The role of laminin-5 and its receptors in mammary epithelial cell branching morphogenesis

In vivo, normal mammary epithelial cells utilize hemidesmosome attachment devices to adhere to stroma. However, analyses of a potential role for hemidesmosomes and their components in mammary epithelial tissue morphogenesis have never been attempted. MCF-10A cells are a spontaneously immortalized line derived from mammary epithelium and possess a number of characteristics of normal mammary epithelial cells including expression of hemidesmosomal associated proteins such as the two bullous pemphigoid antigens, alpha 6 beta 4 integrin and its ligand laminin-5. More importantly, MCF-10A cells readily assemble mature hemidesmosomes when plated onto uncoated substrates. When maintained on matrigel, like their normal breast epithelial cell counterparts, MCF-10A cells undergo a branching morphogenesis and assemble hemidesmosomes at sites of cell-matrigel interaction. Function blocking antibodies specific for human laminin-5 and the alpha subunits of its two known receptors (alpha 3 beta 1 and alpha 6 beta 4 integrin) not only inhibit hemidesmosome assembly by MCF-10A cells but also impede branching morphogenesis induced by matrigel. Our results imply that the hemidesmosome, in particular those subunits comprising its laminin-5/integrin 'backbone', play an important role in morphogenetic events. We discuss these results in light of recent evidence that hemidesmosomes are sites involved in signal transduction.

A population-based study of the usefulness of screening for neuroblastoma

BACKGROUND

Neuroblastoma has many characteristics which suggest that preclinical detection might improve outcome. The Quebec Neuroblastoma Screening Project was initiated to determine whether mass screening could reduce mortality in a large cohort of infants. As an early endpoint, we report whether screening could reduce the incidence of poor-prognosis neuroblastoma in children with advanced-stage disease over 1 year of age.

METHODS

All 476,603 children born in the province of Quebec during the 5-year period of May 1, 1989, to April 30, 1994, were eligible for urinary assay of homovanillic acid and vanillylmandelic acid at 3 weeks and 6 months of age. Children with a positive screen were referred to one of four paediatric cancer centres in the province for uniform evaluation and treatment if necessary. Standardised incidence ratios (SIRs) were calculated for neuroblastoma in the province and two similar population-based controls, the state of Minnesota and the province of Ontario, during the same period of time and with similar ascertainment procedures.

FINDINGS

Compliance with screening in Quebec province was 91% at 3 weeks (n = 425,816) and 74% at 6 months (n = 349,706). Through July 31, 1995, with a follow-up of the birth cohort of 15-75 months, 118 cases of neuroblastoma were diagnosed, 43 detected preclinically by screening, 20 detected clinically before screening at 3 weeks of age, and 55 detected clinically after 3 weeks of age having normal screens (52) or never screened (3). Retrospective analysis of stored samples confirmed that 49 of 52 patients missed by screening had levels of catecholamine metabolites that were too low to be detected at 6 months or earlier. Based on US Surveillance, Epidemiology and End Results data, 54.5 cases of neuroblastoma would have been expected in Quebec province during the study period, for an SIR of 2.17 (95% CI 1.79-2.57, p < 0.0001). For the two control groups, 43 and 80 cases of neuroblastoma were detected, respectively, compared with 37.9 and 85.4 expected, overall SIR 1.00 (not significant). SIRs for Quebec province by age at diagnosis in yearly intervals show a marked increased incidence under 1 year of age (SIR 2.85, 2.26-3.50), with no reduction in incidence in subsequent years. Limiting analysis to only patients diagnosed over 1 year of age with advanced-stage disease, 22 cases were detected in Quebec province versus 14.4 expected (SIR 1.52, 0.95-2.23). Data in the two control groups show no significant increase or decrease in any-stage disease in children under or over the age of 1 year, except for an increase in early-stage disease in Minnesota children over 1 year: 10 versus 3.8 expected (SIR 2.67, 1.27-4.58).

INTERPRETATION

Screening for neuroblastoma increases the incidence in infants without decreasing the incidence of unfavourable advanced-stage disease in older children. It is unlikely that screening for neuroblastoma in infants will reduce mortality for this disease.

