Synovial sarcoma in children and adolescents: the St Jude Children's Research Hospital experience

PURPOSE AND METHODS

We reviewed the clinical records and pathologic findings of 37 children and adolescents with synovial sarcoma treated at our institution over a 30-year period to evaluate the prognostic significance of tumor size, invasiveness, histology, and other features.

RESULTS

The 20 male and 17 female patients with synovial sarcoma had a median age of 13.7 years at diagnosis. Primary tumor sites were the extremities (n = 27), trunk (n = 8), and head and neck (n = 2). Disease stage (clinical group) was as follows: group I, n = 21; group II, n = 7; group III, n = 4; and group IV, n = 5. Nineteen patients had invasive (T2) lesions, 20 had tumors more than 5 cm in diameter, and 14 had histologic grade 3 lesions. The estimated 5-year survival rate (+/- SE) for patients with group I or II disease was 80% +/- 9%, compared with 17% +/- 15% for those with group III or IV tumors (P = .0003). An exact log-rank test, adjusted for clinical group, showed that tumor invasiveness and grade independently predicted overall and progression-free survival (P < .05); tumor size was significantly correlated with progression-free survival. A borderline significant relationship with overall survival was found for both tumor size and histologic subtype (P = .09).

CONCLUSION

A controlled trial of adjuvant chemotherapy is merited in children with resected synovial sarcoma (clinical group I or II) who present with unfavorable clinicopathologic features such as large, invasive, or grade 3 lesions. Children with unresected or metastatic disease fare poorly despite multimodality therapy and require novel treatment approaches.

The cellular transcription factor USF cooperates with varicella-zoster virus immediate-early protein 62 to symmetrically activate a bidirectional viral promoter

The mechanisms governing the function of cellular USF and herpesvirus immediate-early transcription factors are subjects of considerable interest. In this regard, we identified a novel form of coordinate gene regulation involving a cooperative interplay between cellular USF and the varicella-zoster virus immediate-early protein 62 (IE 62). A single USF-binding site defines the potential level of IE 62-dependent activation of a bidirectional viral early promoter of the DNA polymerase and major DNA-binding protein genes. We also report a dominant negative USF-2 mutant lacking the DNA-binding domain that permits the delineation of the biological role of both USF-1 and USF-2 in this activation process. The symmetrical stimulation of the bidirectional viral promoter by IE 62 is achieved at concentrations of USF-1 (43 kDa) or USF-2 (44 kDa) already existing in cells. Our observations support the notion that cellular USF can intervene in and possibly target promoters for activation by a herpesvirus immediate-early protein.

The nuclear receptor steroidogenic factor 1 acts at multiple levels of the reproductive axis

Steroidogenic factor 1 (SF-1), an orphan nuclear receptor, regulates the enzymes that produce sex steroids, and disruption of the Ftz-F1 gene encoding SF-1 precludes adrenal and gonadal development. We now study the role of SF-1 at other levels of the hypothalamic/pituitary/gonadal axis. In Ftz-F1-disrupted mice, immunohistochemical analyses with antibodies against pituitary trophic hormones showed a selective loss of gonadotrope-specific markers, supporting the role of SF-1 in gonadotrope function. In situ hybridization analyses confirmed these results; pituitaries from Ftz-F1-disrupted mice lacked transcripts for three gonadotrope-specific markers (LH beta, FSH beta, and the receptor for gonadotropin-releasing hormone), whereas they exhibited decreased but detectable expression of the alpha-subunit of glycoprotein hormones. SF-1 transcripts in the developing mouse pituitary, which first became detectable at embryonic day 13.5-14.5, preceded the appearance of FSH beta and LH beta transcripts. In adult rat pituitary cells, SF-1 transcripts colocalized with immunoreactivity for the gonadotrope-specific LH. Finally, SF-1 interacted with a previously defined promoter element in the glycoprotein hormone alpha-subunit gene, providing a possible mechanism for the impaired gonadotropin expression in Ftz-F1-disrupted mice. These studies establish novel roles of this orphan nuclear receptor in reproductive function.

