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Biochemical and clinical aspects of the human flavin-containing monooxygenase form 3 (FMO3) related to trimethylaminuria.

Trimethylaminuria is a rare metabolic disorder that is associated with abnormal amounts of the dietary-derived trimethylamine. Excess unmetabolized trimethylamine in the urine, sweat and other body secretions confers a strong, foul body odor that can affect the individual's ability to work or engage in social activities. This review summarizes the biochemical aspects of the condition and the classification of the disorder into: 1) primary genetic form, 2) acquired form, 3) childhood forms, 4) transient form associated with menstruation, 5) precursor overload and 6) disease states. The genetic variability of the flavin-containing monooxygenase (form 3) that is responsible for detoxication and deodoration of trimethylamine is discussed and put in context with other variant forms of the flavin-containing monooxygenase (forms 1-5). The temporal-selective expression of flavin-containing monooxygenase forms 1 and 3 is discussed in terms of an explanation for childhood trimethylaminuria. Information as to whether variants of the flavin-containing monooxygenase form 3 contributes to hypertension and/or other diseases are presented. Discussion is provided outlining recent bioanalytical approaches to quantify urinary trimethylamine and trimethylamine N-oxide and plasma choline as well as data on self-reporting individuals tested for trimethylaminuria. Finally, trimethylaminuria treatment strategies and nutritional support are described including dietary sources of trimethylamine, vitamin supplementation and drug treatment and issues related to trimethylaminuria in pregnancy and lactation are discussed. The remarkable progress in the biochemical, genetic, clinical basis for understanding the trimethylaminuria condition is summarized and points to needs in the treatment of individuals suffering from trimethylaminuria.

Animals↗

[MRI of the brain in the evaluation of children with developmental delay].

PURPOSE: To analyze the diagnostic value of MRI in children with developmental delay. Materials and Methods. From 1991 to 1997, 224 examinations were performed. Retrospective analysis of clinical findings and diagnostic yield was carried out. RESULTS: MRI was abnormal in 109 cases. It never resulted in any patient care modification. 55 malformations, 12 cases of cerebral atrophy, 7 cases of white matter disease and 2 patients with phakomatose were identified. Myelination delay (26 cases), increased signal of posterior white matter on T2-weighted images (9 cases) or widened Virchow-Robin spaces (3 cases) were frequently encountered, but it remained unclear whether they represented normal variants or true abnormalities. Post ischemic lesions were identified in 10 cases. Frequency of abnormal studies was significantly lower in children with developmental delay and behavioral disorders than in patients with other clinical presentation. CONCLUSION: Diagnostic yield of cerebral MRI can justify its performance by comparison to other imaging modalities. It should be correlated with other investigations performed in a specialized unit. Its main interest is for classification and research. Risk of sedation or anesthesia should also be taken in account. Risk can be lowered using adequately equipped MR units and organizing procedures in collaboration with anesthesiologists.

Adolescent↗

Histopathologic variability of the congenital nephrotic syndrome.

Five cases of congenital nephrotic syndrome (CNS) were studied with light microscopic (LM), transmission electron microscopic (TEM) and immunofluorescence microscopic (IFM) techniques. All patients, aged between three weeks and one year, had a nephrotic syndrome (NS) and died soon after the diagnosis. Three patients showed mesangial proliferation, thinning of glomerular basement membranes (GBM) and no deposits by IFM or TEM. They probably represent variants of the Finnish type of CNS. One patient had diffuse sclerosis of the mesangium, irregular and thickened GBMs and electron dense deposits, consistent with the diagnosis of diffuse mesangial sclerosis (DMS). The fifth case also showed changes suggestive of DMS, but was clinically atypical, with an early onset and rapid course. Our findings confirm the morphologic heterogeneity of the CNS and point out the difficulties of classification based on clinical and histological manifestations.

Female↗

Spinal and cutaneous schwannomatosis is a variant form of type 2 neurofibromatosis: a clinical and molecular study.

