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Anastomotic leakage represents a devastating post-surgical event with surgeon- and patient-related causes. The early lag phase of healing (day 0–4) is a time of increased vulnerability. The current role of tissue sealants as anastomotic adjuncts remains unclear, with controversial results reported. Platelet-rich plasma provides a reliable source of growth factors supporting wound healing. We aimed to assess the impact of a novel autologous platelet-rich fibrin (PRF) agent (Obsidian-ASG® matrix; GergMed Medizintechnik, Baiern, Germany) on colonic anastomotic healing in a porcine model. Left-sided colonic anastomoses were constructed in 16 pigs with reinforcement using the Obsidian-ASG® matrix in 12 animals. Animals were sacrificed on days 0, 4, 10 and 30, with histologic assessment of the anastomotic line along with evaluation of fibrotic tissue maturation, foreign body reactivity and mucin production. Collagen maturity and immunohistochemical changes of angiogenesis and infiltrating macrophage profiles were determined as well. There was no observable effect in matrix-treated animals on epithelial line thickness, granulation tissue formation, foreign body reactivity or mucosal restitution. Matrix-treated animals showed higher mucin production on day 4 accompanied by a more mature collagen and a greater degree of early angiogenic response with a higher infiltration density of M2 macrophages. Additionally, anastomotic burst pressure in matrix-treated animals was higher on day 0, 4, 10 and 30 (100, 100, 210, 160 vs. 40, 30, 60, 20 mm Hg, respectively). Obsidian-ASG® matrix may have beneficial effects on anastomotic healing by shifting the inflammatory response towards a mature and more stable collagen phenotype in the early phase.

To analyze treatment and survival in a series of resected patients with primary or recurrent retroperitoneal sarcoma (RPS) treated and prospectively followed at a single institution. Between July 1994 and December 2015, 89 patients (36 M, 53 F; mean age 60 years, range 25–79) were evaluated. For the purpose of analysis, complete resection was defined as removal of gross tumor with histologically confirmed clear resection margins. Eighty-three out of the 89 patients (93%), 46 of whom affected by primary RPS, and 37 by recurrent RPS, underwent surgical exploration. Sixty-two had a grossly and microscopically complete resection. Fifty-three out of 83 patients (64%) underwent removal of contiguous intra-abdominal organs. Preoperative mortality was nil and significant preoperative complications occurred in six cases only (7%). High-grade tumor pointed out to be a significant variable for a worse survival in all 83 patients amenable to undergo surgical resection (57% 5 years survival for low grade vs 14% for high grade; P = 0.0004). Among completely resected patients, only histologic grade clearly affected disease-free survival (72% 5 years survival for low grade vs 50% for high grade; P = 0.04), while the role of preoperative blood transfusions (67% 5 years survival for non-transfused patients vs 29% for transfused patients; P = 0.05) has to be evaluated in connection to patient complexity. Histological grade and recurrence are the most valuable prognostic predictors; in this clinical subset, an aggressive surgical approach in both primary and recurrent RPS is associated with a best long-term survival and disease-free survival.

The incidence of non-melanomatous skin cancer (NMSC) increases with age and there are specific considerations regarding management of NMSC for the older patient population. Here we will review current data regarding treatment considerations and options for older patients with NMSC. Hypofractionated regimens and high-dose brachytherapy may be non-surgical treatment options for older patients with NMSC. Other less aggressive strategies such as active surveillance can also be considered in some settings. Management of NMSC in the older patient population requires a thorough assessment of comorbidities, frailty, and life expectancy. Additionally, discussions regarding goals of care and quality of life (QOL) issues are especially important in this population. Older patients with NMSC in particular may benefit from a tailored treatment plan based on current available data rather than a broad application of general treatment guidelines for NMSC.

