树突状细胞对胃癌前病变的免疫保护分析

摘要 目的：探究树突状细胞(Dendritic cells,DC)对胃癌的免疫保护作用。方法：选择2016年1月至2018年1月于我院接受治疗的145例胃癌、39例慢性萎缩性胃炎、21例不典型增生、27例肠上皮化生以及20例正常对照组患者为研究对象,分别采集其胃粘膜标本进行染色,记录和比较其胃粘膜中S100⁺、CD4⁺和CD8⁺细胞的数量、平均面积以及平均吸光度,并将胃癌患者分为中分化腺癌(49例)、低分化腺癌(53例)和未分化癌(43例)进行对比。结果：(1)胃癌组、慢性萎缩性胃炎组、不典型增生、肠上皮化生组的胃粘膜S100⁺阳性细胞计数明显高于正常对照组（P<0.05）,胃癌组平均吸光度低于对照组,其他3组平均吸光度显著高于对照组,(P<0.05);胃癌组平均面积与正常对照组相比无差异(P>0.05),其他三组平均面积显著高于对照组（P<0.05）;(2)慢性萎缩性胃炎组、肠上皮化生组、不典型增生组患者CD4⁺细胞数均低于对照组(P<0.05);胃癌组、慢性萎缩性胃炎组、肠上皮化生组患者平均面积均低于对照组(P<0.05);胃癌组、慢性萎缩性胃炎组、不典型增生、肠上皮化生组平均吸光度均低于对照组(P<0.05);(3)慢性萎缩性胃炎组、肠上皮化生组、不典型增生组患者CD8⁺细胞数明显高于对照组(P<0.05),胃癌组稍低于对照组(P>0.05);胃癌组患者平均面积低于对照组(P<0.05);胃癌组患者平均吸光值低于对照组,慢性萎缩性胃炎组、肠上皮化生组患者高于对照组(P均<0.05);(4)随着胃癌分化程度的降低,胃癌患者DC细胞数有降低趋势。结论：胃癌前病变患者胃粘膜中DC数量会显著增多,免疫功能加强,DC细胞数量会随胃癌分化程度的降低而减少,分析其原因与DC细胞能够抑制癌前病变有关。     

Sequential alterations in gastric biopsies and tumor tissues support the multistep process of carcinogenesis

Gastric cancer is the second leading cause of cancer related death worldwide. In the UAE, recent data show an increase in the number of patients with gastric cancer highlighting the need for greater understanding of its pathogenesis. Gastric cancer is generally believed to develop on a background of chronic atrophic gastritis which eventually leads to intestinal metaplasia, dysplasia and finally invasive carcinoma. Recently this multistep process of carcinogenesis has been challenged. Therefore, the aim of this study is to define alterations in antral mucosal biopsies and cancer tissues to investigate whether they could be used to assemble a tissue array supporting the multistep model of carcinogenesis. Gastric mucosal tissues were obtained from informed individuals undergoing endoscopy (for upper gastrointestinal symptoms) and gastrectomy (for adenocarcinoma) in Tawam Hospital. All tissues were processed for microscopic examination. Eighty nine antral biopsies were categorized as: normal (33%), mild superficial gastritis (34%) and severe atrophic gastritis (33%). About 5% of the latter exhibited evidence of intestinal metaplasia. Cancer tissues obtained from three patients were microscopically examined in three regions: safe resected margin, tumor edge and tumor center. Progressive changes in mucosal thickness, dysplasia and cellular transformation were observed, and when compared with alterations in biopsies, all appeared to represent a continuum of progression toward invasive adenocarcinoma. In conclusion, the tissue array presented in this study supports the multistep process of gastric carcinogenesis and will be helpful in examining the expression pattern of tumor markers or molecules that could help in the early detection of gastric cancer.     

