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Prompted by the recently reported expression of POU5F1 (OCT3/4) in epididymis, a panel of markers for carcinoma in situ (CIS) testis and testicular germ cell tumours (TGCT), including AP-2γ(TFAP2C), NANOG, OCT3/4, KIT, placental-like alkaline phosphatase (PLAP), M2A/PDPN and MAGE-A4 were examined by immunohistochemistry or in situ hybridisation in urogenital epithelia, which may interfere with detection of CIS cells in semen. In addition to OCT3/4, the expression of AP-2γ and NANOG or their variants was detected in urogenital epithelia, while other CIS markers, including PLAP/alkaline phosphatase were absent. A combination of immunocytological staining for AP-2γ or OCT3/4 and rapid cytochemical alkaline phosphatase reaction was subsequently developed. This approach was tested in 22 patients with TGCT. In 14 patients (63.6%), double stained cells were found and thus the method was proven suitable for the detection of CIS cells in semen. In conclusion, transcription factors related to pluripotency and undifferentiated state of cells, which most likely have several variants or modifications, are unexpectedly detected using currently available antibodies in urogenital epithelial cells which may be shed into semen. Combining the immunohistochemical nuclear markers with a rapid cytochemical alkaline phosphatase reaction for detection of CIS cells in ejaculates may provide a more reliable diagnostic method.

Genes mutated in congenital malformation syndromes are frequently implicated in oncogenesis, but the causative germline and somatic mutations occur in separate cells at different times of an organism's life. Here we unify these processes to a single cellular event for mutations arising in male germ cells that show a paternal age effect. Screening of 30 spermatocytic seminomas for oncogenic mutations in 17 genes identified 2 mutations in FGFR3 (both 1948A>G, encoding K650E, which causes thanatophoric dysplasia in the germline) and 5 mutations in HRAS. Massively parallel sequencing of sperm DNA showed that levels of the FGFR3 mutation increase with paternal age and that the mutation spectrum at the Lys650 codon is similar to that observed in bladder cancer. Most spermatocytic seminomas show increased immunoreactivity for FGFR3 and/or HRAS. We propose that paternal age-effect mutations activate a common 'selfish' pathway supporting proliferation in the testis, leading to diverse phenotypes in the next generation including fetal lethality, congenital syndromes and cancer predisposition.

Summary Background: Up to 45% of operations with curative intent for non-small-cell lung cancer (NSCLC) can be regarded as futile, apparently because the stage of the disease is more advanced than expected preoperatively. During the past decade several studies have evaluated the usefulness of endoscopic ultrasound guided fine needle aspiration biopsy (EUS-FNA) in lung cancer staging with promising results. However, no randomised trials have been performed, in which a staging strategy with EUS-FNA performed in all patients is compared with a conventional workup. Methods: Before surgery (i.e. mediastinoscopy and subsequent thoracotomy) 104 patients from one hospital were randomly assigned to either a conventional workup (CWU), including EUS-FNA only for selected patients, or a strategy where all patients were offered EUS-FNA (routine EUS-FNA) in addition to CWU. Patients were followed up for a median period of 1.3 years (range 0.2–2.4 years). Thoracotomy was regarded as futile if the patient had an explorative thoracotomy without tumour resection or if a resected patient had recurrent disease or died from lung cancer during follow-up. Analysis was by intention to treat. Results: Fifty-three patients were randomly assigned to routine EUS-FNA and 51 patients to CWU. EUS-FNA was performed in 50 patients (94%) in the routine EUS-FNA group and in 14 patients (27%) in the CWU group. In the routine EUS-FNA group five patients (9%) had a futile thoracotomy, compared with 13 (25%) in the CWU group, p = 0.03. Conclusion: Addition of routine-EUS-FNA to standard workup in routine clinical practice improved selection of surgically curable patients with NSCLC.

Exact mediastinal evaluation of patients with non-small-cell lung cancer (NSCLC) is mandatory to improve selection of resectable and curable patients for surgery. Mediastinoscopy (MS) and endoscopic ultrasound guided fine needle aspiration biopsy (EUS-FNA) are considered complementary, MS covering the anterior- and EUS-FNA the posterior mediastinum. Both methods can reach the paratracheal- and subcarinal-regions, but little is known about which method is most accurate, when compared in patients having both procedures performed. The aim of this study was to assess and compare the diagnostic value of MS and EUS-FNA with regard to mediastinal malignancy in the paratracheal- and subcarinal-regions.Sixty patients considered to be potential candidates for resection of verified or suspected NSCLC underwent MS and EUS-FNA. The EUS-FNA diagnoses were confirmed either by open thoracotomy, MS or clinical follow-up.MS and EUS-FNA were conclusive for paratracheal or subcarinal mediastinal disease in 6 and 24 patients, respectively. Two patients with N2 disease diagnosed by EUS-FNA were upstaged to N3 by MS. The sensitivity for lymph node metastases in the right paratracheal region (2/4R) was 67% for EUS-FNA versus 33% for MS (p=0.69). In the left paratracheal region (2/4L) the sensitivity of EUS-FNA was 80% versus 33% for MS (p=0.06). In the subcarinal region (7) the sensitivity of EUS-FNA was 100% versus 7% for MS (p0.01). The sensitivity for lymph node metastases in region 2/4L and/or 2/4R and/or 7 was 96% for EUS-FNA versus 24% for MS (p0.01).In our hands EUS-FNA was superior to MS in the examination of paratracheal- and subcarinal-regions of patients considered for resection of lung cancer.

Aims: Spermatocytic seminoma is a rare germ cell derived tumour of the testis that occurs mainly in older men. We analysed the expression of recently discovered markers for germ cell differentiation and the mitosis–meiosis transition in order to define the antigen profile for diagnostic purposes and to clarify the biology and histogenesis of spermatocytic seminoma. Methods and results: Twenty-five spermatocytic seminomas were examined for immunohistochemical expression of germ cell-specific onco-fetal antigens and proteins involved in regulation of germ cell division, DNA repair and differentiation. The panel included Chk2, p19INK4d, p53, MAGE-A4, KIT, TRA-1-60, neurone-specific enolase and placental-like alkaline phosphatase. Four of these proteins/antigens have never before been investigated in spermatocytic seminoma. Proteins highly expressed in gonocytes and spermatogonia, such as Chk2, MAGE-A4 and neurone-specific enolase, were consistently present in spermatocytic seminoma. Antigens expressed in embryonic germ cells but not in the normal adult testis, e.g. TRA-1-60, were undetectable, with the exception of p53 protein, which was demonstrated in 80% of cases. A proto-oncogene p19INK4d, which is involved in the transition from mitotic to meiotic division in germ cells, was not detected in spermatocytic seminoma. Conclusions: The investigation provided new information concerning the expression of Chk2, MAGE-A4, neurone-specific enolase and p19INK4d in spermatocytic seminoma. The pattern of expression is highly consistent with the origin of spermatocytic seminoma from a premeiotic germ cell, which has lost embryonic traits and has committed to spermatogenic lineage but has not yet passed the meiotic checkpoint, most probably from the spermatogonium of the adult testis.

