Parental Occupation and Other Environmental Factors in the Etiology of Leukemias and Non-Hodgkin'S Lymphomas in Childhood: A Case-Control Study

We report the results of a hospital-based, case-control study on acute lymphocytic leukemia (ALL), acute non-lympocytic leukemia (AnLL) and non-Hodgkin lymphoma (NHL) in childhood. The study was conducted from 1981 to 1984 in Turin (Italy). One hundred and forty-two children with ALL, 22 with AnLL and 19 with NHL were included, as well as 307 controls. Information on parental smoking habits, parental occupation, ionizing radiation and childhood diseases were collected using a standard questionnaire during a personal interview of the relative attending the child in the hospital. The odds ratios for antenatal diagnostic radiation were 1.1 (NS) for ALL and 2.4 (NS) for AnLL. No association was found with diseases in childhood. Paternal and maternal smoking habits were similar for ALL cases and controls. Both maternal and paternal smoking were associated with NHL: for paternal smoking, odds ratios were around 5, but without a correlation with number of cigarettes. Positive associations observed with maternal employment were: ALL with teacher and cleaner; AnLL and textile worker; NHL and baker. Corresponding association with paternal jobs were: ALL with clerks, farmers and employment in office equipment production; AnLL and workers in building, tire or textile industries; NHL and lorry drivers, workers in the building or in the wood and furniture industry.

Risk Factors for Soft Tissue Sarcomas in Childhood: A Case-Control Study

A hospital-based case-control study on soft tissue sarcomas (STS) was conducted in 1983-84 in Torino and in Padova (Italy). Cases (36 children with rhabdomyosarcoma (RMS) and 16 non RMS-STS) were compared to 326 controls. Histories of parental smoking habits and occupations, parental and children's exposure to ionizing radiation, children's diseases and some other variables were collected through interviews to the relatives attending the child in the hospital. A non statistically significant association was observed with both maternal age above 30 at child's birth (STS: OR = 1.5, C.I. = 0.8-2.9; RMS: OR = 1.9, C.I. = 0.9-4.0) and « in utero » exposure to diagnostic radiation (STS: OR = 1.9, C.I. = 0.5-6.5, based on 4 cases). No association was found with children's previous diseases. Paternal and maternal smoking habits were similar for RMS and STS cases and controls. Some positive associations with either maternal or paternal occupational histories were identified. They are difficult to interpret in view of the large number of comparisons and small absolute figures. They included maternal employment as medical doctor and nurse, farmer, textile worker and machine tool operator. An association was also observed with paternal occupation as butcher, building worker or employment in the production of domestic appliances. One case and no controls reported a maternal aunt affected by breast cancer.

Physical Impairment and Social Life, Goals among Adult Long-term Survivors of Childhood Cancer: A Population-based Study from the Childhood Cancer Registry of Piedmont, Italy

Aims and Background

The study describes the health status and the attainment of life goals in the adult survivors of childhood cancer recorded at the Childhood Cancer Registry of Piedmont.

Methods and Study Design

A postal questionnaire was sent to the general practitioner of the 690 cases born before 1976 and alive in 1991 after at least 5 years from diagnosis. The answer was received for 485 (72.9%) included in the analyses. Items in the questionnaire were: sequelae related to cancer and its treatment, health-related quality of life (according to Bloom's criteria), educational level attained, and employment status.

Results

Vital and marital status were obtained for all 690 cases at the offices of the town of residence. No medical condition was reported for 309 cases (63.7%). The overall proportion with a high school or university education was compared to corresponding figures for Piedmont in 1991, adjusted by age, and was as high as in the general population. Similar results are observed for occupation. Patients of both genders were married less than expected. Patients with leukemia (112 cases), non-Hodgkin's lymphoma (34) or Hodgkin's lymphoma (52) were reported to have the highest quality of life. In contrast, patients with tumors of the central nervous system (151) had the highest frequency of sequelae and the lowest score for health-related quality of life. They also presented the lowest educational achievement, the lowest proportion of employment and, among males, the lowest frequency of marriage.

Conclusions

Our study shows a good social adjustment of adult survivors from childhood cancer, with the exception of central nervous system tumors. From the methodologic point of view, the present study shows the feasibility of surveillance surveys on health-related quality of life with the contribution of general practitioners.

Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines for rasburicase therapy in the context of G6PD deficiency genotype

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is associated with development of acute hemolytic anemia (AHA) induced by a number of drugs. We provide guidance as to which G6PD genotypes are associated with G6PD deficiency in males and females. Rasburicase is contraindicated in G6PD-deficient patients due to the risk of AHA and possibly methemoglobinemia. Unless preemptive genotyping has established a positive diagnosis of G6PD deficiency, quantitative enzyme assay remains the mainstay of screening prior to rasburicase use. The purpose of this article is to help interpret the results of clinical G6PD genotype tests so that they can guide the use of rasburicase. Detailed guidelines on other aspects of the use of rasburicase, including analyses of cost-effectiveness, are beyond the scope of this document. Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines are published and updated periodically on https://www.pharmgkb.org/page/cpic to reflect new developments in the field.

Persistence of expression of the TMPRSS2:ERG fusion gene after pre-surgery androgen ablation may be associated with early prostate specific antigen relapse of prostate cancer: preliminary results

BACKGROUND

The recently identified TMPRSS2: ERG fusion gene is a candidate oncogene for prostate cancer (PCa).

SUBJECTS AND METHODS

We have tested for the presence of this gene in tumor samples from 84 patients who had radical prostatectomy in 1998-2000. Sixty patients (group A) had surgery only; 24 patients (group B) received androgen ablation therapy for 3 months before surgery. The occurrence of the rearrangement was evaluated by RT-PCR and by fluorescent in situ hybridization analysis.

RESULTS

A TMPRSS2:ERG fusion gene was present and expressed, as demonstrated by RT-PCR, in 84% of patients in group A and in 54% of patients in group B (p=0.01). The presence of TMPRSS2:ERG transcripts and the levels of ERG RNA, measured by quantitative Real Time-PCR, did not correlate significantly with clinical and pathologic characteristics of the tumors. In patients of group A, but not in those of group B, ERG expression showed a negative correlation with the Gleason score (p=0.0001). Histochemical analysis showed that ERG expression is limited to tumor cells, and in group A patients (but not in group B patients) it is limited to those glands that express TMPRSS2:ERG.

CONCLUSION

The lower proportion of patients expressing TMPRSS2: ERG in group B suggests that androgen ablation inhibits the expression of TMPRSS2:ERG. Moreover, in group B, but not in group A, patients with expression of the fusion gene had earlier prostate specific antigen recurrence (p=0.007). Although preliminary, the data indicate that tumors in which pre-surgery androgen ablation fails to suppress expression of the fusion gene have a higher risk of recurrence.

Familial erythrocytosis with over-production of erythropoietin

A family is described in which the father and son had erythrocytosis associated with a normal Hb oxygen affinity. Growth of erythroid colonies in vitro (BFU-E) exhibited normal erythropoietin dependence. In the son there was an enlarged erythroid precursor compartment, while the father (who had been treated by busulphan) showed marked reduction of circulating BFU-Es. Serum erythropoietin (Epo), estimated by radio-immunoassay, was 96 miu/ml in the son and 360 miu/ml in the father (normal 25, SD 6, n = 46). We conclude that erythrocytosis in this family is due to a genetically determined hyper-production of Epo. The finding in the father of a high Hb level associated with increased Epo and decreased BFU-Es might support the hypothesis that red cell mass is regulated by Epo at the level of bone marrow CFU-Es rather than BFU-Es.

Genetic variation in the host and adaptive phenomena in Plasmodium falciparum infection

The in vitro culture of Plasmodium falciparum, after synchronization, lends itself well to an analysis of the asexual schizogonic cycle. We have found in this system that DNA synthesis and RNA synthesis are associated mainly with the trophozoite stage, with the latter peaking slightly ahead of the former. Distinctive patterns of protein synthesis are seen at serial times along the cycle, with a number of 'stage-specific' bands identifiable on SDS gels. The fate of the infection can be influenced by the genotype of the host cell. Thus, glucose-6-phosphate dehydrogenase (G6PD)-deficient erythrocytes are invaded normally, but maturation of intracellular parasites is delayed and impaired. However, the parasites that do develop will then have a normal behaviour in their next rounds in G6PD-deficient cells, suggesting that an adaptive change has taken place. These results fit well with the relative protection against P. falciparum in vivo of girls heterozygous for G6PD deficiency but not of hemizygous G6PD-deficient boys.

