Development of a multiplex RNA urine test for the detection and stratification of transitional cell carcinoma of the bladder

PURPOSE

New markers that enable the percentage of transitional cell carcinomas (TCC) of the bladder that are diagnosed before invasion of the bladder muscle layers to be increased would reduce the morbidity and mortality associated with this disease. The purpose of this study was to develop a simple, accurate urine test based on mRNA markers and simple gene signatures that (a) could detect TCC before muscle invasion while maintaining high specificity in patients with hematuria or urinary tract infections and (b) identify patients most likely to have grade 3 or stage > or =T1 disease.

EXPERIMENTAL DESIGN

RNA markers with high overexpression in stage Ta tumors and/or T1 to T4 tumors but low expression in blood or inflammatory cells were characterized by quantitative reverse transcription-PCR using 2 mL of voided urine from 75 TCC patients and 77 control patients with other urological diseases.

RESULTS

A combination of the RNAs CDC2, MDK, IGFBP5, and HOXA13 detected 48%, 90%, and 100% of stage Ta, T1, and >T1 TCCs, respectively, at a specificity of 85%. Detection of Ta tumors increased to 60% for primary (non-recurrent) Ta tumors and 76% for Ta tumors > or =1 cm in diameter. Test specificity was 80% for the 20 control patients with urinary tract infections. The combination of CDC2 and HOXA13 distinguished between grade 1 to 2 TCCs and grade 3 or stage > or =T1 TCCs with approximately 80% specificity and sensitivity.

CONCLUSIONS

Simple gene expression signatures can be used as urine markers for the accurate detection and characterization of bladder cancer.

Primary tumours of the synovium. A report of four cases of malignant tumour

Four patients who developed malignant synovial tumours are described; one with chondromatosis developed a synovial chondrosarcoma and three with pigmented villonodular synovitis developed malignant change. The relevant literature is discussed.

A knee-sparing distal femoral endoprosthesis using hydroxyapatite-coated extracortical plates

We used a knee-sparing distal femoral endoprosthesis in young patients with malignant bone tumours of the distal femur in whom it was possible to resect the tumour and to preserve the distal femoral condyles. The proximal shaft of the endoprosthesis had a coated hydroxyapatite collar, while the distal end had hydroxyapatite-coated extracortical plates to secure it to the small residual femoral condylar fragment. We reviewed the preliminary results of this endoprosthesis in eight patients with primary bone tumours of the distal femur. Their mean age at surgery was 17.years (14 to 21). The mean follow-up was 24 months (20 to 31). At final follow-up the mean flexion at the knee was 102° (20° to 120°) and the mean Musculoskeletal Tumour Society score was 80% (57% to 96.7%).

There was excellent osteointegration at the prosthesis-proximal bone interface with formation of new bone around the hydroxyapatite collar. The prosthesis allowed preservation of the knee and achieved a good functional result. Formation of new bone and remodelling at the interface make the implant more secure. Further follow-up is required to determine the long-term structural integrity of the prosthesis.

Non-invasive distal femoral expandable endoprosthesis for limb-salvage surgery in paediatric tumours

We report our early experience with the use of a non-invasive distal femoral expandable endoprosthesis in seven skeletally immature patients with osteosarcoma of the distal femur. The patients had a mean age of 12.1 years (9 to 15) at the time of surgery. The prosthesis was lengthened at appropriate intervals in outpatient clinics, without anaesthesia, using the principle of electromagnetic induction. The patients were functionally evaluated using the Musculoskeletal Tumour Society scoring system. The mean follow-up was 20.2 months (14 to 30). The prostheses were lengthened by a mean of 25 mm (4.25 to 55) and maintained a mean knee flexion of 110° (100° to 120°). The mean Musculoskeletal Tumour Society score was 68% (11 to 29). Complications developed in two patients; one developed a flexion deformity of 25° at the knee joint, which was subsequently overcome and one died of disseminated disease. The early results from patients treated with this device have been encouraging. The implant avoids multiple surgical procedures, general anaesthesia and assists in maintaining leg-length equality.

Free Vascularized Fibula Grafts in Limb-Salvage Surgery

The authors review the outcome of a consecutive series of 24 free vascularized fibular grafts performed as part of a limb-salvage procedure following tumor excision. There were 15 women and nine men with a mean age of 26 years (range: 6 to 52 years). The minimum follow-up was 12 months. The mean length of the graft was 13.1 cm. (range: 4.5 to 25 cm). Fifteen grafts were used in the upper limb, eight in the lower limb, and one in the pelvis. Bony union was achieved in 21/24 patients at a mean of 9.3 months. Complications occurred in 13/24 patients of whom 11 required a second operation. Four patients died of metastatic disease. The mean Musculoskeletal Tumor Society (MSTS) functional score in the remaining 20 was 84.5 percent, with 16 patients having a good or excellent outcome. Free vascularized fibula grafts offer a reliable method of reconstruction after excision of bone tumors. Although the incidence of complications appears high, they are relatively easy to correct, bony union is achieved in the majority, and functional outcome is good.