Cancer/testis genes are potential targets for therapeutic genetic and immunologic approaches, and are highly expressed in a large variety of human cancers. However, they are not expressed in normal tissues, with the exception of the testis. The NY-ESO-1 gene is the most recently identified member of the cancer/testis family and its product is one of the most immunogenic tumor antigens. We used immunohistochemistry to investigate the expression of NY-ESO-1 in healthy human prenatal and adult testes and in 59 human testicular tumors of different subtypes. We found that NY-ESO-1 was expressed from 18 weeks until birth in human fetal testes. In the adult testis, NY-ESO-1 was strongly expressed in spermatogonia and in primary spermatocytes, but not in post-meiotic cells or in testicular somatic cells. NY-ESO-1 was not expressed in the Sertoli cells, Leydig cells, classical seminomas, or nonseminomatous germ cells in the 59 testicular tumors. In contrast, NY-ESO-1 was expressed both in carcinomas in situ, which are the earliest stage of testicular tumors (7 of 15 cases), and in spermatocytic seminomas, which are believed to be derived from spermatogonia or primary spermatocytes (8 of 16 cases). We conclude that NY-ESO-1 is a marker that can be used to follow the early progression of testicular tumorigenesis when the tumors present a similar pattern of expression to the cells from which they originated, although the later tumors cease to express NY-ESO-1.

Background: A study was undertaken to evaluate the clinical impact of endoscopic ultrasound guided fine needle aspiration biopsy (EUS-FNA) in patients with mediastinal masses suspected of malignancy. Methods: From April 1993 to December 1999, 84 patients were referred for EUS-FNA. In all patients CT scanning had shown a lesion of the mediastinum suspected of malignancy located adjacent to the oesophagus. In order to evaluate the clinical impact of EUS-FNA, the history of each patient up to referral for EUS-FNA was reviewed. A board of thoracic specialists was asked to decide the further course of the patient if EUS-FNA had not been available, and this diagnostic strategy was compared with the actual clinical course after EUS-FNA. Results: For the 79 patients in whom sufficient verification was obtained, EUS-FNA had a sensitivity of 92%, specificity of 100%, PPV of 100%, NPV of 80%, and an accuracy of 94% for cancer of the mediastinum. In 18 of 37 patients (49%) a thoracotomy/thoracoscopy was avoided as a result of EUS-FNA, and in 28 of 41 patients (68%) a mediastinoscopy was avoided. The direct result of the cytological diagnosis obtained by EUS-FNA was that a final diagnosis of small cell lung cancer was made in eight patients resulting in referral for chemotherapy, and in another three patients with benign disease specific treatment could be initiated (sarcoidosis, mediastinal abscess, and leiomyoma of the oesophagus). Conclusions: EUS-FNA is a safe and sensitive minimally invasive method for evaluating patients with a solid lesion of the mediastinum suspected by CT scanning. EUS-FNA has a significant impact on patient management and should be considered for diagnosing the spread of cancer to the mediastinum in patients with lung cancer considered for surgery, as well as for the primary diagnosis of solid lesions located in the mediastinum adjacent to the oesophagus.

RESUMO: O correcto estadiamento do cancro do pulmão é fundamental, não só na determinação do prognóstico mas também na orientação terapêutica.A avaliação da extensão tumoral ao mediastino, por invasão directa ou metastática ganglionar, é um dos passos deste estadiamento. A TAC torácica é falível na detecção de metástases ganglionares, sendo o exame anatomopatológico mais fidedigno. Das várias técnicas de punção e biópsia, o método transbrônquico tornou-se uma rotina em diversos centros, sendo contudo a sua sensibilidade variável (técnica cega).Os autores descrevem um novo método de diagnóstico de lesões sólidas, incluindo gânglios mediastínicos e hilares através de ecografia endoscópica transbrônquica com biópsia aspirativa guiada em tempo real.Onze doentes com idade média de 58 anos foram submetidos a esta técnica: 3 com o diagnóstico de cancro do pulmão e suspeita de metástases ganglionares mediastínicas; 4 com suspeita de recorrência de tumor com metástases ganglionares; 3 com metástases ganglionares mediastínicas e hilares de etiologia desconhecida e um com suspeita de metastização ganglionar de cancro da mama. Todos os doentes tinham previamente efectuado broncofibroscopia que foi inconclusiva.O broncofibroscópio (BFC) ecográfico utilizado foi um protótipo criado pela Olympus, com uma sonda endoscópica na extremidade distal e com um grau de penetração em profundidade de 5 cm e um ângulo de varredura de 50º. Os doentes realizaram o exame sob anestesia geral, com introdução do BFC através de um tubo orotraqueal.A endoscopia foi efectuada em contacto directo com a parede brônquica e, ao localizar a lesão, a agulha de aspiração era introduzida através do canal de trabalho com visualização endoscópica directa da inserção e da biópsia.Quize lesões com dimensões de 7 a 80 mm foram puncionadas, sem registo de complicações, identificandose células malignas em 13 e células benignas em 2 lesões. Com base nestes achados, 8 doentes foram submetidos a quimioterapia, 1 submetido a pneumectomia, 1 a mastectomia e 1 a toracotomia exploradora que revelou carcinoma do esófago inoperável.O novo protótipo de BFC utilizado, além de manter um melhor estadiamento T e N do tumor, consegue em simultâneo realizar endoscopia e biópsia ou punção aspirativa. Com esta técnica conseguiuse o diagnóstico em todos os casos, sempre com repercussão na opção terapêutica e sem necessidade de recorrer a exames mais invasivos. O objectivo deste estudo foi exactamente verificar se este método é exequível, o que foi cumprido, tendo como futura intenção realizálo com anestesia local, para o diagnóstico de lesões sólidas adjacentes aos brônquios e traqueia e estadiamento ganglionar. Os autores referem a necessidade de uma experiência mais alargada e de estudos comparativos com a punção aspirativa transbrônquica convencional e a mediastinoscopia. COMENTÁRIO: A TAC torácica detecta algumas situações que afastam a hipótese de cirurgia curativa no cancro do pulmão, nomeadamente a invasão da artéria pulmonar ou da parede do ventrículo esquerdo, mas não é muito sensível na detecção de pequenas metástases ganglionares que podem tornar o doente inóperavel. A tomografia emissora de positrões (PET) é mais sensível na detecção de metástases, contudo também possui limitações, apresentando 25% de falsos positivos a nível ganglionar mediastínico e 31% nas lesões à distância. A necessidade de obtenção de tecido ganglionar é pois relevante para o diagnóstico, estadiamento e decisão terapêutica.O diagnóstico e estadiamento do cancro do pulmão pode ser difícil de obter por broncofibroscopia. A mediastinoscopia é o exame mais utilizado na obtenção de tecido ganglionar do mediastino, sendo porém um exame invasivo e não isento de riscos. Deste modo, um exame minimamente invasivo na obtenção de biópsias, como a aspiração com agulha transbrônquica (TBNA), tem vindo a ganhar importância, particularmente quando associada a ecografia endoscópica para localização mais precisa das lesões. A TBNA em conjugação com o escovado endobrônquico, o lavado e as biópsias por fórceps, aumenta significativamente o diagnóstico do tumor. A endoscopia endobrônquica só nos últimos anos tem despertado o interesse como meio de localização de lesões sólidas adjacentes à árvore brônquica e gânglios mediastínicos e hilares.Apesar destas vantagens, da sensibilidade e do baixo número de complicações, a TBNA ainda é uma técnica pouco utilizada. Por exemplo, nos Estados Unidos apenas 11,8% dos broncologistas a utilizam no diagnóstico de lesões malignas, sendo portanto necessário um maior investimento e treino nesta área. Este estudo, no fundo, vem reforçar os bons resultados obtidos através da biópsia transbrônquica, especialmente se guiada por ecografia endoscópica, revelando a experiência com um novo protótipo de broncofibroscópio que acopla ecografia e permite visualizar ao vivo as biópsias, não existindo para já nenhum aparelho deste tipo disponível comercialmente. Palavras chave: ecografia endoscópica transbrônquica, biópsia transbrônquica guiada