胃肠癌发生和预防中表观遗传修饰与信号通路的相关研究

仁济消化学科胃肠肿瘤研究团队是教育部"创新团队",长期从事消化系肿瘤发生机制和防治研究.在胃癌发生和预防中的表观遗传学与信号通路相关研究中作了一定工作.初步明确了我国胃癌癌前疾病慢性萎缩性胃炎的转归情况;建立并验证了预测慢性萎缩性胃炎发生与转归的数学模型.分析了我国症状人群中大肠癌癌前疾病大肠腺瘤患病情况及变迁状况,腺瘤内镜下摘除后再发情况.进一步明确了胃肠癌发生中包括DNA甲基化、组蛋白修饰和非编码RNA(miRNA和天然反义转录本)的作用;阐明了与细胞增殖相关的JAK/STAT信号通路的作用意义;并初步证实了上述表观遗传修饰和信号通路的相互关系.证明了大肠腺瘤患者血浆叶酸和粪便短链脂肪酸及产短链脂肪酸的肠道菌群情况,为有效得干预预防奠定基础.多中心随机对照研究证明,叶酸可有效预防超过50岁人群的大肠腺瘤的发生,且作用与干预前后叶酸含量上升情况有关.并以第一完成单位和第一完成人获2005年上海市科技进步一等奖("表观遗传修饰及其在胃癌发生和预防中的应用")、2007年中华医学科技一等奖和2008年国家科技进步二等奖("叶酸和丁酸盐在胃肠癌发生和预防中的作用")及2014年教育部高等学校科学研究优秀成果(科技进步)一等奖.     

人慢性胃炎与神经内分泌G、D细胞关系的研究

探讨神经内分泌G、D细胞与慢性胃炎的关系,用免疫细胞化学方法对52例慢性胃炎及9例对照者进行胃窦粘膜内G、D细胞密度计数。结果显示慢性胃炎病人的G、D细胞数均低于对照组,特别是萎缩性胃炎G、D细胞显著减少,同时还发现不同组别、不同程度的萎缩性胃炎,其G细胞的数量均大于D细胞,G／D细胞的比值在中、重度性胃炎与其它组相比有显著性差异（P＜0.01）。资料还显示G、D细胞的计数不仅可以判断胃窦粘膜的萎缩程度,而且可作为观察临床疗效的一项重要指标。     

Qualitative and quantitative characteristics of estrogen receptors in patients with atrophic gastritis and stomach cancer

The article deals with the comparative estimation conducted both in the normal and atrophic gastric mucosa, its cancer tumoral tissues. All the results obtained have been studied in dependence on the atrophic gastritis variants. The process various stages as well as on the patients sex. The findings obtained evidence about more high frequency of identification and more high estrogens receptors level in the patients suffering from the cancer if compare with suffering from atrophic gastritis one.     

Helicobacter pylori: immunoproteomics related to different pathologies

Helicobacter pylori is a Gram-negative bacterium that causes ulcer, atrophic gastritis, adenocarcinoma and mucosa-associated lymphoid tissue lymphoma. Moreover, an ongoing controversial role of this bacterium infection has been suggested in the etiopathogenesis of some extradigestive diseases. The humoral response to H. pylori during a natural infection can be used for diagnostic purposes and as a basis for vaccine development. Host–pathogen interactions may be investigated by means of immunoproteomics, which provides global information about relevant specific and nonspecific antigens, and thus might be suitable to identify novel vaccine candidates or serological markers of H. pylori infection as well as of different related diseases. In this review, we describe how several research groups used H. pylori proteomics combined with western blotting analysis, using sera from patients affected with different H. pylori-related pathologies, to investigate potential associations between host immune response and clinical outcomes of H. pylori infection, resulting in the rapid identification of novel, highly immunoreactive antigens.     

The state of lipid peroxidation and antioxidant protection system in parietal cells under experimental chronic atrophic gastritis development

The lipid peroxidation state and the system functioning of antioxidant protection in parietal cells under rat chronic atrophic gastritis development was investigated. It was detected that the compensatory increase of superoxide dismutase and catalase activity did not affect the lipoperoxidation process and this resulted in accumulation of toxic TBA reactive substances and diene conjugates during the whole stages of the experimental pathology development. It was shown that the reserved power of the glutathione antioxidant system is sufficient to provide adoptable response in the acute period of the disease owing to increasing intracellular found of the reduced glutathione, but it is insufficient to prevent its decreasing in parietal cells in case of the chronic atrophic gastritis development. Our findings suggest that glutathione system is involved in processes of gastric atrophy. The obtained results testify about considerable system dysfunctions of lipid peroxidation and the antioxidant protection in processes of the rat experimental atrophic gastritis development.     

