Sarcoglycanopathies: a clinico-pathological study

BACKGROUND

Limb girdle muscular dystrophy (LGMD) is a heterogeneous group of disorders characterized by limb girdle weakness. There are no clear clinical features that distinguish various types of LGMD.

MATERIALS AND METHODS

We studied 26 patients with chronic progressive weakness in limb girdle distribution without early facial involvement with muscle biopsies suggestive of dystrophy/myopathy and positive for dystrophin antibodies. Immunohistochemistry studies of muscle biopsies were done on all patients to classify different types of sarcoglycanopathies.

RESULTS

The mean age of presentation was in the third decade. There were 14 male and 12 female patients. The common pattern of inheritance was autosomal recessive, seen in 53.8%. The more frequent type of LGMD was sarcoglycanopathy (SGP) (53.8%). Amongst the SGPs, alpha-SGP (26.9%) was the most common followed by beta-SGP (15.3%), gamma-SGP (3.8%) and delta-SGP (7.6%). Calf hypertrophy was noted in 53.5% of LGMD and 57.1% of SGPs, extensor digitorum brevis hypertrophy in 42% of LGMD and 35.7% of SGPs, winging of scapula in 39.2% of the LGMD group and 35.7% of the SGPs, valley sign in 28.5% of the LGMD group and 21.4% of the SGPs. Hip abductor sign was positive in 71.4% of LGMD and 64.2% of SGPs. Differential weakness of knee flexors was more common in SGP (57.1%). The mean creatine phosphokinase (CK) value was 2519IU/L and was elevated in 92.8% patients. Muscle biopsy showed a dystrophic pattern in 75% of LGMD and a myopathic pattern in the remaining. Symptomatic cardiac involvement was seen in one patient. ECG changes were seen in 44% of LGMD patients and 50% of the SGP. The common changes noted were T wave inversion in V1, V2 (16%), left ventricular hypertrophy LVH (12%) and right bundle branch block (RBBB) in 12% of the LGMD group.

CONCLUSION

Sarcoglycanopathy is a more frequent form of LGMD whereas alpha type is the most common among the SGP. The four types of SGP do not differ in the pattern of muscle involvement. A relatively earlier onset, selective weakness of knee flexors and a very high CK may help differentiate SGP from other forms of LGMD. Immunohistochemistry is very useful in classifying the different types of LGMD prior to genetic analysis.

Tumor cell quantification and normalized multi-gene expression analysis of micrometastatic cells in blood and bone marrow of cancer patients: introduction of the embedded tumor cell calibrator technique

Abstract #5029

Background: The purpose of this study was the validation of a new preanalytical enrichment and molecular detection method using embedded tumor cell calibrators (ETC) for process control, relative tumor cell enumeration and quantitative gene expression analysis of circulating tumor cells (CTC) in breast cancer patients.
 Methods: Samples from every patient were devided in native probes and matched calibrator probes containing either 2, 4 or 8 breast carcinoma tumor cells (ETC). The high affinity antibodies BM7 (MUC-1) and VU1D9 (EpCAM) were used for immunomagnetic tumor cell enrichment in 10 mL of peripheral EDTA-blood of patients with primary and metastatic breast cancer. Mononuclear cells from bone marrow of patients with primary breast cancer were analysed in parallel by standardized cytospin immunocytology techniques (2x106 cells) and by the immunobead enrichment technique (1x107 cells). Separated cells were lysed and used for mRNA isolation and c-DNA synthesis. A real-time quantitative RT-PCR approach for the tumor identifier cytokeratin 19 (CK19) and mammaglobin 1 (MG1) and the surrogate markers HER-2, survivin (Sur), prostate-specific ets factor (PSE), CXCR4, Nanog, CD276 and FGFR2 was established using primers and FAM-labeled TaqMan probes selected with the UniversalProbeLibrary system (Roche AG, Basel, CH).
 Results: Positivity rate of ETC controlled realtime RT-PCR on the basis of CK19 and MG1 was 6.9% in 205 patients with primary breast cancer and 61.1% in patients with metastatic disease. Clonal selection or conversion from a HER2 negative (histology) to a HER2 positive phenotype was determined by qRT-PCR in 21 from 73 (28.8%) patients. During a 18 months follow-up of 92 patients with primary breast cancer, multimarker positivity was determined in 10 patients, and in three of these patients early metastasis was clinically confirmed. Tumor cell detection rate in bone marrow on the basis of
 1x107 cells was 10.5% (11/104) while cytology at the level of 2x106 cells resulted in a positivity rate of only 1% (1/104).
 Conclusion: For the first time we describe embedded tumor cells (ETC) as internal calibrators for accurate process control and normalization of the complex techniques of the immunobead separation and the quantitative RT-PCR technique. Tumor cell quantification was performed with the tumor identifiers CK19 and MG1, while corresponding expression levels of surrogate markers were determined on the basis of spiked calibrator cells. The ETC technique improved monitoring and gene expression analysis of disseminated tumor cells in peripheral blood and bone marrow significantly.
 Characterization of clinically relevant markers from the networks of apoptosis (Sur, PSE), tumor related/induced angiogenesis (CD276), growth factor receptors (HER-2, FGFR2) and cytostatica resistence (ABCG2) may improve early detection of metastasis, monitoring of treatment regimes and prediction of (new) therapeutic targets.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5029.