Testicular spermatocytic seminoma (SS) is a rare tumor type predominantly found in elderly men. It is thought to originate from spermatogonia and shows cytological and genetic heterogeneity. In this study, we performed for the first time a comprehensive analysis of epigenetic modifications in a series of 36 SS samples. We assessed by immunohistochemistry tumor DNA methylation levels, the expression of methyltransferases DNMT3A, DNMT3B and DNMT3L as well as levels of histone modifications H3K9me2, H3K27me3, H3K4me1, H3K4me2/3, H3K9ac, and H2A.Z. We did not identify any epigenetic marks that matched the pattern of the supposed cell-of-origin, the spermatogonia, and found no correlation between specific marks and the size of the SS cells. The emerging epigenetic picture of SS is a heterogeneous "salt-and-pepper"-like pattern, with neighboring cells displaying very variable levels of epigenetic marks. We conclude that SS cells display apparent epigenetic heterogeneity and instability, with loss of the organized manner typical for normal germ cell maturation in the adult testis, likely due to the lack of regulatory signals from the absent somatic cell niche.

Prompted by the recently reported expression of POU5F1 (OCT3/4) in epididymis, a panel of markers for carcinoma in situ (CIS) testis and testicular germ cell tumours (TGCT), including AP-2γ(TFAP2C), NANOG, OCT3/4, KIT, placental-like alkaline phosphatase (PLAP), M2A/PDPN and MAGE-A4 were examined by immunohistochemistry or in situ hybridisation in urogenital epithelia, which may interfere with detection of CIS cells in semen. In addition to OCT3/4, the expression of AP-2γ and NANOG or their variants was detected in urogenital epithelia, while other CIS markers, including PLAP/alkaline phosphatase were absent. A combination of immunocytological staining for AP-2γ or OCT3/4 and rapid cytochemical alkaline phosphatase reaction was subsequently developed. This approach was tested in 22 patients with TGCT. In 14 patients (63.6%), double stained cells were found and thus the method was proven suitable for the detection of CIS cells in semen. In conclusion, transcription factors related to pluripotency and undifferentiated state of cells, which most likely have several variants or modifications, are unexpectedly detected using currently available antibodies in urogenital epithelial cells which may be shed into semen. Combining the immunohistochemical nuclear markers with a rapid cytochemical alkaline phosphatase reaction for detection of CIS cells in ejaculates may provide a more reliable diagnostic method.

Spermatocytic seminoma (SS) is a rare testicular neoplasm that occurs predominantly in older men. In this study, we aimed to shed light on the histogenesis of SS by investigating the developmental expression of protein markers that identify distinct subpopulations of human spermatogonia in the normal adult testis. We analysed the expression pattern of OCT2, SSX2-4, and SAGE1 in 36 SS cases and four intratubular SS (ISS) as well as a series of normal testis samples throughout development. We describe for the first time two different types of SS characterized by OCT2 or SSX2-4 immunoexpression. These findings are consistent with the mutually exclusive antigenic profile of these markers during different stages of testicular development and in the normal adult testis. OCT2 was expressed predominantly in Adark spermatogonia, SSX2-4 was present in Apale and B spermatogonia and leptotene spermatocytes, whilst SAGE1 was exclusively present in a subset of post-pubertal germ cells, most likely B spermatogonia. The presence of OCT2 and SSX2-4 in distinct subsets of germ cells implies that these markers represent germ cells at different maturation stages. Analysis of SAGE1 and SSX2-4 in ISS showed spatial differences suggesting ongoing maturation of germ cells during progression of SS tumourigenesis. We conclude that the expression pattern of OCT2, SSX2-4, and SAGE1 supports the origin of SS from spermatogonia and provides new evidence for heterogeneity of this tumour, potentially linked either to the cellular origin of SS or to partial differentiation during tumour progression, including a hitherto unknown OCT2-positive variant of the tumour likely derived from Adark spermatogonia. Copyright © 2011 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

A new method of endoscopic ultrasound (EUS) guided fine needle aspiration using an ultrasonic endoscope with a curved array transducer mounted in front of the optic lens was developed. As a result of the sector shaped sound field and the direction of the scanning plane it was possible to visualise ultrasonically a needle inserted through the biopsy channel. EUS guided biopsy was performed in 37 patients (with 39 lesions) using three types of needles. Based upon initial testing of several prototype needles a 160 cm long, 0.8 mm diameter needle placed in a Teflon catheter was developed after preliminary results with the first two types were unsatisfactory (positive results for malignancy in 3/11 and 4/8 cases). The third prototype was tested in seven patients with malignant tumours of the upper GI tract. In these patients EUS guided biopsy was positive for malignancy in 7 of 8 solid lesions. Problems related to the technique and criteria for a successful outcome are discussed. The preliminary results show that it is possible to advance a needle into a malignant lesion inside or outside the GI wall during EUS examination and aspirate material for cytologic examination from various lesions. Controlled studies are needed to determine the indications for use and the accuracy of the technique.

In a nationwide cancer registry analysis of second primary malignancies in 6187 men with testicular cancer in the period 1943-1987, 13 sarcomas were found, yielding a 4-fold increase of the relative risk (RR). The majority of sarcomas occurred in men with seminoma, and the increased incidence was seen irrespectively of time since the diagnosis of testicular cancer. The interval between the testicular cancer and the sarcoma varied from 5-34 years. After investigation of the hospital records and re-examination of the histological specimens, 3 patients were excluded. In spite of this, the RR was still considerably increased (at least 3-fold). Seven of the 10 sarcomas were found to be located within the field of the radiation treatment administered and three at the periphery. The absolute number of these secondary sarcomas is low, but the risk of developing such neoplasms and other malignancies should, even so, be kept in mind in the follow-up of testicular cancer patients.