Previous laboratory studies have shown that angiotensin II is produced locally in the rat internal anal sphincter causing potent contraction. The aim of this first human study was to evaluate the safety and manometric effects of topical application of captopril (an ACE inhibitor) on the resting anal pressure in healthy adult volunteers.Ten volunteers, mean age 32.5 years (range, 19-48 years), underwent anorectal manometric evaluation of the mean anal resting pressure (MRAP) and the length of the high-pressure zone (HPZ) before 20 and 60 min after topical application of captopril (0.28 %) cream. Cardiovascular variables (systolic blood pressure, diastolic blood pressure and pulse) were measured before and for up to 1 h after cream application. Side effects were recorded. Adverse events and patient comfort after the cream application were evaluated within a 24-h period by completing a questionnaire.There was no significant change overall in MRAP following captopril administration, although in half the patients, there were reductions in MRAP after treatment. Half the patients had a reduction in the mean resting HPZ length; however, there was no overall difference between pre- and post-treatment values. There was no effect on basic cardiovascular parameters and no correlation between manometric and cardiovascular variables.Topical application of captopril cream may result in a reduction in MRAP in volunteers without anorectal disease. Its use is associated with minimal side effects. It may be a new potential therapeutic option in the treatment of anal fissure. Further studies are required to determine the optimal concentration, dose and frequency of application.

Between 25 and 80 % of patients undergoing a low or very low anterior resection will suffer postoperatively, from a constellation of symptoms including fecal urgency, frequent bowel movements, bowel fragmentation and incontinence, collectively referred to as the low anterior resection syndrome (LARS). The etiology of LARS is multifactorial with the potential of sphincter injury during anastomosis construction, alterations in anorectal physiology, the development of a pudendal neuropathy, and a lumbar plexopathy with exacerbation of symptoms if there is associated anastomotic sepsis or the use of adjuvant and neoadjuavnt therapies. The symptoms of LARS may be obviated in part by the construction of a neorectal reservoir which may take the form of a colonic J-pouch, a transverse coloplasty, or a side-to-end anastomosis. This review outlines the factors contributing to LARS symptomatology along with the short- and medium-term functional results of comparative trials with the different types of neorectal reconstructions.

The etiology of anal incontinence (AI) is often multifactorial. There is little data on the relationship between the etiology of AI, symptom severity, and the need for surgery. The aim of our study was to investigate this association in a large number of unselected patients with AI referred to a tertiary specialist coloproctological practice. Patients with AI seen at our unit between 1983 and 2008 were analyzed. The main etiologies were categorized as congenital, traumatic, neurologic, idiopathic, post-operative, post-obstetric, secondary to rectal prolapse, or inflammatory bowel disease. The severity of AI was graded using the validated Pescatori incontinence scale. Overall, 1,046 patients were studied. The AI score was higher in patients with congenital (4.7 ± 1.1), traumatic (4.6 ± 1.4), and neurological (4.4 ± 1.2) incontinence. Surgical treatment was indicated in 214 cases (20.5%). Patients with AI related to trauma and congenital anomalies required surgery in 43.5 and 31.4% of cases, respectively, a percentage significantly higher than that for patients with other etiologies (P = 0.002). Prolapse-related AI usually responded to correction of the prolapse. Patients with congenital, traumatic, and neurological AI tend to have greater symptom severity. Traumatic, rectal prolapse-related, and congenital AI cases more often require surgery.

Although the Hinchey scoring system has guided surgical decision making for perforated diverticulitis, what constitutes optimal surgical management is controversial. We report our experience of selective primary closure of the perforation without use of a transverse colostomy and the specific circumstances in which this may be safe.All cases of perforated diverticular disease of the sigmoid colon with Hinchey grade IV (faecal) peritonitis seen over a 4-year period from one surgical unit were reviewed.Primary closure without a diverting stoma was performed in six of the eight patients studied since the bowel was deemed healthy, and resection and primary end-to-end anastomosis were performed in the other two patients because there was associated scarring and stricture formation distally. In the primary closure patients, the site of the perforation was dissected and closed with attendant omentoplasty and a meticulous peritoneal toilet. In one of these cases, a diverting stoma was later fashioned after the patient developed a short-lived faecal fistula.The status of the underlying bowel, not the degree of peritoneal soiling, is the most significant consideration in defining the role of minimally invasive surgical treatment options for perforated diverticulitis. A new classification system that remains to be validated, taking into account the degree of colonic scarring and stricture formation, is proposed as a guide for surgical decision making in patients with perforated left-sided diverticulitis with faecal peritonitis.