Corticobasal syndrome due to a thalamic tuberculoma and focal cortical atrophy

Corticobasal syndrome (CBS) is characterised by asymmetric apraxia, cortical sensory loss, extrapyramidal features and cognitive decline. Although CBS is classically described as a taupathy, heterogeneity of its aetiology is increasingly recognised. Clinical presentation of CBS appears to reflect areas of the brain involved and not necessarily the nature of the underlying pathology. We report a patient in whom resolution of a thalamic tuberculoma was associated with progressive atrophy of the parietotemporal cortex, resulting in an unusual presentation of CBS.

Prosthetic rehabilitation of an adolescent with hypohidrotic ectodermal dysplasia with partial anodontia: case report

Ectodermal dysplasia is a hereditary syndrome characterized by dysplasia of tissues of ectodermal origin (hair, skin, nails, and teeth) and occasionally, dysplasia of mesodermally derived tissues. The triad of nail dystrophy (onychodysplasia), alopecia, or hypotrichosis (scanty, fine, light hair on the scalp and eyebrows) and palmoplantar hypohidrosis is usually accompanied by lack of sweat glands and partial or complete absence of primary and permanent dentition. Hypohidrotic ectodermal dysplasia usually has an X-linked inheritance and affects only males severely, while female heterozygotes show only minor defects. The clinical management of children with ectodermal dysplasia provides a unique opportunity for cooperative effort between the pedodontist and the prosthodontist. The following case report discusses the management of a young boy with hypohidrotic ectodermal dysplasia. Removable prostheses were employed in the treatment. The aim was to rehabilitate the adolescent prosthodontically and boost him psychologically.

Non-invasive ventilation in chronic obstructive pulmonary disease: management of acute type 2 respiratory failure

Non-invasive ventilation (NIV) in the management of acute type 2 respiratory failure in patients with chronic obstructive pulmonary disease (COPD) represents one of the major technical advances in respiratory care over the last decade. This document updates the 2002 British Thoracic Society guidance and provides a specific focus on the use of NIV in COPD patients with acute type 2 respiratory failure. While there are a variety of ventilator units available most centres now use bi-level positive airways pressure units and this guideline refers specifically to this form of ventilatory support although many of the principles encompassed are applicable to other forms of NIV. The guideline has been produced for the clinician caring for COPD patients in the emergency and ward areas of acute hospitals.

Post-ischaemic myocardial dysfunction (stunning) results from myofibrillar oedema

OBJECTIVE

To test the hypothesis that myocardial stunning is due to myofibrillar oedema.

