Brain metastases as the only manifestation of an undetected primary tumor

BACKGROUND: The prognosis of patients with brain metastasis as the only manifestation of an undetected primary tumor generally is considered to be poor. Therefore, most treatment is palliative. The authors reviewed the clinical outcomes and treatment results of patients presenting with brain metastasis from an undetected primary tumor at The University of Texas M. D. Anderson Cancer Center. METHODS: Between 1977-1996, 220 patients were referred to the study department for the treatment of brain metastasis from an undetected primary tumor. The patients' records were reviewed to identify those for whom brain metastasis was the only manifestation of the primary tumor. The majority of patients were excluded from the current analysis because extracranial metastasis also were present. Thirty-nine patients qualified for this retrospective review. The level of neurosurgical excision varied, but all patients received radiotherapy. Tumor control in the brain and survival were analyzed by various tumor-related and treatment-related factors. RESULTS: In 31 patients, the brain metastasis were adenocarcinomas, whereas the remaining patients had tumors of various other histologies. In 12 patients, the primary tumor eventually was found, most commonly in the lung. The median survival time for all patients was 13.4 months. Overall survival rates (OS) at 1, 3, and 5 years were 56%, 19%, and 15%, respectively. Intracranial disease control was 72% at 5 years. Patients who received gross total resection (GTR) and radiotherapy had significantly better OS than patients who received radiotherapy alone. The OS of patients whose primary tumor was identified was similar to that of patients in whom the primary tumor remained occult. CONCLUSIONS: Brain metastasis as the only manifestation of an unknown primary tumor is a distinct clinical entity. The prognosis for patients with this presentation is better than that of patients with brain metastasis in general. Although the majority of patients die of extracranial disease, a few will achieve long term survival. Treatment to the brain is effective in controlling local disease; aggressive treatment with GTR and radiotherapy is recommended.     

Glycated hemoglobin reference limits obtained by high performance liquid chromatography in adults and pregnant women

Pentachlorophenol (PCP) and molybdate have been shown to inhibit the sulfoconjugation of various chemicals in rats and therefore are useful to examine the role of sulfoconjugation on the toxicity of a chemical. PCP inhibits sulfation by competing with substrates for phenol-sulfotransferases, but not hydroxysteroid-sulfotransferases. In contrast, molybdate decreases sulfation by limiting sulfate availability and thereby decreasing the synthesis of 3'-phosphoadenosine 5'-phosphosulfate (PAPS), which is the obligate cosubstrate for sulfation. Therefore, it was of interest to determine whether PCP or molybdate is effective in decreasing the in vivo sulfation of dehydroepiandrosterone (DHEA), which is a substrate for hydroxysteroid-sulfotransferases. PCP (40 micromol/kg ip) or molybdate (7.5 mmol/kg po) was given 45 min and 4 h, respectively, prior to the start of DHEA infusion. The effects of these two sulfation inhibitors on DHEA sulfation were dependent on the rate of DHEA infusion in rats. PCP had different effects on the sulfation of various infusion rates of DHEA in rats. PCP had little effect on the sulfation after the two lowest infusion rates of DHEA (12.5 and 25 mg/kg) and actually increased (233%) DHEA-sulfate serum concentrations with the highest DHEA infusion rate (50 mg/kg). Although molybdate had little affect on the sulfation of the lowest DHEA infusion rate, it significantly decreased (50-85%) DHEA-sulfate serum concentrations with the two higher DHEA infusion rates. These data indicate that molybdate, unlike PCP, decreases the sulfation of DHEA and may be a useful tool to decrease the sulfation of other substrates of hydroxysteroid-sulfotransferases.     

Cutaneous lymphoma with extensive periarticular involvement in a horse

Two months after colic surgery, subcutaneous masses were found on the ventral and lateral portions of the thorax of a 3-year-old Hanoverian-cross filly. Six months later, the filly was admitted for evaluation of severe lameness. Arthrocentesis of the tarsocrural joint yielded clotted sanguineous material; however, unusual multinucleated giant cells were seen. Radiography of the right tarsus revealed soft tissue opacity and degenerative joint disease. The filly was euthanatized to prevent further suffering. At necropsy, multiple soft-tissue masses were located throughout the fascial planes of the tarsi and in the subcutis of the ventral and lateral portions of the thorax. Neoplasms consisted primarily of a large number of mature well-differentiated T lymphocytes. On the basis of these findings, the diagnosis was cutaneous lymphoma with unusual involvement of periarticular tissues. Severe degenerative joint disease in the right tarsus did not appear to be associated with the tumors.     