The purpose of the study was the measurement of the anal cushion area using static transperineal ultrasound in a group of patients with symptomatic grade III and IV haemorrhoids about to undergo haemorrhoidectomy and compare them with a group of age-matched normals and the measured area following haemorrhoidectomy. Transperineal sonography was performed using a linear transducer measuring the anal cushion area by subtracting the measured luminal diameter of the undisturbed anal canal from the inner border of the internal anal sphincter. Measures were made 6 weeks following haemorrhoidectomy. Comparisons were made between 22 normals and 36 patients with haemorrhoids (31 evaluable post-operatively). The median area of normals was 0.78 cm2, that of pre-operative patients 2.25 cm2 and that of post-operative cases 1.20 cm2. There was a significant difference between pre- and post-operative cases with cushion areas of normal patients being significantly lower than post-operative cases. Variance of measurement in all 3 groups was negligible. Static transperineal sonography measuring the anal cushion area is reproducible and shows marked differences between normals and patients with symptomatic haemorrhoids. There is a marked effect on measured area resultant from haemorrhoidectomy.

Der zu fruhe Tod von Professor Ahmed Shafik veranlasste die Autoren, eine Analyse seiner veroffentlichten Arbeiten zur Anatomie und Physiologie des Anorektums vorzunehmen und dabei seine Daten mit den aktuellen bildgebenden und physiologischen Untersuchungen abzugleichen. Alle bei PubMed katalogisierten verfugbaren Arbeiten, das Anorektum betreffend, wurden gesichtet und beurteilt. Die anatomischen Daten wurden mit historischen Darstellungen und aktuellen Bildgebungsmethoden verglichen. Die ursprungliche „Triple Loop“-Theorie der anatomischen Beschaffenheit des externen analen Sphinkters wurde durch koronare und koronar rekonstruierte Abbildungen bestatigt. Es gibt einen Unterschied zwischen den Beschreibungen von Shafik und anderen Autoren hinsichtlich der Anatomie des Langsmuskels und dessen Bedeutung bei der Definition perianaler Raume, die eine wichtige Rolle bei der Ausbreitung perirektaler Entzundungen und bei intersphinktaren rektalen Praparationen spielen. Die aktuelle dynamische Defakographie wurde eine komplexere Levatorfunktion beim Pressen und Kneifen nahelegen, als ursprunglich von Shafik angenommen wurde, der die Funktion des Levatormuskels in einer primaren Entleerungsrolle sah. Die Arbeiten von Professor Shafik waren grundlegend fur unser heutiges Verstandnis des externen analen Sphinkters sowie der Funktion des Levatormuskels wahrend der Defakation. Weitere Studien sollten die anatomischen und physiologischen Unterschiede unter Einsatz neuer Gesundheitstechnologie und in spezifischen Krankheitsstadien untersuchen.

The life and times of the coloproctologist David Henry Goodsall (1843-1906) is presented outlining his contribution to surgery in general and to the field of colorectal surgery, in particular giving a reassessment of his well-known rule regarding anal fistulae.

Following the untimely death of Professor Ahmed Shafik, the authors decided to analyse his published work on the anatomy and physiology of the anorectal area, reconciling this body of data with current imaging and physiological techniques. All available papers as indexed by PubMed pertaining to the anorectal area were obtained and reviewed. The anatomical data was compared with historical representations and current new imaging modalities. The original 'triple-loop' theory of the anatomical disposition of the external anal sphincter has been confirmed by coronal and coronally reconstructed imaging modalities. There is variance between the Shafik and other descriptions of the anatomy of the longitudinal muscle and its importance in the definition of perianal spaces which are important in the spread of perirectal sepsis and in intersphincteric rectal dissection. Current dynamic defaecography would suggest a more complex levator plate function in squeeze and straining than that originally suggested by Shafik as a primary defaecatory role for the levator muscle. The body of work by Professor Shafik has reorganized our understanding of the external anal sphincter and the function of the levator during defaecation. Future studies should assess anatomical and physiological variances using new technology in health and in specific disease states.

