Biomedical subjects
Publications and source records attributed to W F Chandler.
The authors present a unique case of an intradural extramedullary ganglioneuroma in the thoracic spine of an adult. Intraspinal ganglioneuromas are rare, benign tumors of sympathetic nervous tissue origin, but exclusively intradural ganglioneuromas have not been reported.
The University of Michigan Medical School was founded in 1847, 30 years after the university itself. The first hospital in Ann Arbor was a 20-bed unit converted from a private house, that admitted only charity patients. The second University Hospital was built in 1925. The Section of Neurosurgery was founded by Dr. Max Peet, who was followed by Drs. Kahn and Schneider as section heads.
This presentation summarizes the use of in situ hybridization in the study of pituitary abnormalities. The basic techniques, technical problems and pitfalls in in interpretation and the application of in situ hybridization are discussed.
To study the relationship between null cell adenomas, oncocytomas and gonadotroph adenomas, we analyzed 32 surgically removed formalin-fixed paraffin-embedded pituitary tumors for the expression of pituitary hormone messenger RNAs (mRNAs) by in situ hybridization (ISH). Most tumors were also analyzed for chromogranin A mRNA. To identify the cell type constituting the tumors and to assess hormone content, all tumors were investigated by histology, transmission electron microscopy and immunohistochemistry. Most null cell adenomas (6/11) and gonadotroph adenomas (9/10) expressed the mRNAs for alpha-subunit of glycoprotein hormones whereas only 2/11 oncocytomas expressed alpha-subunit mRNA. FSH beta and/or LH beta mRNA were present in most null cell and gonadotroph adenomas but only in a few oncocytomas. Prolactin (PRL) mRNA was detected in two null cell tumors and in one gonadotroph adenoma, whereas GH and POMC mRNA were present in one null cell adenoma. Chromogranin A mRNA, which codes for the major secretory granule protein, was present in 25/26 tumors including all tumors that were negative for pituitary hormone mRNAs, indicating adequate preservation of specific mRNA transcripts in the paraffin-embedded sections of tumor cells. These results indicate that null cell adenomas and gonadotroph adenomas are closely related neoplasms and that oncocytomas may represent a functionally defective form of null cell adenoma characterized by mitochondrial abundance, which has retained the capacity to synthesize the major secretory granule protein chromogranin A. Although the cytogenesis of null cell adenomas and oncocytomas is not clear, it can be suggested that these two tumor types are derived from a pluripotential precursor cell that is capable of undergoing multidirectional differentiation and synthesizing various hormones, mainly glycoproteins.
In the course of a study on glioblastoma tissue and cultured cell lines, a glitter drop technique for random sampling was introduced (1). Here, we report the initial description of the details of this procedure and its application to cell counts from explant slides and to determining bromodeoxyuridine (BUdR) labeling indices (LI) in tissues. The method is without bias, easy to perform and takes only a short time. It compares well with three other generally used random sampling procedures.
In the 1950's it was first observed that mammalian cells exposed to the halogenated deoxyuridines were more sensitive to ultraviolet light and radiation than untreated cells. This prompted early clinical trials with bromodeoxyuridine (BUdR) which showed mixed results. More recently, several Phase I studies, while establishing the feasibility of continuous intravenous (IV) infusion of BUdR, have reported significant dose limiting skin and bone marrow toxicities and have questioned the optimal method of BUdR delivery. To exploit the high mitotic activity of malignant gliomas relative to surrounding normal brain tissue, we have developed a permanently implantable infusion pump system for safe, continuous intraarterial (IA) internal carotid BUdR delivery. Since July 1985, 23 patients with malignant brain tumors (18 grade 4, 5 grade 3) have been treated in a Phase I clinical trial using IA BUdR (400-600 mg/m2/day X 8 1/2 weeks) and focal external beam radiotherapy (59.4 Gy at 1.8 Gy/day in 6 1/2 weeks). Following initial biopsy/surgery the infusion pump system was implanted; BUdR infusion began 2 weeks prior to and continued throughout the 6 1/2 week course of radiotherapy. There have been no vascular complications. Side-effects in all patients have included varying degrees of anorexia, fatigue, ipsilateral forehead dermatitis, blepharitis, and conjunctivitis. Myelosuppression requiring dose reduction occurred in one patient. An overall Kaplan-Meier estimated median survival of 20 months has been achieved. As in larger controlled series, histologic grade and age are prognostically significant. We have shown in a Phase I study that IA BUdR radiosensitization is safe, tolerable, may lead to improved survival, and appears to be an efficacious primary treatment of malignant gliomas.
The objective of this study was to determine whether nuclear parameters were associated with prognosis in glioblastoma multiforme. DNA indices, cell cycle parameters, and nuclear population densities were compared with patient survival. Selection criteria included the pathologic diagnosis of a cerebral glioblastoma multiforme, absence of therapy before surgery, and adequate tissue to measure each nuclear parameter studied. Nine cases accrued over a two year period. The amount of DNA per nucleus was quantified in fresh tissue specimens by nuclear-isolation flow cytometry in Vindelov's solution. One particular association was significant when tested by Cox models: The percentage of nuclei with S-phase amounts of nuclear DNA was a significant predictor of decreased survival (regression coefficient = 0.20, p = 0.04). The percentage of nuclei in the G0/G1 peak was marginally associated with longer survival. These data are evidence of an association between nuclei in certain phases of the DNA cell cycle and postoperative survival.