Biological monitoring of workers' exposure to bromine

The use of serum bromine concentration (SeBr) as a measure of exposure was examined in an occupational cohort. Associations with work site, department type, chemical handling, and occupation, as proxy measures of exposure, were studied. SeBr was associated with all of these measures. SeBr was also associated with various demographic characteristics (age, country of origin, and education) in men. In women, there was no association between SeBr and age, country of origin, or education. The use of SeBr as a measure of exposure is discussed. The conclusion is that the exposure to bromine can be assessed by regular monitoring of SeBr.

Metastatic osteosarcoma of the kidney presenting as renal hemorrhage

PURPOSE

Renal osteosarcoma may arise as a metastasis from a primary bone osteosarcoma or as a primary renal tumor. Metastatic renal osteosarcoma has been found at autopsy in approximately 10% of patients who die of this disease.

PATIENT AND METHODS

A case report of a young Chinese patient presenting with acute onset of renal infarction and hemorrhage from a renal metastasis of osteosarcoma is presented, as well as a review of the literature.

RESULTS

Some patients with solitary renal metastatic osteosarcoma may have long-term disease-free survival after nephrectomy. Early diagnosis and thus increased awareness of this condition is important.

Stimulation and inhibition of human mammary epithelial cell duct morphogenesis in vitro

We previously determined that normal human mammary epithelial cells (HMECs) placed on the basement membrane-like substance Matrigel form structures, whereas malignant breast cells do not (1). In the present study, we determined that the structures formed by normal cells on Matrigel resembled breast ducts in vivo by electron microscopy, and the process of their formation recapitulated what is known of duct formation in vivo. We therefore used this model to study less well-understood aspects of breast morphogenesis. Two priming signals appeared necessary for initiation of morphogenesis: one provided by the Matrigel and one by the cells in an autocrine fashion. Evidence for this included diminished duct formation by cells plated low-concentration Matrigel or at low cell densities, and the reversal of the latter by conditioned medium from high-density cells on Matrigel. Antibodies to bFGF inhibited morphogenesis, suggesting a stimulatory autocrine role for this factor, and antibodies to TGF-beta 1 stimulated duct formation, suggesting an inhibitory autocrine role. Added TGF-beta 1 abolished morphogenesis and stimulated normal cells to wander through Matrigel as do malignant cells. Conditioned medium from normal cells did not stimulate malignant cells to form ducts, but conditioned medium from tumor cells diminished normal morphogenesis, suggesting that malignant cells secrete an inhibitor of morphogenesis.

Preoperative strategies in the management of Wilms tumor

Prenephrectomy therapy is well tolerated and results in easier operations, with significantly fewer tumor ruptures during surgery, and a favorable stage distribution as determined by the surgical specimen. As in other solid tumors of childhood, acceptable disease-free and actual survival figures with a minimum of early, intermediate, and late complications remain the aim of this strategy.

Hospice and palliative care: attitudes and practices of the physician faculty of an academic hospital

It has been suggested that physicians, particularly in academic hospitals, are resistant to the hospice approach to palliative care for terminally ill patients. It is of interest, therefore, to assess the attitudes and practices of the physician faculty of an academic hospital where a hospice program has been in existence for more than 10 years. This was assessed with two faculty surveys. All 966 physician faculty that were on staff at Northwestern Memorial Hospital in the fall of 1993 were sent a survey about their opinion of hospice care (Survey A). Then, all physicians who had referred patients to the hospice program between September 1993 and September 1994 at Northwestern Memorial Hospital received a survey letter after the death of their patient (Survey B). Seventy-seven percent of faculty physician respondents to Survey A had either referred patients, or knew of colleagues who had referred patients to a hospice program. Ninety-four percent of those who answered "yes" to the question about referrals reported satisfaction with their care. Ninety-four percent would refer patients in the future and 96 percent thought the hospice program was a valuable resource to the medical center. Of the respondents to Survey B, nearly 100 percent thought the referral had been handled in an "excellent" or "good" fashion, that communication with hospice staff was "excellent" or "good," that symptom control was "excellent" or "good," that their patients and families had received "excellent" or "good" psychosocial support, and that their patients and families were satisfied with the hospice care they received.(ABSTRACT TRUNCATED AT 250 WORDS)