Separation of the mesoderm-derived muscular structures and the endoderm-derived structures of the hindgut and reclassification of their involvement based on their embryological origin may be of clinical importance in providing anatomical support for a more standardized perineal resection during abdominoperineal resection. The aim of this study was to utilize magnetic resonance images and histological studies of fetal and neonatal specimens to redefine the T3/T4 distinction by reassessment of the intersphincteric plane and the pelvic diaphragm as they pertain to cancer infiltration and as part of the embryological development of the pelvic floor muscles and their connective tissue compartments.Pelvic floor anatomy was studied in seven newborn children and 120 embryos and fetuses. Anatomical data were completed by magnetic resonance imaging in 82 patients with T3 and T4 rectal cancers (64 T3, 18 T4; 35 women and 47 men) undergoing neoadjuvant chemoradiation for locally advanced (T3 or T4) rectal cancers.Clear demarcation between mesodermal and endodermal structures of the pelvic floor, which is equally evident in plastinated sections and magnetic resonance images, is already visible in early fetal stages. There is a constitutive overlap between the endoderm- and the ectoderm-derived components of the pelvic floor.Our data suggest that the current classification of rectal cancer staging is confusing, where the routinely used TNM classification system unnecessarily differentiates between embryologically identical muscular structures. Tumor spread along the musculature of the hindgut beyond the dentate line could possibly explain the occasional involvement of lymph nodes outside the conventional mesorectum.

Accurate delineation of anal fistula anatomy in recurrent cases will assist in surgical fistula eradication whilst preserving continence. Recently, transperineal ultrasonography (TPUS) has been used in perirectal inflammation where there may be advantage over endoanal ultrasonography (EAUS) in complex fistulae- in-ano which lie outside the focal range of the endoanal probe. We assessed the sensitivity of these two imaging modalities to characterize fistula-in-ano, compared to surgical findings.Hand-held 7.5 MHz TPUS was performed in the axial and sagittal planes in never-operated (Group 1, n=10) and recurrent (Group 2, n=10) cryptogenic fistulae where the ultrasonographer was blinded to the initial operative findings. This was compared with hydrogen peroxide-enhanced EAUS using a 7.5 MHz rotating probe, assessing the fistula anatomy, site of the internal opening, confirmation of Goodsall's rule and the presence of secondary tracks, abscess collections and significant horsehoeing of the track.Overall sensitivity for the detection of trans-sphincteric and extrasphincteric fistulae was 100% using both techniques with a 90% sensitivity for TPUS and an 85% sensitivity for EAUS in the prediction of the internal fistula opening site. The TPUS sensitivity for horseshoeing was poor (28.6%) as was the detection of ancillary abscesses confirmed at surgery (63.6%) but TPUS demonstrated rectovaginal fistulae.TPUS is a novel technique for use in perirectal infection which has a significant learning curve but which is highly accurate for prediction of the anatomy of complex recurrent as well as simple anal fistulae.

