Level II, prospective, randomized of low-level.

Immunoblastic lymphoma at the site of an impacted vitallium bone plateThe authors report a case of immunoblastic lymphoma occurring at the site of an osteosynthesis complicated by infection. The hypothetical carcinogenic roles of the infection and of the alloy used in the prosthesis are discussed in the light of recent literature. It is suggested that both may have acted synergistically either as inducing or, more likely, as localizing factors of the lymphoma.

SUMMARY DNA synthesis activity in the epithelium of the human gallbladder was studied through in vitro labelling of mucosal specimens with 3H-thymidine and autoradiography. The specimens were taken at the time of a surgical operation. Eight 'normal' gallbladders and six distended gallbladders from patients with carcinomatous obstruction of the common bile duct were examined. Proliferative activity was very low in the normal and significantly higher in the distended gallbladders.The use of labelled precursors of DNA and of autoradiography has allowed the study of cell proliferation in the gallbladder of experimental animals. Recent studies have reported an increased incorporation of 3H-thymidine in the epithelium of the gallbladder after ligation of the common bile duct (Scott, 1974) and during administration of lincomycin (Scott, 1976) or of a lithogenic diet (Scott, 1978) to rodents. The study of cell renewal in the normal human gallbladder has not been undertaken because ethical considerations stood in the way of injecting patients with tritiated thymidine. However, the in vitro labelling of surgical specimens with tritiated thymidine makes it possible to observe and to count the cells in DNA synthesis in biopsy specimens without previous injection of radiolabelled compounds (Willems et al., 1970). This method was recently applied to human gallbladders and permitted the observation that epithelial cell proliferation in this organ is significantly increased in patients with gall stones (Putz and Willems, 1978).In the present work, in vitro labelling was used for observing the changes in proliferative activity in the human gallbladder under the effect of distension. Adequate conditions for this study in man were found in surgical patients with complete obstruction of the distal bile duct by a malignant tumour. Methods SPECIMENSThe gallbladders from five patients with a cancer of the head of the pancreas and one patient with a Received for publication 9 October 1978 malignant ampulloma were used for this study. Obstructive jaundice and an increasingly distended gallbladder were observed in all patients. The patency of the cystic duct and the complete obstruction of the distal choledocus were verified by preoperative cholangiography. Five of the patients underwent a palliative cholecystoduodenostomy, and a 1 x 0(5 cm piece of the gallbladder wall was excised by the surgeon at the site of the future anastomosis. In one patient a cholecystectomy and a duodenopancreatectomy were performed; a similar piece of the gallbladder wall was taken in this case immediately after the cholecystectomy was done.Eight human gallbladders that were considered to be 'normal' by the surgeon (one of us) were taken as controls; three of them were resected during right hepatectomies, one was taken within three minutes after death in a patient with a ruptured abdominal aneurysm and four came from decerebrated donors of kidney grafts and were excised immediately after bilateral nephrectomy. All these gallbladders were flaccid at the time of...

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Surgical specimens from 9 normal human gallbladders and from 9 lithiasic gallbladders were incubated in vitro with [3H]thymidine. Autoradiography was used to observe the cells in DNA synthesis in the mucosal epithelium. The percentages of labeled cells (labeling index) and of mitotic figures (mitotic index) were estimated. In the normal gallbladder, the labeling index was low and mitotic figures were exceptional; the labeled cells in the epithelium were observed against the basal membrane. In the lithiasic gallbladder, the labeling index was 23 times higher (P less than 0.01) and a definite number of mitotic figures was seen; the uptake of [3H]thymidine was not restricted to basal epithelial cells and occurred at any level of the mucosa. Our data showed that the proliferative activity was increased in the mucosa of the human lithiasic gallbladder. To the extent that the labelled cells against the basal membrane in the normal gallbladder represent the epithelial progenitors, our results also indicated modifications in the spatial distribution of labeled cells in the lithiasic gallbladder mucosa. Such concomitant quantitative and qualitative changes in cell kinetics could have a parallel in known precancerous conditions in the digestive tract.

A cholesterol-cholic acid lithogenic diet was administered to mice for periods from 2 days to 12 weeks. Intraperitoneal injections of tritiated thymidine and autoradiographs were used for the estimation of the proliferative parameters in the gallbladder epithelium. The total DNA content of the gallbladder was determined. Significantly higher labeling (p < 0.01) and mitotic (p < 0.01) indices were observed from the 2nd day and the total DNA content of the gallbladder was increased (p < 0.01) from the 2nd week of the diet. Increased proliferative activity was followed by hyperplasia of the gallbladder epithelium. A significant dilatation of the gallbladders was also noted from the 2nd day of the diet (p < 0.01). Gallstones appeared after at least 4 weeks. Our results indicate that gallstone formation is preceded by a higher proliferative activity in the gallbladder mucosa. Distension of the gallbladder could be one of the factors explaining this phenomenon in mice, but the influence of intraluminal modifications in the bile salt composition cannot be excluded.

A 22-year-old African male with known sickle cell anaemia was referred by a Congolese medical centre with a request to improve his poor physical condition. He was unable to walk, stand or sit because his large joints and his spine were either ankylosed or very rigid. Radiographs showed joint fusion from the third to the fifth cervical vertebrae, of both hips, of the left knee, and a bilateral osteonecrosis of the humeral head. There was no scintigraphic evidence for an active osteomyelitis (99mTc-MDP (methyldiphosphonate) bone scan, Tc monoclonal antigranulocyte scan and 99mTc sulphur colloid scan). To improve his mobility the right femoral head was resected in June 1997; 14 days later the left femoral head was resected. Four months after the resection of the right hip, a right uncemented total hip prosthesis was implanted on this side. One month later the same type of hip arthroplasty was performed on the left side. During the postoperative rehabilitation period the patient regained autonomy. We have found no previous reports of such severe and multiple joint complications in a single patient suffering from sickle cell anaemia.

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