Evaluation of risk for development of myeloproliferative disorders, myelodysplastic syndromes, or acute leukemias with long-term eculizumab therapy in paroxysmal nocturnal hemoglobinuria (PNH) patients

7087

Background: PNH is a rare bone marrow failure disorder defined by stem cell clones with somatic mutations in the PIG-A gene. These mutations result in peripheral blood cells deficient in GPI-anchored proteins including complement inhibitors CD55 and CD59. Chronic lysis of PNH RBCs leads to severe anemia, life-threatening thrombosis, debilitating fatigue, and impaired quality of life. Previous studies have indicated an increased frequency of myeloproliferative disorders, MDS, and acute leukemias in PNH. In a previous retrospective analysis of 1,760 PNH patients, 6.8% developed either myeloid or lymphoid disorders and 1% developed acute leukemias. Eculizumab (Soliris) is a humanized antibody that prevents terminal complement activation. Long-term eculizumab treatment has been evaluated in 195 PNH patients (>250 patient years of exposure) and shown to significantly restore the endogenous PNH RBC clone resulting in improved anemia, as well as significant improvements in thrombosis, fatigue, and quality of life. Methods: Leukocyte clone sizes were assessed at baseline and 26 weeks for patients receiving eculizumab in the Phase III clinical trials (TRIUMPH and SHEPHERD) using flow cytometry. The frequency of MDS and leukemia was calculated as a percentage of the eculizumab-treated patients across all eculizumab trials. Results: PNH leukocyte clone size did not increase with eculizumab treatment (median 96.1% at baseline vs 95.5% at week 26; P=0.80, signed rank test) suggesting that inhibition of terminal complement does not destroy or result in the proliferation of PNH leukocyte clones. Additionally, the frequency of new MDS (1/195 patients, 0.5%) and CMML (1/195 patients, 0.5%) during the treatment period was not increased over that expected. The single case of CMML occurred in a patient previously diagnosed with and was attributed to high grade myelodysplasia. Conclusions: To date, eculizumab treatment of PNH patients does not increase the risk for the development of myeloproliferative disorders, MDS or acute leukemias. Patients on eculizumab will continue to be followed in a Global PNH Safety Registry.

No significant financial relationships to disclose.

Safety and efficacy of eculizumab in paroxysmal nocturnal hemoglobinuria evolving from patients with myelodysplastic syndrome and aplastic anemia

7033

Background: Myelodysplastic syndrome (MDS) and aplastic anemia (AA) have been reported to be associated with the development of the acquired clonal hemolytic and bone marrow failure disorder, paroxysmal nocturnal hemoglobinuria (PNH). Two recent phase 3 clinical studies have demonstrated significant benefit of the complement inhibitor eculizumab (Soliris) in a heterogeneous population of patients with PNH (n=140). Methods: To investigate whether eculizumab was safe and effective in PNH patients with a history of MDS or AA (n=37), efficacy parameters were examined in the MDS/AA patient subpopulation. Results: Intravascular hemolysis, as assessed by plasma levels of the enzyme lactate dehydrogenase (LDH), was reduced from a mean of 1871 ± 159 U/L at baseline to 300 ± 21 U/L at week 26 in patients with a history of MDS or AA (p<0.001, signed rank test; normal range 103–223 U/L). Anemia was improved as packed RBC transfusion requirements were substantially reduced with eculizumab in these patients from a median of 8 units per patient in the 6 months before treatment to 0 units per patient during eculizumab treatment (p<0.001, signed rank test). Despite history of bone marrow failure, eculizumab treatment markedly improved fatigue with an 11.6 point increase over baseline using the FACIT-Fatigue instrument (p<0.001, signed rank test; a 3 or more point increase in this instrument has been shown to be clinical meaningful). Fatigue was similarly improved with the fatigue scale of the EORTC QLQ-C30 instrument (p<0.001, signed rank test). Eculizumab appeared to be well tolerated when administered to PNH patients with a history of MDS or AA. The significant clinical improvements in hematologic and quality of life outcomes with eculizumab treatment in PNH patients with a history of MDS or AA were similar to the clinical improvements demonstrated the overall PNH patient population. Conclusions: These analyses show that eculizumab treatment may provide important clinical benefit when administered to PNH patients with a history of bone marrow failure.

No significant financial relationships to disclose.

