Activated effector and memory T cells contribute to circulating sCD30: potential marker for islet allograft rejection

T-cell activation up-regulates CD30 resulting in an increase in serum soluble CD30 (sCD30). CD4+ T cells, a major source for sCD30, play a significant role in the pathogenesis of rejection. In this study, sCD30 was measured pre- and posttransplant in mouse islet allograft models and human islet allograft recipients. sCD30 was measured by ELISA in diabetic C57BL/6, CD4Knockout (KO) and CD8KO islet allograft recipients. sCD30 increased significantly prior to rejection (1.8 +/- 1 days) in 80% of allograft recipients. Sensitization with donor splenocytes, or a second graft, further increased sCD30 (282.5 +/- 53.5 for the rejecting first graft vs. 374.6 +/- 129 for the rejecting second graft) prior to rejection suggesting memory CD4+ T cells contribute to sCD30. CD4KO failed to reject islet allograft and did not demonstrate sCD30 increase. CD8KO showed elevated (227 +/- 107) sCD30 (1 day) prior to rejection. High pretransplant sCD30 (>20 U/ml) correlated with poor outcome in human islet allograft recipients. Further, increase in sCD30 posttransplant preceded (3-4 months) loss of islet function. We conclude that sCD30 is released from activated CD4 T cells prior to islet allograft rejection and monitoring sCD30 can be a valuable adjunct in the follow-up of islet transplant recipients.

Choices: a study of preferences for end-of-life treatments in patients with advanced heart failure

BACKGROUND

The purpose of this study is to describe the treatment preferences of patients with heart failure among three distinct treatment options--optimal medical management, oral inotropes or left ventricular device (LVAD) support--to determine if there were differences in preferences between patients with mild heart failure (New York Heart Association [NYHA] Class II) and severe heart failure (NYHA Class IV), and also to determine whether quality of life, perceived severity of symptoms and overall health influenced treatment preferences.

METHODS

We enrolled 91 patients who completed the Minnesota Living with Heart Failure Questionnaire (MLHFQ); visual analog scales for depicting their perceived severity of overall health, dyspnea and fatigue; and a treatment trade-off tool.

RESULTS

The most preferred treatment options were oral inotropes, LVAD and standard medical management. There were no differences in treatment preferences between NYHA II and NYHA IV patients. Patient preferences correlated poorly with MLHFQ, symptom and overall health scores. Although not statistically significant, there was a trend toward patients with worse quality of life and symptom scores preferring more aggressive treatment.

CONCLUSIONS

The results of our study identified two distinct groups of patients: one group preferring treatments that prolonged survival time and another group that favored strategies that improved quality of life but reduced survival time. Treatment preferences were independent of functional or symptom status, suggesting that preferences may be decided early in the course of illness.

Myotonic dystrophy in a patient of celiac disease: a new association?

Celiac disease (CD) has long been known to be associated with neurological and psychiatric manifestations; its in association with myotonic dystrophy however has not yet been reported. We report the case of a 27-year old female patient who presented to us with diarrhoea, weight loss, easy fatigability, irritability and alopecia of 8 months duration and was diagnosed to have celiac disease and put on gluten free diet. 8 weeks later she developed neurological symptoms and was found to have myotoni dystrophy in addition. At six month follow up patient had gained 5 kg, but the neurological symptoms remained the same. Treatment of neurological symptoms associated with gluten hypersensitivity depends on the type of neurological syndrome associated. Only exceptionally do these symptoms improve with gluten restriction and, in some patients, the neurological manifestations even progress despite resolution of both pathologic findings and intestinal symptoms.

The correlation of regression in primary melanoma with sentinel lymph node status

BACKGROUND

The significance of regression in primary melanoma has been disputed for many years. Some have suggested regression as a marker for poor prognosis while others have reported a negligible or even a favourable effect, on prognosis.

AIM

To understand the significance of regression in melanoma and provide further information on whether patients should be subjected to sentinel lymph node biopsy (SLNB) on the basis of regression.

METHODS

146 melanoma cases who had undergone SLNB were included in the study. The histological criteria for offering SLNB were melanoma >1 mm in thickness, Clark's level IV or those with regression.

RESULTS

A statistically significant greater proportion of individuals without regression showed sentinel lymph node (SLN) positivity (p = 0.028) compared with those which do show regression. Metastatic disease correlated with growth phase of the primary lesion. All the node positive cases were in the vertical growth phase; none of the cases in radial growth phase and showing regression were associated with nodal metastasis (p = 0.029). 62 cases had melanomas with thickness <1 mm and were in radial growth phase, yet were offered SLNB because of regression. Of these, 44 showed features of regression and all were node negative. The remaining 16 cases of thin melanomas did not show regression; 2 of these had sentinel node metastasis.