The transcription factor OCT4 plays a crucial role in the earliest differentiation of the mammalian embryo and in self-renewal of embryonic stem cells. However, it remains controversial whether this gene is also expressed in somatic tissues. Here, we use a combi- nation of RT-PCR on whole and microdissected tissues, in situ hybridization, immunohistochemistry and western blotting to show that OCT4 and SOX2 together with downstream targets, UTF1 and REX1/ZFP42, are expressed in the human male urogenital tract. We further support these results by the analysis of DNA methylation of a region in the OCT4 promoter. In culture, human primary epididymal cells formed spheres that continued to express the investigated genes for at least 20 days. Transcriptomic analysis of cultured cells showed up-regulation of CD29, CD44 and CD133 that are normally associated with sphere-forming cancer stem cells. Furthermore, stimulation with retinoic acid resulted in down-regulation of OCT4 expression, however, without multilineage differentiation. Our results show that OCT4 and associated genes are expressed in somatic epithelial cells from the urogenital tract and that these cells can form spheres, a general marker of stem cell behaviour.

Udgivelsesdato: 2009-Jul-2 BACKGROUND: Fast and accurate staging is essential for choosing treatment for non-small-cell lung cancer (NSCLC). The purpose of this randomized study was to evaluate the clinical effect of combined positron-emission tomography and computed tomography (PET-CT) on preoperative staging of NSCLC. METHODS: We randomly assigned patients who were referred for preoperative staging of NSCLC to either conventional staging plus PET-CT or conventional staging alone. Patients were followed until death or for at least 12 months. The primary end point was the number of futile thoracotomies, defined as any one of the following: a thoracotomy with the finding of pathologically confirmed mediastinal lymph-node involvement (stage IIIA [N2]), stage IIIB or stage IV disease, or a benign lung lesion; an exploratory thoracotomy; or a thoracotomy in a patient who had recurrent disease or death from any cause within 1 year after randomization. RESULTS: From January 2002 through February 2007, we randomly assigned 98 patients to the PET-CT group and 91 to the conventional-staging group. Mediastinoscopy was performed in 94% of the patients. After PET-CT, 38 patients were classified as having inoperable NSCLC, and after conventional staging, 18 patients were classified thus. Sixty patients in the PET-CT group and 73 in the conventional-staging group underwent thoracotomy (P=0.004). Among these thoracotomies, 21 in the PET-CT group and 38 in the conventional-staging group were futile (P=0.05). The number of justified thoracotomies and survival were similar in the two groups. CONCLUSIONS: The use of PET-CT for preoperative staging of NSCLC reduced both the total number of thoracotomies and the number of futile thoracotomies but did not affect overall mortality. (ClinicalTrials.gov number, NCT00867412.)

Summary Severe thermal injury induces immunosuppression, involving all parts of the immune system, especially when large fractions of the total body surface area are affected. An animal model was established to characterize the burn-induced immunosuppression. In our novel mouse model a 6% third-degree burn injury was induced in mice with a hot-air blower. The third-degree burn was confirmed histologically. The mice were allocated into five groups: control, shave, burn, infection and burn infection group. At 48 h, a decline in the concentration of peripheral blood leucocytes was observed in the group of mice with burn wound. The reduction was ascribed to the decline in concentration of polymorphonuclear neutrophil leucocytes and monocytes. When infecting the skin with Pseudomonas aeruginosa, a dissemination of bacteria was observed only in the burn wound group. Histological characterization of the skin showed a more polymorphonuclear neutrophil granulocytes (PMNs)-dominated inflammation in the group of mice with infected burn wound compared with the with burn wound group. In contrast, a higher degree of inflammation was observed in the burn wound group compared with the group of mice with infected burn wound. Furthermore, the oxidative burst and the phagocytic capacity of the PMNs were reduced in the group of mice with burn wound. Using this novel mouse model of thermal injury a decline of peripheral leucocytes was observed, whereas the increased local inflammatory response at the site of infection showed reduced capacity to contain and eliminate the infection.

From December 1980 to January 1984, all patients with stage I nonseminomatous testicular cancer in Denmark entered a randomized trial comparing surveillance only with radiotherapy after orchiectomy. One hundred fifty patients were assessable for the final analysis. Relapse occurred in 23 patients in the surveillance group and in 11 patients in the radiotherapy group. Radiotherapy completely prevented retroperitoneal relapse; 14 retroperitoneal relapses occurred in the surveillance-only group. All relapsing patients in the surveillance-only group are without evidence of disease with a median observation time after chemotherapy of 67 months. Two of the patients with relapse in the radiotherapy group died with disease; the others are alive without evidence of disease, with a median observation time after relapse treatment of 72 months. In the surveillance group, four relapses occurred later than 2 years after orchiectomy; only one such late relapse occurred in the radiotherapy group. Four of the retroperitoneal relapses occurred without concomitant increase in the serum marker levels (alpha-fetoprotein [AFP] and human chorionic gonadotropin [HCG]). It is concluded that surveillance only should replace radiotherapy after orchiectomy as standard treatment for clinical stage I nonseminomatous testicular cancer. Improved methods for control of retroperitoneal relapses, especially of embryonal carcinomas, are needed.

BACKGROUND: UTF-1 and REX-1/ZFP42 are transcription factors involved in pluripotency. Because of phenotypic similarities between pluripotent embryonic stem cells and testicular germ cell tumours (TGCT) and the derivation of pluripotent cells from testes, we investigated the expression of UTF-1 and REX-1 during human gonadal development and in TGCT. METHODS: Expression of UTF-1 and REX-1 was studied in 52 specimens from human gonadal development and in 86 samples from TGCT. RESULTS: UTF-1 and REX-1 were expressed throughout male gonadal development. In the mature testis, UTF-1 was expressed in spermatogonia, whereas REX-1 was expressed in meiotic cells and, together with OCT-3/4, in primary oocytes. Both UTF-1 and REX-1 were expressed in testicular carcinoma in situ and in TGCT. Contrarily to REX-1, UTF-1 was expressed in all spermatocytic seminomas. CONCLUSIONS: Unlike other pluripotency markers NANOG and OCT-3/4, UTF-1 and REX-1 are expressed throughout human testes development. The expression pattern indicated that UTF-1 plays a possible role in spermatogonial self-renewal, whereas expression of REX-1 in meiotic cells from both testes and ovary indicate a role in meiosis. UFT-1 and REX-1 are expressed in TGCT and the high abundance of UTF-1 in spermatocytic seminomas is consistent with the hypothesis that this tumour type originates from spermatogonia.