Atrophic gastritis, Helicobacter pylori, and colorectal cancer risk: a case-control study

BACKGROUND: Helicobacter pylori is a major risk factor for atrophic gastritis and gastric cancer. Various extragastric manifestations of H. pylori infection have also recently been suggested. However, the correlation between H. pylori and colorectal cancer (CRC) is controversial. The aim of this study was to examine the correlation between H. pylori, serum gastrin level, and atrophic gastritis with CRC. MATERIALS AND METHODS: Subjects were patients with CRC; controls were participants of a health check-up program that was conducted between October 1998 and March 2002 at four hospitals in Nagano Prefecture. For 121 newly diagnosed CRC cases, two controls matched by age (within 3 years), gender, and residence were randomly selected from the program participants. We conducted questionnaires and obtained blood samples from the cases and their controls. Consequently, the CRC cancer pairs consisted of 113 cases and 226 controls. RESULTS: Neither H. pylori infection nor gastrin level nor atrophic gastritis showed any association with a risk for CRC. However, serologically determined atrophic gastritis demonstrated significant elevation in odds ratios (ORs) for rectal cancer (OR = 3.15, 95% confidence interval; 1.19-8.35). CONCLUSIONS: Gastric conditions such as chronic H. pylori infection and atrophic gastritis are unlikely to increase the risk for CRC, although atrophic gastritis may increase the risk of rectal cancer.     

Comparative proteomics and immunoproteomics of Helicobacter pylori related to different gastric pathologies

Helicobacter pylori is a Gram-negative bacterium which causes ulcer, atrophic gastritis, adenocarcinoma, or mucosa-associated lymphoid tissue lymphoma. A comparative proteomic and immunoproteomic analysis was chosen to identify the antigenic patterns of three different H. pylori strains. These strains were probed against single sera from H. pylori-positive patients affected by gastric adenocarcinoma or duodenal ulcer. We found a quite heterogeneous antigenic pattern, both from strain and sera points of view, thus underlying both a strain- and a host-specificity. The different antigenic repertoires introduced the importance of the strain to be used for immunoblotting as a diagnostic test.     

Previous Helicobacter pylori infection–induced atrophic gastritis: A distinct disease entity in an understudied population without a history of eradication

Individuals with chronic atrophic gastritis who are negative for active H. pylori infection with no history of eradication therapy have been identified in clinical practice. By excluding false‐negative and autoimmune gastritis cases, it can be surmised that most of these patients have experienced unintentional eradication of H. pylori after antibiotic treatment for other infectious disease, unreported successful eradication, or H. pylori that spontaneously disappeared. These patients are considered to have previous H. pylori infection–induced atrophic gastritis. In this work, we define these cases based on the following criteria: absence of previous H. pylori eradication; atrophic changes on endoscopy or histologic confirmation of glandular atrophy; negative for a current H. pylori infection diagnosed in the absence of proton‐pump inhibitors or antibiotics; and absence of localized corpus atrophy, positivity for autoantibodies, or characteristic histologic findings suggestive of autoimmune gastritis. The risk of developing gastric cancer depends on the atrophic grade. The reported rate of developing gastric cancer is 0.31%‐0.62% per year for successfully eradicated severely atrophic cases (pathophysiologically equal to unintentionally eradicated cases and unreported eradicated cases), and 0.53%‐0.87% per year for spontaneously resolved cases due to severe atrophy. Therefore, for previous H. pylori infection–induced atrophic gastritis cases, we recommend endoscopic surveillance every 3 years for high‐risk patients, including those with endoscopically severe atrophy or intestinal metaplasia. Because of the difficulty involved in the endoscopic diagnosis of gastric cancer in cases of previous infection, appropriate monitoring of the high‐risk subgroup of this understudied population is especially important.     

Helicobacter pylori: immunoproteomics related to different pathologies

Helicobacter pylori is a Gram-negative bacterium that causes ulcer, atrophic gastritis, adenocarcinoma and mucosa-associated lymphoid tissue lymphoma. Moreover, an ongoing controversial role of this bacterium infection has been suggested in the etiopathogenesis of some extradigestive diseases. The humoral response to H. pylori during a natural infection can be used for diagnostic purposes and as a basis for vaccine development. Host-pathogen interactions may be investigated by means of immunoproteomics, which provides global information about relevant specific and nonspecific antigens, and thus might be suitable to identify novel vaccine candidates or serological markers of H. pylori infection as well as of different related diseases. In this review, we describe how several research groups used H. pylori proteomics combined with western blotting analysis, using sera from patients affected with different H. pylori-related pathologies, to investigate potential associations between host immune response and clinical outcomes of H. pylori infection, resulting in the rapid identification of novel, highly immunoreactive antigens.     

