Using DNA-cytometric analysis, Ihrler et al.’s [37] study described the presence of chromosomal alterations in salivary gland MALT lymphoma in SS. Regarding the key role of BAFF in SS proposed by some authors [4,39], the assessment of BAFF levels in serum is an exciting field for future research. Our study showed a high prevalence (86·7%) of B cell clonality in patients with SS and a direct relationship with the degree of focal lymphocytic infiltrates. In healthy control groups, we observed a direct correlation between Target Selective Inhibitor Library the degree of CS and the presence of oligo- or monoclonal bands. Therefore, this study supported the hypothesis that an increasing

number of patients with different degrees of CS may result in clonal B infiltration of the gland, showing an association between the severity of the MSG inflammation pattern and the presence of clonality. The finding of clonality in samples from this group of individuals is interesting, and possible explanations of these results are: (i) the development of reactive clonal population, distributed widely in the salivary glands, as has been reported in other studies [33,34]; and (ii) PCR is a very sensitive learn more technique, and could detect a few cells among a normal cellular background. According to our results, we show in this paper that the detection of B cell clonality by

PCR in MSG of SS patients is a predictor of clonal expansion. Clonal expansion during chronic gland inflammation of B cell mutations takes place regularly, accompanied by mutations of tumour-suppressor genes, p53 mutations and a high level of BAFF expression. Together, these alterations constitute a risk factor for the development of lymphoma in SS patients [4–6,29,30,34,40]. We conclude that the presence of B cell clonality in MSG can be used as an index of an altered microenvironment, which could enable the development of lymphoma in SS patients. This research was supported by funds of the Public Institute of Health from Chile, Bagó Laboratory and Chile Laboratory. All authors declare

4��8C no conflicts of interest. “
“It is now well established that allergic diseases have an extremely high prevalence in developed societies, and are increasing in emerging countries. In fact, allergy is probably the most prevalent immunological disease. It is currently estimated that up to 30% of Europeans suffer from allergic rhinitis or conjunctivitis, while up to 20% suffer from asthma and 15% from allergic skin conditions 1. The worldwide numbers are equally worrying. Almost half a billion suffer from rhinitis 2, 3 and approximately 300 million from asthma 4. Compared with other chronic diseases, allergic diseases are more common than Parkinson’s, Alzheimer’s, stroke, coronary heart disease, cancer or diabetes.

In a CD4-dependent

model of GVHD, Warren and Mark Shlomchik and colleagues from Yale 8 were the first to show that irradiated allogeneic recipients of either total CD4+ T cells or CD44− CD62L+ TN cells developed severe GVHD, whereas Selleckchem NVP-LDE225 recipients of CD44+CD62L− TMP cells remained entirely well and free of GVHD. Furthermore, rapid reconstitution of the peripheral T-cell compartment in the BMT recipients by TMP cells permitted robust recall immunity to third party antigens, indicative that responses to persistent and acquired infections might be preserved. Importantly, protection from GVHD did not rely upon the presence of regulatory T cells within the TMP-cell fraction. Several other groups have since confirmed and extended these findings in experimental BMT by selecting for TMP cells in the bulk T-cell population or from individual CD4+ or CD8+ T-cell subsets of unprimed mice, and by using BMT models that involve MHC mismatches or that are MHC-matched but mismatched for multiple minor histocompatibility (H) antigens 9–13. In general, the results have been broadly similar, although whether CD44+ CD62L+ TMP cells are as disabled as CD44+CD62L− TMP cells in inducing GVHD is less clear 11, 14. Caution is required, however, before assuming

that transfer of human memory T cells can successfully be applied to the clinic because the TMP-cell populations in mice housed under specific pathogen-free conditions are likely to be distinct in several respects from the memory T-cell populations found in humans. In such mice, TMP FK866 cells arise U0126 nmr as a result of lymphopenia-induced proliferation as new thymic emigrants enter the periphery of neonatal mice 15

or represent the proliferation of cells in response to environmental antigens or allergens. In humans, T cells expressing memory markers will include a greater proportion of cells that have been primed previously following exposure to pathogens. A very high proportion of human memory T-cell lines or clones specific for viruses such as EBV or CMV demonstrate cross-reactivity with allogeneic peptide:HLA, a consequence of the degenerate TCR recognition of peptide:HLA ligands 16. Although alloreactivity is also demonstrable in the human TN-cell pool 17, memory populations, which contain unprimed TMP cells as well as primed effector memory T (TEM) cells, could be potentially more harmful than TN cells since they are less stringent in their requirements for TCR stimulation or costimulation than their TN-cell counterparts 1. Reduced susceptibility to apoptosis or to peripheral tolerance mechanisms in the host might also make such human memory T-cell populations more dangerous than TN cells 1. This increased alloreactivity could also be relevant in cases where the donors and recipients are HLA-matched, but the donors are female and have previously been primed to male antigens as a result of pregnancy 18.