Archaic structure of the gene encoding transcription factor USF

The upstream stimulatory factor (USF) is a helix-loop-helix transcription factor that interacts with specific sites on the DNA that are also recognized by the MYC oncoproteins. We isolated genomic clones to the murine 44-kDa form of USF (USF2 gene). This unique gene spans 13 kilobases of DNA and is composed of 10 exons. The gene seems to have maintained its archaic structure, since many of the exons encode discrete functional domains of the transcription factor originally identified by protein sequence comparisons. A particularly striking HpaII tiny fragment island, extending over nearly 2,000 base pairs, surrounds the USF2 translation initiation site. This region, which includes the USF2 promoter and the first four exons, is characterized by an overall GC content greater than 74%. Analysis by S1 mapping and transient transfection assays revealed that the USF2 transcripts originate from an initiator element located within a highly GC-rich region that is surrounded by two long polyadenylate stretches and functions as a bidirectional promoter. Different forms of USF2 messages result from the presence or absence of the fourth exon in the processed USF2 mRNA. Alternative splicing correlates with the lack of a consensus lariat branch point in the third intron. Transient cotransfection assays revealed that the presence or absence of the amino acid sequences encoded by exon 4 affects considerably the transcription activation properties of the USF2 protein.

Complete hematologic remissions induced by 2-chlorodeoxyadenosine in children with newly diagnosed acute myeloid leukemia

The majority of children with acute myeloid leukemia (AML) who are treated exclusively with chemotherapy die of progressive disease. Improvement in outcome will likely require new active drugs capable of eradicating resistant blast cells early in the clinical course. We therefore assessed the cytoreductive potential of 2-chlorodeoxyadenosine (2-CdA), a halogenated purine analogue, in 22 consecutive children with newly diagnosed AML. The drug was administered as a single 120-hour continuous infusion (8.9 mg/m2 of body surface area per day) before the introduction of standard remission induction therapy. Six patients (27%) had complete hematologic remissions by a median of 21 days after treatment with the nucleoside (range, 14 to 33 days). Seven others had partial responses, yielding a total response rate of 59%. The drug also eliminated leukemic cells from cerebrospinal fluid in 4 of the 6 patients tested. Concentrations of 2-CdA in cerebrospinal fluid on day 5 after the initiation of treatment ranged from 12.4% to 38.0% (mean, 22.7%) of the steady-state plasma concentrations. Severe but reversible myelosuppression and thrombocytopenia developed in all patients. Analysis of factors that may have influenced the complete remission rate suggested a better outcome in patients with myeloblastic leukemia (M0-M2 subtypes in the revised French-American-British classification system). These results demonstrate clinically significant activity by 2-CdA against previously untreated AML in children, including leukemic blast cells in the central nervous system. Its use in combination chemotherapy may improve the outlook for patients with this often fatal hematologic cancer.

Ethnic differences in erythrocyte catechol-O-methyltransferase activity in black and white Americans

Catechol-O-methyltransferase (COMT) catalyzes the O-methylation of catecholamine and catechol drugs such as levodopa and methyldopa. Human COMT activity is inherited as an autosomal co-dominant trait; approximately 25% of white individuals have low activity consistent with homozygosity for a low activity allele, about 50% have intermediate activity (i.e., heterozygous genotype) and 25% have high activity. COMT activity has not been characterized in African-Americans or other black populations. To investigate potential ethnic and gender differences in COMT, we measured erythrocyte COMT activity in 195 unrelated black and 202 unrelated white healthy individuals living in the Southeast United States. Overall, the black population had significantly higher COMT activity than the white population (median 15.7 vs. 11.4 U/ml of packed red blood cell volume; P < .001). Maximum likelihood estimation of COMT activity distribution identified significant ethnic differences, with high activity in 23% of whites and 55% of blacks, intermediate activity in 50% of whites and 38% of blacks and low activity in 27% of whites and 7% of blacks. No greater differences in COMT activity were observed in either ethnic group. We conclude that red blood cell COMT activity is significantly higher in black subjects than white subjects. Hardy-Weinberg estimates indicate that this ethnic difference is due to a higher frequency of high activity COMT alleles in blacks vs. whites (0.74 vs. 0.48).