Staple line hemorrhage and leak are the 2 most dreaded complications of laparoscopyassisted resection of colorectal cancer (LARCC). Recently, anastomotic staple lines have been reinforced with a range of absorbable and non-absorbable bioprosthetic reinforcement materials. This pilot prospective study used the bioabsorbable Seamguard (BSG; WL GoreAssociates, Flagstaff, AZ) for routine reinforcement of the mesenteric vascular staple transection to prevent mesenteric hemorrhage and to assess its safety and feasibility in a consecutive series of laparoscopic colonic resections.Twenty-five patients consecutively scheduled to undergo LARCC were enrolled in the study. All operations were performed with a standard LARCC technique which included loading of the BSG sleeves onto the jaws of the cutter/stapler.There were 23 wholly LARCC cases and 2 open conversions. BSG was used in all 25 patients. No patient experienced staple-line bleeding or other complications during the surgical procedure. The mean number of staple-line reinforcement sleeves used was 2.6 (range, 2-4). The mean operative time was 118 minutes (range, 65-184 minutes). Additional measures to achieve hemostasis were not required in any case. The mean cost was US 475.20 dollars for the procedure.This small pilot study has shown the routine use of BSG mesenteric staple line reinforcement to be safe, quick and effective during LARCC.

The use of specialized imaging to assess cryptogenic fistula-in-ano is selective, aimed at delineation of the site of the internal fistula opening and the relationship of the primary and secondary tracks and collections to the main levator plate. Advanced imaging also permits definition of the destructive effects of perirectal sepsis (e.g. internal or external anal sphincter damage, perineal body destruction and an ano- or rectovaginal fistula), which may require secondary reconstructive surgery.We performed a PubMed search of outcomes for fistula management in the English and non-English literature, and summarized results regarding the accuracy of internal opening and horseshoe detection as well as the operative correlation for cryptogenic and non-cryptogenic fistula-in-ano using endoanal ultrasound (EAUS) and magnetic resonance (MR) imaging. Only literature defining these characteristics was included.The advantages and limitations of the main forms of imaging are discussed in this review with emphasis on EAUS and endoanal or pelvic phased-array MR fistulography. The new technique of transperineal sonography is highlighted. A small but important group of patients with complex fistula-in-ano require specialized imaging. There are specific limitations of endoanal ultrasound (EAUS) which necessitate pelvic phased-array MR imaging. Initial work suggests that EAUS may have a role in intraoperative use for image-guided drainage of recurrent abscesses where operative interpretation can be difficult. The coloproctologist in a tertiary referral center must acquire the skills of ultrasound performance in order to successfully treat fistulous disease, suggesting a role for formal imaging accreditation as part of coloproctological training.Future studies should determine both what sequential imaging algorithms for imaging are cost-effective as well as predictive of fistula cure.

Birt-Hogg-Dubé syndrome (BHD) is a rare, inherited genodermatosis characterized by hair follicle hamartomas, kidney tumors and spontaneous pneumothorax. The BHD locus was mapped to chromosome 17p11.2 by linkage analysis, and germline mutations in a novel gene (BHD) were identified in a panel of BHD families. Using RNA interference to decrease expression of the Drosophila BHD homolog (DBHD), we have demonstrated that DBHD is required for male germline stem cell (GSC) maintenance in the fly testis. Reduction of DBHD gene activity suppresses the GSC overproliferation phenotype associated with overexpression of either unpaired (upd) or decapentaplegic (dpp). Further genetic interaction experiments suggest that DBHD regulates GSC maintenance downstream or in parallel of the JAK/STAT and Dpp signal-transduction pathways. These findings suggest that the BHD protein may regulate tumorigenesis through modulating stem cells in human.

This study reviewed the results of surgery for distal rectal cancer (where the tumour was within 6 cm of the anal verge) following the introduction of total mesorectal excision for rectal cancer in one institution. One hundred and fifty-three patients who had undergone elective curative surgical resection of rectal cancer within 6 cm of the anal verge were included. The demographic, operative and follow-up data were collected retrospectively. Comparisons were made between patients who had different surgical procedures. The overall operative mortality rate was nil, and the morbidity 41%. With a mean follow-up of 37 months (range 5–100 months), local recurrence occurred in 18 of the patients. The 5-year actuarial local recurrence rates for double-stapled anastomosis, low-strength anastomosis and abdominoperineal resection (APR) were 39, 17 and 11% respectively. The local recurrence rate was significantly higher for double-stapled low anterior resection than for the other types of operation (P=0.007). On multivariate analysis type of surgery (P=0.025) and tumour stage (P=0.043), were associated with local recurrence, but only stage was a significant prognosticator of overall survival (P=0.0006). With the practice of total mesorectal excision, APR was still necessary in 40% of patients with rectal cancer within 6 cm of the anal verge. The local recurrence rate was lower in patients treated with APR than in those with double-stapled low anterior resection; however, survival rates were similar in these two groups.