55 IL-27, an IL-2 family cytokine, is a negative regulator of Th17 development.56 This cytokine also induces Tr1 cells, a Treg population characterized by IL-10 expression.57 IL-10 is also a negative regulator of Th17 development.58 Mice deficient in the IL-27 receptor, WSX-1, show exuberant Smoothened Agonist proliferation of Th17 cells in EAE suggesting that IL-27 inhibits the development of disease.59 These interactions help explain how relatively minor disruptions

in Treg homeostasis by inflammation in genetically susceptible animals initiated by a critical inflammatory trigger may precipitate autoimmunity through a default pathway, i.e. Th17 differentiation. The IL-17A receptor has recently been reported to be expressed on differentiated Th1 cells. In vitro experiments show that IL-17A is capable downregulating expression of the Th1 transcription factor, T-bet.60 These findings suggest that apart from its pleiotropic pro-inflammatory functions,

Th17 cells are capable of regulating pathogenic Th1-mediated tissue inflammation.61 In the absence of TGF-β and in the presence of IL-12 or IL-23, differentiated Th17 cells lose IL-17A and IL-17F secretion and become IFN-γ-producing cells.62 This switch is dependent on the Th1 transcriptions factors, STAT4 and T-bet, and suggests that Th17 cells are not terminally differentiated PD98059 but are capable of substantial plasticity. Direct evidence that Th17, as well as Th1 cells can induce proliferative GN has been published using a planted foreign antigen model, where ovalbumin is planted in glomeruli of Rag1−/− mice (deficient in T and B cells). Injection

Cetuximab manufacturer of either ovalbumin-specific Th1 or Th17 polarized cells induced proliferative GN.63 Th17 cell induced injury developed early and correlated with increased neutrophil recruitment, while Th1 cell-mediated GN was more delayed and featured enhanced macrophage activation. This system has the advantage of being able to definitively demonstrate that it is the Th cells as effectors that are directing the injury, without potential confounding effects of CD8+ cells, B cells or antibody. These findings support a model in which some forms of proliferative GN, where effectors of cell mediated immunity are prominent, may be Th17 cell predominant, while others are Th1 mediated. It suggests that Th17 cells might dominate glomerular diseases that are neutrophil rich, although other recent evidence in autoimmune renal disease64 (discussed below) suggests a role for Th17 in macrophage recruitment. Types of GN and its association with the Th17 cell subset are listed in Table 2. Anti-GBM GN disease has been believed to be Th1 mediated due to the presence of DTH effectors65 and the predominance of the Th1-associated IgG antibody subclasses (IgG1 and/or IgG3) deposited in the kidney.

It is made of a single polypeptide chain and contains 10 lectin domains, which is a deviation from the eight lectin domains of the MMR family. Named from the first observations of its abundant expression on DCs and thymic epithelial cells in mice using the rat monoclonal antibody non-lymphoid dendritic cells (NLDC)-145 [73,74], DEC-205 has a more diverse distribution. B cells from various sources such as spleen, lymph node and peritoneal exudates express

DEC-205, but at a much lower level than on DCs [75]. Immunohistochemical staining showed see more expression of DEC-205 on the follicular B cells, bone marrow stroma and pulmonary airway epithelium [76]. Although found predominantly on DCs, DEC-205 is not expressed ubiquitously on all DC subsets. In the mouse thymus, all DC show DEC-205 expression, the majority of which are CD8+[77]. In contrast, murine spleen shows three subsets of DC: CD4+CD8-DEC205-CD11b+, CD4-CD8-DEC205-CD11b+ and