Neuroendocrine tumor in gastric adenoma: a diagnostic pitfall mimicking invasive adenocarcinoma

ABSTRACT: Neuroendocrine tumor (NET) in adenoma of the gastrointestinal tract is a rare mixed glandular-endocrine neoplasm and has uncommonly been described mostly in the colon. Histologically, this tumor is composed of a predominant proportion of benign adenomatous component and a small portion of well-differentiated NE component. Only three cases of NET in gastric adenoma have been reported in the literature. We present 4 cases of NET in gastric adenoma mimicking invasive adenocarcinoma. The NETs were 0.62 mm to 4.1 mm in size and located at the basal lamina propria, muscularis mucosa and submucosa. Histologically, NETs consisted of nests, cords, tubules, and clusters of cells that predominantly interposed between the foveolar base without disturbing the overall polyp architecture. The lesions were completely removed by endoscopic submucosal dissection in three cases and in one case, subtotal gastrectomy was performed because endoscopic biopsy was invasive adenocarcinoma. The patients' clinical course was uneventful without an evidence of recurrence or metastasis. The recognition of NET in gastric adenoma will help avoid potential diagnostic pitfalls masquerading as invasvie adenocarcinomas posed by their infiltrative pattern into submucosa.Virtual slidesThe virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1688552293761001.     

Plasma obestatin levels in men with chronic atrophic gastritis

Obestatin is a recently discovered active peptide isolated from the stomach. The purpose of the present study was to investigate the modification of plasma obestatin levels in men with chronic atrophic gastritis. Men older than 65 years undergoing upper gastrointestinal endoscopy were included. All patients with chronic atrophic gastritis underwent multiple biopsies. Fasting plasma obestatin and ghrelin levels were examined in 50 men with chronic atrophic gastritis and 50 healthy men. Plasma obestatin levels were significantly lower in patients with chronic atrophic gastritis than in healthy subjects. Plasma ghrelin levels and ghrelin to obestatin ratio was decreased in men with chronic atrophic gastritis. There was a significant relationship between atrophy and decreased obestatin. A negative correlation was found between circulating obestatin levels and body mass index (BMI) in healthy subjects, but not in patients with chronic atrophic gastritis. The data indicated that chronic atrophic gastritis influenced plasma obestatin levels as well as ghrelin to obestatin ratio in elderly men.     

Fascin regulates chronic inflammation‐related human colon carcinogenesis by inhibiting cell anoikis

By a proteomics‐based approach, we identified an overexpression of fascin in colon adenocarcinoma cells (FPCKpP‐3) that developed from nontumorigenic human colonic adenoma cells (FPCK‐1–1) and were converted to tumorigenic by foreign‐body‐induced chronic inflammation in nude mice. Fascin overexpression was also observed in the tumors arising from rat intestinal epithelial cells (IEC 6) converted to tumorigenic in chronic inflammation which was induced in the same manner. Upregulation of fascin expression in FPCK‐1–1 cells by transfection with sense fascin cDNA converted the cells tumorigenic, whereas antisense fascin‐cDNA‐transfected FPCKpP‐3 cells reduced fascin expression and lost their tumor‐forming ability in vivo. The tumorigenic potential by fascin expression was consistent with their ability to survive and grow in the three‐dimensional multicellular spheroids. We found that resistance to anoikis (apoptotic cell death as a consequence of insufficient cell‐to‐substrate interactions), which is represented by the three‐dimensional growth of solid tumors in vivo, was regulated by fascin expression through caspase‐dependent apoptotic signals. From these, we demonstrate that fascin is a potent suppressor to caspase‐associated anoikis and accelerator of the conversion of colonic adenoma cells into adenocarcinoma cells by chronic inflammation.     