The intestinal epithelium is characterized by rapid cellular turnover with continuous proliferation of multipotential stem cells within Lieberkuhn's crypts, cellular migration along the crypt-villus axis, cellular differentiation, polarization, apical apoptosis, and luminal shedding. These processes are critical for the development and maintenance of normal intestinal epithelial architecture and function and involve complex cell-cell and cell-substratum interactions, which are mediated by epithelial (E)-cadherin and the integrins, respectively. This review outlines the role of E-cadherin and its cytoplasmic binding proteins, the catenins, as well as the interplay with other mucosal adhesion and restitution molecules during physiological processes in the intestinal epithelium mediating embryogenesis, cellular differentiation, cellular migration, and mucosal repair, as well as what is known about the dysregulation of assembly of the E-cadherin-catenin adhesion complex in inflammatory bowel disease.

Defecating proctography has been traditionally used to assess patients with evacuatory dysfunction. More recently, dynamic transperineal ultrasound has been described, defining the interaction between the infralevator viscera and the pelvic floor at rest and during straining. This study compared qualitative diagnosis and quantitative measurement obtained by defecography and dynamic transperineal ultrasonography in patients with evacuatory difficulty.Thirty-three women were examined using both techniques with both examiners blinded to the results of the other method. Quantitative measurement was made of rectocele depth, anorectal angle (at rest and during maximal straining) and anorectal junction position at rest and movement during straining.There was good agreement for the diagnoses of rectocele, rectoanal intususseption, and rectal prolapse. Dynamic transperineal ultrasound was more likely than defecography to make multiple diagnoses or to diagnose an enterocele when a rectocele was present. There was no difference noted between the two techniques for the measurement of anorectal angle at rest, anorectal junction position at rest, or anorectal junction movement during straining. The mean anorectal angle during straining was 123.3+/-4.3 degrees as measured by defecography and 116.4+/-3.3 degrees as measured by dynamic transperineal ultrasound, nearly reaching statistical significance.Dynamic transperineal ultrasound is a simple and accurate technique for assessment of the pelvic floor and soft-tissues in patients with evacuatory dysfunction.

Background: Anal intraepithelial neoplasia (AIN) is a well-described pathological precursor of invasive squamous cell carcinoma which has recently been detected with increasing frequency in immunocompromised patients, particularly those with seropositivity for human immunodeficiency virus (HIV). The epidemiology and natural history of this entity is somewhat unclear, since the overall prevalence in the HIV seronegative population is unknown. Discussion: There is a clear etiological association between AIN and high-risk human papillomavirus (HPV) subtype infection although there is great variability in HPV DNA detection of cytological and histological material in these patients. It appears that there is an antigen-specific hyporesponsiveness by cytotoxic lymphocytes against HPV peptide sequences or recombinant proteins encoded by oncogenic HPV subtypes in these patients, which is dependent upon the stage of their HIV-associated disease. Although the molecular biology of AIN and cervical or vulvar intraepithelial neoplasia are comparable, in AIN there is less significance of tumor suppressor gene mutations, proto-oncogenic growth factor activation, and genomic instability. Conclusion: Current concepts in the epidemiology and etiology of AIN are discussed, as well as its immunological response in the HIV-positive population, drawing parallels where possible between other HPV-related preinvasive disorders, and concluding with a suggested management protocol