Gastrointestinal stromal tumors: overview of pathologic features, molecular biology, and therapy with imatinib mesylate

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. These tumors develop at any site but are most commonly reported in the stomach. They originate from the neoplastic transformation of the intestinal pacemaker cell, the interstitial cell of Cajal. GISTs strongly express the receptor tyrosine kinase KIT and have mutations in the KIT gene, most frequently in exon 11 encoding the intracellular juxtamembranous region. Expression of KIT is seen in almost all GISTs, regardless of the site of origin, histologic appearance, or biologic behavior, and is therefore regarded as one of the key diagnostic markers. Distinction from smooth muscle tumors, such as leiomyosarcomas, and other mesenchymal tumors is very important because of prognostic differences and therapeutic strategies. Predicting the biologic behavior of GISTs is often difficult by conventional pathologic examination; tumor size and mitotic rate are the most important prognostic indicators. The prognostic significance of KIT mutations is controversial and thus far has not been clearly linked with biologic behavior. KIT mutations are associated with tumor development, and cytogenetic aberrations are associated with tumor progression. The pathogenesis of GISTs involves a gain-of-function mutation in the KIT proto-oncogene, leading to ligand-independent constitutive activation of the KIT receptor. KIT-wild-type GISTs have shown mutually exclusive platelet-derived growth factor receptor (PDGFR) mutation and activation. The use of imatinib mesylate (also known as Gleevec or STI-571) has greatly increased the therapeutic efficacy for this otherwise chemotherapy-resistant tumor. GISTs with very low levels of KIT expression may respond to imatinib mesylate therapy if the receptors are activated by specific mechanisms. KIT-activating mutations fall into two groups: the regulatory type and the enzymatic site type. The regulatory type of mutation is conserved at the imatinib binding site, whereas the enzymatic site mutation has a structurally changed drug-binding site, resulting in drug resistance. Resistance to the drug is the major cause of treatment failure in cancer therapy, emphasizing the need for researchers to understand KIT signaling pathways so as to identify new therapeutic targets. This review summarizes the pathologic features of GISTs, recent advances in understanding their molecular and biologic features, and therapy with imatinib mesylate.

Reduction in DNA binding activity of the transcription factor Pax-5a in B lymphocytes of aged mice

Aging has been associated with intrinsic changes of the humoral immune response, which may lead to an increased occurrence of autoimmune disorders and pathogenic susceptibility. The transcription factor Pax-5 is a key regulator of B cell development. Pax-5a/B cell-specific activator protein and an alternatively spliced isoform, Pax-5d, may have opposing functions in transcriptional regulation due to the lack of a transactivation domain in Pax-5d. To study B cell-specific changes that occur during the aging process, we investigated expression patterns of Pax-5a and 5d in mature B cells of young and aged mice. RNase protection assays showed a similar transcriptional pattern for both age groups that indicates that aging has no affect on transcription initiation or alternative splicing for either isoform. In contrast, a significant reduction in the DNA binding activity of Pax-5a but not Pax-5d protein was observed in aged B cells in vitro, while Western blot analyses showed that similar levels of Pax-5a and 5d proteins were present in both age groups. The observed decrease in Pax-5a binding activity correlated with changes in expression of two Pax-5 target genes in aged B cells. Expression of the Ig J chain and the secreted form of Ig mu, which are both known to be suppressed by Pax-5a in mature B cells, were increased in B cells of aged mice. Together, our studies suggest that changes associated with the aging phenotype cause posttranslational modification(s) of Pax-5a but not Pax-5d, which may lead to an abnormal B cell phenotype in aged mice, associated with elevated levels of J chain, and secretion of IgM.

Delivery of a stringent dimerizer-regulated gene expression system in a single retroviral vector

Small molecule-regulated transcription has broad utility and would benefit from an easily delivered self-contained regulatory cassette capable of robust, tightly controlled target gene expression. We describe the delivery of a modified dimerizer-regulated gene expression system to cells on a single retrovirus. A transcription factor cassette responsive to the natural product dimerizer rapamycin was optimized for retroviral delivery by fusing a highly potent chimeric activation domain to the rapamycin-binding domain of FKBP-rapamycin-associated protein (FRAP). This improvement led to an increase in both the potency and maximal levels of gene expression induced by rapamycin, or nonimmunosuppressive rapamycin analogs. The modified transcription factor cassette was incorporated along with a target gene into a single rapamycin-responsive retrovirus. Cell pools stably transduced with the single virus system displayed negligible basal expression and gave induction ratios of at least three orders of magnitude in the presence of rapamycin or a nonimmunosuppressive rapamycin analog. Levels of induced gene expression were comparable to those obtained with the constitutive retroviral long terminal repeat and the single virus system performed well in four different mammalian cell lines. Regulation with the dimerizer-responsive retrovirus was tight enough to allow the generation of cell lines displaying inducible expression of the highly toxic diphtheria toxin A chain gene. The ability to deliver the tightly inducible rapamycin system in a single retrovirus should facilitate its use in the study of gene function in a broad range of cell types.

Inhibition of the transcription factor nuclear factor-kappa B by adenoviral-mediated expression of I kappa B alpha M results in tumor cell death

BACKGROUND

The activation of transcription factor nuclear factor-kappa B (NF-kappa B) by extracellular stimuli has been shown to protect cells from apoptotic cell death. Inhibition of NF-kappa B activity should result in increased tumor cell killing in response to apoptotic stimuli. This study evaluated the effect of inhibition of NF-kappa B on a series of sarcoma and normal cell lines.

