The use of the Rusch balloon for management of severe postpartum haemorrhage

Tamponade techniques using a uterine balloon in management of postpartum haemorrhage has been reported increasingly in recent years. The aim of this retrospective study is to evaluate the use of the Rusch hydrostatic balloon in the management of severe postpartum haemorrhage not controlled by medical measures. All women had risk factors for PPH. The Rusch balloon was used in all cases of PPH apart from traumatic PPH, which is considered as a contraindication for its use. The Rusch balloon was successful in seven out of the eight cases treated. We have introduced guidelines for using the Rusch balloon and they are provided in this paper.

Leiomyoma in a young woman with Mayer-Rokitansky-Huster-Hauser syndrome

A 20 years old, unmarried woman attended OPD with the complaints of amenorrhoea (primary) and lower abdominal pain for last 3 months. Per abdominal examination revealed a mobile mass in the lower abdomen at the level of pubic symphysis. Per rectal examination revealed a midpelvic mass. Per vagina examination revealed vaginal opening was blind. On laparotomy a solid mass (8cm x 7cam) with bosselated surface was seen arising from the uterine bulb on the left side, which appeared and histopathologically correlated to be leiomyoma. The patient was discharged with a plan for further surgery of vaginoplasty.

The better bisphosphonate in patients with bone metastasis: Zoledronic acid or ibandronic acid? A study from Eastern India

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Background: Ibandronic acid is a third generation bisphosphonate which acts by inhibition of osteoclasts. Zoledronic acid also has a similar mechanism of action. This study was designed to study superiority or inferiority of either agent over other in terms of efficacy in reducing bone pain and complications in patients with bone metastases. Methods: From Jan 2005 to Dec 2008, 240 patients of various malignancies with bone metatstasis were enrolled and were randomized on a 1:1 basis to receive monthly IV infusions of ibandronate or zoledronate and were analysed for pain relief, skeletal related events and adverse events. Results: Patients in both the arms were well matched for their diagnosis, stage of disease, burden of skeletal disease and performance status. Different diagnoses were, carcinoma breast (n=99), carcinoma prostate (n=54), myeloma (n=48), carcinoma lung (n=23), others (n=20). Median follow up was 18 months. At 18 months, mean increases in British Pain Inventory pain scores were lower with zoledronate compared to ibandronate (0.43 vs 0.88 [p=0.02]). Analgesic use as defined by 4 point analgesic scale was less with zoledronate as compared to ibandronate. Incidence of skeletal related events was not significantly different between two arms (33% for zoledronate vs 39% for ibandronate [p=0.2]). Median time to first skeletal related event was not reached in either arm. At 18 months of median follow up, percentage of patients with skeletal related events were 39% in zoledronate arm vs 43% in ibandronate arm (p=0.06). Zoledronate caused fever in 30 (12.5%) patients and hypocalcemia in 10 patients. Ibandronte caused hypocalcemia in 3 patients. No cases of osteonecrosis of jaw were observed. Conclusions: Zoledronate is the preferred bisphosphonate in developing countries for its shorter infusion time and availability of cheaper generic brands. This study also indicates that it may be slightly better than ibandronate in reducing bone pain and preventing skeletal related events.

No significant financial relationships to disclose.