Novel Association of Duodenal Gastrinoma and Atrophic Gastritis: Case Report and Literature Review

ObjectiveTo describe a patient with a duodenal gastrinoma in a setting of atrophic gastritis and hypergastrinemia.MethodsWe present historical features and results of laboratory and genetic evaluation in a woman with duodenal gastrinoma and hypergastrinemia due to atrophic gastritis.ResultsIn a 46-year-old woman with a history of stable pituitary microprolactinoma, multiple gastrointestinal symptoms developed and prompted the performance of an esophagogastroduodenoscopy in conjunction with small bowel biopsies. A 2-mm duodenal gastrin-producing neuroendocrine tumor was discovered. The tumor stained negative for serotonin and somatostatin and involved the mucosa and submucosa. Immunohistochemical staining of the gastrinoma tissue with a monoclonal antibody to the cholecystokinin-B (gastrin) receptor was negative. The patient’s random serum gastrin level was elevated at 990 pg/mL. She had been taking pantoprazole for 4 weeks before that test. After pantoprazole therapy was discontinued, the serum gastrin level remained elevated at 403 pg/mL. There was no family history of multiple endocrine neoplasia type 1, and genetic testing for the MEN1 mutation was negative. An upper endoscopy with measurement of gastric pH and performance of gastric biopsies confirmed the presence of chronic atrophic gastritis. This finding was consistent with the patient’s persistently elevated serum gastrin levels.ConclusionPatients with atrophic gastritis and associated hypergastrinemia are known to have a high frequency of hypergastrinemia-induced gastric carcinoid tumors, some of which are actual gastrinomas or are thought to arise from the G cells of the stomach. Gastrin is a well-recognized growth factor for many tissues. We postulate that hypergastrinemia in this patient might have had a trophic effect on the duodenal G cells and led to gastrinoma development. No gastrin receptors were detected on the gastrinoma cells; however, that result might have been attributable to technical (fixation or antibody) or tumor (dedifferentiation) problems. (Endocr Pract. 2007;13: 770-775)     

Immunohistochemical detection of carcinoembryonic antigen (CEA) in non-cancerous and cancerous gastric mucosa

Carcinoembryonic antigen (CEA) was stained by the PAP immunoperoxidase method in cancerous and non-cancerous gastric mucosa of 40 patients (25 non-cancerous dyspeptic patients and 15 patients with gastric carcinoma). The pattern of CEA localization was apical or membranous-cytoplasmic and immuno-reactivity was mild (+), moderate (++) or intensive ( ). No CEA immunoreactivity was detected in normal gastric mucosa whereas it was marked in gastric mucosa of non-cancerous dyspeptic patients with chronic atrophic gastritis and dysplasia (intense). In patients with superficial gastritis and epithelial hyperplasia it was mild or absent. The CEA localization pattern was also apical in non-cancerous dyspeptic patients with microscopic changes, e.g. superficial or chronic atrophic gastritis, epithelial hyperplasia and dysplasia, and in non-cancerous mucosa and cancerous tissue of patients with well (G1) and moderately (G2) differentiated adenocarcinoma.     

血清胃蛋白酶原联合G-17对萎缩性胃炎及胃癌早期诊断价值

目的:探索检测血清胃蛋白酶原Ⅰ(PGⅠ)、胃蛋白酶原Ⅱ(PGⅡ)、胃泌素-17(G-17)在萎缩性胃炎及胃癌中的诊断价值。方法:收集医院2015年2月至12月门诊及住院的慢性非萎缩性胃炎44例(非萎缩性胃炎组),慢性萎缩性胃炎47例(萎缩性胃炎组),早期胃癌42例(胃癌组)。采用酶联免疫吸附试验(ELISA)测定各组血清PGⅠ、PGⅡ、G-17的水平,同时计算PGⅠ/PGⅡ的比值(PGR),比较各组指标间的差异,同时绘制各指标筛查萎缩性胃炎及胃癌的受试者工作曲线(ROC)曲线,分别评价其诊断价值。结果:胃癌组及萎缩性胃炎组的血清PGⅠ、PGR水平较非萎缩性胃炎组明显下降,且胃癌组下降更明显,差异均具有统计学意义(P0.05),萎缩性胃炎组血清PGⅡ显著低于非萎缩性胃炎组,差异均具有统计学意义(P0.05);胃癌组的血清G-17水平较非萎缩性胃炎组及萎缩性胃炎组均升高,差异有统计学意义(P0.05)。血清PGⅠ筛查萎缩性胃炎的最佳界值为PGⅠ90 ng/m L,其灵敏度和特异度分别为71.5%和51.0%,血清PGR筛查萎缩性胃炎的最佳界值为PGR8,其灵敏度和特异度分别为71.9%和54.0%,血清G-17筛查萎缩性胃炎的最佳界值为G-175 pmol/L,其灵敏度和特异度分别为66.1%和64.0%。血清PGⅠ筛查胃癌的最佳界值为PGⅠ73 ng/m L,其灵敏度和特异度分别为86.0%和74.9%;血清PGR筛查胃癌的最佳界值为PGR3,其灵敏度和特异度分别为90.2%和62.5%;血清G-17筛查胃癌的最佳界值为G-174 pmol/L,其灵敏度和特异度分别为62.5%和61.3%。结论:胃癌及萎缩性胃炎患者血清PGⅠ、PGR水平下降明显,且胃癌患者的血清G-17异常升高,血清PG联合GS-17测定可用于萎缩性胃炎及胃癌的早期筛查。     