Safety and efficacy of eculizumab with concomitant erythropoietin therapy in patients with paroxysmal nocturnal hemoglobinuria (PNH)

3032

Background: Erythropoietins (EPO) are commonly used to improve anemia in patients with bone marrow failure syndromes and in patients with chemotherapy-induced anemia. Two recent phase 3 clinical studies have demonstrated significant benefit of the terminal complement inhibitor, eculizumab (Soliris), in a heterogeneous population of patients with the acquired clonal hemolytic and bone marrow failure disorder, PNH (n=140). While previous studies have shown that EPO is associated with only moderate improvements in fatigue in anemic cancer patients (effect size of 0.5), eculizumab has demonstrated large improvements in fatigue in PNH patients (effect size of 1.1). Methods: To investigate whether eculizumab provides further benefit to PNH patients receiving EPO, efficacy parameters were examined in the EPO subpopulation (n=8). Results: Intravascular hemolysis, as assessed by plasma levels of lactate dehydrogenase (LDH) area under the curve, was reduced 268,271 U/L x day to near normal levels in EPO-treated patients during 26 weeks of eculizumab therapy (p=0.008, signed rank test). Anemia was improved as packed RBC transfusion requirements were substantially reduced with eculizumab in EPO patients from a median of 7.5 units per patient in the 6 months before treatment to 1 unit per patient during eculizumab treatment (p=0.031, signed rank test). Despite pre-existing EPO and transfusion support, eculizumab treatment markedly improved fatigue with a 7.3 point increase over baseline using the FACIT-fatigue instrument (p=0.016, signed rank test; a 3 or more point increase in this instrument has been shown to be clinically meaningful). Eculizumab was well tolerated when administered to PNH patients treated with concomitant EPO with adverse events similar to the overall population. The significant clinical improvements in hematologic and quality of life outcomes with eculizumab treatment in PNH patients receiving concomitant EPO were similar to the clinical improvements demonstrated in the overall PNH patient population. Conclusions: These analyses show that eculizumab treatment provides important clinical benefit when administered to PNH patients receiving EPO support for bone marrow failure.

No significant financial relationships to disclose.

[Breast surgery in HIV-positive women]

The increasing of HIV infection in young women as well as prolonged survival let us to register an important rising of breast cancers in such type of patients. The Authors report the case of a 48 year old HIV-positive woman, who underwent surgery because of the histological positivity for cancer of the right breast. It was decided to perform a quadrantectomy and reconstruction with implant, because of the absence of immunodepression. The Authors discuss about indications for reconstructive surgery in seropositive women with breast cancer.

[Is the Lauren classification an independent parameter for the prognostic evaluation of surgically treated gastric cancer patients? Analysis of a case series]

The Authors highlight the efficacy of the Lauren's classification in 28 surgically treated gastric cancer patients. Lauren's classification allows a prognostic evaluation corresponding to the effective gastric cancer natural history. Present histo-morphological classification criteria appear not to coincide with the clinical evolution; as a matter of fact over- or understaging is possible in gastric cancer patients. 64,28% of the Lauren's classification intestinal type patients survive after a four year follow up vs. 42,85% of the diffuse type patients. The Authors discuss about new biomolecular knowledge in gastric cancer oncogenesis.

[Telementoring in surgery]

Tele-mentoring is an interactive experimental method that allows young surgeons' education by distant learning tutoring of an expert surgeon. The problem about assessment of efficacy and quality of computer-assisted instruction is under evaluation today. Tele-mentoring is supported by videoconferencing system and it is not an exclusive methodology but an additional methodology to traditional didactic for clinicians and surgeons. It allows personal virtual trainings by computers and telecommunication systems. Videoconference allows tutoring for telemedicine, teletriage and telesurgery also.

[Changes in the expression of cellular alpha and beta tubulins in patients with sporadic type colorectal cancer]

The aim of this preliminar report is to evaluate alfa and beta tubulins, components of cellular microtubules, alterated expression in sporadic colorectal cancer patients. The Authors considered 16 patients who underwent surgery for sporadic colorectal carcinoma with radical intent. Alfa and beta tubulins were evaluated in tumoral mucosa by immunohistochemistry. In 56.2% of the examined patients a low expression of alfa and beta tubulins was showed while the alteration of alfa tubulin was showed in 81.2% of the patients. This finding supports the hypothesis of Porter that alterations in microtubule structure might be part of the cellular response to DNA damage.

[From molecular biology to new treatment approaches to colorectal cancer: basic research, experimental trials and surgical implications]

The Authors review the natural history of colorectal cancer from the point of view of molecular biology and genetics from aberrant crypts foci and familiar adenomatous polyposis to hereditary non polyposis colon cancer and sporadic colorectal cancer. They carry out international literature about basis knowledges, experimental trials and personal studies. Up to day traditional colorectal cancer surgical treatments and adjuvant or neoadjuvant pharmacological therapy cannot be modified, nevertheless "new drugs generation" known as signal transduction inhibitor could, in the future, prove to be an effective cancer treatment. The Authors highlight recent experimental clinical trials probably able to prevent sporadic colorectal cancer spreading and precursor evolution.