Background and study aims It would be desirable to develop minimally invasive methods of tissue diagnosis from lymph nodes as well as solid lesions in the mediastinum. The aim of the present study was to test the combined method of transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the evaluation of mediastinal lesions. Patients and methods EUS-FNA and EBUS-TBNA were compared in 33 patients, for the staging of lung cancer in patients with an established diagnosis of non-small-cell lung cancer (n = 20) or for diagnosis of a suspicious mediastinal lesion in patients with suspected lung cancer (n = 13). EBUS-TBNA and EUS-FNA were unsuccessful in one patient each. The diagnoses were verified in 28 of the remaining 31 patients either at thoracotomy (n = 9) or during the clinical follow-up (n = 19). Results A total of 119 lesions were sampled by EUS-FNA (n = 59) and EBUS-TBNA (n = 60). EUS-FNA and EBUS-TBNA demonstrated cancer in 26 and 28 lesions, respectively, and benign cytology in 30 and 28 lesions, respectively. Suspicious cells were found in three and four lesions by EUS-FNA and EBUS-TBNA, respectively. When the 60 EBUS-TBNA samples were compared with the 59 EUS-FNA samples, 11 additional cancer diagnoses and three samples with suspicious cells were obtained by EBUS-TBNA that had not been obtained by EUS-FNA. Conversely, EUS-FNA diagnosed 12 additional cancer diagnoses, one suspicious and one specific benign diagnosis (sarcoidosis) in addition to EBUS-TBNA. With a combined approach (EUS-FNA + EBUS-TBNA) in 28 of the 31 patients in whom a final diagnosis was obtained in the evaluation of mediastinal cancer, 20 patients were found to have mediastinal involvement, whereas no mediastinal metastases were found in eight patients. The accuracy of EUS-FNA and EBUS-TBNA, in combination, for the diagnosis of mediastinal cancer was 100 % (95 % CI, 83 - 100 %). Conclusions EUS-FNA and EBUS-TBNA appear to be complementary methods. A combined approach with both EUS-FNA and EBUS-TBNA may be able to replace more invasive methods for evaluating lung cancer patients with suspected hilar or mediastinal metastases, as well as for evaluating unclear mediastinal or hilar lesions.

Background: The aim of the present study was to gain experience with a new method of endoscopic transbronchial ultrasonography with direct, real time guided fine needle aspiration biopsy (EBUS-FNA). Methods: EBUS-FNA was performed in 11 patients. Selection of the patients for EBUS-FNA was based on computed tomographic (CT) scanning in 10 patients and on positron emission tomography in one. The ultrasonic bronchoscope used was a prototype with an outer diameter of 6.9 mm. The instrument has a small curved array transducer located in front of a 30° oblique forward viewing optic lens and a biopsy channel of 2 mm. The procedures were performed under general anaesthesia. EBUS-FNA was performed by direct transducer contact with the trachea or main bronchi with a prototype 22 gauge needle. Results: A total of 15 lesions were punctured. No complications were experienced. Four lesions were targeted in region 10L, four in region 10R, one in region 4L, three in region 4R, one in region 1, one in region 7, and one in region 2R. The size of the lesions ranged from 7 mm to 80 mm. EBUS-FNA identified malignant cells in 13 lesions and benign cells in two. Conclusions: EBUS-FNA is a promising technique for lymph node staging of lung cancer as well as for the primary diagnosis of solid lesions located adjacent to the trachea and main bronchi and not accessible by other methods apart from surgical intervention.

Spermatocytic seminoma is a rare germ cell derived tumour of the testis that occurs mainly in older men. We analysed the expression of recently discovered markers for germ cell differentiation and the mitosis-meiosis transition in order to define the antigen profile for diagnostic purposes and to clarify the biology and histogenesis of spermatocytic seminoma.Twenty-five spermatocytic seminomas were examined for immunohistochemical expression of germ cell-specific onco-fetal antigens and proteins involved in regulation of germ cell division, DNA repair and differentiation. The panel included Chk2, p19INK4d, p53, MAGE-A4, KIT, TRA-1-60, neurone-specific enolase and placental-like alkaline phosphatase. Four of these proteins/antigens have never before been investigated in spermatocytic seminoma. Proteins highly expressed in gonocytes and spermatogonia, such as Chk2, MAGE-A4 and neurone-specific enolase, were consistently present in spermatocytic seminoma. Antigens expressed in embryonic germ cells but not in the normal adult testis, e.g. TRA-1-60, were undetectable, with the exception of p53 protein, which was demonstrated in 80% of cases. A proto-oncogene p19INK4d, which is involved in the transition from mitotic to meiotic division in germ cells, was not detected in spermatocytic seminoma.The investigation provided new information concerning the expression of Chk2, MAGE-A4, neurone-specific enolase and p19INK4d in spermatocytic seminoma. The pattern of expression is highly consistent with the origin of spermatocytic seminoma from a premeiotic germ cell, which has lost embryonic traits and has committed to spermatogenic lineage but has not yet passed the meiotic checkpoint, most probably from the spermatogonium of the adult testis.

A comparative morphological analysis of parenchyma adjacent to testicular germ cell tumours (TGCT) was performed in a series of 181 orchidectomy specimens: 86 with seminomas (Se), 72 with nonseminomatous germ cell tumours (NS) and 23 with combined tumours (CT, which have a Se and a NS component). The following morphological features were semiquantitatively scored: spermatogenesis (modified Johnsen score); amount of tubular atrophy; amount of carcinoma in situ (CIS); amount of intertubular tissue. Absence and presence was scored for the following features: lymphocytic infiltrate surrounding and invading CIS; intratubular seminoma (ISe); intratubular nonseminoma (INS); microlithiasis; diffuse and nodular hyperplasia of Leydig cells; angioinvasiveness; testicular angiopathy. Using non-parametric statistics these features were correlated with each other and with tumour type, tumour size and age of the patient. Se-patients presented at significantly higher age than NS-patients (36 vs 29 years, p=0.001). The age of patients with CT (32 years) was in between that of Se- and NS-patients. No correlation was found between patient age and tumour size. Parenchyma adjacent to Se, compared to parenchyma adjacent to NS had the following significant differences: a lower Johnsen score (5.6 vs 7.2, p=0.005); less frequent (85% vs 97% of specimens, p=0.016) and a lesser amount of CIS (26% vs 32% of tubules, p=0.015); more frequent peri- (80% vs 60% of specimens, p=0.001) and intratubular (68% vs 30% of specimens, p=0.001) lymphocytic infiltrates; more extensive tubular atrophy (36% vs 15% of tubules, p=0.001); and a larger area of intertubular tissue (42% vs 34% of parenchyma area, p=0.016). The pooled Se and CT had a significantly higher frequency of ISe than the NS (31% vs 17% of specimens, p=0.036). With one exception INS was only found adjacent to NS or CT, with a frequency of 16%, and 20% of the specimens, respectively. It was significantly associated with angio-invasiveness. In specimens lacking angio-invasion the frequency of INS was 6%. The correlation of INS with tumour size and patient age was studied in a series of 145 NS and CT (95 from the original series supplemented by 50 newer cases). In this series INS was significantly associated with smaller tumours and younger patients. Extensive tubular atrophy was significantly correlated with higher age, the diagnosis of Se, a low Johnsen score, and the presence of angiopathy. The more tubular atrophy, the less CIS (both in incidence and amount). Inversely, a higher Johnsen score is associated with smaller tumours, the diagnosis of NS or CT, a higher incidence and a larger amount of CIS, and little tubular atrophy. Tubules with mature spermatogenesis were found in 42% of the specimens regardless of tumour type. We conclude that ISe and INS are probably frequent intermediate stages between CIS and Se and NS, respectively. The features of parenchyma adjacent to Se are probably due to the host response elicited by the invasive Se, which secondarily also affects CIS. The long time to clinical presentation allows the host to eradicate most of the CIS by the time the tumour is surgically removed. The much less extensive morphological features of a host response in parenchyma adjacent to NS support the contention that NS originates as INS, behind the blood/testis barrier, without exposure of the host to tumour cells with a seminomatous phenotype (CIS- or Se cells). Microlithiasis and testicular angiopathy are frequent, but not specific findings in parenchyma next to TGCT. Their relationship with the development with TGCT is unexplained.