CONCLUSION

Results suggest that regression is usually a favourable process, particularly in thin melanomas and that metastasis in "thin melanomas showing regression" is real but rare. Variant vertical growth phase, mitoses and other prognostically significant variables may be more important predictors of metastatic potential in thin melanomas.

Chemoprotection by VEGF: Rationale for combination nab-paclitaxel and bevacizumab

1064

Background: Nanoparticle albumin-bound (nab-) paclitaxel (ABX) has shown greater efficacy and less toxicity than solvent-based paclitaxel (TAX) in xenograft models and clinical trials. The goal of this study was to determine the effects of VEGF modulation in human MDA-MB-231 breast tumor cell line and the effects of ABX and VEGF-neutralizing antibody bevacizumab (AVA) combination on the growth and metastasis of orthotopically implanted MDA-MB-231 tumors. Methods: VEGF expression was evaluated by ELISA in MDA-MB-231 tumor extract one week after treatment (qdx5) with saline, doxorubicin (10 mg/kg), TAX (10 mg/kg), or ABX (15 mg/kg). VEGF-receptor expression in MDA-MB-231 was quantitated by RT-PCR. MDA-MB-231 cytotoxicity with ABX, VEGF, AVA alone or in combination was measured by cytotoxicity and clonogenic assays. Implanted MDA-MB-231 tumors expressing luciferase were treated with saline, 2 cycles of ABX (10 mg/kg, two qdx5 cycles separated by 1 week, N=5) alone or in combination with AVA (2, 4 and 8 mg/kg, 2/wkx6). Tumor lymph node and pulmonary metastasis was determined by measuring luciferase activity. Results: Compared with saline, MDA-MB-231 tumors following chemotherapies exhibited significant tumor shrinkage (p≤0.006, t-test) and VEGF induction (p<0.0001, t-test). MDA-MB-231 was shown to express VEGFR2. Exogenous VEGF had a protective effect on MDA-MB-231 tumor cells by reducing cytotoxicity of ABX in both cytotoxicity and clonogenic assays. Sequestration of VEGF with AVA increased cytotoxicity of ABX in vitro. Treatment of MDA-MB-231 breast tumors with ABX and AVA combination resulted in greater than additive antitumor response and significantly reduced metastasis to the lungs (p=0.025 vs control) and LN (p=0.022) at the highest AVA dose. Conclusions: Chemotherapies induced VEGF expression in MDA-MD-231 breast tumor in vivo. In vitro, VEGF exerted a protective effect against ABX chemotherapy in VEGFR2-expressing MDA-MD-231 cells, which was abrogated by addition of AVA. In vivo, ABX and AVA combination significantly inhibited the metastatic potential of MDA-MB-231 tumor cells. These data provide a rational basis for the combination of nab- paclitaxel and bevacizumab in VEGF-receptor expressing tumors.

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Protective effect of a brisk tumor infiltrating lymphocyte infiltrate in melanoma: An EORTC melanoma group study

8519

Background: Tumor-infiltrating lymphocytes (TILs) in melanoma are responsible for tumor killing and may induce spontaneous regression. Brisk TILs in the melanoma vertical growth phase (VGP) is a strong, albeit not independent, prognostic factor associated with superior survival. This study investigated whether more detailed classes of TIL patterns, based on topography and intensity, are independent prognostic factors and identify patients with good prognosis. Methods: The study included 1,171 patients with cutaneous VGP melanoma with at least 3 years of follow up for whom slides were available for review. TIL infiltrate was assessed for pattern (absent, non brisk, brisk), intensity (scanty, moderate, dense), and topography (peripheral, central, both). Pattern was assessed qualitatively: brisk TIL infiltrate was defined as a continuous band of lymphocytes at the base of the melanoma, or throughout the tumor. Other studied variables were: thickness, mitotic count (MC), ulceration, gender, age, anatomic site, melanoma-related death (MRD). Subsequently, Chi-square tests, Kaplan-Meier curves (KM), logrank tests, and Cox models were applied to examine the relation between MRD, TIL categories and interaction with other variables. Results: A brisk infiltrate was observed in 21.2% of the cases. Adjusted hazard ratio for MRD as compared to the absent category was 0.82 (95% CI=0.64–1.06) in the non-brisk category, and 0.43 (95% CI=0.28–0.68) in the brisk category. Based on the Cox model, brisk TIL was an independent prognostic factor for MRD (p<0.001) controlling for thickness, MC, ulceration, gender, age and site. Intensity was significantly associated with MRD for melanomas with peripheral and central brisk TILs (p=0.027) but not for other melanomas. Remarkably, no death was observed in the 5.5% of melanomas with dense, brisk TIL infiltrate at ten years. Conclusions: A brisk TIL pattern was shown to have prognostic value for MRD underscoring the importance of TILs in the outcome of VGP melanoma patients. Furthermore, we identified a small population of “super-responder” patients whose tumor was characterised by a continuous and dense TIL infiltrate and who did not display signs of tumor progression.

No significant financial relationships to disclose.