This study was performed to evaluate the use of total colonoscopy as the optimal screening test in asymptomatic individuals with a family history of colorectal cancer (CRC).Colonoscopy was performed in 249 asymptomatic individuals who had one or two first-degree relatives (FDRs) with CRC; individuals with three or more FDRs with CRC were excluded.Eighty-six colonic lesions were found in 51 individuals (51 of 249; 20.5%). Among these 51 subjects, 27 had neoplastic polyps (n = 38) and 29 had metaplastic polyps (n = 44). Although no invasive cancer was detected, in 14 individuals the lesions had a high malignancy potential because of their size and histopathology. We did not confirm a statistically significant difference in the incidence of neoplastic polyps according to the number of affected FDRs. Finally, the presence of metaplastic polyps was a very strong indication for the concomitant presence of metaplastic polyps (P.0001).Total colonoscopy is the optimal screening procedure for the examination of asymptomatic individuals with a family history of CRC.

A personal view of the clinical importance and usage of magnetic resonance imaging (MRI) in coloproctology is presented. The real advantage of this modality lies in the assessment of complex recurrent perirectal sepsis. Recent research shows a potential value of dynamic surface MRI in patients with functional disorders of evacuation.

Minor defects in continence following open lateral sphincterotomy are relatively common. This study prospectively assessed 28 patients undergoing lateral sphincterotomy for chronic anal fissure. There were substantial differences in both resting and squeeze anal pressures and vector volumes in the incontinent cohort when compared to the continent post-operative cases. Mean preoperative high pressure zone was 37.6 mm, significantly higher than the postoperative value of 17.0 mm (p < 0.001). There was a significant difference in percent asymmetry of the anal canal at rest between incontinent and continent post-sphincterotomy cases, with a 6.7% increase in the former group and a 3.1% fall in the latter group (p < 0.001). It is unknown whether these changes are predictive for long-term continence.

To examine the localization of von Hippel–Lindau (VHL) protein in human tissues, we produced four novel monoclonal antibodies against human VHL protein. Western blot analysis revealed that two of these antibodies recognized the epitope in amino acid sequence 60–89 of the VHL protein and the others recognized sequences 54–60 and 189–213. In a wild-type VHL gene-transfected cell line, immunocytochemistry and immunoelectron microscopy demonstrated the intracytoplasmic localization of VHL protein, particularly in mitotic cells. In normal human tissues, VHL protein was detected immunohistochemically in epithelial cells covering the body surface and the alimentary, respiratory, and genitourinary tracts; in secretory epithelial cells of exocrine and endocrine organs; in parenchymal cells of visceral organs; in cardiomyocytes; in neurons in nervous tissue; in lymphocytes in lymphoid tissue; and in macrophages. In pathological specimens, VHL protein was expressed in VHL-related tumor, as well as in endothelial cells, fibroblasts, and pericytes, all of which are involved in active angiogenesis. These findings suggest that these monoclonal antibodies can be useful for various immunological assays and that the VHL protein plays fundamental roles in physiological and pathological situations, especially in neovascularization.

We have isolated the 3' untranslated region (3'UTR) of the human von Hippel-Lindau (VHL) tumor suppressor gene from a P1 phage containing the entire VHL genomic sequence. Several putative noncanonical (ATTAAA) poly(A) signals were identified, and the functional significance of these signals was examined by preparing VHL mammalian expression constructs with this DNA fragment and the previously isolated partial cDNA. Northern blot analysis from transfected renal carcinoma cells showed that both the endogenous and transgene VHL transcripts were the same length. Use of VHL transgene deletion mutants indicated that an ATTAAA sequence located between nucleotide (nt) +4237 and nt +4379 most likely serves as an active poly(A) signal in renal carcinoma cells, yielding a 3.6-kb 3'UTR. This work indicates that, together with the 5'UTR and the coding region, these sequences comprise the full-length human VHL cDNA. Sequence analysis revealed a 300- to 600-bp region conserved in human, murine, and rat VHL UTRs. In addition, the human 3'UTR was extremely rich in Alu repetitive elements.