Ceramides are bound to structural proteins of the human foreskin epidermal cornified cell envelope

An important component of barrier function in human epidermis is contributed by ceramides that are bound by ester linkages to undefined proteins of the cornified cell envelope (CE). In this paper, we have examined the protein targets for the ceramide attachment. By partial saponification of isolated foreskin epidermal CEs followed by limited proteolysis, we have recovered several lipopeptides. Biochemical and mass spectroscopic characterization revealed that all contained near stoichiometric amounts of ceramides of masses ranging from about 690 to 890 atomic mass units, of which six quantitatively major species were common. The array of ceramides was similar to that obtained from pig skin, the composition of which is known, thereby providing strong indirect data for their fatty acid and sphingosine compositions. The recovered peptides accounted for about 20% of the total foreskin CE ceramides. By amino acid sequencing, about 35% of the peptides were derived from ancestral glutamine-glutamate-rich regions of involucrin, an important CE structural protein. Another 18% derived from rod domain sequences of periplakin and envoplakin, which are also known or suspected CE proteins. Other peptides were too short for unequivocal identification. Together, these data indicate that involucrin, envoplakin, periplakin, and possibly other structural proteins serve as substrates for the attachment of ceramides by ester linkages to the CE for barrier function in human epidermis.     

Systemic venous collateral development after the bidirectional cavopulmonary anastomosis. Prevalence and predictors

OBJECTIVES: To determine the prevalence of systemic venous collaterals after the bidirectional cavopulmonary anastomosis and the factors associated with their development. BACKGROUND: Systemic venous collaterals have been found after cavopulmonary anastomosis. Methods. Cardiac catheterization was performed in 103 patients before and after a bidirectional cavopulmonary anastomosis. RESULTS: After surgery, 51 venous collaterals were identified in 32 patients (31%). Collateral development was associated with an abnormal superior vena caval connection (56% incidence vs. 26% with a single right superior vena cava, p = 0.01) and postoperative factors including pulmonary artery distortion (53% incidence vs. 22% without distortion, p = 0.002); increased superior vena caval mean pressure (14 +/- 5 mm Hg versus 11 +/- 4 mm Hg with no collaterals, p = 0.0002); increased pulmonary artery mean pressure (13 +/- 4 mm Hg vs. 11 +/- 4 mm Hg with no collaterals, p = 0.02); lower right atrial mean pressure (5 +/- 2 mm Hg vs. 6 +/- 3 mm Hg with no collaterals, p = 0.04); and increased mean gradient between superior vena cava and right atrium (8 +/- 3 mm Hg vs. 5 +/- 4 mm Hg with no collaterals, p = 0.0002). Using multiple logistic regression, only this last factor was independently associated with collateral development with an odds ratio per 1 mm Hg of 1.33 (95% CI 1.12-1.58, p = 0.001) for their presence. CONCLUSIONS: Systemic venous collaterals occur frequently after a bidirectional cavopulmonary anastomosis and are found postoperatively when a significant pressure gradient occurs between cava and right atrium.     

The predictive value of intraoperative somatosensory evoked potential monitoring: review of 244 procedures

INTRODUCTION: There is some controversy regarding the value of intraoperative neurophysiological monitoring in predicting postoperative neurological deficits. We discuss our experience with the use of intraoperative somatosensory evoked potentials (SSEPs) during surgery of cranial base tumors. METHODS: We retrospectively reviewed all of the procedures that had been performed for the resection of cranial base tumors from July 29, 1993, through March 16, 1995. One hundred ninety-three consecutive patients had undergone a total of 244 procedures. SSEP waveforms were classified as follows: Type I, no change; Type II, change that reverts to baseline; Type III, change that does not revert to baseline; and Type IV, complete flattening of the SSEP waveform without improvement. Two patients had no waveforms from the beginning of the case (Type V) and were excluded from further analysis. New immediate postoperative neurological deficits were recorded. RESULTS: There were 64 male and 129 female patients, with a mean age of 46.6 years. One hundred seventy-seven patients had Type I SSEP waveforms, 13 of whom had postoperative deficits (7%). Fifty-six patients had Type II SSEPs, and nine (16%) of them had postoperative neurological deficits. Six patients had Type III SSEPs, and three had Type IV SSEPs, all of whom (100%) had postoperative deficits. There was a correlation between SSEP type and the results of the postoperative neurological examinations. The positive predictive value is 100%, and the negative predictive value is 90%. Although a change in the waveform that did not revert to baseline (Types III and IV) always predicted a postoperative deficit, a normal waveform did not always rule out postoperative deficits. Pathological abnormality, vessel encasement, vessel narrowing, degree of cavernous sinus involvement, brain stem edema, middle fossa location, final amount of resection, age, and tumor size correlated with a high predictive value of SSEP monitoring on univariate analysis (P < 0.05). None of these variables correlated significantly on multivariate analysis (P > 0.05), although brain stem edema was close (P = 0.0571). CONCLUSION: Intraoperative SSEPs have a high positive predictive value during surgery for cranial base tumors, but they do not detect all postoperative deficits.