CD4-CD8+DEC205+CD11b-[77]. Two additional populations can be traced in the lymph nodes, which show lower expression of CD8 but high to moderate expression of DEC-205 [78]. Moreover, non-lymphoid DCs such as the Langerhans cells of the skin and also BMDCs generated in the presence of GM-CSF show high expression of DEC-205 [75,79]. While humans do not have a DC subset that is CD8+, most DCs BVD-523 order in the T cell areas of human spleen and lymph nodes co-express CD11c and DEC-205 [80,81]. In a pioneering study, Hawiger and colleagues fused an immunogenic peptide from hen egg lysozyme (HEL) to the carboxyl terminus of the heavy chain of NLDC-145 [20]. They injected mice with the hybrid antibody and found that the anti-DEC-205/HEL could deliver antigen to DCs leading to CD4+

T cell activation and proliferation. However, further investigation showed that this treatment led ultimately to the deletion of many Exoribonuclease of the antigen-specific T cells and that the remaining T cells were unresponsive and could not mount an immune response to subsequent challenge with HEL administered with complete Freund’s adjuvant (CFA), showing the induction of HEL-specific tolerance. However, when the same treatment was performed in conjunction with an agonistic anti-CD40 antibody, the outcome was prolonged T cell activation and immunity. Thus, it could be inferred that DCs in the steady state, i.e. in the absence of additional stimuli, act as inducers of antigen-specific peripheral tolerance. Subsequently, ovalbumin (OVA) was coupled chemically to anti-DEC-205 and was found to permit DCs to present a cognate peptide to OVA-specific CD8+ T cells [35]. The antibody-mediated delivery was much more efficient than administration of soluble OVA alone. In agreement with the earlier study that utilized anti-DEC-205/HEL and CD4+ T cells [20], when anti-DEC-205/OVA was targeted to DCs in the steady state in vivo there was an initial burst of proliferation of the OVA-specific CD8+ T cells which was followed by their deletion.

, 2007). To ensure correct measurement of gene expression in drug-treated bacteria,

it is of the utmost importance to use appropriate controls. To address that issue, we conducted the present study to compare RNA and DNA as internal gene expression controls. A problem associated with using RNA as an internal control is that the relative expression of target mRNA may vary https://www.selleckchem.com/products/PD-98059.html extensively, depending on the control RNA that is used. In the current experiments, the use of different internal control RNAs led to diverse effects on target gene expression in C. pneumoniae (Fig. 2). Variation in the behavior of the internal control RNAs was determined by analyzing the stability of those molecules. The results of that assessment revealed marked differences in stability, with half-lives ranging from <5 min (rpoD) to 139 min (16S rRNA) (Fig. 3, Table 2). If transcription is blocked, for example by treatment with a compound such as INP0010 or exposure to an environmental signal, the level of the 16S rRNA will remain almost unaltered for more than an hour, whereas practically all rpoD transcripts will disappear PI3K Inhibitor Library in a shorter amount of time. Thus, relating target mRNA expression to such control mRNAs will yield different results, because the transcript stabilities will affect the relative

expression of any target mRNA differentially. We also found that the relative level of each control RNA varied between the phases in the developmental cycle, which yielded false results regarding relative target mRNA expression over time (Fig. 4). The relative amount of any given transcript can be related to the synthesis and decay of the target and control RNA: Hence, when using RNA as a control, the relative gene expression is

correlated with the expression of both the target and the control mRNA, as well PTK6 as with the degradation of the target and control transcripts (four independent parameters). Consequently, the observed increase or decrease in the relative expression of a certain gene can be due to several different factors and not necessarily altered transcription of that target gene. The complexity of using RNA as an internal gene expression control is illustrated by our results regarding rpoA. Although the relative amount of the rpoA transcript was reduced in the presence of INP0010 (Fig. 5), the stability of that transcript was slightly increased under these conditions (Fig. 3, Table 2). Moreover, the expression of rpoA in untreated cells increased >20-fold between 2 and 14 h p.i. (Fig. 4), which resulted in a reduced expression of any low-induced target mRNA that was temporally correlated with expression of rpoA. Consequently, due to their varied expression and stability, rpoA and other control RNAs are disqualified from being used as internal controls for measuring gene expression, at least in the early phase of the Chlamydia developmental cycle. Possibly, a more reliable control would be a combination of several control RNAs.

