Spinal deformity after intra-operative radiotherapy for paediatric patients.

The purpose of this study was to clarify the incidence and characteristics of late-onset complications of the spine in children who underwent intra-operative radiation therapy (IORT) for common paediatric malignant tumours. 12 children with more than 4 years of follow-up after IORT were included and, in 11 of these, thoracic and/or lumbar spines were irradiated. To compare doses of irradiation to the spine with the resulting deformities, dose simulations of IORT were carried out on two selected cases using a radiation treatment planning system with a pencil-beam algorithm. The mean follow-up period was 135 months (range, 53-234 months). Radiographic reviews found spinal deformity in six patients. Only one patient was symptomatic and the spinal deformity was severe (Grade 3), whereas spinal deformity was mild in the remaining five patients without clinical symptoms (Grade 1). In all of the six patients, anterior wedge-shaped deformity was dominant, and scoliosis was found in only two patients. In one particular case with nephrectomy, irradiation had penetrated much deeper than usual at the site of nephrectomy, and dose distribution was asymmetric, causing clinically significant spinal deformity with scoliosis. In conclusion, specific deformities of the spine observed after IORT can be explained on the basis of dose distribution of the electron beam to the spine.

Changing profile of abdominal wall defects in Japan: results of a national survey.

BACKGROUND/PURPOSE: The incidence of gastroschisis has increased over the past 3 decades in a number of countries. To elucidate the Japanese status of anterior abdominal wall defects, the Japanese Society of Pediatric Surgeons conducted a national survey in Japan. METHODS: Information was obtained by sending out a questionnaire to 192 University Hospitals, Children's hospitals, and general hospitals that each had more than 200 beds. The characteristics of the patients including the birth date, birth weight, gestations, rate of associated anomalies, rate of antenatal diagnosis and prognosis, maternal age, gravidity, history of smoking, and drug use were analyzed. RESULTS: The authors obtained answers from 149 institutions, including 1,785 cases of omphalocele and 970 cases of gastroschisis, which were treated between 1975 to 1997. There was a significant increase in the incidence of gastroschisis, from 0.131 in 1975 to 1980, 0.269 in 1981 to 1985, 0.337 in 1986 to 1990, 0.461 in 1991 to 1995 to 0.467 per 10,000 births in 1996 to 1997. The incidence of omphalocele was 0.322 in 1975 to 1980, 0.567 in 1981 to 1985, 0.657 in 1986 to 1990, 0.741 in 1991 to 1995 to 0.626 per 10,000 births in 1996 to 1997, respectively. In the omphalocele group, 43.1% of the mothers were between 25 to 29 years of age, whereas in the gastroschisis group 42.6% of the mothers were 20 to 24 years of age. In the gastroschisis group, the number of primipara mothers was larger than that of multipara mothers. In the omphalocele group, approximately 10% of the mothers smoked during each period, whereas in the gastroschisis group, the percentage of smoking mothers increased chronologically from 12.9% in 1981 to 1985, 18.7% in 1986 to 1990, 23.5% in 1991 to 1995 and 29.3% in 1996 to 1997. A history of drug use by the mother was approximately 10% for both the omphalocele and gastroschisis groups. In the omphalocele group, 55.9% had associated anomalies against 21.8% in the gastroschisis group. Approximately 10% in the omphalocele group and less than 3% in the gastroschisis group showed chromosomal abnormalities. From 1986, a significant number of cases detected antenatally has been observed. CONCLUSIONS: There have been substantial changes in the incidence of anterior abdominal wall defects, particularly regarding gastroschisis in Japan. The reasons for such changes are most likely multifactorial, further epidemiological monitoring is thus called for.

Müllerian inhibiting substance gene expression in the cycling rat ovary correlates with recruited or graafian follicle selection.

Throughout the estrous cycle, Müllerian inhibiting substance (MIS) mRNA signals, as detected by in situ hybridization, were found to be intense in granulosa cells of growing preantral and small antral follicles, especially in the layer closest to the oocyte. Neither primordial follicles, typical atretic follicles, nor CL expressed detectable signals. MIS mRNA signals seen in the cumulus cells of preovulatory follicles at 1000 and 1600 h of proestrus sharply declined at 2400 h, just before ovulation. MIS mRNA signals were intense and uniform in all newly recruited growing antral and Graafian follicles (> 350 microns) at 1000 h of estrus but became heterogeneous in their expression of MIS on metestrus and diestrus and notably absent in atretic follicles; these findings suggest that MIS expression is correlated with recruited follicle selection and suppression with selection for atresia. The fact that all the MIS-positive growing follicles contain oocytes arrested in meiosis, coupled with previous experimental evidence that MIS inhibits germinal vesicle breakdown, suggests that MIS also might act as a regulator of oocyte maturation.