METHODS

Human sarcoma cell lines (HT1080, SKLMS-1, and MFH) and normal cell lines (NLF and BSMC) were infected with an adenoviral dominant-negative mutant Ad5I kappa B alpha M in vitro. Control cells were infected with the empty adenoviral vector and mock-infected with media alone. Viable cell counts were determined by microscopic evaluation on days 1 to 6 after infection. Cell proliferation was determined at 48 hours by MTT (1-[4,5-dimethylthiazol-2-yl]-3,5-dephenylformazan) assay.

RESULTS

All cell lines showed evidence of successful adenoviral infection as evidenced by the infection of all cell lines with the adenoviral marker gene Ad5 LacZ. All the tumor cells were found to have a significant decrease in cell viability and proliferation after treatment with the Ad5I kappa B alpha M gene compared with both mock-infected cells and cells infected with empty vector (P < .0001). The normal cell lines, although able to be successfully infected, did not show a significant decrease in cell viability or proliferation with adenoviral-mediated I kappa B alpha M infection.

CONCLUSIONS

Inhibition of NF-kappa B through adenoviral-mediated infection of the dominant-negative inhibitor I kappa B alpha M resulted in a significant decrease in tumor cell viability and proliferation while having no deleterious effect on normal cell lines. The Ad5I kappa B alpha M gene therefore could be potentially used as a clinical treatment for patients with soft-tissue sarcoma.

Nonoperative treatment of fixed flexion deformity of the proximal interphalangeal joint

Sixty-one stiff, stable proximal interphalangeal joints were treated by exercise and splinting. The average range of movement was 24 degrees to 67 degrees before treatment; this increased to 8 degrees to 98 degrees after treatment. The indications and technique are described.

Wild-type p53 and a p53 temperature-sensitive mutant suppress human soft tissue sarcoma by enhancing cell cycle control

Soft-tissue sarcomas are a heterogeneous group of tumors that are putatively mesenchymal in origin. Therapeutic advances in this disease have been limited over the past several decades. Approximately one-half of all patients will ultimately succumb, usually to uncontrollable pulmonary metastases. Although little is known about the underlying molecular determinants driving soft-tissue sarcoma inception, proliferation, and metastasis, mutation of the p53 gene is the most frequently detected molecular alteration in this disease. Accordingly, we were interested in determining whether transduction of wild-type (wt) p53 into soft-tissue sarcomas bearing mutated p53 genes might alter the malignant phenotype. SKLMS-1 is a human-derived leiomyosarcoma cell line with a codon 245 p53 point mutation. Cationic liposome was used to transfect wt p53 or 143Ala temperature-sensitive mutant p53 into this cell line. SKLMS-1 stable transfectants expressing wt p53 had decreased cell proliferation in vitro, decreased in vitro colony formation in soft agar, and decreased tumorigenicity in severe combined immunodeficient mice in vivo. Flow cytometric analysis of cell cycle components demonstrated markedly increased G1 cell cycle arrest and decreased entry into S phase, which corresponded to the induction of p21cip1 protein in the transfectants. Using SKLMS-1 stable transfectants expressing the 143Ala p53 temperature-sensitive mutant, we demonstrated the kinetics of and the causal relationship between wt p53 expression, the wt p53-dependent induction of cell cycle inhibitor p21cip1, and inhibition of cell cycle progression in p53-transfected SKLMS-1 cells. The ability to restore wt p53 growth-regulatory functions in soft-tissue sarcoma may ultimately be useful as a future therapy in patients with soft-tissue sarcomas.

New methods for inactivation of lipid-enveloped and non-enveloped viruses

Two new methods are described for inactivating lipid-enveloped and non-enveloped viruses in plasma-derived products such as coagulation factors and intravenous immunoglobulin (IGIV). Iodine/Sephadex delivers iodine to IGIV solutions in a slow, controlled way and allows for inactivation of > or = 4 logs of porcine parvovirus (PPV), a hardy non-enveloped virus, under conditions which do not measurably damage the structural or functional properties of the IGIV, and with essentially no iodination of the protein. All detectable enveloped and non-enveloped viruses were inactivated by this treatment. Gamma irradiation has been successfully used to inactivate viruses at the final vial stage in freeze-dried plasma proteins. Four logs of PPV were inactivated by irradiation in the presence of fibrinogen, factor VIII and alpha 1-proteinase inhibitor (API) at doses of 23, 28 and 30 kiloGray (kGy) respectively, while retaining 93% of fibrinogen solubility, 67% of factor VIII activity and over 80% of API activity. Bovine viral diarrhea virus (BVDV), a lipid-enveloped model for hepatitis C virus, was completely inactivated by radiation doses of 20-30 kGy in these products. Gamma irradiation was less effective in inactivating viruses in freeze-dried IGIV.

Isolated limb perfusion in the sarcoma-bearing rat: a novel preclinical gene delivery system

Reliable site-specific delivery of genetic constructs remains a challenging component of gene-based therapy of solid tumors. Isolated limb perfusion (ILP) continues to be evaluated for treatment of locally advanced soft tissue sarcomas because this approach uniquely directs therapeutic agents into the tumor-bearing extremity without significant systemic leak. In light of these considerations, we tested the hypothesis that ILP could be used to deliver genes carried in viral vectors to the sarcoma-bearing rat extremity, resulting in demonstrable gene transfer into the tumor. ILP was performed in rats by cannulating the femoral artery and vein, isolating the hind limb from systemic circulation by tourniquet, and cycling perfusate for 15 min at a rate of 2.4 ml/min. Leakage into the systemic circulation was 7.5% of the total perfusate concentrated in the isolated limb, as determined by perfusion with technetium 99m-tagged RBCs. We used the ILP technique to perfuse rat hind limbs bearing syngeneic fibrosarcoma tumor nodules with the replication-defective adenovirus Ad5LacZ, which expresses the bacterial beta-galactosidase. 5-Bromo-4-chloro-3-indolyl-beta-D-galactoside staining of the perfused limb tissues confirmed gene transfer to the tumor and peritumoral tissue, demonstrating that the tumor was part of the perfusion circuit and that gene therapy delivered via this method was feasible. These results suggest that adaptation of this preclinical gene delivery model to administer genetic constructs aimed at controlling tumor growth may prove beneficial to patients with extremity sarcomas.