Understanding the causes for the suboptimal long-term graft survival in these patients is fundamental, particularly if such therapies are

to be offered to young patients with an expectation of lifetime benefits. Understanding how transplanted tissue behaves in a severely diseased brain is also of critical importance for the future of stem cell therapy, which will be facing the same challenges. The observations derived from these unique autopsied transplanted HD cases will be invaluable in extending our understanding of HD pathology itself and may very well lead to the improvement and development of cell-based treatments or other similar therapeutic strategies. The authors wish to thank Mr Gilles Chabot for artwork. Both authors were involved in the literature search, the design of tables and schematics as well Smoothened Agonist as in the writing of the manuscript. The authors declare no conflict of interest. “
“H. Madarame, T. Seuberlich, C. Abril, A. Zurbriggen, M. Vandevelde and A. Oevermann (2011) Neuropathology and Applied Neurobiology37, Selleckchem BGB324 753–767 The distribution of E-cadherin expression in listeric rhombencephalitis of

ruminants indicates its involvement in Listeria monocytogenes neuroinvasion Aim: To investigate the expression of E-cadherin, a major host cell receptor for Listeria monocytogenes (LM) internalin A, in the ruminant nervous system and its putative role in brainstem invasion and intracerebral spread of LM in the natural

disease. Methods: Immunohistochemistry and double immunofluorescence was performed on brains, cranial nerves and ganglia of ruminants with and without natural LM rhombencephalitis using antibodies against E-cadherin, protein gene product 9.5, myelin-associated glycoprotein and LM. Results: In the ruminant brain, E-cadherin is expressed in choroid plexus epithelium, meningothelium PI-1840 and restricted neuropil areas of the medulla, but not in the endothelium. In cranial nerves and ganglia, E-cadherin is expressed in satellite cells and myelinating Schwann cells. Expression does not differ between ruminants with or without listeriosis and does not overlap with the presence of microabscesses in the medulla. LM is observed in phagocytes, axons, Schwann cells, satellite cells and ganglionic neurones. Conclusion: Our results support the view that the specific ligand–receptor interaction between LM and host E-cadherin is involved in the neuropathogenesis of ruminant listeriosis. They suggest that oral epithelium and Schwann cells expressing E-cadherin provide a port of entry for free bacteria offering a site of primary intracellular replication, from where the bacterium may invade the axonal compartment by cell-to-cell spread.

The newly identified population of BM B-1 cells shows many

of the phenotypic characteristics of splenic B-1 cells but is distinct from B-1 cells in the peritoneal cavity, which generate at best very small amounts of IgM. Antibody-secreting spleen and BM B-1 cells are distinct also from terminally differentiated plasma cells generated from antigen-induced conventional B cells, as they express high levels of surface IgM and CD19 and lack expression of CD138. Overall, these data identify populations of non-terminally differentiated B-1 cells in spleen and BM as the most significant producers of natural IgM. A significant proportion of circulating serum antibodies are “natural antibodies”, mainly of the IgM isotype, i.e. antibodies that are produced even in the complete absence of any antigenic stimulation as seen in gnotobiotic animals 1–3. Natural antibodies are often polyreactive and will bind to multiple antigens, with overall low PI3K Inhibitor Library affinities (Kd=10−3 to 10−7 mol/L) 4. Despite their low affinities, these antibodies are important in host defense. Following infection with viral or bacterial pathogens, pre-existing IgM antibodies directly

neutralize and inhibit early pathogen replication, in part via complement GPCR Compound Library cost binding, and thereby increase survival from infection 5–10. Natural IgM also enhances the ensuing pathogen-specific IgG responses 6, 11, possibly via the formation of antibody-antigen complexes for their deposition on follicular DCs 6, 12. Analogous “natural” poly-specific IgA antibodies exist at mucosal surfaces where they might act as a first layer of immune defense 13, 14. Thus, natural antibodies constitute an important component of pre-existing protective immunity. Another function of natural antibodies is N-acetylglucosamine-1-phosphate transferase their involvement in the maintenance of tissue integrity and homeostasis. Natural antibodies facilitate uptake of apoptotic cells via binding to surface antigens such as phosphatidylcholine (PtC), Annexin IV 15, phosphorylcholine

16 and malondialdehyde, the latter a reactive aldehyde degradation product of polyunsaturated lipids 16–19 and xenoantigens 20. This seems to facilitate increased phagocytosis by immature DCs 18, while also limiting tissue inflammation 18. Consistent with this, the genetic ablation of secreted IgM results in increased autoimmunity, with accelerated, pathogenic IgG responses and resulting disease progression 21. Similarly, inappropriate and/or enhanced local secretion of natural IgM secretion and ensuing IgM–self antigen complex formation can result in local activation of the complement cascade and tissue damage, as seen during ischemia-reperfusion injury 15, 22. Natural antibody binding to self-antigens seem to be involved also in atherosclerosis development, where these antibodies contribute to plaque formation via their binding to oxidation-specific epitopes on low-density lipoproteins and cardiolipins 16, 19.