Chromogranin-A-positive pituitary adenomas include glycoprotein hormone-producing adenomas, null cell adenomas, and a few other pituitary adenomas. We studied the effects of GnRH, CRF, dexamethasone, and phorbol 12-myristate 13-acetate on FSH and LH secretion and on FSH beta and chromogranin-A and -B mRNA expression in 10 chromogranin-A-positive adenomas in vitro to analyze the regulation of FSH and chromogranin-A and -B expression in these neoplasms. Most adenomas responded to GnRH stimulation during 7 days in culture with a 2- to 10-fold increase in FSH and LH secretion and a 2- to 7-fold increase in FSH beta mRNA compared to control values. CRF and phorbol 12-myristate 13-acetate also stimulated FSH and LH secretion 2- to 5-fold in five of seven and three of three cases, respectively, during 7 days in culture. Dexamethasone stimulated both FSH and LH secretion in two of three cases as well as FSH beta mRNA in vitro in the one case examined. GnRH treatment consistently produced a 2-fold increase in chromogranin-B mRNA, but not in chromogranin-A mRNA, after 7 days of culture. These results indicate that many chromogranin-A-positive adenomas respond to GnRH and CRF in vitro by increased hormone secretion and that GnRH stimulation leads to increased amounts of FSH beta and chromogranin-B mRNAs. The differential response of chromogranin-A and -B mRNAs after GnRH stimulation indicates that the chromogranin genes are highly regulated in these tumors.
Color Doppler flow ultrasound (US) was used to locate and image intracerebral arteriovenous malformations (AVMs). US was deemed useful in eight of 12 patients who underwent AVM resection. Blood flow in the eight lesions was clearly evident, and major feeding arteries and draining veins, such as the superior sagittal sinus, were identified. Color Doppler flow imaging was used to differentiate adjacent hematoma from AVM in three patients, locate a small (6-mm) AVM deep in the brain in two patients, detect a deep major feeding artery in one patient, detect a residual unresected AVM in one patient, and confirm complete resection in all eight patients.
Acidophilic pituitary adenomas commonly produce growth hormone (GH) or prolactin (PRL), according to studies employing immunohistochemical and ultrastructural methods. To examine this question, in situ hybridization with oligonucleotide probes was done on routinely processed tissues received in the pathology laboratory to analyze for the presence of GH and PRL messenger RNA (mRNA) in 4 normal pituitaries, 10 prolactinomas, and 16 GH-secreting adenomas. Most acidophilic cells in normal pituitaries expressed either GH or PRL hormone and the respective mRNAs, but GH mRNA and PRL hormone were also detected in some of the same cells. Patients with a clinical diagnosis of prolactinoma had cells with only PRL mRNA in their tumors, while most (14 of 16) patients with a clinical diagnosis of acromegaly or gigantism had both GH and PRL mRNAs in their tumors. The GH adenomas varied in these studies. In situ hybridization was helpful in characterizing the adenoma from a patient with acromegaly who had immunoreactive PRL, but no immunoreactive GH in the resected tumor; in situ hybridization analysis revealed mRNAs for both GH and PRL in the same tumor cells. Our findings indicate that pituitary adenomas from patients with acromegaly commonly express PRL mRNA. It is concluded that in situ hybridization provides new information about the clinical biology and the histopathologic classification of pituitary adenomas.
A primate toxicity study was performed to test the hypothesis that BUdR does not increase the likelihood of unilateral or bilateral central nervous system damage secondary to radiation therapy. BUdR, a halogenated pyrimidine analog is incorporated into DNA of dividing cells and sensitizes them to radiation. It is best given unilaterally, intra-arterially by continuous infusion because of its regional advantage (Rd) estimated to be between 11 and 16. Six rhesus monkeys were implanted with a Model 400 Infusaid pump perfusing the right internal carotid artery. Three of the six monkeys received intra-arterial (IA) BUdR infusion plus whole brain external beam radiation (6,000 R over 6 weeks) and three received radiation alone. The two BUdR treated animals completing radiation developed symmetric bilateral high signal aberrations on MRI in the frontal, parietal, and occipital centrum semiovale and corona radiata at nine months. At autopsy, confluent microinfarcts were found to correspond topographically to the MRI abnormalities. In the radiation alone group, two animals had normal MRI and autopsy while the third animal had bilateral MRI high signal aberrations develop sequentially with corresponding microinfarcts at autopsy. These changes were greater in severity than those seen in the BUdR treated animals. We support previous evidence that there is differential intraspecies sensitivity to radiation. We find that BUdR produces no unilateral potentiation of radiation toxicity.