[Retinopathy and serum uric acid in diabetics]

Low serum uric acid (UA) levels have been reported in diabetics. In a group followed for 15 years it was reported that low UA levels preceded the onset of diabetic retinopathy. We studied 95 consecutive diabetic clinic patients between July and September 1992. There was no significant difference in UA levels between those with or without retinopathy: 5.0 +/- 1.2 (SD) mg--vs. 5.3 +/- 1.3, respectively. Multiple regression analysis showed that higher UA levels were related independently to high body mass index (overweight, obesity), and male gender, but not to age, duration of diabetes, glycosylated hemoglobin, diabetic treatment or retinopathy.

Co-amplification of MYCN and a DEAD box gene (DDX1) in primary neuroblastoma

DEAD box proteins are putative RNA helicases that have been implicated in cellular processes involving alteration of RNA secondary structure, such as translation initiation and splicing. These proteins share eight conserved amino acid motifs, including Asp(D)-Glu-(E)-Ala(A)-Asp(D) which is part of a more extended motif. Recently, we have shown that the novel DDX1 gene containing a DEAD box motif maps to the same chromosome band as MYCN at 2p24 and is co-amplified with MYCN in retinoblastoma cell lines. Here, we show that the DDX1 gene is co-amplified with the MYCN gene in 2 of three neuroblastoma cell lines and that DDX1 RNA levels correlate with DDX1 gene copy number. Since amplification of MYCN is an indicator of poor prognosis in neuroblastoma, it was of interest to determine whether co-amplification with DDX1 occurred in clinical samples of neuroblastoma and whether such a finding carried any additional prognostic significance. We determined the gene copy number of DDX1 in 32 neuroblastoma patient samples (representative of all stages): 13 were MYCN amplified and 19 had normal copy numbers of the MYCN gene. Of the 13 neuroblastomas that were MYCN amplified, seven were also DDX1 amplified. Of the 19 that were not MYCN amplified, none were DDX1 amplified. This is the first example of a gene that is co-amplified with MYCN at a high frequency in neuroblastoma. While there was a trend towards a worse clinical outcome with co-amplification, the numbers were too small to reach significance.

[Cost of insulin-dependent diabetes vs cost of its prevention]

Accumulating evidence suggests that insulin-dependent diabetes mellitus (IDDM) is an autoimmune disease which can be predicted from immunologic markers. Encouraging results of recent IDDM prevention trials with insulin raises the question of cost benefit of such procedures, in addition to the obvious medical benefit. We estimated the expected cost benefit of national screening and preventive efforts in Israel (population 5 million in 1993). Due to the expense of immunological testing, we considered only relatives of IDDM patients who have a 3-5% risk of developing overt disease. Our screening showed that 225 (3.4%) of 7500 in this group (aged 1-54 years) carried islet autoantibodies, and about 50% progressed to diabetes within 3 years. The cost of testing for serological and metabolic markers was $6000 per subject; an additional $3,000 per subject is estimated to be the cost of preventive treatment. On comparing these numbers to only the minimal, life-long, direct cost of an IDDM patient ($30,000, based on 3 different analyses), we conclude that there is a cost benefit of programs for screening for IDDM and preventive treatment.

Evaluating treatments for childhood cancer. A process for critical appraisal of the literature and a summary of the results

An overview of published studies on three common cancers in childhood was conducted to estimate the effectiveness and consequences of treatment. Of 1,016 separate citations, 316 were reviewed in detail but only 162 were deemed to be "useful." An approach to a structured appraisal of the literature is presented.

Housestaff training in cancer pain education

A program for improving housestaff education in cancer pain control was piloted on an inpatient oncology unit during academic year 1992-93. Housestaff (four or five first-year residents and two more senior residents per month) received a three-day lecture series each month. A total of 32 housestaff participated. A questionnaire (Test A) about cancer pain was administered before the series. The subjects scored 58% correct (range 49-69). When Test A was repeated at the end of each rotation, the subjects scored 83% correct (range 82-86, p < 0.0001). A quiz on analgesic dosing (Test B) was also administered. The subjects scored 38% (range 20-56) before the lectures, 81% (range 72-93) immediately after the lectures, and 57% (range 44-67) at the end of the rotation. The authors conclude that this pilot project improves knowledge about cancer pain, but sustained reinforcement is needed if analgesic dosing skills are to be maintained.

