing an alternative pathway of cancer histogenesis.

A member of a hereditary non-polyposis colorectal cancer (HNPCC) family developed two colorectal cancers and multiple polyps within four years of a negative colonoscopic examination. One of the cancers was only 4 mm in diameter and showed the gross and endoscopic appearances of a de novo carcinoma. Microscopic examination of multiple levels revealed a mixed hyperplastic polyp/adenoma (mixed polyp) in contiguity with the cancer. The colon harboured additional polyps of which five were tubular adenomas, seven were hyperplastic polyps and seven were mixed polyps (architecturally compatible with hyperplastic polyps but with atypical cytology). Atypical features of the mixed polyps included tripolar mitoses, bizarre chromatin aggregations and multinucleation. One mixed polyp showed DNA microsatellite instability. Under the influence of the mutator defect, hyperplastic polyps may develop atypical or adenomatous features and show progression to carcinoma. Such an alternative morphogenetic pathway could explain the differing molecular and pathological profiles of cancers showing DNA microsatellite instability.

Colorectal neoplasms detected colonoscopically in at-risk members of colorectal cancer families stratified by the demonstration of DNA microsatellite instability.

This study compared colonoscopic findings in families meeting the Amsterdam criteria (A) for hereditary non-polyposis colorectal cancer (HNPCC) but stratified according to whether the familial cancers showed DNA microsatellite instability. DNA was extracted from paired samples of normal and cancer, and microsatellite instability was analysed at up to six loci. Families were termed replication error positive (RER+) when at least 50% of tumours tested per family were positive. Of 26 families studied 17 were RER+ and 9 were RER-. Cancers in the A/RER- families showed no right-sided predilection (P < 0.001). Colonoscopies have been performed on 182 at-risk members of A/RER+ families and 60 members of A/RER- families. More of the at-risk members of A/RER-families were found to have adenomas at colonoscopy (P = 0.095), but these were smaller than those of A/RER+ families (P = 0.19). The adenoma:carcinoma ratio was twice as high in A/RER- families (13:1) as in A/RER+ families (7:1). One of the A/RER- families had hyperplastic polyposis. The others do not appear to have attenuated familial adenomatous polyposis and are similar to the adenoma families or late-onset colorectal cancer families described by others. This study illustrates the importance of molecular technology in separating HNPCC from syndromes with overlapping phenotypes.

Familial giant hyperplastic polyposis predisposing to colorectal cancer: a new hereditary bowel cancer syndrome.

A mother and five of her ten offspring developed colonic cancers, the mother and one of the offspring being younger than 50 years of age at diagnosis. Despite fulfilling the Amsterdam criteria for hereditary non-polyposis colorectal cancer (HNPCC), several features pointed towards the possibility that this represented a different syndrome of familial cancer. Most notable was the presence of large, multiple hyperplastic polyps and mixed polyps in four of the subjects whose pathology was available for review. In addition, three of the four subjects had cancers that were negative for DNA replication errors (RER-). The subject with an RER+ cancer had a second RER+ cancer and three adenomas, one in contiguity with the second cancer. This subject also had multiple, large hyperplastic polyps, thereby combining hyperplastic polyposis and a proneness to multiple RER+ tumours. One of the hyperplastic polyps was also RER+. Two of five young asymptomatic descendants have been found to harbour multiple colorectal polyps. It is suggested that giant hyperplastic polyposis is a new familial syndrome predisposing to colorectal cancer.

Cardioplegic protection of hearts with pre-arrest ischaemic injury: effect of glucose, aspartate, and lactobionate.