A cell-specific nuclear receptor is essential for adrenal and gonadal development and sexual differentiation

Studies in adrenocortical cells have implicated the orphan nuclear receptor SF-1 in the gene regulation of the steroid hydroxylases. We used targeted disruption of the Ftz-F1 gene, which encodes SF-1, to examine its role in intact mice. Despite normal survival in utero, all Ftz-F1 null animals died by postnatal day 8; these animals lacked adrenal glands and gonads and were severely deficient in corticosterone, supporting adrenocortical insufficiency as the probable cause of death. Male and female Ftz-F1 null mice had female internal genitalia, despite complete gonadal agenesis. These studies establish that the Ftz-F1 gene is essential for sexual differentiation and formation of the primary steroidogenic tissues.

Roles of CCAAT/enhancer-binding protein and its binding site on repression and derepression of acetyl-CoA carboxylase gene

The gene for acetyl-CoA carboxylase, the rate-limiting enzyme in the biosynthesis of long-chain fatty acids, contains two distinct promoter regions, denoted PI and PII, which control the generation of different forms of mRNA. Multiple forms of acetyl-CoA carboxylase (ACC) mRNA with 5'-end heterogeneity are generated as a result of differential splicing of two primary transcripts formed under the control of these two promoters. PI is responsible for the generation of class I mRNAs of ACC, which are induced in a tissue-specific manner under lipogenic conditions. PII generates class II mRNAs of ACC, which are expressed constitutively. Possible mechanisms for the regulation of PI under normal physiological conditions and agents that activate the promoter have been investigated. PI contains a TATA and a CCAAT box. In addition to these sequences, this promoter contains a 28-CA repeat sequence 220 bases upstream from the transcription initiation site; the presence of this sequence leads to about 70% repression of the basal promoter activity. Repression by the 28-CA repeat sequence requires the GCAAT sequence in the CCAAT box. The negative effect of the 28-CA repeat sequence is relieved by a CCAAT/enhancer-binding protein (C/EBP), which binds to the GCAAT sequence. Insertion of the 28-CA repeat sequence into the thymidine kinase promoter results in repression that can also be relieved by the C/EBP gene product. However, the same sequence exerts no effect on ACC promoter II, which has no CCAAT box. During the differentiation of 30A5 preadipocytes into adipocytes, the expression of class I ACC mRNA and C/EBP mRNA is coordinately increased. Therefore, the presence of the CA repeat in the promoter may be responsible for the inactivity of PI, and C/EBP may be one of the factors that is responsible for the activation of PI under lipogenic conditions. Interaction of the CA repeat and the CCAAT box in the repression and derepression of the ACC gene provides a novel function for the CCAAT box and C/EBP in gene regulation.

Role of MB isoforms (isomers) in the early diagnosis of acute myocardial infarction

In addition to electrocardiogram (ECG), analysis of creatinine phosphokinase (CPK), lactate dehydrogenase (LDH) and their isoenzymes is commonly employed to diagnose acute myocardial infarction (AMI). The aim of this study was to observe the efficiency of isomers of CPK for early diagnosis of AMI. ECG, though useful in many ways, is not 100% sensitive. The drawback involved with CPK and LDH isoenzymes is the time lag factor in diagnosing AMI early enough for interventional therapy. Recently the subunits of these isoenzymes, namely MM and now the MB isomers are being tested for their effectiveness in the early diagnosis of AMI. In our experience MB isomers were found to be accurate markers in the early diagnosis of AMI. They were especially valuable in diagnosing myocardial infarction not detectable by ECG in cases such as non-Q AMI, cardiomyopathy, and bundle branch block among other such cases.

[Chemiluminescent immunoassay for anti-granulocyte antibody IgG]

In this paper is reported solid phase competitive chemiluminescent immunoassay (CLIA) for anti-granulocyte antibody (AGAb) IgG with N-(4-amiobytul)-N-ethylisoluminol (ABEI) labelled rabbit antibody IgG against granulocyte competing with the analyte and ABEI-CoCl2-H2O2 as the chemiluminescent system. The absolute limit of detection was 3.0 x 10(-14) mol ABEI/tube. One hundred and thirty one individuals were divided into three groups: leukocytopenic group (n = 58), control group (n = 41) and normal group (n = 32). Chemiluminescent index (CLI) was used as the diagnostic criterion for AGAb in serum. The results showed that the positive rate of the leukocytopenic group was significantly higher than that of the control group (P < 0.005), and the sensitivity, specificity and accuracy of the method were 43.1%, 90.2% and 62.6%, respectively.