A hospice/palliative medicine rotation for fellows training in hematology-oncology

A clinical hospice/palliative medicine rotation for physicians enrolled in a three-year hematology/oncology fellowship was established in academic year 1993-1994 as a way to accomplish important training goals in pain management and the palliative care of patients with terminal illness. This study was conducted to obtain initial information about its effectiveness. Ten fellows, one at a time, evaluated new hospice/palliative medicine consultations, supervised the care of patients on an inpatient hospice/palliative care unit, and visited patients at home. For the first 13 months, seven fellows were assigned to this rotation for one month each, and three fellows were assigned to spend two separate months each. A self-report evaluation of the experience was administered at the end of each service month. In five of these 13 evaluations, the fellows reported their skills in managing pain and symptoms to be much improved, and in eight they indicated their skills were improved; none stated that there had been no change. Comfort and skill with discussing death, dying, and advanced directives with patients and families were reported by the fellows to be much improved in nine evaluations, improved in three, and unchanged in one. In nine evaluations, the fellows reported their understanding of hospice/palliative care as a program and approach to patient care was much improved; in two, improved; and in two, unchanged. All of the fellows would recommend this rotation to other fellows. A clinical rotation in palliative medicine and hospice care is a useful addition to the curriculum of fellows training in hematology-oncology.

Acute tumour lysis syndrome with no evidence of tumour load

Acute tumour lysis syndrome (ATLS) is a well-recognised complication of the treatment of a variety of malignant disorders in which a large mass of disease is obvious. ATLS may, however, occur even in the absence of bulk disease. We present two cases which, together with a review of previously reported cases, suggest that a cause of this rare phenomenon is primary renal lymphoma which subsequently develops into the leukaemic phase. This is supported by the observation that some bone marrow aspirates which are normal at the time of ATLS have shortly afterwards demonstrated lymphoblasts. Renal biopsy may not exclude primary lymphoma of the kidney. In excluding lymphoproliferative disease in the differential diagnosis of acute hyperuricaemia, the importance not only of bone marrow examination but of exhaustive investigation of the kidneys is stressed.

Concurrent RhGM-CSF does not offset myelosuppression from intensive chemotherapy: randomized placebo-controlled study in childhood acute lymphoblastic leukemia

To determine whether recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) can offset the myelosuppressive effects of intensive chemotherapy, we carried out a double-blind placebo-controlled trial in which 40 patients with acute lymphoblastic leukemia (ALL) were randomized into two groups of 20 each. One group received rhGM-CSF (5.5 micrograms/kg SC) coadministered with chemotherapy and the other, placebo coadministered with chemotherapy from day 5 to day 11 and from day 19 to day 25 of the 28-day intensification phase of our institutional high-risk protocol for childhood ALL. The results indicate that, at the dose and schedule used, rhGM-CSF did not prevent neutropenia or shorten the number of days required to complete this phase of therapy. In addition, the treated and placebo groups showed no significant difference in absolute neutrophil counts, number of days with neutropenia, number of days with fever, number of days spent in hospital, or number of days on antibiotics during the 28-day study period. There was also no difference between the two groups in the number, type, or severity of infectious episodes. Two of 20 patients in the treatment group have relapsed, whereas none of the patients in the placebo group has yet relapsed (follow-up: 3-37 months), but these events were not statistically significant. We conclude that treatment with rhGM-CSF at the dose and schedule employed is not clinically beneficial.