Prospective analysis of minimal bone marrow infiltration in pediatric Burkitt's lymphomas by long-distance polymerase chain reaction for t(8;14)(q24;q32)

The chromosomal translocation t(8;14)(q24;q32) represents a characteristic marker for Burkitt's lymphoma (BL). This translocation involves the MYC oncogene on chromosome 8 and the immunoglobulin heavy-chain (IgH) locus on chromosome 14. Since the translocation does not produce a fusion gene, we established a long-distance polymerase chain reaction (LD-PCR) assay that can detect the t(8;14) at the genomic level. The sensitivity of the LD-PCR was 10(-4). We used the LD-PCR assay to prospectively study 78 BL patients and found a specific PCR product in 52 of them. Among the 52 positive patients, we could test both the tumor and the bone marrow (BM) at diagnosis in 33 and determined the prevalence of minimal disseminated disease (MDD) at diagnosis. In 12/33 patients, BM was positive by LD-PCR and in 10 of them we conducted a study of minimal residual disease (MRD). Eight out of 10 children showed a clearance of MRD after one cycle of chemotherapy. The only two patients who did not achieve a negative MRD status died of disease progression. The comparative analysis of sensitivity of BM aspirate, BM biopsy and LD-PCR in t(8;14)-positive patients demonstrated a superiority of the molecular method in the assessment of MDD. The LD-PCR for t(8;14) is an important tool to study minimal BM infiltration at diagnosis and to determine its response kinetics in BL.

Dynamics of hematopoiesis in paroxysmal nocturnal hemoglobinuria (PNH): no evidence for intrinsic growth advantage of PNH clones

PNH is characterized by expansion of one or more stem cell clones with a PIG-A mutation, which causes a severe deficiency in the expression of glycosylphosphatidylinositol (GPI)-anchored proteins. There is evidence that the expansion of PIG-A mutant clones is concomitant with negative selection against PIG-A wild-type stem cells by an aplastic marrow environment. We studied 36 patients longitudinally by serial flow cytometry, and we determined the proportion of PNH red cells and granulocytes over a period of 1-6 years. We observed expansion of the PNH blood cell population(s) (at a rate of over 5% per year) in 12 out of 36 patients; in all other patients the PNH cell population either regressed or remained stable. The dynamics of the PNH cell population could not be predicted by clinical or hematologic parameters at presentation. These data indicate that in most cases the PNH cell expansion has already run its course by the time of diagnosis. In addition, since in most cases no further expansion takes place, we can infer that the tendency to overgrow normal cells is not an intrinsic property of the PNH clone.

[Periareolar subcutaneous quadrantectomy: a new approach in breast cancer surgery]

Plastic and oncological breast surgery are becoming more and more closer as one surgical treatment. The term "oncoplastic surgery" refers to the use of plastic surgery techniques in breast cancer surgery, in order to avoid and to correct the adverse aesthetic findings. The care of cosmetic sequelae of breast cancer surgery has reached an important therapeutic role for psychological consequences of disease and because of the higher patients expectations of a good aesthetic result. Considering the concept of oncoplastic surgery, since 1999 the Authors began to use a periareloar approach in the breast conserving therapy (BCT), associated to axillary dissection performed through the same periareolar incision. This technique, original from the oncological point of view, is not different from the traditional quadrantectomy in the extension of the glandular resection, while the skin may be preserved in according to the conventional protocols of BCT. Oncological and aesthetic results have proved to be safe and satisfactory.

Association of clonal T-cell large granular lymphocyte disease and paroxysmal nocturnal haemoglobinuria (PNH): further evidence for a pathogenetic link between T cells, aplastic anaemia and PNH

There is mounting evidence to suggest that T-cell-mediated suppression of haemopoiesis is a pathogenetic mechanism in three bone marrow failure syndromes: aplastic anaemia (AA), paroxysmal nocturnal haemoglobinuria (PNH) and myelodysplasia (MDS). T-cell microclones can be detected by sensitive polymerase chain reaction (PCR)-based methods in all three disorders. Recently, larger clonal populations of T-cell large granular lymphocytes (T-LGLs) have been observed in some patients with AA and MDS. Here, we report the development of a large clonal T-LGL population in a patient with bona fide PNH. In this patient, we defined part of the sequence of the T-cell receptor (TCR) beta-chain gene, and we have shown that the large T-LGL population emerged from a background of multiple smaller T-cell clones. Thus, T-LGL clones in AA, MDS and PNH probably expand as a result of antigenic stimulation. It is postulated that the antigen driving clonal T-cell proliferations in these disorders exists on haemopoietic stem cells.