An immunocytochemical investigation of the relationship between substance P and the neurokinin-1 receptor in the lateral horn of the rat thoracic spinal cord

The relationship between substance P-containing axons and sympathetic preganglionic neurons possessing the neurokinin-1 receptor was investigated in the lateral horn of the rat thoracic spinal cord. Sympathetic preganglionic neurons were labelled retrogradely with Fluorogold. Sections containing labelled cells were reacted with antibodies against choline acetyltransferase, substance P and the neurokinin-1 receptor and examined with three-colour confocal laser scanning microscopy. In all, 95 sympathetic preganglionic neurons were examined and 79% of these were immunoreactive for the neurokinin-1 receptor. Substance P-immunoreactive axons not only made contacts with preganglionic neurons which were immunoreactive for the receptor but also made contacts with cells which did not express the receptor. Dendrites, labelled with immunoreactivity for choline actyltransferase, also received contacts from substance P-immunoreactive varicosities but this was not related to the presence or the absence of receptor. An electron microscopic analysis was performed to investigate the relationship between substance P-containing boutons and dendrites possessing the neurokinin-1 receptor. Immunoreactivity for substance P was detected with peroxidase immunocytochemistry and immunoreactivity for the receptor was detected with the silver-intensified gold method. Substance P-containing boutons made synapses with dendrites which were positively and negatively labelled for the receptor. Receptor immunoreactivity was not usually present at synapses formed by substance P boutons with neurokinin-1-immunoreactive dendrites. It is concluded that substance P may modulate much of the activity of sympathetic preganglionic neurons through an indirect non-synaptic mechanism.

A versatile synthetic dimerizer for the regulation of protein-protein interactions

The use of low molecular weight organic compounds to induce dimerization or oligomerization of engineered proteins has wide-ranging utility in biological research as well as in gene and cell therapies. Chemically induced dimerization can be used to activate intracellular signal transduction pathways or to control the activity of a bipartite transcription factor. Dimerizer systems based on the natural products cyclosporin, FK506, rapamycin, and coumermycin have been described. However, owing to the complexity of these compounds, adjusting their binding or pharmacological properties by chemical modification is difficult. We have investigated several families of readily prepared, totally synthetic, cell-permeable dimerizers composed of ligands for human FKBP12. These molecules have significantly reduced complexity and greater adaptability than natural product dimers. We report here the efficacies of several of these new synthetic compounds in regulating two types of protein dimerization events inside engineered cells--induction of apoptosis through dimerization of engineered Fas proteins and regulation of transcription through dimerization of transcription factor fusion proteins. One dimerizer in particular, AP1510, proved to be exceptionally potent and versatile in all experimental contexts tested.

The Pax-5 gene is alternatively spliced during B-cell development

The transcription factor Pax-5 is expressed during the early stages of B-cell differentiation and influences the expression of several B-cell-specific genes. In addition to the existing isoform (Pax-5, which we have named Pax-5a), we have isolated three new isoforms, Pax-5b, Pax-5d, and Pax-5e, from murine spleen and B-lymphoid cell lines using library screenings and polymerase chain reaction amplification. Isoforms Pax-5b and Pax-5e have spliced out their second exon, resulting in proteins with only a partial DNA-binding domain. Isoforms Pax-5d and Pax-5e have deleted the 3'-region, which encodes the transactivating domain, and replaced it with a novel sequence. The existence of alternative Pax-5 transcripts was confirmed using RNase protection assays. Furthermore, Pax-5a and Pax-5b proteins were detected using Western blot analysis. Pax-5a was detectable in pro-, pre-, and mature B-cell lines, but not in two plasmacytomas; Pax-5b was shown to be present at low levels in mature B-cell lines and, unexpectedly, in one plasma cell line, but not in pro-B-cell or T-cell lines. Mobility shift assays showed that in vitro translated Pax-5a and Pax-5d, but not Pax-5b or Pax-5e, could interact with a B-cell-specific activator protein-binding site on the blk promoter. Using this assay, we also showed that Pax-5d was present in nuclear extracts of some (but not all) B-lymphoid lines and interacts with the B-cell-specific activator protein-binding site. The pattern of differential expression of alternatively spliced Pax-5 isoforms suggests that they may be important regulators of transcription during B-cell maturation.