Pegylated liposomal doxorubicin in ovarian cancer patients with renal compromise

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Background: Ovarian cancer patients with renal compromise poses problem in choosing chemotherapy for them. Pegylated liposomal doxorubicin (PLD) can be used in such cases. However there is not much data regarding the efficacy and toxicity of PLD. We used PLD in a few renal compromised ovarian and peritoneal cancer patients. Methods: The clinical records of patients with recurrent ovarian and peritoneal cancer patients with high creatinine or low creatinine clearance level who were given PLD at the Netaji Subhas Chandra Bose Cancer Research institute) (NCRI) from July 2005 to July 2008 was reviewed retrospectively to study efficacy and toxicity. Results: Twenty-one patients were identified, which included 16 with epithelial ovarian cancer, 5 with peritoneal cancer. Renal compromise was diagnosed and graded according to creatinine clearance test (CCT) as severe when less than 28 mL/min/1.5 m2, moderate when CCT is 28–55 mL/min/1.5 m2, and mild when CCT is 55–84 mL/min/1.5 m2. Normal value was taken as 85 mL/min/1.5 m2. Patients had distribution as mild: 4 patients, moderate:7 patients, and severe:10 patients. The initial doses of PLD were classified into regular initial dose (40 mg/m2/4 weeks) and lower initial dose (20–30 mg/m2/4 weeks). The median cycle was 5 (range 1–12). We used lower dose for moderate and severe renal disease. The incidence of palmar-plantar erythrodysesthesia 5/21 (23.8%), stomatitis 6/21(28.5%), and hematologic toxicity 3/21(14.2 %). Dose reduction due to toxicities occurred in 19.04 % (4/21) patients. Amongst 21 cases no patient had deterioration of renal function while and after the treatment with PLD. However we had primary treatment with PLD in four cases (2 moderate and 2 severe) while others had platinum based initial treatment. We did not have any complete responder though we had 6 (28.5%) partial responders, 8 (38.1%) stable diseases and 7(33.3%) progressive diseases. Conclusions: Patients with renal compromise who received PLD therapy at an initial dose lower than 40 mg/m2/4 weeks tolerated their treatment well. They required subsequent dose reduction due to mucocutaneous and cardiological toxicities in 19% cases. Treatment response in this population with ovarian and peritoneal cancer was similar to that of patients with normal renal function.

No significant financial relationships to disclose.

The role of iron chelation activity of wheat grass juice in patients with myelodysplastic syndrome

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Background: A pilot study with wheat grass juice in major thalassaemia patients was done by a group of clinicians in IPGMR, Chandigarh, India. We performed a study of 200 patients of intermediate thalassaemia with wheat grass juice and found 80% patients becoming transfusion independent. During the study in majority of the patients, serum ferritin level was significantly less as compared to pretreatment values. The aim of our study was to see the effect of wheat grass juice in reducing Ferritin level in myelodysplastic syndrome and also do the biochemical analysis of the wheat grass juice. Methods: During period from January 2003 to December 2007 we selected 20 patients of transfusion dependent myelodysplastic syndrome in the oncology department of Netaji Subhash Chandra Bose Cancer Research Institute. The age range of the patients was 42 years to 72 years (median 55 years). The fresh leaves of 5–7-day-old wheat grasss including stems were made fresh juice and had given 30 mL of juice daily to all 20 patients for continuous 6 months. Wheat grass juice was analyzed by column chromatography and found to be rich in oxalic and malic acid which might have some role in dietary absorption of iron from intestine. Beside that the wheat grass juice was found to contain two unique active ingredients with iron chelating property which was performed by deoxyribose degradation assay. We compared aqueous soluble extract of 5–7-day-old plant and dose-dependent study showed a significant iron chelating activity of crude extract in comparison to known standard iron chelator desferroxamine (DFO). The active compounds of crude extract of wheat grass may chelate catalytic iron in iron overload disorders when taking systematic dose. Result: The mean serum Ferritin level of the patients was 2,250 (range 650–4,800) before wheat grass treatment. The mean reduced to 950 (range 68–1680) (p < 0.0001). The performance status was improved from 60% to 80% (Karnofsky) after wheat grass treatment. The mean interval between transfusions was found increased. Conclusions: Wheat grass juice is an effective iron chelator and its use in reducing serum ferritin should be encouraged in myelodysplastic syndrome and other diseases where repeated blood transfusion is required.

No significant financial relationships to disclose.