OBJECTIVE: To delineate the clinical phenotype, molecular basis, and implications for screening in patients and families with multiple schwannomas not generally involving the cranium. METHODS: As part of a United Kingdom clinical and genetic study of type 2 neurofibromatosis (NF2) patients and families with multiple schwannomas who do not fulfil diagnostic criteria for NF2 have been identified. The clinical phenotype was studied in the extended families and molecular analysis was carried out at the NF2 gene locus on chromosome 22. RESULTS: Patterns of inheritance in five families with schwannomatosis are consistent with inheritance of an autosomal dominant gene. The consistency of phenotype, with relative sparing of the cranium, is constant in these families. However, families which initially seem to be indicative of schwannomatosis may develop into classic NF2 as shown by a sixth family. Many of the tumours found in these families were referred to as "neurofibroma" when they were clearly schwannomas. This difference in classification has major implications for the relative risk of each particular type of neurofibromatosis and neuropathological review may be important in some cases. Genetic linkage analysis in the two largest families is entirely consistent with primary involvement of the NF2 gene. CONCLUSIONS: Variant forms of neurofibromatosis have presented a dilemma in classification and determination of recurrence risks in families. Previous reports have suggested that schwannomatosis is a sporadic non-hereditary condition. Patients with multiple schwannomas are likely to have a variant form of NF2 and up to a 50% risk of passing on a gene predisposing to multiple schwannoma.

Adolescent↗

[Coagulopathic hemorrhages in the surgical treatment of cancer patients].

The hemostasis system was examined before surgery, during the principle stages of the intervention, and in the immediate postoperative period in 280 patients with various malignant tumors. The volume of blood loss during the operation varied from 280 to 14,000 ml. The studies demonstrated that blood loss due to traumatic surgical interventions is the principal factor causing the most profound disorders in the hemostasis system leading to the development of grave coagulopathic hemorrhages in cancer patients. Coagulopathic bleedings most frequently develop at a blood loss of more than 3,000 ml and course as variants and stages of the disseminated intravascular coagulation (DIC) syndrome or hemodilution coagulopathy. A massive blood loss was found to be detrimental primarily for the platelet component of the hemostasis system; besides thrombocytopenia, the aggregability of these cells reduced, this being conducive to development of hemorrhages from the small vessels. Laboratory signs of acute DIC syndrome diagnosed during surgery were shown to anticipate its clinical manifestation. A working classification of surgical hemorrhages and rapid methods for their diagnosis have been developed.

Adult↗

[Classification of broncho-pulmonary cancers (WHO 1999)].

Tumour classification systems provide the foundation for tumour diagnosis and patient therapy and a critical basis for epidemiological and clinical studies. This updated classification was developed with the aim to adhere to the principles of reproducibility, clinical significance, and simplicity in order to minimize the number of unclassifiable lesions. Major changes in the revised classification as compared to the previous one (WHO 1981) include the addition of two pre-invasive lesions to squamous dysplasia and carcinoma in situ: atypical adenomatous hyperplasia (AAH) and diffuse idiopathic pulmonary neuroendocrine cell hyperplasia. Another change is the subclassification of adenocarcinoma: the definition of bronchioloalveolar carcinoma has been restricted to non-invasive tumours. There has been substantial evolution of concepts in neuroendocrine lung tumour classification. Large cell neuroendocrine carcinoma (LCNEC) is now recognized as a histologically high-grade non-small cell carcinoma showing histopathological features of neuroendocrine differentiation as well as immunohistochemical neuroendocrine markers. The large cell carcinoma class has been enriched with several variants, including the large cell neuroendocrine carcinoma and the basaloid carcinoma, both of which have a poor prognosis. Finally, a new class has been defined called carcinoma with pleomorphic, sarcomatoid, or sarcomatous elements, which gathers a number of proliferations characterized by a spectrum of epithelial to mesenchymal differentiation. Immunohistochemistry and electron microscopy are invaluable techniques for diagnosis and subclassification, but our intention was to render the classification simple and practical to every surgical laboratory so that most lung tumours can be classified by light microscopic criteria.

Adenocarcinoma↗

[Burkitt's and Burkitt-like lymphoma. Molecular definition and value of the World Health Organisation's diagnostic criteria].