Influence of alloferin on neuromuscular function in myasthenia patients undergoing thymectomy

Myasthenia gravis patients are hypersensitive to nondepolarizing relaxants, such as alcuronium, an intermediate-long nondepolarizing agent. This study observed the effects of alcuronium treatment in myasthenia gravis patients as compared with non-MG patients during operation. Ten MG patients (Ossermann class I-IV, scheduled for thymectomy) and 10 non-MG patients (ASA class I-II, scheduled for operation) were selected. An induction dose of alcuronium 0.2 mg/kg and thiopental 4-6 mg/kg was given, followed by intubation and ventilation with 50% nitrous oxide in oxygen and 0.5-1.5% ethrane. Neuromuscular transmission was monitored using an accelerograph and degrees of neuromuscular function at different depths were recorded. There were statistically significant differences between the two groups. The effect of alloferin in the MG group was quicker and deeper. This study also found a relation between MG class and the recovery of respiration: Respiratory recovery was quicker in classes I-II than in classes III-IV.

Characterization of the mouse FTZ-F1 gene, which encodes a key regulator of steroid hydroxylase gene expression

The cytochrome P450 steroid hydroxylases are coordinately regulated by steroidogenic factor 1 (SF-1), a protein expressed selectively in steroidogenic cells. Based on its expression in steroidogenic tissues and DNA-binding specificity, we isolated a putative SF-1 cDNA from an adrenocortical cDNA library. As evidence that this cDNA encodes SF-1, we now show that it is selectively expressed in steroidogenic cells, that an antiserum against its protein product specifically abolishes the SF-1-related gel-shift complex, and that its coexpression increases promoter activity of the 21-hydroxylase 5'-flanking region in transfection experiments. Sequence analyses of the SF-1 cDNA revealed that it is the mouse homolog of fushi tarazu factor I (FTZ-F1), a nuclear receptor that regulates the fushi tarazu homeobox gene in Drosophila. A second FTZ-F1 homolog, embryonal long terminal repeat-binding protein (ELP), was recently isolated from embryonal carcinoma cells. SF-1 and ELP cDNAs are virtually identical for 1017 base pairs, including putative DNA-binding domains, but diverge at their 5'- and 3'-ends. One genomic clone contained both SF-1- and ELP-specific sequences, confirming their origin from a single gene. Characterization of this gene defined shared exons encoding common regions and alternative promoters and 3'-exons leading to differences between the two FTZ-F1 transcripts. We used in situ hybridization with transcript-specific probes to study the ontogeny of SF-1 and ELP expression. ELP transcripts were not detected from embryonic day 8 to adult, consistent with its previous isolation from embryonal carcinoma cells and its postulated role in early embryonic development.(ABSTRACT TRUNCATED AT 250 WORDS)

Tumor-cell DNA content predicts outcome in children and adolescents with clinical group III embryonal rhabdomyosarcoma. The Intergroup Rhabdomyosarcoma Study Committee of the Children's Cancer Group and the Pediatric Oncology Group

PURPOSE

The prognostic value of tumor-cell DNA content (ploidy) was evaluated in children with unresectable, nonmetastic rhabdomyosarcoma of embryonal histology.

PATIENTS AND METHODS

Flow-cytometric techniques were used to estimate the ploidy of tumor specimens from 34 patients with embryonal rhabdomyosarcoma who were enrolled in the intergroup rhabdomyosarcoma study III (IRS III) from 1985 to 1991. Tumors were classified as diploid or hyperdiploid (DNA content, 1.1 to 1.8 times that of normal diploid cells). The influence of ploidy on clinical outcome was assessed by the Kaplan-Meier technique and Cox regression analysis with stepwise selection.

RESULTS

Twelve of the tumor specimens were diploid and 22 were hyperdiploid. The patient groups defined by diploid or hyperdiploid tumors had similar presenting characteristics (eg, age, tumor size, and anatomic site). Significantly more children with hyperdiploid tumors achieved a complete response than did children with diploid tumors (85% v 42%; P = .01). The probability of progression-free survival at 5 years (+/- SE) was 91% +/- 6% for the hyperdiploid group, compared with 17% +/- 11% for the diploid group (P < .001). Hyperdiploidy was also associated with a significantly higher overall survival rate at 5 years: 96% +/- 4% versus 50% +/- 14% (P = .004). Ploidy retained its prognostic significance after adjustment for tumor site in the Cox regression model.