This study compared the cardioprotective effects of three oxygenated "extracellular" crystalloid cardioplegic solutions. These were MBS (containing glucose, aspartate, and lactobionate [GAL]), St. Thomas' Hospital No. 2 (STH), and modified STH (added glucose, aspartate, and lactobionate) (STHGAL). Isolated working rat hearts (45) were initially injured with 10 min of global normothermic ischaemia and then arrested for 4 hr at (30 degrees C) with multidose cardioplegia (2 min every 30 min). The hearts (n = 9 per group) were then reperfused for 7 min in the non-working mode and for a further 23 min in the working mode. MBS-treated hearts rapidly resumed spontaneous sinus rhythm (0.69 +/- 0.06 minutes) with nearly complete recovery of function (aortic flow 93.3 +/- 5.4%, cardiac output 95.7 +/- 3.6%, stroke volume 95.3 +/- 3.7%, heart rate 102.2 +/- 3.7%, and aortic pressure 88.3 +/- 3.2% of pre-ischaemic control values). With either STH or STHGAL these indices were significantly (p < 0.01) lower (aortic flow 25.5 +/- 10.4% or 69.5 +/- 6.5%, cardiac output 30.1 +/- 11.1% or 67.6 +/- 6.6%, aortic pressure 36.5 +/- 7.7% or 63.9 +/- 8.0%, respectively). Total lactate efflux (indicating glycolysis) during cardioplegia was increased (p < 0.01) by inclusion of GAL (MBS 63.7 +/- 1.8, STHGAL 68.7 +/- 2.2, STH 28.5 +/- 1.3 mumol/heart). Progressive increase in coronary vascular resistance was observed during STH-based cardioplegia but not during MBS-based. The improved recovery of function was associated with reduced depletion of adenosine triphosphate (MBS 9.44 +/- 0.79, STHGAL 8.21 +/- 1.00, STH 1.02 +/- 0.10 mumol/g dry wt), total adenine nucleotide pool (14.61 +/- 0.83, 16.81 +/- 0.85, 7.33 +/- 0.52 mumol/g dry wt) and energy charge (0.767 +/- 0.019, 0.620 +/- 0.037, 0.248 +/- 0.012) during arrest, and significantly (p < 0.01) better resynthesis during reperfusion (ATP: 66%, 16%, 40%; TAN: 64%, 22%, 43% of control respectively). These findings indicate that the novel cardioplegic solution MBS (US Pat. No. 5,290,766) provides better myocardial protection than STH in hearts with pre-arrest ischaemic injury not only by providing metabolic substrates but also because of its more appropriate balance of cations.

Diagnostic use of microsatellite instability in hereditary non-polyposis colorectal cancer.

50 families with a history of colorectal cancer were divided according to whether criteria for hereditary non-polyposis colorectal cancer (HNPCC) were fulfilled totally (A, n = 19) or partly (B, n = 31) and stratified by the demonstration that at least half the cancers tested per family were positive for DNA replication errors (RER+). Accepted clinical and pathological characteristics of HNPCC were found to cluster within 12 A/RER+ families in which the mean number of affected individuals per family was 10.1. Reliance upon clinical data alone may result in over-diagnosis of HNPCC, in small families who just meet the minimum criteria, whereas underdiagnosis is rare. The criteria could be refined by inclusion of RER status.

Microvascular incompetence and the failure of hearts to recover contractile function after cardioplegia.

The relationship between the development of microvascular incompetence and the loss of potential for functional recovery following cardioplegia was investigated using St. Thomas' Hospital No. 2 solution (STH) in isolated working rat hearts. Cardiac function was measured prior to cardioplegia and again after 30 min of reperfusion at 37 degrees C following 1, 2 or 4 h arrest at 30 degrees C (n=5). The hearts were then fixed by perfusion with 2.5% glutaraldehyde and then nuclear track emulsion was perfused as an intravascular marker of competent capillaries. Following cardioplegia for 1 h hearts showed 95.4% recovery of aortic flow in the working mode, and a high proportion of the capillaries in the subendocardial (84.6 +/- 2.3%), middle (94.6 +/- 3.0%) and subepicardial (89.1 +/- 4.9%) thirds of the left ventricular myocardium transmitted perfusate. Two hours arrest resulted in significantly diminished recovery of left ventricular function (aortic flow: 56.6 +/- 7.6% and aortic pressure: 64.4 +/- 2.5% and heart rate 56.0 +/- 23.1%). This loss of the remaining two thirds of the potential for functional recovery was associated with significant (P<0.02) reductions in the proportions of competent capillaries (subendocardial, middle and subepicardial thirds to 10.9%, 19.2% and 14.2%, respectively). These non-functional capillaries had open lumina and showed no sign of structural alteration, obstruction or compression, although some focal collections of myocytes (<30%) showed evidence of reperfusion damage including contraction band necrosis. Despite reductions in microvascular competence overall, coronary flow rates (non-working) did not decline, suggesting shunting via large arterio-venous channels. It seems likely that the loss of the first third of the potential for rapid functional recovery following cardioplegia is due to loss of high energy phosphates, whereas the loss of the remaining two-thirds is associated with endothelial cell mediated constriction of small arterial vessels which produces the capillary incompetence demonstrated in this study.

Myocardial protection during prolonged ischaemic cardiac arrest: experimental evaluation of three crystalloid cardioplegic solutions.