Among aggressive mature B-cell lymphomas, a reproducible morphological and immunohistological distinction between Burkitt's lymphoma and diffuse large B-cell lymphoma (centroblastic variant) is impossible in a substantial number of cases. The German reference centres for hematopathology collected 220 retrospective cases of aggressive mature B-cell lymphoma whose classification according to the current World Health Organisation criteria was reviewed. Gene expression analysis (Affymetrix) was performed in all cases and chromosomal translocations were determined using fluorescence in situ hybridization. Chromosomal losses and gains were analysed by matrix comparative genomic hybridisation and clinical data were successfully collected for most patients. The application of a novel bioinformatics method led to the identification of a stable and reproducible gene expression signature specific for Burkitt's lymphoma. A total of 44 cases were identified by this molecular signature [designated molecular Burkitt's lymphoma (mBL)]. These molecular Burkitt's lymphomas showed the morphology and immunohistology of classical or atypical Burkitt's lymphoma cases in 29 instances. However, 15 of the molecular Burkitt's lymphoma cases had the morphology of diffuse large B-cell lymphoma or could not be further specified. All molecular Burkitt's lymphomas showed an expression of BCL-6 and CD10, but a MYC translocation was not demonstrable in more than 10% of cases. Of significance is that more than 20% of the molecular Burkitt's lymphomas expressed BCL-2, although weakly in most instances. Our data demonstrate that: (1) the morphological, immunophenotypical and genetic spectrum of Burkitt's lymphoma is broader than previously expected, and (2) our molecular Burkitt's lymphoma signature enables a more precise and extended definition this lymphoma.

Burkitt Lymphoma↗

The pathology of low-grade adenosquamous carcinoma of the breast. An immunohistochemical study.

Low-grade adenosquamous carcinoma of the breast is a variant of metaplastic mammary carcinoma characterized by a locally invasive growth pattern and a low risk for metastases. In this study none of the carcinomas exhibited greater than 5 percent nuclear immunoreactivity for estrogen or progesterone receptors, and as a result they were classified as negative for these receptors. Reactivity for cathepsin D was found in 39 percent of the tumors, largely limited to areas of epidermoid differentiation. Membrane immunoreactivity for HER-2/neu oncogenes was present in glandular components of 46 percent of the carcinomas. Immunoreactivity for p53 (greater than 10 percent of nuclei) was present in 13 percent of the tumors, also in glandular elements. Six different patterns of coexpression of p53, HER-2/neu and cathepsin D were found, the most frequent being the following: HER-2/neu(+), p53(-), cathepsin D(-) (9 cases, 39%); cathepsin D(+), p53(-), HER-2/neu(-) (5 cases, 22%); and the three markers negative (5 cases, 22 percent). Coexpression of the two oncogenes was found in only one tumor which was also positive for cathepsin D. These results indicate that the expression of various immunohistochemical prognostic markers may be heterogeneous and that there may not be a specific pattern of marker coexpression within a carefully defined histologic subtype of mammary carcinoma. Furthermore, characteristics reported to be associated with an unfavorable prognosis (negative hormone receptors, presence of cathepsin D, and expression of oncogenes such as HER-2/neu) may be found in a substantial proportion of tumors that comprise this clinically and histologically low-grade variant of mammary carcinoma. This disassociation between expected prognosis based on expression of current prognostic markers and observed prognosis occurs in other forms of mammary carcinoma. Medullary carcinoma, when diagnosed on the basis of rigorously defined criteria, has an excellent prognosis despite the fact that these tumors are characterized by absence of estrogen and progesterone receptors and a high proliferative rate. The histological classification of mammary carcinomas is itself an important prognostic variable that may take precedence over selected biochemical markers.

Adult↗

Reinvestigation of the classification of five cell strains of xeroderma pigmentosum group E with reclassification of three of them.

Xeroderma pigmentosum is a photosensitive syndrome caused by a defect in nucleotide excision repair or postreplication repair. Individuals of xeroderma pigmentosum group E (xeroderma pigmentosum E) have a mild clinical form of the disease and their cells exhibit a high level of nucleotide excision repair as measured by unscheduled DNA synthesis, as well as biochemical heterogeneity. Cell strains from one group of xeroderma pigmentosum E patients have normal damage-specific DNA binding activity (Ddb+), whereas others do not (Ddb-). Using a refinement of a previously reported cell fusion complementation assay, the previously assigned Ddb+ xeroderma pigmentosum E strains, XP89TO, XP43TO, and XP24KO, with various phenotypes in DNA repair markers, were reassigned to xeroderma pigmentosum group F, xeroderma pigmentosum variant, and ultraviolet-sensitive syndrome, respectively. The Ddb- xeroderma pigmentosum E strains, XP82TO, and GM02415B, which showed almost normal cellular phenotypes in DNA repair markers, however, remained assigned to xeroderma pigmentosum group E. With the exception of the Ddb+ strain XP89TO, which demonstrated defective nucleotide excision repair, both Ddb- and Ddb+ xeroderma pigmentosum E cells exhibited the same levels of variation in unscheduled DNA synthesis that were seen in normal control cells. By genome DNA sequencing, the two Ddb- xeroderma pigmentosum E strains were shown to have mutations in the DDB2 gene, confirming previous reports for XP82TO and GM02415B, and validating the classification of both cells. As only the Ddb- strains investigated remain classified in the xeroderma pigmentosum E complementation group, it is feasible that only Ddb- cells are xeroderma pigmentosum E and that mutations in the DDB2 gene are solely responsible for the xeroderma pigmentosum E group.