Serum lactate dehydrogenase isoenzyme I catalytic concentration (S-LD-1) was measured in patients with testicular seminoma clinical stage I followed with surveillance after orchiectomy. The serum samples were obtained before orchiectomy in 110 patients (group A) and soon after orchiectomy in 55 patients (group B). In group A, 60 patients (55%) had elevated S-LD-1 and 10 patients (9%) had elevated serum human chorionic gonadotropin concentrations (S-hCG). In group B, median S-LD-1 was lower than that of group A and decreased with increasing time after orchiectomv (p = 0.001, Jonckheere-Terpstra test, one-sided). After a median follow-up of 5.1 years, 23 patients (21%) in group A had relapses. The patients with elevated S-LD-1 and those with normal S-LD-1 had a similar relapse-free survival (p = 0.79, log-rank test). Thus patients with seminoma stage I had elevated S-LD-1 more often than elevated S-hCG but an elevation in S-LD-1 did not predict a relapse during follow-up with surveillance. Further studies are required to elucidate the value of S-LD-1 in monitoring the surveillance of patients with seminoma stage I.

Microinvasive testicular germ cell tumour (GCT) is defined as invasion of the interstitium by malignant germ cells without palpable tumour formation [1]. Microinvasive GCTs can also accompany overt tumours.

The use of surveillance in patients with stage I testicular germ cell tumours is increasing internationally. The aim of this study was to elucidate pathological and clinical aspects of serum lactate dehydrogenase isoenzyme 1 catalytic concentration in this setting.

As EUS-FNA is an interventional procedure and similar to other interventional procedures, there is a potential risk of complications from either the needle puncture itself or endoscopic manipulation. However, if risky procedures are avoided and basic principles are adhered to, EUS-FNA can be regarded as a safe procedure. In our multicenter study (Wiersema 1997*), complications were reported in up to 2% of the cases. Most of these were of a minor nature. Minor bleeding is always seen at the puncture site, but this is limited to a few ml in most cases. Major bleeding requiring surgery has been described in only a few cases. Perforation, mainly due to trying to advance the endoscope through a stenotic tumor may be seen. However, this cannot be regarded as a direct consequence of the biopsy procedure itself. Naturally, one should avoid maneuvering the endoscope with the biopsy needle already introduced, since the exposed part of the metal sheath may injure the gastrointestinal wall.

A rapidly expanding number of studies on EUS-FNA are being published. Most of these studies, however, were performed in specialized centers. Beginners have to overcome several challenges before acceptable diagnostic results can be expected. First, the interpretation of the difficult anatomy as seen with a curved linear array transducer has to be learned before EUS-FNA of different lesions can begin. Second, the biopsy technique has to be adequately mastered before sufficient material can be obtained from a lesion. Third, an experienced cytopathologist should be available for interpretation of the aspirates.

At present, different endoscope models are available for performing EUS-FNA. The beginner is faced with several choices. Most endoscopists will, based on their own experience with conventional endoscopes, believe that a FNA endoscope with an elevator is preferable. The possibility of increasing the angle of the needle into a deeper position seems advantageous, but there are some draw-backs to this, in our experience. First, an elevator incorporated into the endoscope increases the length of the elongated stiff part of the distal end of the endoscope. This results in more difficulty in the maneuvering of the endoscope. Second, the additional force that the elevator exerts on the needle at their point of contact makes back and forth movement of the needle somewhat more difficult. We prefer instruments without elevators. Instead, we prefer echoendoscopes with a biopsy channel that is constructed with a predefined angle at the distal end of the endoscope.

The value of SPECT scanning in diagnosis and growth potential of vestibular schwannoma (VS) was investigated in a series of 29 patients. SPECT demonstrated all tumours0.8 cm3, but had limitations as a diagnostic modality of small intracanalicular tumours, when compared to gadolinium DTPA enhanced MR. SPECT was found to be valuable in determining VS growth potential as it reflects tumour vascularity, which is essential for tumour growth. A high radioactive tracer uptake in the tumour corresponded to high tumour vascularity, indicating a high growth rate and vice versa. It seems that we now have an in vivo functional radiological modality capable of providing data on VS vascularity and determination of growth potential in the individual tumour.

Vestibular schwannoma (VS) growth potentials were studied in an in situ model, in which the cycling cellular fraction was determined immunohistochemically by applying the mouse monoclonal Ki-67 antibody, and the tumor ploidy was estimated by DNA flow cytometry in a consecutive series of 124 VSs. The tumors were classified according to the average number of positively stained nuclei in 10 high-power fields into three groups: 28 highly (10), 33 moderately (5-10) and 63 low proliferating (or = 5). The intratumoral proliferative variation was studied in 10 tumors. Only slight variation in the number of the positively stained nuclei were observed. Six of seven tumors removed because of macroscopically documented growth by computed tomography (CAT) scan were moderately or highly proliferative. Proliferation of VS was correlated to prospectively registered clinical data. A statistically significant relation was found between VS proliferation and the prediagnostic duration of symptoms (p = 0.0001). The proliferative status was unrelated to age, sex, and tumor size. Flow-cytometric determination of DNA index of the 124 tumors revealed 12 tetraploid (DNA index = 2), 110 diploid (DNA) index = 1) and two nondiploid tumors. A statistically significant relation was noted between tumor ploidy and proliferation status expressed by Ki-67 (p = 0.024). The tetraploid tumors showed significantly lower proliferation compared with the diploid tumors. Tumor ploidy was statistically unrelated to age, sex, tumor size, and duration of symptoms. The results of this study provide a link between the immunohistochemical, flow cytometric findings, and clinical data, which could probably be relevant in identifying patients at risk for rapid tumor growth and tumor recurrences, because a rapid test for cell proliferation is now available.