CONCLUSION

Tumor-cell ploidy strongly correlates with outcome in children with nonmetastic, unresectable embryonal rhabdomyosarcoma. The two biologically distinct groups identified by this measure would benefit from further refinements in risk-directed therapy.

[Evaluation of pulmonary arterial pressure by pulsed Doppler echocardiography compared with cardiac catheterization]

Twenty-six patients undergoing right cardiac catheterization were examined by pulsed doppler echocardiography (PDE), spectrum analysis of the shape of flow velocity curve of the pulmonary arteria during systole was made. Pulmonary arterial pressure (PAP) was qualitatively and qualitatively evaluated by right ventricular systolic time interval (RSTI) derived from pulmonary doppler blood flow velocity pattern. The correlation between PAP and the values of RSTI was evaluated, multiple stepwise regression analysis was performed. The pulmonary flow pattern and the values of RSTI measured from right ventricular outflow tract (RVOT) and main pulmonary artery (MPA) were compared. The results showed that: 1. Qualitative evaluation of PAP: (1) the triangular configuration of the pulmonary flow pattern was the feature of the pulmonary ejection flow in pulmonary hypertension (PH). (2) AT < 100ms AT/ET < 0.30 and PEP/AT > 1.1 indicated PH (PAMP > or = 2.7 kPa, AT < 100 ms, sensitivity 92.3%, specificity 100%). 2. Quantitative evaluation of PAP: (1) simple regression analysis: AT, AT/PEP especially AT showed a good inverse correlation with PAP, which was improved when a logarithmic function was applied, but not improved by the square root of heart rate. The liner regression equation and the correlation coefficient were: log PASP = -6.3617 AT +2.825 (r = -0.7925, P < 0.001); log PADP = -0.4569 AT +74.182 (r = -0.8513, P < 0.001); log PAMP = -0.0073 AT +2.198 (r = -0.8635, P < 0.001). (2) multiple stepwise regression analysis: the stepwise analysis of six parameters (PEP, ET, AT, AT/ET, AT/PEP, square root of R-R) showed that AT, PEP were the best parameters correlated with PAP.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum interleukin-2 receptor levels in Hodgkin disease and other solid tumors of childhood

Serum levels of interleukin-2 receptor (IL2R) were determined in children with newly diagnosed Hodgkin disease (n = 68), Wilms tumor (n = 20), osteosarcoma (n = 18), rhabdomyosarcoma (n = 18), or Ewing sarcoma (n = 15). Measurements of soluble IL2R were positively correlated with disease stage in Hodgkin disease but not in other tumors. Very high levels of soluble IL2R (> or = 5000 U/ml) were significantly associated with a poorer treatment outcome in Hodgkin disease (p = 0.006) and retained significance in a multivariate analysis (p = 0.03). The addition of soluble IL2R measurements to existing prognostic models may improve risk assignment in children with Hodgkin disease.

Serum intercellular adhesion molecule-1 in childhood malignancy

Levels of soluble intercellular adhesion molecule-1 (ICAM-1) were measured in serum samples taken at diagnosis from pediatric patients with Hodgkin's disease (n = 69), acute lymphoblastic leukemia (n = 28), Wilms' tumor (n = 20), osteosarcoma (n = 17), rhabdomyosarcoma (n = 18), or Ewing's sarcoma (n = 15). Median levels of serum ICAM-1 were significantly higher in acute lymphoblastic leukemia and Hodgkin's disease than in controls and other malignancies. Levels were positively correlated with disease stage for patients with Hodgkin's disease, Ewing's sarcoma or Wilms' tumor, and with the frequency of relapse in Hodgkin's disease (P = .016). Serum levels were normal in all of 76 patients tested in remission. It remains to be determined whether increased serum ICAM-1 levels simply reflect a greater tumor burden or whether this molecule contributes directly to the progression of childhood malignancies.