The rising prevalence of HIV-1 infection in patients attending an inner city accident and emergency department

The recently published findings of the unlinked anonymous HIV prevalence study in England and Wales showed unchanging HIV prevalence in groups such as homo/bisexual men, and declining rates in non-injecting heterosexual men attending genitourinary medicine clinics. However, this multicentre study did detect a significant rise in seroprevalence rates in pregnant women in England and Wales and sentinel groups within hospitals in London, warning that changing patterns of HIV infection might account for these variable results. In 1992-1993 a seroprevalence study of adult patients attending the accident and emergency department at St. Mary's Hospital in West Central London showed a rate of HIV-1 infection of 1 in 77. We have repeated the seroprevalence study over the same calendar months in 1994-1995 to gain further information about HIV positive patients attending the department and to see whether a change in the patterns of HIV infection in the population served by St Mary's Hospital had occurred.

A humanized system for pharmacologic control of gene expression

Gene therapy was originally conceived as a medical intervention to replace or correct defective genes in patients with inherited disorders. However, it may have much broader potential as an alternative delivery platform for protein therapeutics, such as cytokines, hormones, antibodies and novel engineered proteins. One key technical barrier to the widespread implementation of this form of therapy is the need for precise control over the level of protein production. A suitable system for pharmacologic control of therapeutic gene expression would permit precise titration of gene product dosage, intermittent or pulsatile treatment, and ready termination of therapy by withdrawal of the activating drug. We set out to design such a system with the following properties: (1) low baseline expression and high induction ratio; (2) positive control by an orally bioavailable small-molecule drug; (3) reduced potential for immune recognition through the exclusive use of human proteins; and (4) modularity to allow the independent optimization of each component using the tools of protein engineering. We report here the properties of this system and demonstrate its use to control circulating levels of human growth hormone in mice implanted with engineered human cells.

Yeast SUB1 is a suppressor of TFIIB mutations and has homology to the human co-activator PC4

Activation of transcription in eukaryotes depends upon the interplay between transcriptional activators and general transcription factors. While direct contacts between activators and general factors have been demonstrated in vitro, an additional class of proteins, termed co-activators, is also required of transcriptional activation. Here we describe a yeast protein, SUB1, that was isolated as a suppressor of the cold-sensitive TFIIB R78H mutant. The N-terminal third of SUB1 is highly similar to the mammalian co-activator PC4. We show that increased expression of SUB1 suppresses two alleles of TFIIB (E62G, R78H) specifically and that the deletion of SUB1 is lethal in combination with these same two alleles. We show that SUB1 binds to TFIIB in vitro and that it specifically inhibits the formation of TBP-TFIIB-promoter complexes. Furthermore we show that increasing the copy number of SUB1 stimulates transcriptional activation in vivo. Based on our results and recent observations of others, we propose that SUB1 plays a role in the release of TFIIB from the transcription complex during transcription initiation.

Natural immunity in breast cancer patients during neoadjuvant chemotherapy and after surgery

Breast cancer is the most common cancer in women. Surgery, and more recently neoadjuvant chemotherapy, are being utilized as the initial treatment for breast cancer; however little is known about their effects on the natural immune system. The natural immune system (natural killer [NK] cells) is thought to be important in immune surveillance, including protection from metastasis during the intravascular tumour seeding that occurs during surgery. To investigate the effects of surgery on the natural immune system, we studied the pre-operative and post-operative peripheral blood lymphocytes (PBL) of 10 patients with stage I or II breast cancer: there was a 71.6 +/- 25.3% post-operative reduction in NK cell function (P < 0.005, Student's paired t-test). To investigate the effects of neoadjuvant chemotherapy and surgery, we examined PBL from five patients with stage III breast cancer: NK cell function dropped 95.7 +/- 1.9% after neoadjuvant chemotherapy, and there was a further 51.0 +/- 23.4% decrease after surgery (P < 0.05, Student's paired t-test). Neither group of patients had decreased numbers of NK cells, changes in the percentage of T helper or suppressor cells, or alterations in the production of cytotoxic factor by NK cells. These findings suggest that the impairment in NK cell function reflects a defect in the ability of NK cells to recognize and/or bind to tumour target cells. We conclude that the initial treatment of breast cancer patients, whether it involves surgery alone or with neoadjuvant chemotherapy, profoundly impairs their natural immune system and could increase the risk of metastasis. Further studies are needed to delineate the mechanism of this derangement in natural immunity and possibly alter its course.

Reflections on radiotherapy in Vietnam: political lessons still to be learned

Radiotherapy in Vietnam represents a stark contrast to the level of care available in the United States. The issue of efficient administration of cancer care with available resources is common to both nations. The challenge for each country is to develop treatment strategies and political policies for effective and accessible care within budgetary constraints. Results of therapy, defined as the restoration of function, must be the measure of efficacy and efficiency. This demands a balance between control of tumor-related symptoms and treatment-related morbidity. The most inefficient use of resources is an ineffective treatment that results in complications, as we observed in Vietnam. As health care policies continue to develop in the United States, we must not fail to focus upon therapeutic outcome as the single most important parameter for measuring success relative to the personal and public investment in medicine.

Radiation therapy for alveolar soft-part sarcoma

A clinical experience with radiotherapy in 18 patients with alveolar soft-part sarcoma is presented. Adjuvant radiotherapy was associated with prolonged local control in six of six patients without metastatic disease at diagnosis; later one patient relapsed systematically. Meaningful palliation was achieved in all patients with extra-skeletal (and possibly skeletal) metastatic disease. Radiation therapy may be beneficial for patients with alveolar soft-part sarcoma by enhancing local control achieved with limited surgery, by retarding progression of metastatic deposits, and by providing meaningful palliation.