Helicobacter pylori attaches to NeuAc alpha 2,3Gal beta 1,4 glycoconjugates produced in the stomach of transgenic mice lacking parietal cells

Helicobacter pylori infection of the human stomach is associated with altered acid secretion, loss of acid-producing parietal cells, and, in some hosts, adenocarcinoma. We have used a transgenic mouse model to study the effects of parietal cell ablation on H. pylori pathogenesis. Ablation results in amplification of the presumptive gastric epithelial stem cell and its immediate committed daughters. The amplified cells produce sialylated oncofetal carbohydrate antigens that function as receptors for H. pylori adhesins. Attachment results in enhanced cellular and humoral immune responses. NeuAc alpha 2,3Gal beta 1,4 glycoconjugates may not only facilitate persistent H. pylori infection in a changing gastric ecosystem, but by promoting interactions with lineage progenitors and/or initiated cells contribute to tumorigenesis in patients with chronic atrophic gastritis.     

Mechanism of dissociation of cortisol and adrenal androgen secretion after removal of adrenocortical adenoma in patients with Cushing's syndrome

We investigated the mechanism of dissociation of cortisol and dehydroepiandrosterone sulfate (DHEA-S) secretion by the adrenal glands after the removal of an adrenal gland containing an adrenocortical adenoma in a patient with Cushing's syndrome. After removal of the adrenocortical adenoma, the serum cortisol rapidly decreased from 24.6 +/- 6.4 micrograms/dl (mean +/- SD, n = 6) to 0.7 +/- 0.5 micrograms/dl. Serum DHEA-S levels were 15 +/- 14 micrograms/dl and 6 +/- 9 micrograms/dl before and after surgery, respectively, and significantly lower than the control values. Serum cortisol levels reverted to normal levels 1.5 to 3 years after the surgery. On the other hand, DHEA-S levels reverted to normal 5 to 7 years after the serum cortisol levels had normalized. Monolayer cultures of normal human adrenal cells obtained at adrenalectomy in patients with advanced breast cancer and atrophic adrenal cells adjacent to the adrenocortical adenoma in patients with Cushing's syndrome were used to study the mechanism of the dissociation of cortisol and DHEA-S secretion. ACTH caused significant increases in the productions of pregnenolone (P5), progesterone (P4), 17-hydroxypregnenolone (17-OH-P5), 17-hydroxyprogesterone (17-OH-P4), DHEA, DHEA-S, androstenedione (delta 4-A), and cortisol. The amounts of 17-OH-P5 and 17-OH-P4 produced by ACTH in atrophic adrenal cells were significantly greater than those in normal adrenal cells. The amounts of DHEA, DHEA-S and delta 4-A produced by ACTH in atrophic adrenal cells were significantly smaller than those of normal adrenal cells. The conversion rate of 17-OH-[3H]P5 to 17-OH-[3H]P4 and 11-deoxy-[3H] cortisol was higher in atrophic adrenal cells than in normal adrenal cells, but the conversion rate to [3H]DHEA, [3H]DHEA-S and [3H]delta 4-A was significantly lower in atrophic adrenal cells than in normal adrenal cells. These results suggest that the dissociation of cortisol from DHEA-S after the removal of adrenocortical adenoma is a probably due to diminished C17,20-lyase activity in the remaining atrophic adrenal gland.