Idiopathic pulmonary haemosiderosis (IPH) is a rare disease of unknown aetiology. The clinical and paraclinical findings consist of recurrent haemoptysis, pulmonary infiltrates and iron deficiency anaemia. Examination of sputum or bronchoalveolar lavage fluid obtained at fiberoptic bronchoscopy discloses large numbers of haemosiderin-laden alveolar macrophages. Pulmonary interstitial fibrosis may develop. As pulmonary haemosiderosis can be observed in association with several diseases, IPH is basically a diagnosis made by exclusion of other causes. The treatment consists of immunosuppression with steroids and cytotoxic drugs.

During a 7-year period bronchoalveolar lavage (BAL) was performed as a routine diagnostic procedure at fiberoptic bronchoscopy in 172 consecutive patients with diffuse pulmonary lesions. In 42 patients, BAL was technically insufficient or data were incomplete. These patients were excluded. The remaining 130 patients consisted of 78 men and 52 women with a median age of 43 years (range 19-79); 59 were smokers. They were divided into 6 groups: I. sarcoidosis (n = 77); II. cryptogenic fibrosing alveolitis (n = 16); III. secondary fibrosing alveolitis (n = 7); IV. malignancy (n = 7); V. allergic alveolitis (n = 6); VI. miscellaneous (n = 17). Group VI was not included in the statistical evaluation, which involved only the 113 patients in groups I-V. BAL was performed in a segment of the right middle lobe with 150-200 ml isotonic saline. The return fluid (BALF) was filtered through two layers of cotton gauze, and total and differential cell counts were assessed. Median BALF return volume was 67% (range 35-90). Eighty percent of the procedures were performed by the same operator. Total cell count displayed no significant difference amongst the five diagnostic groups (p = 0.06). Differential cell count displayed differences amongst the groups respecting macrophages (p = 0.002), lymphocytes (p = 0.0004), neutrophils (p = 0.0001) and eosinophils (p = 0.04). Patients with sarcoidosis had a higher percentage of lymphocytes, patients with secondary fibrosis a higher percentage of neutrophils, and patients with cryptogenic fibrosis a higher percentage of eosinophils than the other groups. Malignant cells were observed in BALF in 14.3% of patients with malignant lesions. Among the patients with sarcoidosis, 75% had a lymphocyte-dominated BALF (10%) compared with 31% of the patients with cryptogenic fibrosis, 14% of the patients with secondary fibrosis, and 43% of the patients with malignancy. Dominance of neutrophils (10%) and/or eosinophils (5%) in BALF was observed in cryptogenic and secondary fibrosis. In most patients, BAL cannot provide a definite diagnosis, but may support the clinical suspicion of a specific diagnosis. In clinical practice, BAL seems to be of limited value in the diagnostic evaluation of radiologically detected diffuse, non-infectious pulmonary lesions.

Basaloid proliferations of epidermis overlying dermatofibromas and morphologically resembling superficial basal cell carcinomas might possess a malignant potential. In order to elucidate whether these basaloid proliferations share phenotypic characteristics with malignancy, we examined immunohistochemically 19 cases of dermatofibroma with overlying epidermal basaloid proliferations, 10 dermatofibromas with overlying simple epidermal proliferations, and 10 invasive basal cell carcinomas for expression of p53. Simple and basaloid proliferations showed sparse positive immunostaining for p53, as seen in normal epidermis. No differences in staining pattern or number of positive keratinocytes could be demonstrated between these conditions. The dermatofibromas were negative. The invasive basal cell carcinomas showed abundant p53 positivity. The lack of p53 immunoreactivity in the epidermal basaloid proliferations overlying dermatofibromas indicates that these lesions have not acquired a phenotype as seen in malignant conditions.

In te res t in endoscopic u l t rasonography (EUS) has increased during recent years. Several s tudies have shown tha t the use of h igh-f requency ul trasonic t ransducers bui l t into the t ip of a flexible endoscope makes it possible to depict lesions in and a round the gast ro intes t inal t r ac t accurately. TM However , it is not possible to different ia te be tween mal ignan t and benign lesions using EUS. 512 In an a t t e m p t to solve this problem, a new technique for EUS-gu ided fine-needle aspi ra t ion (FNA) has been developed. T h e aim of this s tudy is to p resen t our experience with EUS-gu ided F N A biopsy of lesions in and around the uppe r gast rointes t inal tract .

Primary lung cancer in young patients is rare, patients under 40 years of age constituting between 1.2 and five percent of all cases. Three cases of primary lung cancer in young patients are presented, and the typical manifestations of primary lung cancer in young patients are discussed.

A case of erythema elevatum diutinum showing an unusual distribution is reported. Hard nodules were located on the patient's fingertips and pulps while the extensor surfaces were not involved. The disease was initially misinterpreted based on both clinical and histologic examination. Dapsone therapy was followed by a remarkable recovery. The clinical and histologic features of erythema elevatum diutinum are summarized.

In a nationwide cancer registry analysis of second primary malignancies in 6187 men with testicular cancer in the period 1943-1987, 13 sarcomas were found, yielding a 4-fold increase of the relative risk (RR). The majority of sarcomas occurred in men with seminoma, and the increased incidence was seen irrespective of time since the diagnosis of testicular cancer. The interval between the testicular cancer and the sarcoma varied from five to 34 years. After investigation of the hospital records and re-examination of the histological specimens, three patients were excluded. In spite of this, the RR was still considerably increased (at least three-fold). Seven of the 10 sarcomas were found to be located within the field of the radiation treatment administered and three at the periphery. The histological type of sarcomas varied, with leiomyosarcoma as the most frequent (three cases), followed by malignant fibrous histiocytoma (two cases) and fibrosarcoma (two cases). Since none of these patients had received chemotherapy and did not harbour sarcomatous components within the primary testis cancer, the sarcomas were probably caused by the radiation treatment. The absolute number of these secondary sarcomas is low, but the risk of developing such neoplasms and other malignancies should, even so, be kept in mind in the follow-up of testicular cancer patients.

Coccidioidomycosis is an acute, generally mild, respiratory disease that rarely becomes chronic or disseminated and fatal. The aetiologic agent is Coccidioides immitis, a dimorphic fungus growing in soil. The fungus is endemic in hot semi-arid areas in the USA and South America. Human beings and animals become infected by inhaling dust with arthroconidia. The fungus gives rise to either a purulent or a granulomatous inflammation or both. Clinically and radiologically, it can be confused with neoplasms and tuberculosis. The disease may be fatal in immuno-deprived persons who are also at risk of reactivation of a latent infection. Coccidioidomycosis can be detected serologically. The standard treatment of severe illness is Amphotericin B. The authors present the first histologically and serologically verified case of pulmonary coccidioidomycosis in Denmark. An increased number of coccidioidomycosis can be expected with increased travelling and an increased number of immuno-deprived persons.