DNA↗

International Commission for Protection against Environmental Mutagens and Carcinogens. ICPEMC Working Paper 5/6. Perspectives in mutation epidemiology, 6. A 1983 view of sentinel phenotypes.

A sentinel phenotype is a clinical disorder or syndrome that (1) occurs sporadically as a consequence of a single, highly penetrant mutant gene, (2) is a dominant or X-linked trait of considerable frequency and low fitness, and (3) is uniformly expressed and accurately diagnosable with minimal effort at or near birth. Although 1828 autosomal dominant traits are known in human beings, 36 can be considered as candidate sentinel phenotypes, along with 5 X-linked disorders. Based on surveys of malformations in infants and children, 16 additional traits are proposed beyond previous lists. In Hungary, the 24 syndromes or defects with reliable manifestations in newborn infants occur with a frequency of 2.5-3.3 per 10 000 live births. As markers of human mutations, sentinel phenotypes have the advantage of representing germinal mutations that result in significant health problems. There are severe disadvantages that have, to date, prevented the launching of a field demonstration of the value of these phenotypes in mutation epidemiology. Agreement on a list of phenotypes has been delayed by continued recognition of two or more distinct genetic diseases within what was once thought to be a single disorder. For the same reason, most of the candidate sentinel phenotypes have not been assigned unique codes in the International Classification of Diseases. Each of the disorders is so rare and has features that overlap with so many other syndromes that highly trained clinical dysmorphologist and pediatric ophthalmologists would have to be engaged in any study. The sentinel phenotype approach, like other strategies in mutation epidemiology, would encounter problems with linkage among files of data, privacy, and access to sufficiently large populations. In contrast with the approach using multiple protein variants (as in the study of blood from offspring of survivors of the atomic bombs in Hiroshima and Nagasaki), the sentinel phenotype approach would likely be much less expensive and would encounter far fewer false attributions of paternity, but also would require a much larger study population. The best option for the present, in our opinion, is to broaden and sustain critical discussion of the approach. Perhaps the goal should be to plan a field demonstration by involving appropriate clinicians, epidemiologists, and public health officials. A pilot effort underway in Hungary may well give insight to applying the approach in a significantly larger population.

Chromosome Aberrations↗

Characterization of streptococci and enterococci associated with septicaemia in broiler parents with a high prevalence of endocarditis.

Increased mortality due to septicaemia, where 29% of the affected birds had developed valvular endocarditis, was observed in a flock of broiler parents affected by myelocytomatosis. Bacterial investigations resulted in isolation of streptococci, the classification of which was unknown according to present taxonomy. Strains were isolated from the liver, spleen, heart and salpinx in clinical cases of septicaemia from the affected flock of Ross broiler parents aged between 26 and 56 weeks. Phenotypic characterization followed by genotypic investigation by ribotyping with HindIII and pulsed-field gel electrophoresis (PFGE) with SmaI demonstrated three ribotypes and six different PFGE profile types, respectively. Ribotype A with variant A1, together with the PFGE profile type represented by the three subtypes Ia, Ib and Ic, dominated the outbreak constituting 85% of the strains investigated, indicating clonality. 16S rRNA sequencing of strains representing this genotype demonstrated the occurrence of a recently described new Streptococcus sp., Streptococcus gallinaceus. Sequence analysis of the other genotypes demonstrated in the outbreak, resulted in identical 16S rRNA sequences to the type strain of Enterococcus faecalis. S. gallinaceus appears to represent a new opportunistic pathogen within the poultry industry.

