Anne Agur

Ki-67 in pituitary neoplasms: a review--part I.

KI-67, A MARKER of cellular proliferation, has been studied extensively in pituitary neoplasia. It is of relevance to various clinicopathological parameters, including tumor subtype, size, invasiveness, and recurrence, as well as patient age and sex. Generally, pituitary tumors behaving aggressively have increased Ki-67 labeling indices. Nonetheless, there is considerable overlap in Ki-67 labeling between noninvasive and invasive adenomas as well as between adenomas and pituitary carcinomas. Not only is there no general agreement regarding the relationship of Ki-67 labeling index and tumor invasiveness, but the same is also true of the association with pituitary tumor size, growth fraction, and recurrence. Whereas a number of studies found conclusive associations of Ki-67 labeling indices with aggressive behavior, size, and/or adenoma subtype, others fail to do so. It is evident that discrepant data regarding tumor behavior in part has its basis in nonuniform study criteria. For example, different investigators use varying criteria of tumor invasion and recurrence. Herein, we review the literature relating Ki-67 expression and various other clinicopathological parameters and conclude that uniform definitions and methods, as well as new markers, are key to improved treatment of pituitary tumors.

Cadaveric and MRI Study of the Musculotendinous Contributions to the Capsule of the Symphysis Pubis

OBJECTIVE The purpose of this article is to define the relations of the symphysis pubis and capsular tissues to the adductor and rectus abdominis soft-tissue attachments on cadaver dissection and correlate with MRI of the anterior pelvis. SUBJECTS AND METHODS Seventeen cadavers (8 males and 9 females; mean age, 80 years) were dissected bilaterally. Rectus abdominis and adductor muscles were traced to the pubis and further attachments to the pubic symphysis were defined. Ten asymptomatic (mean age, 17; age range, 16.5-29 years) male athletes underwent 1.5-T MRI of the anterior pelvis with two surface microcoils (each 42 mm in diameter). An axial T2-weighted turbo spin-echo (TSE) sequence (TR/TE, 2,609/106; voxel size, 0.4 mm) was obtained. Axial and sagittal 3D T1-weighted fast-field echo (FFE) sequences (25/4.9; voxel size, 0.3 mm) were obtained. Sequences were repeated incorporating fat suppression and i.v. gadolinium. The relation of the symphysis pubis, disk, and capsular tissues to the insertions of the rectus abdominis, adductor muscles, and gracilis were independently evaluated by two experienced radiologists blinded to all clinical details. RESULTS In all 17 cadaver specimens, the adductor longus and rectus abdominis attached to the capsule and disk of the symphysis pubis, whereas the adductor brevis had an attachment to the capsule in seven specimens and the gracilis in one. All adductor tendons attached to the pubis. In all 10 athletes, the adductor longus and rectus abdominis bilaterally contributed to the capsular tissues and disk. This was only the case for the adductor brevis in four athletes. No other tendons involved the capsular tissues. CONCLUSION Cadaver and MRI findings show an intimate relationship between the adductor longus; rectus abdominis; and symphyseal cartilage, disk, and capsular tissues.

Three‐dimensional study of the musculotendinous architecture of lumbar multifidus and its functional implications

Lumbar multifidus (LMT) is a key muscle, which provides stability to the lumbar spine, and has been shown to have altered neuromuscular recruitment following acute episodes of low back pain. Architectural parameters are important determinants of function, but have not been well documented for LMT. Therefore, the purpose of this study is to model and quantify the architecture of LMT throughout its volume. Nine male and one female formalin‐embalmed cadaveric specimens (average age 80 ± 11 years) without any evidence of spinal deformity/pathology were used. The musculotendinous components of LMT were serially dissected and digitized. Next, the data were imported into MAYA™ to create a three‐dimensional model of each segment of LMT from which architectural parameters including fiber bundle length (FBL), fiber bundle angle (FBA), and tendon length were quantified. Water displacement was used to determine volume. The data were analyzed using paired t‐tests and ANOVA followed by Tukeys post‐hoc test (P ≤ 0.05). LMT (L1–L4) has three architecturally distinct regions: superficial, intermediate, and deep. Intermediate LMT was absent in all specimens at L5. Mean FBL decreased significantly (P ≤ 0.05) from superficial (5.8 ± 1.6 cm) to deep (2.9 ± 1.1 cm) as did volume (superficial, 5.6 ± 2.3 ml; deep, 0.7 ± 0.3 ml) measured at each region. By contrast, mean FBA increased from superficial to deep. The current study lends further evidence to support the role of different regions within LMT to serve distinct functions particularly to produce movement and/or control stability. Clin. Anat. 21:539–546, 2008.