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The reverse hemolytic plaque assay (RHPA) was used to study hormone release from cultured normal and neoplastic human pituitary cells. The RHPA revealed a lower percentage of GH- and PRL-producing cells in normal and neoplastic pituitaries compared to the percentage of these cells revealed by immunocytochemical (ICC) staining for GH and PRL. Normal pituitary tissues as well as some PRL- or GH-producing adenomas contained large numbers of mammosomatotropic (MS) cells when analyzed by RHPA, combined RHPA-ICC, and ultrastructural immunohistochemistry with immunogold labeling. The percentage of GH and PRL cells in normal pituitaries ranged from 37-51% and 30-60%, respectively, by RHPA, while the percentage of MS cells ranged from 29-49%. The percentage of GH and PRL cells in normal pituitaries estimated by ICC ranged from 53-65% and 32-55%, respectively, while the percentage of MS cells estimated with this technique ranged from 26-50%. Double labeling with the immunogold technique detected GH and PRL in the same cells and within the same granules in both normal and neoplastic pituitary cells. These results indicate that MS cells are present in normal human pituitaries as well as in some pituitary adenomas, and in some pituitaries these two hormones are stored within the same secretory granules.
Ten patients with previously untreated acromegaly and invasive pituitary macroadenomas were treated with the long-acting somatostatin analog SMS 201-995 (Sandoz) for 3-30 weeks before transsphenoidal or subfrontal pituitary adenomectomy. Preoperatively, treatment with SMS 201-995 reduced mean 24-h plasma GH concentrations from 8.5-66.7 to below 4.6 micrograms/L in eight patients and by 60-80% in the remaining two patients. Pituitary tumor size decreased 20-54%. Morphologically, the tumors showed decreased total cell, cytoplasmic, and nuclear areas; varying degrees of perivascular fibrosis; and dense granularity. Postoperatively, plasma GH and insulin-like growth factor I concentrations fell into the normal range, and GH dynamics became normal in eight patients. In the remaining two patients mild GH hypersecretion persisted after surgery (mean fasting and random plasma GH, 6.1 and 7.9 micrograms/L), and in one of them GH secretion became normal 1 yr after pituitary irradiation. Thus, preoperative administration of SMS 201-995 consistently induced shrinkage of GH-producing pituitary tumors, and the apparent remission rate was high in the treated patients.
The use of intraoperative color-flow Doppler sonography to image cerebral and spinal arteriovenous malformations (AVM's) and a giant aneurysm is reported in 10 patients. The technique is a useful adjunct in localizing vascular lesions, identifying feeding or draining vessels, and confirming intraoperative surgical excision of AVM's or ligation of giant aneurysms. Imaging of lesions deeper than 4 to 5 cm is, however, limited with the equipment design now commercially available.
Bromodeoxyuridine (BUdR), a nonhypoxic radiosensitizing drug, is a halogenated pyrimidine analog that is incorporated into the deoxyribonucleic acid of dividing cells in a competitive process with thymidine; BUdR also sensitizes these cells to radiation therapy. Neurons and glial cells have a very low mitotic rate. They will not incorporate BUdR and will not be sensitized. Bromodeoxyuridine is best delivered intra-arterially because of its regional advantage, calculated to be between 6 and 16. An 8-week BUdR infusion is delivered before and during radiation therapy through a permanently implanted pump with a catheter placed retrograde into the external carotid artery. Eighteen patients with malignant glioma (15 grade IV, and three grade III) were entered into a Phase I dose-escalation protocol with BUdR dosages ranging from 400 to 600 mg/sq m/day. The maximum dose that can be tolerated appears to be 400 mg/sq m/day for 8 weeks. The 18 patients entered in this study have a median Kaplan-Meier estimated survival time (+/- standard error of the mean) of 22 +/- 5 months with 11 patients still alive. Three patients are alive at 30, 29, and 21 months after diagnosis with no evidence of tumor on computerized tomography. There have been no vascular complications. Side effects in all patients have included anorexia, fatigue, ipsilateral forehead dermatitis, blepharitis, iritis, and nail ridging. Myelosuppression requiring dose reduction occurred in one patient. One patient had a Stevens-Johnson syndrome requiring termination of BUdR. It is concluded that intra-arterial BUdR may improve survival times in patients with malignant gliomas.
Seventeen intraoperative spinal sonographic examinations were performed in 14 patients with intramedullary spinal cord neoplasms. Results of the ultrasound exams were correlated with preoperative imaging studies, surgical findings, and histopathologic analysis of the tumors. Intraoperative spinal sonography accurately localized the intramedullary tumors, often revealing the need for extension of the initial laminectomy. The neoplasms appeared as expansile echogenic masses, with cystic components in over half. Ultrasound was as accurate as preoperative imaging in the evaluation of solid neoplasms, and was superior to computed tomography (CT) and magnetic resonance imaging (MRI) for delineating the cystic components of neoplasms. Intraoperative sonography should be used routinely in all surgical cases of intramedullary spinal cord neoplasms.