Pediatric malignant pheochromocytoma

Pediatric malignant pheochromocytomas are very rare tumors, and no institution has more than one or two of these problem cases. The authors report on two children with such tumors, over a 9-year period, from two hospitals. In 1984, D.B. (14 years of age) presented with symptoms and signs of extradural metastasis from a right adrenal primary; he also had lung and bone metastases. After spinal decompression almost 4 years. He has remained well and is in remission 6 years later. In 1987, G.R. (13 years of age) presented with a larger right adrenal malignant pheochromocytoma invading surrounding structures; he also had liver metastasis. Preoperative chemotherapy did not shrink the tumor much; it was grossly resected, and there were many postoperative problems. In 1990, bone metastases developed, for which radiotherapy and chemotherapy were used. Three years later, the metastases have not disappeared; he remains on chemotherapy, and his liver function is borderline. From our small experience as well as a literature review, it appears that surgical excision remains the treatment of choice for the pediatric malignant phoechromocytoma. Unresectable tumors may be rendered resectable by intensive chemotherapy (similar to that used for neuroblastoma); adjuvant chemotherapy should be used for residual disease after surgery and for metastatic disease.

Gestational diabetes among Bedouins in southern Israel: comparison of prevalence and neonatal outcomes with the Jewish population

Differences in the prevalence of gestational diabetes mellitus (GDM) have recently been reported between various ethnic populations. In the Negev region of Israel, a universal free screening programme for GDM was implemented in 1985. Between 1 March 1987 and 31 July 1988 11,003 deliveries occurred at the Soroka Medical Center, which provides free delivery and postnatal care to the whole Jewish and Bedouin population of the region. GDM was found in 5.7% of Jewish and in 2.4% of Bedouin women (odds ratio, 2.3, 95% confidence interval (CI) 1.8-2.9; P < 0.0001). Ethnicity was unrelated to maternal outcome, perinatal mortality or to any of the examined morbidity conditions of the newborn. The incidence of major congenital malformations was significantly higher in Jewish than in Bedouin infants of GDM women (Fisher's Exact Test, P < 0.03). Conversely, Jewish infants had fewer minor congenital anomalies (odds ratio 0.26, 95% CI 0.09-0.73). In a multivariate logistic regression model, gestational age, mode of delivery and insulin requirement during pregnancy were the only factors independently associated with neonatal morbidity. The results of this study suggest that in our health care system, among women with GDM ethnicity is not associated with an excess of unfavourable maternal or infant outcomes.

Relation of carotid artery wall thickness to diabetes mellitus, fasting glucose and insulin, body size, and physical activity. Atherosclerosis Risk in Communities (ARIC) Study Investigators

BACKGROUND AND PURPOSE

We tested the hypothesis that body mass, waist-to-hip circumference ratio, physical inactivity, diabetes, hyperglycemia, and fasting insulin are each positively associated with asymptomatic carotid artery wall thickness.

METHODS

Average intimal-medial carotid wall thickness (an indicator of atherosclerosis) was measured noninvasively by B-mode ultrasonography in cross-sectional samples of 45- to 64-year-old adults, both blacks and whites, free of symptomatic cardiovascular disease, in four US communities.

RESULTS

Sample mean carotid wall thickness was approximately 0.7 mm in women (n = 7956) and 0.8 mm in men (n = 6474). Body mass, waist-to-hip ratio, work physical activity, diabetes, and fasting insulin were associated (P < .05) with carotid wall thickness in the hypothesized direction. Adjusted for age, race, smoking, body mass index, artery depth, and Atherosclerosis Risk in Communities field center, mean wall thickness was greater by 0.02 mm in women and 0.03 mm in men for a 0.07-unit (one SD) larger waist-to-hip ratio. Adjusted mean wall thickness was about 0.07 mm thicker in participants with diabetes mellitus and 0.02 mm thicker in participants with hyperglycemia (fasting glucose 6.4 to 7.7 mmol/L) than in subjects with fasting glucose < 6.4 mmol/L. Adjusted mean wall thickness increased by about 0.02 mm with an increase of 100 mmol/L in fasting serum insulin.

CONCLUSIONS

Abdominal adiposity, physical inactivity, and abnormal glucose metabolism are associated positively with carotid intimal-medial wall thickness, suggesting these factors contribute to atherogenesis.

Acute tumour lysis syndrome complicating treatment of stage IVS neuroblastoma in infants under six months old

Acute tumour lysis syndrome (ATLS) is a common complication of the treatment of haematopoietic malignancies. It is also well recognized in many nonhaematopoeitic malignancies of adults. There are very few reports of the syndrome occurring during therapy for the nonhaematopoeitic malignancies of childhood, and none has previously been reported in the treatment of neuroblastoma. We report the cases of four patients presenting to The Hospital for Sick Children (HSC) between 1985 and 1992 who developed ATLS during treatment for stage IVS neuroblastoma. ATLS is a significant risk in patients undergoing therapy for stage IVS neuroblastoma, particularly where this has been delayed.