From 1985 to 1988, 261 unselected patients entered a nationwide Danish study of surveillance only for testicular seminoma stage I. The median follow-up time after orchidectomy was 48 months, range 6-67 months. 49 patients relapsed (19%). Sites of relapse were paraaortic lymph nodes in 41 patients, pelvic lymph nodes in 5, inguinal lymph nodes in 2 and lung metastases in 1 patient. The median time to relapse was 14 months, range 2-37 months. The 4-year relapse-free survival was 80%. 37 of the relapsing patients (76%) had radiotherapy as relapse treatment. Of these patients, 4 (11%) had a second relapse and received chemotherapy. 1 died of disseminated seminoma. Of the relapsing patients, 12 (24%) had chemotherapy as relapse treatment because of bulky (11 patients) or disseminated disease (1 patient). None of these patients have had a second relapse. However, 2 patients died of infection due to chemotherapy-induced neutropenia. Thus, there have been three seminoma-related deaths (1.1%). The testicular tumour size had an independent prognostic significance. The 4-year relapse-free survivals were 94, 82 and 64% for tumours3, 3 to6 andor = 6 cm, respectively. Patients with tumoursor = 6 cm will now be given prophylactic radiation treatment, whereas we will continue to use surveillance only after orchidectomy for patients with tumours6 cm.

A fetal testis with abnormal germ cells similar to the cells of intratubular germ cell neoplasia (ITGCN) or so-called carcinoma in situ is presented. Elective abortion was performed in week 18 of the pregnancy of a 26-yr-old woman, because of 21 trisomy (Down's syndrome) at amniocentesis. At microscopical examination abnormal germ cells were found, similar to those occurring in the adult testis and with the same distribution as those described in ITGCN in children with dysgenetic gonads and with androgen insensitivity syndrome. PAS positivity and placental-like alkaline phosphatase (PLAP) was demonstrated in the abnormal germ cells. The finding indicates that the first event of germ cell tumor oncogenesis may take place before birth, in utero or even before. The occurrence of ITGCN in Down's syndrome has not been reported previously but is likely to occur, as there is evidence that these patients have increased risk of developing germ cell tumors.

Pretreatment with haemopoietic cytokines prior to marrow harvest may result in improved quality of bone marrow harvested for autologous bone marrow transplantation (BMT). Such improvements may reduce the risk for graft failure and decrease time to engraftment. Patients undergoing autologous BMT received recombinant human G-CSF (rhG-CSF) immediately prior to marrow harvest. rhG-CSF was administered as daily subcutaneous injections for 5 days at 5 micrograms/kg body weight. Comparison of bone marrow samples before and after rhG-CSF treatment showed an increased bone marrow cellularity and a ninefold increase in the number of marrow leucocytes per volume aspirated. The mean marrow myeloid:erythroid ratio increased from 2.6 to 4.0. The mean numbers of immature (CD38 positive) and proliferating (CD71 positive) myeloid cells increased significantly from 41.6 to 50.8% and from 17.0 to 34.8%, respectively. Other subsets studied, including CD34 positive stem cells, were unchanged. The relative numbers of day 7 and 14 granulocyte-macrophage colony-forming units (day 7/14 GM-CFU) were unchanged. Long-term marrow cultures revealed that the numbers of 'long-term culture initiating cells' were unchanged after rhG-CSF treatment in spite of the ninefold increase in cellularity. To date, five of the patients have been transplanted with autologous marrow harvested after rhG-CSF treatment. Time to trilineage engraftment was unchanged compared with historical controls. We conclude that pretreatment with rhG-CSF prior to marrow harvest may improve the graft by increasing the total number of myeloid lineage restricted progenitor cells, resulting in stable but not accelerated myeloid engraftment of autologous marrow.

This investigation is retrospective and comprises 20 patients with bone-marrow insufficiency. During the period 1.4.1988-1.3.1991, these patients were treated with erythropoietin (Epo), the granulocyte-macrophage-colony-stimulating factor (GM-CSF) or the granulocyte-colony-stimulating factor (G-CSF). Thirteen patients had primary bone-marrow insufficiency: six had the myelodysplastic syndrome, three had primary myelofibrosis, two aplastic anemia and two myelomatosis. On account of dominating symptoms of anemia, five patients received Epo while eight received GM-CSF as part of an extensive clinical trial of this preparation. Seven patients with relapse of the haematological malignant disease had bone-marrow insufficiency and pancytopenia secondary to intensive chemotherapy/irradiation: four of these patients received GM-CSF and two received G-CSF with the object of increasing bone-marrow regeneration and to render further chemotherapy possible. One patient received GM-CSF with the object of improving bone-marrow function after autologous bone-marrow transplantation. Treatment with Epo for ten months combined with treatment with interferon for six months resulted in normalization of the haemoglobin concentration in one patient with bone-marrow insufficiency on account of primary myelofibrosis. Treatment with Epo for briefer periods in lower doses was without effect in four other patients with primary bone-marrow insufficiency. Treatment with GM-CSF and G-CSF resulted in neutrophil leukocytosis in 12 out of 15 patients (80%) and, in six out of 14 patients (43%), increased marrow cellularity was demonstrated by means of histological examination of the bone-marrow. One patient showed normal haemoglobin levels during treatment with GM-CSF.(ABSTRACT TRUNCATED AT 250 WORDS)

Bronchiolo-alveolar carcinoma is usually localized to the terminal bronchioles and alveoli, and may present on chest X-ray as interstitial pulmonary disease with diffuse reticulonodular infiltrates. The cytological diagnosis is often difficult to obtain. This case demonstrates that bronchoalveolar lavage can be useful in the diagnostic evaluation of this type of malignancy, in conjunction with transbronchial lung biopsy.

Gaucher's disease is an autosomal recessive disorder caused by deficiency of the enzyme glucocerebrosidase with accumulation of glucocerebroside in the reticuloendothelial system. Affection of the lungs by this disease is extremely rare. When Gaucher cells infiltrate the lung, fibrosis may result. We describe a case with adult type Gaucher's disease who, besides affection of liver, spleen and bone marrow, had severe pulmonary involvement with extensive interstitial fibrosis, increased pulmonary vascular resistance, and pronounced reduction in diffusion capacity.

The first Scandinavian case of mixed germ cell-sex cord stroma tumour is presented. The tumour occurred in an anatomically and genetically normal young adult woman. The tumour exhibited mainly two histopathological patterns. Larger parts consisted of abundant connective tissue containing cellular nests with numerous germ cells and a few sex cord derivatives. Minor parts showed a tubular pattern composed of tubules of sex cord elements containing scattered germ cells. Immunohistochemical stains for cytokeratin, vimentin, placental alkaline phosphatase and various other substances were all negative. This case is in addition the first reported case where the tumour was bilateral. The second tumour occurred in the contralateral ovary three years after excision of the first one and showed the same histopathological pattern as in the predominant part of the first.