Animals↗

Osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is a genetically determined disorder of connective tissue characterized by bone fragility. The disease state encompasses a phenotypically and genotypically heterogeneous group of inherited disorders that result from mutations in the genes that code for type I collagen. The disorder is manifest in tissues in which the principal matrix protein is type I collagen (mainly bone, dentin, sclerae, and ligaments). Musculoskeletal manifestations are variable in severity along a continuum ranging from perinatal lethal forms with crumpled bones to moderate forms with deformity and propensity to fracture to clinically silent forms with subtle osteopenia and no deformity. The differential diagnosis includes other entities with multiple fractures, deformities, and osteopenia. Classification is based on the timing of fractures or on multiple clinical, genetic, and radiologic features. Molecular genetic studies have identified more than 150 mutations of the COL1A1 and COL1A2 genes, which encode for type I procollagen. Various systemic treatments have been attempted; however, these interventions have been ineffective or inconclusive or are still experimental. Gene therapy has the potential to increase the synthesis of type I collagen in mild variants and to correct mutations in severe variants, but there are a great number of technical difficulties to overcome. The goals of treatment of OI are to maximize function, minimize deformity and disability, maintain comfort, achieve relative independence in activities of daily living, and enhance social integration. Attainment of these goals requires a team approach to tailor treatment needs to the severity of the disease and the age of the patient. Nonoperative management is the mainstay of orthopaedic treatment, with the goals of preventing and treating fractures and enhancing locomotion. Operative intervention is indicated for recurrent fractures or deformity that impairs function.

Chromosomes, Human, Pair 17↗

von Willebrand disease: a laboratory approach.

von Willebrand disease (VWD) is a common inherited bleeding disorder. Accurate diagnosis and classification of VWD is crucial for clinical management. A detailed clinical history, including that of bleeding, is required. A family and drug history are also important. Genetic factors such as blood group, and environmental factors such as stress, trauma, pregnancy and inflammation should also be considered. The age, ethnic group and hormonal status could also affect the von Willebrand factor (VWF) levels. No single test is robust enough to detect all variants of VWD. In view of the heterogeneity of the disease and limitations in assays, a battery of tests should be performed before a final diagnosis can be reached. These include the screening coagulation tests, factor VIII:C assay, VWF antigen assay, assessment of functional VWF which includes VWF ristocetin cofactor assays, VWF collagen binding assay, ristocetin-induced platelet aggregation and VWF multimer analysis. The newer ELISA techniques based on VWF binding with factor VIII glycoprotein (Gp) 1b and cerebrosides have also helped in determining certain unusual forms of VWD. The advent of new systems such as platelet function analysers (PFA), thromboelastography (TEG) and clot signature analysers (CSA), which are designed to assess either the primary platelet function or as a global haemostasis screen, have facilitated and simplified the diagnosis. However, few centres all over the world can perform all these expensive tests to provide a final diagnosis of VWD. We reviewed the laboratory investigations required for a diagnosis of VWD. Apart from congenital VWD, the possibility of acquired VWD should be considered in those with a negative past history of bleeding or in the presence of an underlying disease.

Algorithms↗

[Evaluation of the classification of pathological personality development of exogenous organic origin by the main component method].

The author has tested the developed classification of the pathological personality development of the exogenic-organic genesis using the method of main components. On the basis of the mathematical processing of clinical symptomatology in 348 patients with various types of the pathological development (asthenic, hysteriform, hypochondriac, explosive) the author has defined three main components: "excitability", "inhibition" and "hypochondriac anger". An analysis of the distributional pattern of types of the pathological personality development in orthogonal planes of three main components has made it possible to establish the adequacy of the proposed classification of the internal structure of the disease and identify the variants appearing as "unifying" and "distinguishing" borderlines between individual types.

Borderline Personality Disorder↗

Acantholytic epidermolysis bullosa.

BACKGROUND: We describe a new variant of inherited epidermolysis bullosa and elucidate the clinical, histologic, and ultrastructural features of this condition. OBSERVATIONS: This form of epidermolysis bullosa displays an autosomal dominant inheritance pattern, is characterized by acral bullae, and histologically demonstrates suprabasal clefting with acantholysis. Ultrastructural findings are nonspecific but reminiscent of those observed in benign familial pemphigus. CONCLUSION: Acantholytic epidermolysis bullosa is a rare but distinct clinicopathologic entity that warrants inclusion in the nosologic classification of epidermolysis bullosa.