A total of 319 haemodialysis (HD) and 156 peritoneal dialysis (PD) patients formed the database. After stratification by dialysis modality, multivariate Cox proportional-hazards model was constructed with age, sex and co-morbidity as predictive variables. Results:  The annual paediatric ESRD incidence rate was 8.12 per million of age-related populations. The overall 1-, 5-, and 10-year survival rates for PD patients were 98.1%, 88.0% and 68.4%, respectively, and were 96.9%, 87.3% and 78.5% for HD patients. The survival

analysis showed no significant difference between HD and PD (P = 0.4878). Using ‘15–19 years’ as a reference group, the relative risk (RR) Neratinib datasheet of the youngest group (0–4 years) was 6.60 (95% Gefitinib in vivo CI: 2.50–17.38) for HD, and 5.03 (95% CI: 1.23–20.67) for PD. The death rate was 24.66 per 1000 dialysis patient-years. The three major causes of death were infection (23.4%), cardiovascular disease (13.0%) and cerebrovascular disease (10.4%). Hemorrhagic stroke (87.5%) was the main type of foetal cerebrovascular accident. Conclusion:  We conclude that there was no significant difference of paediatric ESRD patient survival between HD and PD treatment in Taiwan. The older paediatric ESRD patients had better survival than younger patients. “
“Our previous article described the principles of conducting an economic evaluation for evidence-based medical decision making. This

article provides some tips for reading, critically appraising and applying the findings of an economic evaluation in clinical practice. “
“The mononuclear phagocyte system is comprised of circulating monocytes, tissue macrophages and dendritic cells (DCs) that play key roles in tissue homeostasis, immune surveillance, and immune and non-immune-mediated tissue injury and repair. This review summarizes the various subsets within this system RANTES that exhibit significant functional and phenotypic diversity that can adapt to their surrounding microenvironments during inflammation and in response to colony-stimulating factor (CSF)-1. The current understanding of the co-ordination of monocyte infiltration

into the homeostatic and diseased kidney through adhesion molecules, chemokines and chemokine receptors, and cytokines are described. Furthermore, the significant confusion and controversy associated with monocyte differentiation into renal macrophages and DCs following infiltration into the kidney, the considerable functional and phenotypic overlap between both tissue populations and their respective roles in immune and non-immune-mediated renal is also discussed. Understanding the factors that control the activation and recruitment of cells from the mononuclear phagocyte system during renal injury may offer an avenue for the development of new cellular and growth factor-based therapies in combination with existing therapies as an alternative treatment option for patients with renal disease.

Albumin activated the canonical NF-kB pathway as demonstrated by the increased nuclear translocation of the NF-kB p65 and p50 subunits and the transcriptional factors activity. These events of canonical NF-kB activation were partially suppressed by BMP-7. Albumin induced apoptosis in PTEC as evidenced by the up-regulated apoptotic index from the TUNEL assay and the increased caspase-8 activity. Interestingly, addition of BMP-7 further exaggerated these apoptotic events in PTEC overloaded with albumin. Conclusion: Our results demonstrated that BMP7 exaggerated the apoptotic events induced

by albumin in cultured PTEC. This amplification of the albumin-induced apoptosis was associated with the reduction of TNF-α synthesis and canonical NF-kB pathway activation. This study is supported by a General Research Fund of the Research Grants Council (#HKU 7770/09M) of Hong Kong and Matching Grant CYC202 from The University of Hong Kong. KODA RYO1,