von Hippel-Lindau (VHL) disease is a dominantly inherited familial cancer syndrome predisposing to retinal, cerebellar and spinal hemangioblastoma, renal cell carcinoma (RCC), pheochromocytoma and pancreatic tumors. Clinically two types of the disease can be distinguished: VHL type 1 (without pheochromocytoma) and VHL type 2 (with pheochromocytoma). We report VHL germline mutations and trends in phenotypic variation in families from central Europe. We identified 28 mutations in 53/65 (81.5%) families with 18 (64%) mutations being unique to this population. Whereas types and distribution of mutations as well as a strong correlation of missense mutations with the VHL 2 phenotype were similar to those identified in other populations, these families have provided new insights into the molecular basis for variability in the VHL 2 phenotype. Seven different missense mutations in exons 1 and 3 varied in their biological consequences from a minimal VHL 2 phenotype with pheochromocytoma only to a full VHL 2 phenotype with RCC and pancreatic lesion. These findings contribute to a better understanding of the fundamental mechanisms of VHL disease and its phenotypic variability. Further, we have provided rapid VHL screening for the families in central Europe, which has resulted in improved diagnosis and clinical management.

Von Hippel-Lindau (VHL) disease is a familial cancer syndrome that has a dominant inherited pattern which predisposes affected individuals to a variety of tumors. The most frequent tumors are hemangioblastomas of the central nervous system and retina, renal cell carcinoma (RCC), and pheochromocytoma. The recent identification and characterization of the VHL gene on human chromosome 3p and mutational analyses confirms the VHL gene functions as a classical tumor suppressor. Not only are mutations in this gene responsible for the VHL syndrome, but mutations are also very frequent in sporadic RCC. VHL expression in human kidney and during embryogenesis, was analyzed by in situ mRNA hybridization with 35S-labeled antisense VHL probes, derived from human and mouse cDNAs, on cryosections of human fetal kidney and paraffin sections of murine embryos. In human fetal kidney, there was enhanced expression of VHL within the epithelial lining of the proximal tubules. During embryogenesis, VHL expression was ubiquitous in all three germ cell layers and their derivatives. Expression occurred in the cerebral cortex, midbrain, cerebellum, retina, spinal cord, and postganglionic cell bodies. All organs of the thoracic and abdominal cavities expressed VHL, but enhanced expression was most apparent in the epithelial components of the lung, kidney, and eye. In human fetal kidney, the enhanced epithelial expression of the VHL gene is consistent with the role of this gene in RCC. There is widespread expression of the VHL gene during embryogenesis, but this is pronounced in areas associated with VHL phenotypes. These findings provide a histological framework for investigating the physiological role of the VHL gene and as basis for further mutational analysis.

Multiple, bilateral renal carcinomas are a frequent occurrence in von Hippel-Lindau (VHL) disease. To elucidate the aetiological role of the VHL gene in human kidney tumorigenesis, localized and advanced tumours from 110 patients with sporadic renal carcinoma were analysed for VHL mutations and loss of heterozygosity (LOH). VHL mutations were identified in 57% of clear cell renal carcinomas analysed and LOH was observed in 98% of those samples. Moreover, VHL was mutated and lost in a renal tumour from a patient with familial renal carcinoma carrying the constitutional translocation, t(3;8)(p14;q24). The identification of VHL mutations in a majority of localized and advanced sporadic renal carcinomas and in a second form of hereditary renal carcinoma indicates that the VHL gene plays a critical part in the origin of this malignancy.

Von Hippel-Lindau disease (VHL) is an inherited multisystem neoplastic disorder. We prepared a 2.5-megabase (Mb) restriction map of the region surrounding the VHL gene and identified and characterized overlapping deletions in three unrelated patients affected with VHL. The smallest nested deletion (100 kb) was located within a 510-kb NruI fragment detected by 19-63'. The rearrangements detected will be useful in isolating and evaluating candidate cDNAs for the VHL gene. The detailed physical map will be useful in studying the organization and structure of genes in the VHL region.