METHODS

Experiments were performed in anaesthetised closed-chest pigs. In 15 pigs (group 1), myocardial stunning was produced by repetitive ischaemia and reperfusion; 5 pigs each were studied at 2 hours, 2 days, and 5 days later. Circumferential left ventricular (LV) mid-wall myocardial strain (E(cc)) was estimated in vivo using tagged magnetic resonance imaging. Myocardial water content (MWC) was measured post mortem, from which interfilament lattice distance (d) was calculated. In 6 pigs (group 2), myocardial dysfunction was produced by intracoronary administration of a mast cell degranulator. Animals were euthanised immediately upon induction of regional LV dysfunction to avoid development of inflammation. In 4 pigs (group 3), transmission electron microscopy (EM) was performed to quantify d in stunned versus normal myocardium.

RESULTS

In group 1 pigs, MWC was raised in the stunned compared with normal myocardium (p<0.02) and decreased over time. An inverse relation was found between E(cc) and MWC in the stunned myocardium (r = -0.81) and between E(cc) and d (r = -0.90). A similar relation was noted between wall thickening and increase in MWC in group 2 (r = -0.84) pigs. In group 3 pigs, d on EM was significantly lower (40 (3) nmol/l) in normal myocardium than in stunned myocardium (46.4 (4) nmol/l), p<0.001.

CONCLUSIONS

Ischaemia-reperfusion results in myocardial oedema, with consequent myocyte swelling and myofibrillar oedema. The latter leads to an increase in d, causing myosin heads to either fail to latch, or to latch improperly, onto the actin filament with poor force generation, leading to myocardial dysfunction. As the myocardial oedema abates, myocyte function improves.

One year trends in the gram-negative bacterial antibiotic susceptibility patterns in a medical intensive care unit in South India

PURPOSE

To describe the changes in antibiotic susceptibility patterns of common intensive care unit pathogens with time from the medical intensive care unit of a tertiary care hospital.

METHODS

A prospective observational study was conducted in the medical intensive care unit (MICU) of a 2100 bed tertiary care hospital in South India. All data regarding patient characteristics, disease characteristics, infective agents, identified along with their antibiotic sensitivity patterns and patient outcomes were prospectively recorded in MICU data base. Various bacterial pathogen antibiotic sensitivity patterns from August 2004 to May 2005 were prospectively documented. During this period 491 patients were admitted to the MICU. Data were analyzed using excel spreadsheets.

RESULTS

Ceftazidime resistance reduced in Klebsiella spp. while cefotaxime resistance increased. In E. coli however, ceftazidime and cefotaxime resistance increased. Klebsiella resistance to cefotaxime and ceftazidime ranged from 25-50% and 14-91%, while E. coli resistance to these antibiotics ranged from 50-70% and 50 to 80% respectively. In Pseudomonas and the non-fermenting gram-negative bacteria (NFGNB) ceftazidime resistance decreased. Third generation cephalosporin resistance seemed to be reducing in the NFGNB, however, carbapenem resistance appeared to be increasing, possibly due to their increasing use.

CONCLUSIONS

This study demonstrates the trend in antibiotic susceptibility pattern (AST) of common gram negative infections seen in intensive care units. It demonstrates the changes seen especially after a change in the protocol antibiotic. Changes in the AST patterns of Klebsiella, E. coli, Pseudomonas and non-fermenting gram negative bacteria were seen. The data on the changing antibiotic susceptibility trends we believe is an important pillar in our efforts at infection control especially in intensive care settings.