Cancer education in Viet Nam: a need for foreign input

In Viet Nam cancer education has a low priority because of political and social factors. Knowledge about cancer staging and basic management principles is stagnated by restricted communication with foreign colleagues and by limitations of available techniques. Participation in either formal residency programs or conferences for continuing education outside Viet Nam is restricted to select individuals of high rank. Most foreign experience is gained from Russia or from the former Eastern-bloc nations. Available foreign textbooks and journals are limited to those published more than 20 years ago. Infectious diseases are the most significant health problem in Viet Nam and they indirectly contribute to the incidence of cancer, including the occurrence of hepatocellular carcinoma. A widespread epidemic of acquired immune deficiency syndrome (AIDS), acquired both outside and within the medical system, is another potential consequence of current health care practices. The need for an international exchange of scientific knowledge is dramatically reinforced through the identification of significant deficits in available medical care and the patterns of mortality in this restricted society.

Babesiosis in Washington State: a new species of Babesia?

OBJECTIVE

To characterize the etiologic agent (WA1) of the first reported case of babesiosis acquired in Washington State.

DESIGN

Case report, and serologic, molecular, and epizootiologic studies.

SETTING

South-central Washington State.

PATIENT

A 41-year-old immunocompetent man with an intact spleen who developed a moderately severe case of babesiosis.

MEASUREMENTS

Serum specimens from the patient were assayed by indirect immunofluorescent antibody (IFA) testing for reactivity with seven Babesia species and with WA1, which was propagated in hamsters inoculated with his blood. A Babesia-specific, ribosomal-DNA (rDNA) probe was hybridized to Southern blots of restriction-endonuclease-digested preparations of DNA from WA1, Babesia microti, and Babesia gibsoni. Serum specimens from 83 family members and neighbors were assayed for IFA reactivity with WA1 and B. microti. Small mammals and ticks were examined for Babesia infection.

RESULTS

The patient's serum had very strong IFA reactivity with WA1, strong reactivity with B. gibsoni (which infects dogs), but only weak reactivity with B. microti. DNA hybridization patterns with the rDNA probe clearly differentiated WA1 from B. gibsoni and B. microti. Four of the patient's neighbors had IFA titers to WA1 of 256. The tick vector and animal reservoir of WA1 have not yet been identified, despite trapping 83 mammals and collecting 235 ticks.

CONCLUSIONS

WA1 is morphologically indistinguishable but antigenically and genotypically distinct from B. microti. Some patients elsewhere who were assumed to have been infected with B. microti may have been infected with WA1. Improved serodiagnostic and molecular techniques are needed for characterizing Babesia species and elucidating the epidemiology of babesiosis, an emergent zoonosis.

Human SRF-related proteins: DNA-binding properties and potential regulatory targets

Serum response factor (SRF) is a transcription factor that binds the sequence CC(A/T)6GG found in a number of growth factor-inducible and muscle-specific promoters. We describe the isolation and characterization of cDNA clones encoding a family of three human SRF-related DNA-binding proteins. Each of these RSRF (related to SRF) proteins contains an 86-amino-acid amino-terminal region related to the SRF DNA-binding domain: In RSRFC4 and RSRFC9, this region is identical, whereas that present in RSRFR2 differs by seven conservative amino acid substitutions. The DNA-binding specificity of the RSRF proteins, which recognize the consensus sequence CTA(A/T)4TAG, is distinct from that of SRF. The entire RSRF common region is required for DNA binding, and the differential sequence specificity of the RSRFs and SRF is the result of differences in the basic amino-terminal part of this domain. The RSRF proteins bind DNA as dimers and can dimerize with one another but not with SRF. Although the RSRF mRNAs are expressed in many cell types, RSRFR2 mRNA is expressed at elevated levels in several B-cell lines. Consistent with this, extracts from many cell types form CTA(A/T)4TAG-binding complexes that contain RSRF proteins, and oligonucleotides containing RSRF-binding sites function as promoter elements in transfection assays. Like SRF-binding sites, RSRF-binding sites are found in the regulatory sequences of a number of growth factor-inducible and muscle-specific genes, and we show that RSRF polypeptides are components of previously characterized binding activities that interact with these elements. We discuss the potential role of RSRF proteins in the regulation of these genes.

A case-control comparison of durability and cost between implanted reservoir and percutaneous catheters in cancer patients

A case-control study was performed to compare the durability and cost of implanted reservoir catheter systems with percutaneous central venous catheters. Twenty cancer patients had reservoir systems placed in 1985 for chemotherapy delivery. The control group consisted of 60 cancer patients, matched according to age, sex, and diagnosis who were part of a group of more than 700 patients with percutaneous catheters inserted during the same period. The reservoir catheters were found to function for a significantly (P less than 0.0001) longer time (495 +/- 54 days) compared to the percutaneous catheters (197 +/- 22 days). The total cost for each system was calculated by adding the charges for an average insertion (reservoir = $1738, percutaneous = $562) to the maintenance charges accumulated over the catheters' lifespan. Reservoir catheters were associated with a significantly greater total cost than percutaneous catheters ($2233 +/- 54, $1453 +/- 102, respectively) but, if the total cost was spread out over the lifespan of the catheter by dividing the total cost by duration of use, reservoir catheters can be less expensive on a per diem basis. The break point occurs at approximately 6 months. For use less than 6 months, percutaneous catheters are cheaper primarily because of their lower insertion costs, but, for longer periods, reservoir catheters become cheaper because of lower maintenance costs and because a second percutaneous catheterization would likely be necessary.