Developmental expression of four novel serine/threonine kinase receptors homologous to the activin/transforming growth factor-beta type II receptor family.

Serine/threonine kinase transmembrane proteins are a new family of growth factor signal transducers that includes several isoforms of the activin type II receptor and the type II receptor for transforming growth factor-beta. In an effort to clone the receptor for Mullerian inhibiting substance, a member of the transforming growth factor-beta superfamily, oligonucleotide primers designed from conserved regions of these receptors' kinase domains were used for PCR amplification of fetal rat urogenital ridge cDNA. We isolated four novel receptors in this manner (designated R1-R4), each of which has structural features of the previously cloned kinases, including a small extracellular ligand-binding domain, a single hydrophobic transmembrane domain, and an intracellular serine/threonine kinase domain. In addition, each has characteristic kinase subdomains and conserved serine/threonine kinase sequences found in this family. Northern analysis revealed mRNA expression of R1-R4 in several tissues, including fetal urogenital ridge, testis, and ovary, as well as brain and lung. In situ hybridization further localized R1 to mesenchyme of the 14.5 to 15-day fetal rat Mullerian duct and to oocytes of preantral and antral follicles, sites that are consistent with the predicted localization of Mullerian inhibiting substance receptor. In addition, R2 localized specifically to seminiferous tubules of the postnatal testis. These newest members of the activin and transforming growth factor-beta type II receptor family should help define the molecular mechanisms by which this ligand superfamily affects cell growth and differentiation via membrane phosphorylation.

Mullerian inhibiting substance messenger ribonucleic acid expression in granulosa and Sertoli cells coincides with their mitotic activity.

In males, Mullerian inhibiting substance (MIS) mRNA was first detected on the medial aspect of the urogenital ridge early on the morning of day 13 of gestation before testicular differentiation was evident, and localized to the more obvious Sertoli cells later on embryonic day 13. MIS transcripts remained at maximal levels between 14.5 and 17.5 days gestation, while the Mullerian duct involutes, and remained high until birth. MIS gene expression decreased progressively after birth and, as germ cell meiosis increased, became barely detectable in the Sertoli cells of the seminiferous tubules. In female rats, MIS mRNA was first detected in the single layer of cuboidal granulosa cells surrounding larger primary follicles 3 days after birth, coincident with the initiation of follicular growth. As follicular growth progressed, MIS mRNA expression was high in preantral and small antral follicles, especially in those granulosa cells closest to the oocyte. MIS mRNA expression decreased gradually in larger antral follicles, remaining prominent only in the cumulus cells and the dividing population of granulosa cells closest to the lumen. MIS gene expression was absent in follicles with features of atresia and in the larger antral follicles. The expression of MIS mRNA in actively dividing Sertoli and granulosa cells correlates with the stages of germ cell division. These findings are suggestive of a role for MIS in the control of germ cell maturation.

Ectopic class II major histocompatibility antigens in Hirschsprung's disease and neuronal intestinal dysplasia.

Although the etiology of Hirschsprung's disease and neuronal intestinal dysplasia remains obscure, both have histological abnormalities involving ganglion cells and neuronal elements. Searching for a common pathway that may inhibit normal maturation of neurogenic precursors, we examined the possible role of an immune mechanism in the maldevelopment of the enteric neural network. Six patients with Hirschsprung's disease were studied by comparing biopsy specimens from diseased colon with ones taken from proximal ganglionic colon in the same patients. These were similarly compared with colonic biopsy specimens from patients studied with chronic constipation or bowel removed at the time of operation for other disorders. Biopsies were taken from four other patients with neuronal intestinal dysplasia. Each was examined by hematoxylin & eosin staining, acetylcholinesterase histochemistry, and immunohistochemistry of major histocompatibility complex (MHC) class I and class II antigens. All rectal samples from Hirschsprung's disease patients exhibited elevated acetylcholinesterase histochemistry and absent ganglia to confirm the diagnosis. These findings were correlated with marked elevation of class II MHC in the aganglionic area, whereas the proximal normal ganglionic segments showed no elevation. Rectal biopsy specimens from patients with chronic constipation exhibited no such elevation. A similar elevation of class II MHC was detected in the mucosa and submucosa of all four patients with the rare neuronal intestinal dysplasia disorder whose diagnosis was confirmed by giant ganglia in Auerbach's plexuses, aberrant Meissner's ganglia in the lamina propria mucosa, and giant neurofibrils in the mucosa and submucosa. The correlation of elevated class II MHC in these two neuronal dysfunction disorders may indicate an underlying autoimmune mechanism as is seen in thyroiditis and insulin dependent diabetes mellitus.(ABSTRACT TRUNCATED AT 250 WORDS)