Variant translocations of chromosome 22 in Ewing's sarcoma

Relatively few variant translocations have been reported in primary Ewing's sarcomas (ES). We report two new variant translocations, both of which involve chromosomal rearrangements of 22q12. Cytogenetic studies of tumor cells from a 12-year-old girl revealed a variant translocation, t(7;22)(p22;q12), the second example reported of a simple variant of the 22q12 reciprocal translocation in this type of sarcoma. The identity of this rearrangement was confirmed by in situ hybridization. In addition, a complex translocation was identified in a dysmorphic 15-year-old girl, t(4;11;22)(q21;q24;q12). No previous cases of variant translocations in ES have involved band 7p22 or 4q21, and there are no previous reports of an association between congenital abnormalities and unusual karyotype abnormalities in ES. Both variant translocations conserve the junction on the der (22), providing additional cytogenetic evidence that the sequences on chromosome 22 are critical.

Malignant benign neonatal sacrococcygeal teratoma

Thirty-six patients with benign neonatal sacrococcygeal teratoma (SCT) were treated in our medical center from 1972 to 1990. Mean gestational age was 38.6 +/- 3.3 weeks with a mean birth weight of 3,484.0 +/- 938.5 g. Twenty-nine patients (89%) were females. The majority of the tumors (75%) contained cystic components and 96% were Altman classification I and II. The initial surgical removal of the SCT (including the coccyx) was carried out during the first 7 days of life. Six patients (22%) developed recurrence of the tumor. Three were benign and reappeared locally after 12 +/- 3 months and were reexcised. The mean serum alpha-fetoprotein level in this group was 13 +/- 1 g/L. The malignant recurrence (all originally reported as being mature benign SCT) appeared at 20.3 +/- 1.5 months and had markedly elevated serum alpha-fetoprotein levels (7,320 +/- 4,630 micrograms/L). All the patients in this group had multimodal therapy including complete excision of the recurrent tumor. We conclude that SCT, although histologically benign, has an alarming potential to recur either as a benign or malignant tumor during the first 2 years of life. Close follow-up for at least 3 years (frequent examination, serum alpha-fetoprotein, and diagnostic imaging) is recommended for all patients who had undergone excision of SCT in the newborn period.

Primary leptomeningeal melanoma: an unusually aggressive tumor in childhood

Primary malignant melanoma of the leptomeninges of the central nervous system is a rare and aggressive tumor in children. We report our experience from 1964 to 1990 with this tumor in eight children. The mean age at diagnosis was 4.9 years (range, 1.3 to 13 yr). Five children presented with signs and symptoms of raised intracranial pressure from hydrocephalus secondary to tumoral obliteration of the basal cisterns, but the time from the initial symptomatology to diagnosis was frequently delayed. Three patients in this series had hairy nevi in association with their leptomeningeal melanoma. Cerebrospinal fluid (CSF) analysis typically showed raised opening pressures, decreased glucose, and increased protein concentrations. Malignant melanoma cells were found in the CSF in three patients. Confirmatory radiographic examinations included air encephalography, myelography, and computed tomographic and magnetic resonance scanning. Four patients were treated with lumboperitoneal shunts, and one patient was treated with a ventriculoperitoneal shunt for hydrocephalus. Two patients underwent craniotomies and subtotal excisions of their tumors. In seven patients, a definitive diagnosis of leptomeningeal melanoma was made by pathological examination of tissues sent at surgery or at post mortem. In one case, the diagnosis was established by a detailed cytological analysis of the CSF. Four children died of fulminant disease and tumor spread before treatment could be instituted. The four children who received treatment had a combination of radiation therapy and chemotherapy. One child received intrathecal methotrexate. The two children with the longest survivals (2 and 3 yr, respectively) received cisplatinum and dimethyltriazenoimidazole carboxamide in addition to craniospinal irradiation.(ABSTRACT TRUNCATED AT 250 WORDS)