Lessons in class

In the second of two articles, Jenny Griffiths and colleagues look at the evolution of health promotion in Oxford region over five years in the light of The Health of the Nation.

A sensitive method for the determination of protein-DNA binding specificities

We describe a sensitive and rapid method for determination of the sequence specificity of DNA binding proteins. The method allows recovery of specific sites using the small amounts of protein present in crude cell extracts or produced by cell-free translation reactions. Extract proteins are incubated with a pool of random sequence oligonucleotides, complexes purified by immunoprecipitation, and bound DNA amplified by the Polymerase Chain Reaction (PCR). This DNA is then used in further rounds of binding, immunoprecipitation, and amplification, until specific binding is detectable. With the transcription factor SRF as a model system, we demonstrate that authentic high affinity binding sites are recovered, and show that epitope tagging can be used to allow recovery of sites when specific antibodies are unavailable. We also show that specific sites bound by the Fos protein, which binds DNA with high affinity only when complexed with other polypeptides, are easily recovered by this technique.

Insulin co-injection suppresses the thermogenic response to glutamate microinjection into the VMH in rats

Selective stimulation of ventromedial hypothalamic nucleus (VMH) neurons by microinjection of the excitatory amino acid glutamate sharply increased interscapular brown adipose tissue (IBAT) and core temperatures in urethane-anaesthetized rats. This effect was blocked by co-injection of insulin (0.1-1 microgram) though not an inactive insulin analog, TNB3 insulin. Injection of insulin (1 microgram) into the contralateral VMH or systemic administration of insulin (1 microgram) had no effect on the thermogenic response to intra-VMH glutamate. These results complement those showing that intra-VMH insulin suppresses the basal firing rate of sympathetic nerves to IBAT and diminishes cold-induced nonshivering thermogenesis in BAT and add support to the view that insulin functions as an inhibitory signal on VMH neurons controlling thermogenesis in BAT.

Apparent biliary pseudolithiasis during ceftriaxone therapy

Biliary pseudolithiasis has been reported in patients who received ceftriaxone therapy. To examine this phenomenon further, serial gallbladder sonograms were evaluated in 44 adult patients who received intravenous ceftriaxone at 2 g or a placebo daily for 14 days in a double-blind controlled study. Ultrasound examinations of gallbladders were performed on days 1 and 14 of therapy and 2 weeks posttherapy if abnormalities were observed on day 14. Eight patients were unevaluable because of abnormal base-line gallbladder sonograms. Thirty-six patients (ceftriaxone, n = 28; placebo, n = 8) demonstrated normal baseline gallbladder sonograms and were evaluated for the development of change. A total of 6 of 28 (21.4%) ceftriaxone-treated patients and 1 of 8 (12.5%) patients who received the placebo demonstrated abnormal gallbladder sonograms on day 14 (P = 0.491). Four of the six ceftriaxone-treated patients demonstrating abnormal sonograms were clinically asymptomatic, while two patients reported vomiting. The abnormal sonograms of gallbladders of patients treated with ceftriaxone returned to normal between 9 and 26 days posttherapy. These data suggest an association between ceftriaxone treatment and the development of gallbladder abnormalities on ultrasound examination which resolve spontaneously on discontinuation of ceftriaxone therapy.

A novel fluorescence-based system for assaying and separating live cells according to VDJ recombinase activity

We describe two retroviral vector-based recombination substrate systems designed to assay for lymphoid VDJ recombinase activity in cultured cells. Both substrates incorporate a constitutive dominant marker gene (the simian virus promoter-driven neo gene) to allow selection of cells that stably integrate the substrate. Both substrates also include a second marker gene that becomes transcriptionally active only when inverted by a site-specific recombination event between flanking immunoglobulin variable-region gene segments. The first vector, similar in structure to previous retrovirus-based recombination substrates, utilizes the bacterial guanine-xanthine phosphoribosyltransferase gene (gpt) as its activatable marker; detection of inversion (VDJ recombinase activity) involves drug selection and Southern blotting analyses. We have used this vector to make a more extensive and quantitative survey of VDJ recombinase activity in B-lineage cell lines than has previously been performed with stable substrates, and we have compared our results with those of other studies that use transient recombination substrates. In the second vector, the activatable gene is the bacterial beta-galactosidase gene (lacZ). Detection for inversional activation of this gene is achieved by a fluorogenic assay, termed FACS-Gal, that detects beta-galactosidase activity in viable cells. The latter assay has the unique advantage of rapidly detecting cells that undergo recombination and also allows viable sorting of cells on the basis of the presence or absence of VDJ recombinase activity. We have used the lacZ vector to rapidly quantitate VDJ recombinase activity in B-lineage cell lines and compared the results with those obtained with the gpt vector. We have also used the lacZ vector to isolate variant pre-B-cell lines with low and high levels of VDJ recombinase activity.