Characterization of the mouse FTZ-F1 gene, which encodes a key regulator of steroid hydroxylase gene expression

The cytochrome P450 steroid hydroxylases are coordinately regulated by steroidogenic factor 1 (SF-1), a protein expressed selectively in steroidogenic cells. Based on its expression in steroidogenic tissues and DNA-binding specificity, we isolated a putative SF-1 cDNA from an adrenocortical cDNA library. As evidence that this cDNA encodes SF-1, we now show that it is selectively expressed in steroidogenic cells, that an antiserum against its protein product specifically abolishes the SF-1-related gel-shift complex, and that its coexpression increases promoter activity of the 21-hydroxylase 5'-flanking region in transfection experiments. Sequence analyses of the SF-1 cDNA revealed that it is the mouse homolog of fushi tarazu factor I (FTZ-F1), a nuclear receptor that regulates the fushi tarazu homeobox gene in Drosophila. A second FTZ-F1 homolog, embryonal long terminal repeat-binding protein (ELP), was recently isolated from embryonal carcinoma cells. SF-1 and ELP cDNAs are virtually identical for 1017 base pairs, including putative DNA-binding domains, but diverge at their 5'- and 3'-ends. One genomic clone contained both SF-1- and ELP-specific sequences, confirming their origin from a single gene. Characterization of this gene defined shared exons encoding common regions and alternative promoters and 3'-exons leading to differences between the two FTZ-F1 transcripts. We used in situ hybridization with transcript-specific probes to study the ontogeny of SF-1 and ELP expression. ELP transcripts were not detected from embryonic day 8 to adult, consistent with its previous isolation from embryonal carcinoma cells and its postulated role in early embryonic development.(ABSTRACT TRUNCATED AT 250 WORDS)

Vitamin D deficiency suppresses cell-mediated immunity in vivo

Severe vitamin D deficiency has been produced in mice as evidenced by severe hypocalcemia and an absence of 25-hydroxyvitamin D in blood. Vitamin D deficiency was accompanied by a slight decrease in body weight and food consumption. Vitamin D-deficient and vitamin D-sufficient mice were sensitized with dinitrofluorobenzene (DNFB). Sensitivity to DNFB was determined by treatment of one ear with DNFB. The ratio of thickness of the treated ear to that of nontreated ear was used as an index of cell-mediated immune reaction. The incorporation of [3H]thymidine into the DNA of the ear was also used as an index of cell-mediated immunity as was the response of thymus lymphocytes to concanavalin A. Vitamin D deficiency markedly decreased the ear thickness ratio and the [3H]thymidine incorporation ratio in DNFB-sensitized mice. Similarly, the incorporation of [3H]thymidine into the DNA of concanavalin A-treated thymus lymphocytes from DNFB-sensitive mice was significantly reduced in vitamin D deficiency. These results show that in vivo vitamin D deficiency impairs cell-mediated immunity. The provision of a vitamin D-sufficient diet for 8 weeks corrected the impaired response of the immune system, while vitamin D administration for 3 weeks did not.

Study on initiation of human lung carcinogenesis

Cigarette smoking condensate and diethylnitrosamine can initiate human lung carcinogenesis as they are able to induce precancerous lesions of bronchioles and the transforming ability of human fetal lung (HFL) DNA. The induction of precancerous lesions in HFL and the acquirement of the transforming ability of HFL DNA by short-term exposure to carcinogens can be combined to yield an ideal model for the initiation of human lung carcinogenesis.

Production of a bifunctional hybrid molecule B72.3/metallothionein-1 by protein engineering

A hybrid anti-tumour B72.3 antibody/metallothionein protein B72.3MT-1 was produced by the construction of the expression vector mpSV2neo-EP1-B72.3MT-1. This vector contained the neo gene as a selection marker, the murine immunoglobulin promoter and enhancer, and the hybrid B72.3 heavy chain gene fragment with mouse metallothionein-1 cDNA gene ligated into its CH2 domain. The expression vector was transfected to the heavy chain loss mutant B72.3Mut(K) cell line. The hybrid protein B72.3MT-1 was purified from transfectant supernates using a Protein G column. We showed that the hybrid protein retained the binding reactivity for the TAG72 antigen as the original B72.3 antibody, and the metal-binding capacity of the native metallothionein molecule. Therefore, the bifunctional hybrid protein B72.3MT-1 may be very useful in cancer imaging when labelled with radionuclides such as 99mTc.