Müllerian inhibiting substance production and cleavage is modulated by gonadotropins and steroids.

Analysis of the ontogeny and localization of the amino (N)-terminal and carboxy (C)-terminal cleavage products of Müllerian Inhibiting Substance (MIS) and their modulation by hormones of the hypothalamic-pituitary gonadal axis by immunohistochemistry and Northern analysis led to the discovery of a novel mode of posttranslational regulation of this differentiating agent. Antibody to both holo- and C-terminal MIS identically stained the cytosol of testicular Sertoli cells from 21-day fetal rats, whereas staining of antibody to N-terminal MIS localized to the basement membrane of seminiferous tubules. In addition, when studied longitudinally, basement membrane staining for N-terminal MIS persisted; cytosolic staining for C-terminal MIS was no longer detectable in post-natal testes, but marked basement membrane staining for the N-terminal fragment could still be observed in the testes of untreated 7-day postnatal animals. When 19-day fetuses were injected with FSH, testes collected 2 days later showed less immunohistochemical staining for holo-, N-, and C-terminal MIS, and less MIS messenger RNA. This suggested that FSH downregulates MIS transcription, as had been shown previously in neonatal testes treated with FSH. Testes collected at 21 days from fetuses treated at day 19 in utero with human CG or testosterone, also showed less staining for holo-MIS, but, surprisingly, increased staining for the N- and C-terminal fragments. These changes in MIS protein were accompanied by no or minimal changes in MIS messenger RNA levels, indicating that human CG and testosterone do not affect transcription, but may regulate the cleavage and/or dissociation of MIS. This study describes a form of post-translational regulation of MIS and shows that both transcription and processing of MIS may be differentially modulated by gonadotropins and sex steroids.

Problems in diagnosis of Hirschsprung's disease by anorectal manometry.

The purpose of this study is to analyze the results of anorectal manometry and to evaluate the merits and disadvantages of this technique for the diagnosis of Hirschsprung's disease. Studies were performed in 268 patients with constipation, including 95 cases of Hirschsprung's disease. It is concluded from the results that Hirschsprung's disease can be confidently diagnosed by manometric studies. If the studies are performed carefully with a suitable probe, reliability is over 95%. Manometry is the most useful method to differentiate Hirschsprung's disease from other conditions, such as extremely short segment aganglionosis, colonic stenosis, and idiopathic megacolon.

Studies on the rectoanal reflex in children and in experimental animals: an evaluation of neuronal control of the rectoanal reflex.

A single-chamber pressure probe for rectal electromanometry was developed which seems to be superior to the complicated multichamber systems not only for clinical but also for experimental purposes. Measurements of rectoanal reflex were carried out in 268 cases with abnormal bowel function, in 103 cases following operation for Hirschsprung's disease, and in 61 cases of imperforate anus to assess postoperative continence. Experimental studies were performed in 36 dogs, 27 of which were used for short-term and 9 for long-term studies. The results of clinical and experimental studies are described and discussed, with accompanying literature. From clinical and experimental studies, the neuronal pathways of the rectoanal reflex are schematized. The normal rectoanal reflex is mediated by both the sacral cord and the myenteric neurons. It is concluded that measurements of the anal resting pressure and the rectoanal reflex constitute a valuable method to distinguish between normal and pathological sacral and myenteric innervation.

Motility of the anorectum after the Soave-Denda operation.

A total of 82 patients were assessed by rectal manometry after operation for Hirschsprung's disease according to the Soave-Denda technique. A positive rectoanal reflex was obtained in 32 cases (39%), whereas the remaining 50 cases (61%) did not exhibit a rectoanal reflex. Among the children examined, 72% showed normal rhythmic activity of the anorectum. Anorectal function tended to increase over the years, 90% having good continence 10 years or more after operation. Patients who encountered postoperative complications had poor continence since such complications may have damaged the levator and sphincter muscles.