The aim of this study is to define the cardioprotective effects (functional and metabolic) of our modified "extracellular" cardioplegic solution (MBS: containing glucose, aspartate and lactobionate), St. Thomas' Hospital No. 2 (STH) and Bretschneider's No. 3 (Bret) solutions during prolonged hypothermic ischaemia (20 degrees C, 6 hours) in the isolated working rat heart. hearts (n = 9-10 in each group) were arrested with, and exposed to, multidose reinfusion (2 minutes every 40 minutes interval) throughout the ischaemic period with cold (4 degrees C) MBS, STH or oxygenated (95% O2: 5% CO2) Bret. All MBS treated hearts resumed spontaneous regular sinus rhythm (0.51 +/- 0.01 minutes) of contraction during post-ischaemic reperfusion for 30 minutes at 37 degrees C with the complete recovery of all the functional indices (aortic flow: 87.4 +/- 3.4%, cardiac output: 94.1% +/- 3.3%, coronary flow: 101.8 +/- 4.1%, heart rate: 99.8 +/- 2.8% and aortic pressure: 105.7 +/- 4.6% of prearrest control values). In contrast, hearts protected with either STH or Bret showed the poor or no post-ischaemic recovery of cardiac pump function (aortic flow: 7.2 +/- 4.8% and 0%, respectively). Recovery of all other left ventricular function indices were also significantly (p < 0.001) decreased with increasing more hearts failing to regain function (MBS: 0/10, STH: 7/9 and Bret: 9/9). The efflux of lactate during 6 hours ischaemic arrest was increased [52.40 +/- 1.50 v 36.8 +/- 1.70 (STH) or 14.45 +/- 0.70 (Bret) mumol/heart, p < 0.001] and the progressive increase in the coronary vascular resistance was completely abolished in MBS treated hearts. These improvements were associated with the reduction in the decline of the myocardial adenosine triphosphate (23.44 +/- 1.08 v 3.79 +/- 1.08 or 4.51 +/- 0.71 mumol/g dry wt), creatine phosphate (30.23 +/- 1.52 v 8.01 +/- 2.21 or 5.41 +/- 0.03 mumol/g dry wt) and guanosine triphosphate (2.26 +/- 0.23 v 0.24 +/- 0.11 or 0.59 +/- 0.07 mumol/g dry wt) during ischaemia, and total resynthesis after reperfusion (ATP: 92% v 36% or 25% and CP: 126% v 92% or 59% of control). These results indicate that the new cardioplegic solution, MBS can meet the metabolic demand of the ischaemic myocardium because of the greater synthesis of intramyocardial ATP and CP during cardioplegic arrest, provide substantially improved protection of hearts from injury and thus increase (double) the safe duration of cardiac arrest.

Protective effects of oxygenated St. Thomas' Hospital cardioplegic solution during ischaemic cardiac arrest: improved function, metabolism and ultrastructure.

The isolated working rat heart model was use to define the cardioprotective effects (function, metabolic and ultrastructure) of the oxygenated St. Thomas' Hospital No. 2 cardioplegic solution (STH) during lengthy, hypothermic ischaemia (20 degrees C, 4 hours and 5 hours). Hearts (n = 9 for each group) were arrested with and exposed to multidose reinfusion (2 min every 40 min interval) throughout the ischaemic period with the cold (4 degrees C) STH or oxygenated (95% O2:5% CO2) STH. Oxygenated STH significantly (p < 0.01) improved the postischaemic recovery of cardiac output from 49.5 +/- 11.1% to 96.8 +/- 1.5% (in 4 hours) and from 20.3 +/- 7.2% to 72.2 +/- 5% (in 5 hours). Other indices of functional recovery showed similar improved performance with the significant decrease in time from the onset of reperfusion to the return of regular sinus rhythm (57 +/- 8 v 495 +/- 150 s). The efflux of lactate during 5 hr ischaemic arrest was decreased (20.62 +/- 1.3 v 26.18 +/- 1.73 mumol/heart for oxygenated STH and STH, respectively, p < 0.05) and the progressive increase in the coronary vascular resistance was abolished in the oxygenated STH treated hearts. These improvements were associated with the reduction in the decline of the myocardial adenosine triphosphate (14.49 +/- 2 v 3.3 +/- 0.19 mumol/g dry wt), creatine phosphate (24.61 +/- 3.47 v 7.48 +/- 1.34 mumol/g dry wt) and guanosine triphosphate (1.69 +/- 0.2 v 0.84 +/- 0.08 mumol/g dry wt) during ischaemia, total resynthesis after reperfusion (ATP: 103% v 36%, CP: 105% v 69% and GTP: 203% v 61% of control) and the total absence of myocardial cells and microvasculature injuries in ischaemic (non-reperfused) hearts. These results confirm that the provision of additional oxygen to the St. Thomas' Hospital solution (with 95% O2:5% CO2) can meet the metabolic demand of the ischaemic myocardium and thus increase the safe duration of cardiac arrest.