Acantholysis↗

Apolipoprotein E isoforms and the development of low and high Braak stages of Alzheimer's disease-related lesions.

In recent research, apolipoprotein-E (apoE) polymorphism has been shown to influence the formation of neurofibrillary changes and the accumulation of beta/A4-amyloid, the histopathological hallmarks of Alzheimer's disease (AD). Clinical studies associate the apoE allele epsilon4 with earlier onset of the disease, although the clinical speed of progression remains unchanged. Time course estimates have also provided evidence which indicates that the clinical phase of AD constitutes only 10-20% of the total time span needed for the development of this slowly progressing degenerative brain disorder. Due to the lack of reliable clinical tests for the detection of pre-symptomatic stages of AD, we set out with an autopsy approach to monitor neuropathology of the long pre-clinical phase of AD. This study examined beta/A4-peptide deposition and the formation of neurofibrillary changes staged according to the Braaks' classification in groups of individuals matched for age and sex with different genotypes. In comparison with epsilon3 homozygotes, the presence of the epsilon4 allele is statistically associated with a higher stage of beta/A4-peptide deposition and neurofibrillary change formation (chi2-test, P<0.01 for beta/A4-stage and P<0.001 for neurofibrillary changes). The effect of the epsilon2 allele differs. Its presence is associated with a lower stage of neurofibrillary pathology in individuals below the age of 80 but with a higher stage thereafter compared to age- and sex-matched epsilon3 homozygotes. Accordingly, the statistical juxtaposition of individuals over 80 years with epsilon4 alleles and those with epsilon2 alleles showed no significant difference with respect to the stages. Our findings indicate that apoE-variants have different effects on the speed of histopathology formation, even in the pre-clinical stages of AD. This suggests that clinical onset, course and pathogenesis of AD are influenced by the apoE genotype.

Alleles↗

Non-von Recklinghausen's neurofibromatosis resembling a giant pigmented nevus.

We report the case of a 30-year-old female patient with non-von Recklinghausen's neurofibromatosis. In our opinion it does not fit within a system of classification recently described. Clinically, the abnormality resembled a giant pigmented nevus; however, light- and electron microscopy findings were consistent with those of a neurofibroma. No other symptoms of classic neurofibromatosis or other diseases were present. The family history showed no evidence of neurofibromatosis. To the best of our knowledge this manifestation of non-von Recklinghausen's neurofibromatosis has not been previously described. The cause and the inheritance pattern of this variant are not clear.

Adult↗

Mixed lineage leukemia-rearranged childhood pro-B and CD10-negative pre-B acute lymphoblastic leukemia constitute a distinct clinical entity.

PURPOSE: Mixed lineage leukemia (MLL) abnormalities occur in approximately 50% of childhood pro-B acute lymphoblastic leukemia (ALL). However, the incidence and type of MLL rearrangements have not been determined in common ALL (cALL) and CD10+ or CD10- pre-B ALL. EXPERIMENTAL DESIGN: To address this question, we analyzed 29 patients with pro-B ALL, 11 patients with CD10- pre-B ALL, 23 pre-B, and 26 cALL patients with CD10 on 20% to 80%, as well as 136 pre-B and 143 cALL patients with CD10 > or = 80% of blasts. They were all enrolled in four Austrian ALL multicenter trials. Conventional cytogenetics were done to detect 11q23 abnormalities and in parallel the potential involvement of the MLL gene was evaluated with a split apart fluorescence in situ hybridization probe set. RESULTS: We found that 15 of 29 pro-B ALL, 7 of 11 CD10- pre-B ALL, and 1 of 2 French-American-British classification L1 mature B-cell leukemia cases had a MLL rearrangement. However, no 11q23/MLL translocation was identified among the CD10+ pre-B and cALL patients. MLL-rearranged pro-B and CD10- pre-B ALL cases had similar clinical and immunophenotypic (coexpression of CDw65 and CD15) features at initial diagnosis. CONCLUSIONS: The striking similarities between the two CD10- ALL subsets imply that CD10- pre-B ALL variants may represent pro-B ALL cases that maintained the propensity to rearrange and express their immunoglobulin heavy chain rather than actual pre-B ALL forms transformed at this later stage of B-cell differentiation. However, direct experimental data are needed to confirm this observation.

Adolescent↗