Transpelvic rectus abdominis flap reconstruction of defects following abdominal-perineal resection

Abdominal-perineal resection for advanced rectal carcinoma may leave a large defect for which complete secondary healing can be slow. In such cases, the inferiorly based rectus abdominis myocutaneous flap, passed through the pelvis into the perineum, can provide a large amount of well-vascularized tissue that may be placed in the defect to facilitate primary healing and allow a quicker recovery. Additional advantages include displacement of the bowel out of the pelvis to facilitate postoperative radiotherapy, and the ability to reconstruct vaginal wall defects. We report a series of seven patients for whom the transpelvic rectus abdominis myocutaneous flap was used to cover perineal defects following abdominal-perineal resection. Although one flap failed, all patients healed rapidly and the only lasting complication was a possibly related small upper-abdominal hernia found one year after surgery.

Intra-ventromedial hypothalamic injection of insulin suppresses brown fat thermogenesis in the anaesthetized rat

Insulin can affect metabolic functions such as glucose production and fat mobilization through action in the ventromedial nucleus of the hypothalamus (VMH), and the VMH has been implicated in the regulation of heat generation in brown adipose tissue (BAT) in the rat. To study the role of insulin in modulating VMH mechanisms concerned with BAT thermogenic activity we evaluated the effect of intra-VMH microinjection of insulin on BAT (T(bat)) and core (T(core)) temperatures and BAT thermogenic activity (T(bat)-T(core)) in anaesthetized rats. Intra-VMH insulin (10 ng, 100 ng and 1 microgram) enhanced the decreases in T(bat) and T(core) resulting from exposure of the anaesthetized rats to mild cold, as well as diminished BAT thermogenic activity in a dose-dependent manner. This effect could be partially reversed by systemic treatment with norepinephrine (400 micrograms/kg). Intra-VMH injection of insulin analogs having reduced binding affinity to insulin receptors and diminished biological activity--i.e., acetyl3 insulin, succinyl3 insulin and TNB3 insulin--was much less effective at enhancing the decrease in T(bat) and T(core) or at inhibiting BAT thermogenic activity. These results demonstrate that insulin can modulate BAT thermogenesis in a specific manner through action in the VMH.

Intra-hypothalamic injection of thyrotropin-releasing hormone suppresses brown fat thermogenesis in the anaesthetized rat

Thyrotropin-releasing hormone (TRH) has diverse effects on body temperature in rodents, but the effector mechanisms that mediate its thermoregulatory actions are not well defined. In the present study, microinjection of 10 ng to 5 micrograms of TRH into the anterior hypothalamus (AHy) dose-dependently suppressed heat production in interscapular brown adipose tissue (BAT) in chloral hydrate-anaesthetized rats tested at a room temperature of 23 +/- 2 degrees C. This effect of TRH was mimicked by the structurally related peptides acid-TRH and luteinizing hormone releasing hormone (LH-RH), and by the TRH analog CG 3509, but not by the TRH fragments pGlu-His and His-Pro. The AHy plays a role in the regulation of BAT thermogenic activity, and the present results suggest that some of the effects of TRH on body temperature involve an AHy-mediated inhibitory action on BAT thermogenesis.

Isolation and properties of cDNA clones encoding SRF, a transcription factor that binds to the c-fos serum response element

The serum response element (SRE) is a sequence required for transient transcriptional activation of genes in response to growth factors. We have isolated cDNA clones encoding serum response factor (SRF), a ubiquitous nuclear protein that binds to the SRE. The SRF gene is highly conserved through evolution, and in cultured cells its transcription is itself transiently increased following serum stimulation. A cDNA clone of SRF expressed in vitro generates protein that forms complexes indistinguishable from those formed with HeLa cell SRF, as judged by DNA binding specificity and the ability to promote SRE-dependent in vitro transcription. SRF binds DNA as a dimer, and the DNA binding/dimerization domain of the protein exhibits striking homology to two yeast regulatory proteins.

Control of recombination events during lymphocyte differentiation. Heavy chain variable region gene assembly and heavy chain class switching

Our recent studies have focused on the organization of immunoglobulin genes in mice and humans and the mechanism and control of the recombination events that are involved in their assembly and expression. This report describes our progress in this area with particular focus on elucidating factors that influence the generation of the antibody repertoire in normal and diseased states. We present a detailed analysis of the organization of the human VH locus, studies that help to elucidate the nature of the recombination defect in mice with severe combined immunodeficiency, and studies of transgenic mice that focus on the mechanism that regulates tissue-specific variable region gene assembly. In addition, we also characterize mechanisms that control the heavy chain class-switch process. Although the latter process apparently involve a recombination system distinct from that involved in variable region assembly, we find that the two recombination events appear to be controlled by similar mechanisms.

Mitogen- and IL-4-regulated expression of germ-line Ig gamma 2b transcripts: evidence for directed heavy chain class switching

Treatment of murine B cells with bacterial lipopolysaccharide (LPS) in the presence or absence of different lymphokines results in cell populations that differentially express particular immunoglobulin heavy chain constant region (CH) genes. This class switch involves recombination between switch regions located upstream of the germ-line CH genes. We have treated Abelson murine leukemia virus-transformed pre-B cells and normal splenic B cells with LPS or LPS plus the lymphokine IL-4 and examined the effect on the germ-line gamma 2b locus and gamma 2b class switching. In both cell types, LPS induces transcription specifically through the germ-line gamma 2b locus before gamma 2b class switching. Furthermore, IL-4 inhibits LPS induction of germ-line gamma 2b transcripts in spleen cells and correspondingly abrogates switching to this CH gene. Thus treatment with mitogens and lymphokines can alter transcription of germ-line CH genes in B lineage cells and thereby directly regulate class switching in the context of a recombinase accessibility mechanism.