YOSHINO ATSUNORI1, IMANISHI YUJI1, KAWAMOTO SHINYA1, UEDA YOSHIHIKO2, YAOITA EISHIN3, KAZAMA JUNICHIRO JAMES4, NARITA ICHIEI4, TAKEDA TETSURO1 1Department of Nephrology, Dokkyo Medical University Koshigaya Hospital; 2Department of Pathology, Dokkyo Medical University Koshigaya Hospital, Japan; 3Department of Structural Pathology, Institute of Nephrology, Graduate School of Medical and Dental Sciences, Japan; 4Division of Clinical Nephrology and Dorsomorphin chemical structure Rheumatology, Niigata University Graduate School of Medical and Dental Science, Japan Introduction: The origin of crescent forming cells in human glomerulonephritis

(GN) remains unknown. Some animal studies demonstrated that parietal epithelial cells of Bowman’s capsule G protein-coupled receptor kinase (PECs) were the main component of proliferating cells and PEC-specific tight junction protein claudin-1 was expressed in crescentic lesions. Methods: We investigated the expression of claudin-1 in human GN. Immunohistochemistry for claudin-1 was performed on 17 kidney biopsy samples with crescent formation. Co-localization of claudin-1 with intracellular tight junction protein ZO-1 was evaluated by immunofluorescence double staining. Expression of occludin, another fundamental intercellular tight junction protein, was also evaluated in crescentic lesion in human glomerulonephritis. Results: Claudin-1 is expressed mainly at the cell to cell contact site of proliferating cells in cellular crescentic lesions in patients with these forms of human GN. Small numbers of crescent forming cells showed extra-junctional localization of claudin-1. Co-localization of claudin-1 with ZO-1 was found at cell to cell contact sites of adjacent proliferating cells. In control samples, staining of claudin-1 was positive in PECs, but not in podocytes. Conclusion: Our findings suggest that claudin-1 contributes to crescent formation as a component of the tight junction protein complex that includes ZO-1.

It is likely that

HS is heterogeneous in aspects of its cause, epileptogenetic mechanisms, network alterations and response to medical and surgical treatments. Future neuropathological studies will contribute to better recognition and understanding of these clinical and patho-aetiological subtypes of HS. “
“A 59-year-old Japanese Enzalutamide in vitro man presented with depressed mood, insomnia, abnormal behavior and dementia. Visual and gait disturbance with ataxia also developed. Diffusion-weighted MRI showed widespread regions of hyperintensity in the bilateral cerebral cortex. The patient died at 62 after a progressive clinical course of 32 months. Myoclonus, periodic GDC-0941 purchase sharp-wave complexes on EEG, and akinetic mutism state were not observed. Neuropathologic examination showed widespread

cerebral neocortical involvement with both large confluent vacuole-type, alongside fine vacuole-type spongiform changes. Mild spongiform degeneration was observed in the striatum and lateral thalamus. Severe neuron loss with hypertrophic astrocytosis in the medial thalamus and inferior olivary nucleus was present. Cerebral white matter showed diffuse myelin pallor indicating panencephalopathic-type pathology. In the cerebellar cortex, severe Purkinje neuron loss was observed, but no spongiform degeneration in the molecular layer or neuron loss in the granular cell layer. PrP immunostaining showed widespread perivacuolar-type PrP, irregular plaque-like PrP, and synaptic-type PrP depositions in the cerebral neocortex. Mild PrP deposition was observed in the striatum, lateral thalamus and brainstem, whereas PrP deposition was not apparent in the medial thalamus and inferior olivary nucleus. PrP gene analysis showed no mutations, and methionine

homozygosity was observed at codon 129. selleck Western blot analysis of protease-resistant PrP showed type 2 PrP pattern. MRI and cerebral neocortical pathology suggested MM2-cortical-type sporadic Creutzfeldt-Jakob disease (sCJD), whereas the clinical course and pathology of the medial thalamus and inferior olivary nucleus suggested MM2-thalamic-type sCJD. We believe this was a combination of MM2-cortical-type and MM2-thalamic-type sCJD, which explains the broad spectrum of MM2-type sCJD findings and symptoms. “
“The occurrence of Ewing sarcoma-peripheral primitive neuroectodermal tumor as a primary intracranial tumor is very rare, with only 29 cases reported in the literature, 19 of which have included molecular studies. We present the clinical, radiologic and pathologic findings of an intracranial Ewing sarcoma in a 22-year-old woman arising from the dura over the right frontal convexity. The patient underwent craniotomy with gross total excision of the tumor.