Implanted user interfaces

We investigate implanted user interfaces that small devices provide when implanted underneath human skin. Such devices always stay with the user, making their implanted user interfaces available at all times. We discuss four core challenges of implanted user interfaces: how to sense input through the skin, how to produce output, how to communicate amongst one another and with external infrastructure, and how to remain powered. We investigate these four challenges in a technical evaluation where we surgically implant study devices into a specimen arm. We find that traditional interfaces do work through skin. We then demonstrate how to deploy a prototype device on participants, using artificial skin to simulate implantation. We close with a discussion of medical considerations of implanted user interfaces, risks and limitations, and project into the future.

Three-dimensional study of pectoralis major muscle and tendon architecture.

A thorough understanding of the normal structural anatomy of the pectoralis major (PM) is of paramount importance in the planning of PM tendon transfers or repairs following traumatic PM tears. However, there is little consensus regarding the complex musculotendinous architecture of the PM in the anatomic or surgical literature. The purpose of this study is to model and quantify the three‐dimensional architecture of the pectoralis muscle and tendon. Eleven formalin embalmed cadaveric specimens were examined: five (2M/3F) were serially dissected, digitized, and modeled in 3D using Autodesk® Maya®; six (4M/2F) were dissected and photographed. The PM tendon consisted of longer anterior and shorter posterior layers that were continuous inferiorly. The muscle belly consisted of an architecturally uniform clavicular head (CH) and a segmented sternal head (SH) with 6–7 segments. The most inferior SH segment in all specimens was found to fold anteriorly forming a trough that cradled the inferior aspect of the adjacent superior segment. No twisting of either the PM muscle or tendon was noted. Within the CH, the fiber bundle lengths (FBL) were found to increase from superior to inferior, whereas the mean FBLs of SH were greatest in segments 3–5 found centrally. The mean lateral pennation angle was greater in the CH (29.4 ± 6.9°) than in the SH (20.6 ± 2.7°). The application of these findings could form the basis of future studies to optimize surgical planning and functional recovery of repair/reconstruction procedures. Clin. Anat. 22:500–508, 2009.

Subacromial morphometric assessment of the clavicle hook plate

BACKGROUND Clavicle hook plates are an effective plate fixation alternative for distal clavicle fractures and severe acromioclavicular joint dislocations. However, post-operative complications associated with the subacromial portion of the hook include acromial osteolysis and subacromial impingement. We examine and quantify the three-dimensional position of the subacromial portion of the hook plate relative to surrounding acromial and subacromial structures in a series of cadaveric shoulders to determine if hook positioning predisposes the shoulder to these noted post-operative complications. MATERIALS AND METHODS Fifteen cadaveric shoulders (seven males, eight females) were implanted with 15- or 18-mm hook plates. Dimensions of the acromion and hook plate were digitised and reconstructed into a three-dimensional model to measure acromion dimensions and distances of the subacromial hook relative to surrounding acromial and subacromial structures. RESULTS Inter-specimen dimensions of the acromion were highly variable. Mean acromion width and thickness were greater in males than in females (p=0.01). The posterior orientation of the subacromial hook varied widely (mean posterior implantation angle=32.5+/-20 degrees, range 0-67 degrees). The hook pierced the subacromial bursa in 13/15 specimens, made contact with the belly of the supraspinatus muscle in 9/15 specimens, and had focal contact at the hook tip with the undersurface of the acromion in 9/15 specimens. CONCLUSIONS The wide range of acromial dimensions leads to a high degree of variability in the positioning of the subacromial hook. The observed frequency of hook contact with surrounding subacromial structures in a static shoulder confirms that the position of the hook portion of the implant can predispose anatomic structures to the post-operative complications of subacromial impingement and bony erosion.

Biomarkers of pituitary neoplasms: a review (Part II).

Several new markers have shown a capacity to predict the clinicopathological behavior of pituitary neoplasms; these markers have shown potential to correlate with tumor subtype and size and patient age and sex. These various markers are involved in a host of cellular functions, including cell-cycle progression, cell proliferation, apoptosis, cell adhesion, and tumor vascularity. In this companion article to our first review of Ki-67 as a marker of pituitary adenomas, we present and analyze the literature regarding matrix metalloproteinases and their inhibitors (tissue inhibitor metalloproteinases), vascular endothelial growth factor, fibroblast growth factor and its receptor, apoptotic markers and p53, as well as cyclooxygenase-2, galectin-3, and pituitary tumor transforming gene. Some of these markers, such as fibroblast growth factor and fibroblast growth factor receptor and matrix metalloproteinases, show particular promise in their ability to identify pituitary tumors that behave in an aggressive manner. We suggest the need for uniform design and application of methods and standardized criteria for the interpretation of results. A uniform approach will establish clinicopathological utility of emerging markers.

Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults

Generalized shoulder pain is a common problem that is difficult to treat and frequently recurrent. The asymptomatic cervical spine must be ruled out as a cause of any shoulder pain, as it can have a similar presentation to an isolated shoulder disorder. Previous studies have shown that lateral cervical glide mobilizations to the asymptomatic cervical spine at C5/6 can affect peripheral pain, but none have examined shoulder pain. A randomized, blinded, placebo-controlled, cross-over trial was used to examine the immediate effects of cervical lateral glide mobilizations on pain intensity and shoulder abduction painful arc in subjects with shoulder pain. Twenty-one subjects received interventions of both cervical mobilization and placebo over two sessions. Pain intensity using a visual analog scale (VAS) and painful arc were assessed prior to and following application of cervical mobilization or placebo intervention. Evaluation of cervical mobilization revealed the shoulder abduction painful arc (12.5 degrees +/-15.6 degrees, p=0.002) and shoulder pain intensity (1.3+/-1.1cm, p<0.001) were significantly decreased. The results of this study suggest that any immediate change in shoulder pain or active shoulder range of motion following cervical mobilizations indicate that treatment directed toward the asymptomatic cervical spine may expedite recovery.

Naming the soft tissue layers of the temporoparietal region: unifying anatomic terminology across surgical disciplines.

BACKGROUND The complexity of temporoparietal anatomy is compounded by inconsistent nomenclature. OBJECTIVE To provide a comprehensive review of the variations in terminology and anatomic descriptions of the temporoparietal soft tissue layers, with the aim of improving learning and communication across surgical disciplines. METHODS MEDLINE (1950–2009) searches were conducted for anatomic studies of the temporoparietal region, and for studies describing temporoparietal anatomy in the context of surgical techniques. RESULTS Sixty-nine articles were included in the review. Naming of the soft tissue layers of the temporoparietal region was inconsistent both within and across surgical disciplines, with several terms utilized for the same layer and occasionally the same term applied to different layers. Studies also varied in their description of the vascular, neural, and soft tissue architecture of the temporoparietal region. CONCLUSION A uniform, descriptive nomenclature is paramount to facilitating surgical education and interpreting future studies. A naming system based on the Terminologica Anatomica is proposed in this review. From superficial to deep, the proposed terms for the soft tissue layers of the temporoparietal region include: temporoparietal fascia, loose areolar tissue plane, superficial leaflet of temporal fascia, fat pad of temporal fascia, deep leaflet of temporal fascia, fat pad deep to temporal fascia, temporalis or temporal muscle, and pericranium.

Investigation of the static and dynamic musculotendinous architecture of supraspinatus

To date, the architecture of supraspinatus (SP) and its relation to joint position has not been investigated. The purpose of this study was to quantify the dynamic architecture of the distinct regions of SP using ultrasound (US). Seventeen subjects (8 M/9 F), mean age 36.4 ± 12.7 years, without tendon pathology were recruited. The SP was scanned in relaxed and contracted states. For the contracted state, SP was scanned with the shoulder actively abducted to 60° and the glenohumeral joint in neutral rotation; 80° external rotation; 80° internal rotation. Fiber bundle length (FBL) and pennation angle (PA) of distinct regions, and muscle thickness were computed. Measurements of the posterior region were limited because of acromion shadowing. Parameters between regions and changes between relaxed and contracted states were analyzed using paired t‐tests and repeated measures ANOVA (P < 0.05). On contraction in the anterior region, mean percentage of FBL shortening ranged between 9% and 21%. However, in the posterior region, shortening of approximately 2% only occurred in two of the three positions; lengthening of approximately 2.5% occurred in internal rotation. For the anterior region, the mean PA increased the least in the externally rotated position, and the mean PA of the middle part was smaller than the deep part for all states. Findings suggest changes in the architecture are not uniform throughout the muscle and joint position may play an important role in force production. The US protocol may serve as an outcome measure of adaptive changes of muscle function following surgery, training, and rehabilitation. Clin. Anat. 23:48–55, 2010.