Quantitative multimarker analysis in circulating tumor cells of patients with breast cancer

1021

Background: The purpose of this study was clinical application of new methods for quantitative gene expression analysis of circulating tumor cells (CTC) in breast cancer patients. Methods: The high affinity antibodies BM7 (MUC-1) and VU1D9 (EpCAM) were used for immunomagnetic tumor cell enrichment in 10 mL of peripheral EDTA-blood of patients with primary breast cancer (n=167) and metastatic disease (n=131). Separated cells were lysed and used for mRNA isolation and c-DNA synthesis. The breast carcinoma- associated markers MUC1 and EpCAM were determined by conventional RT-PCR. The markers cytokeratin 19 (CK19), mammaglobin 1, survivin, HER-2, CXCR4 and prostate-specific ets factor (PSE) were amplified by real-time quantitative RT-PCR using primers and FAM-labeled TaqMan probes selected with the UniversalProbeLibrary system (Roche AG, Basel, CH). The β-actin transcript served as internal process quality control. Specificity of the RT-PCR was confirmed by examination of blood of healthy donors. Results: Sensitivity for every single transcript was adjusted to 2 tumor cells per 5 ml blood. Tumor-associated transcripts were detected in 31 of 167 (18.5%) patients with primary breast cancer. The marker with the highest incidence of 81% was MUC1. Patients with metastatic disease (n=131) had a positivity rate of 56% and were characterized by multiple marker expression. During a 12 (9–15) months follow-up of 81 patients with primary breast cancer, multimarker positivity was determined in 10 patients, and in three of these patients early metastasis was clinically confirmed. In patients with metastatic disease the CK19 positive CTCs co-expressed either survivin, PSE, CXCR4 or HER2 in more than 70% of the cases. Conclusion: Using a combination of preanalytical immunomagnetic tumor cell enrichment, followed by a multigene quantitative RT- PCR approach, we describe a sensitive detection system for rare circulating breast carcinoma cells. By quantitative expression analysis, survivin, PSE, CXCR4 and HER2 together with CK19 were identified as reliable markers for early detection of metastasis and for prediction of risk of recurrence. The marker panel can be extended further to match patients to best drugs and to predict treatment benefits.

No significant financial relationships to disclose.

Low tumor cell detection rate in bone marrow of patients with primary breast cancer after elimination of stroma cells: Comparison of immunocytology and molecular analysis of CK19 and mammaglobin 1

1075

Background: Rapidly self-renewing stroma cells of the bone marrow (RS cells) are MUC-1 and cytokeratin positive at a rate of 56% (475/850). Elimination of RS cells by size exclusion results in a positivity rate of 2.6% (36/1407) in primary breast cancer patients. We have used preanalytical immunomagnetic tumor cell enrichment followed by molecular detection of CK19 and Mammaglobin1 (MA) transcripts for an independent verification of the bright-field immunocytology results. Material and Methods: Mononuclear cells (2x106) from bone marrow of 1,407 patients with primary breast cancer were analysed by standardized cytospin immunocytology techniques. Disseminated tumor cells (DTC) were stained with CK8/18/19 antibodies 5D3 and A45-B/B3 using either the APAAP technique (Dako Techmate 500) or the enhanced SA-FastRed method (Ventana). Parallel DTC consisted of immunomagnetic tumor cell selection of 1x107 BM cells using the cell membrane glycoproteins EpCAM and MUC-1 as targets. CK 19 and MA transcripts were determined by conventional and quantitative real time RT-PCR. Results: Using acetic acid and periodate blocking steps before immunocytology 36 from 1407 (2.6%) breast cancer patients operated between 1999 and 2005 at the University Hspital Heidelberg were scored DCT positive using computer assisted automated (Chromavision ACIS II) picture analysis. From this group 186 bone marrow samples were used for molecular tumor cell detection. By RT-PCR analysis of 1x107 immunomagnetically purified BM cells only 6 from 186 (3.2%) samples were CK19 and MG positive. Discussion: Detection rates of tumor cells in bone marrow from non-metastatic breast cancer patients has been reported to be in the range of 0% to 100%. We show here that proliferating bone marrow stroma cells of the RS type are positive for various antigens including CK polypeptides 7, 8, 18 and 19. Elimination of these cells by size exclusion results in a tumor cell detection rate of 2,6% in 1,407 BM probes. This low detection rate could be verified in 186 BM probes by CK19 and mammaglobin1 RT-PCR. We conclude that standard immunocytology in bone marrow is severely impaired by cytokeratin expression of RS-type stroma cells.

No significant financial relationships to disclose.