Result of adolescent acute lymphoblastic leukemia protocol (MCP 841) from a developing country

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Background: Acute Lymphatic Leukemia is a curable disease in the range of 80 - 90% in developed countries by aggressive protocol like BFM, St. Judes’ but result is much less in adolescence age group (60–70%). In developing countries like ours, patients can't tolerate that aggressive protocol because of socio-economic and nutritional factors. The less aggressive protocol like MCP841 is suitable in developing countries like ours. The aim of our study was to see outcome of adolescent ALL patient with protocol MCP 841 and tolerability of the protocol in Indian-Asian population. Methods: We treated 75 children with age range 13 - 18 years (median age of 15 yrs) with MCP 841 Protocol at Netaji Subhash Chandra Bose Cancer Research Institute, Kolkata, India, a tertiary cancer center from Eastern India during the period of April 1999 to Dec 2007. There was female preponderance in the study. Fever 48 (64.0%), lymphadenopathy 35 (46.7%), and haepatosplenomegaly 28 (37.3%) were the major clinical presentation. Eight (10.7%) patients were present with hyper leukocytosis. T-ALL phenotype was the largest group though the incidence of the C-ALL was quite high 23 (30.7%). Results: Remission induction was seen in 65 (86.7%) of the patients. In a follow-up period of 24 - 88 months (with an average of 54 months) the disease-free survival ( DFS) was 42 (56%) patients with an overall survival of 46 (61.34%) patients. The isolated bone marrow relapse was seen in majority of the cases 28 (37.34%) and the major relapse was in maintenance and first 6 months of completion of therapy. The major cause of morbidity was infection 53 (70.7%) followed metabolic complications 16 (21.34%), pancreatitis 3 (4.0%), hemorrhage 10 (13.3%), neurologic 2 (2.7%), and hepatitis 1 (1.3%). The major cause of the mortality was infection 18% (24.0% patients) followed progressive disease 9 (12.0%) and hemorrhage 2 (2.7%). As compared to our all pediatric ALL group the outcome is much less and complications are much more. Conclusions: The data of acute lymphatic leukemia in adolescent is not satisfactory as compared to other pediatric patients. They also tolerate chemotheraphy badly. Therefore there is need for modified protocol for this age group.

No significant financial relationships to disclose.

Hepatoma-derived growth factor and its role in keloid pathogenesis

Hepatoma-derived growth factor (HDGF) is a novel mitogenic growth factor that has been implicated in many different carcinomas. Its role in keloid biology has not yet been investigated. The present study is aimed at examining the role of HDGF in keloid pathogenesis. Immunohistochemical staining and Western blot analyses were used to examine in vivo localization and expression of HDGF in keloid and normal skin tissue. This was followed by the detection of HDGF expression in fibroblasts cultured in vitro and fibroblasts exposed to serum. To investigate the effect of epithelial–mesenchymal interactions, a two-chamber system was employed in which keratinocytes on membrane inserts were co-cultured with the fibroblasts. HDGF expression levels in all cell extracts and conditioned media were assayed through Western blot analysis. In another set of experiments, the effect of exogenous recombinant HDGF on keloid fibroblasts (KF) and normal fibroblasts (NF) was examined. Cell proliferation was assessed by the MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assay and by quantifying proliferating cell nuclear antigen (PCNA) expression. Downstream targets of HDGF were identified by detecting their expression through Western blot analysis. Our results indicate that there was an increase in HDGF expression in the dermis of keloid compared with normal skin tissue. The application of serum and epithelial–mesenchymal interactions did not seem to have any effect on intracellular HDGF expression levels. However, co-culturing keloid keratinocytes with KFs resulted in increased HDGF secretion when compared with monoculture or normal controls. Furthermore, treatment with exogenous recombinant HDGF was found to increase the proliferation of KFs, activate the extracellular signal-regulated kinase (ERK) pathway and up-regulate the secretion of vascular endothelial growth factor (VEGF).

Fine mapping of loci involved with glucosinolate biosynthesis in oilseed mustard (Brassica juncea) using genomic information from allied species

Fine mapping of six seed glucosinolate QTL (J2Gsl1, J3Gsl2, J9Gsl3, J16Gsl4, J17Gsl5 and J3Gsl6) (Ramchiary et al. in Theor Appl Genet 116:77-85, 2007a) was undertaken by the candidate gene approach. Based on the DNA sequences from Arabidopsis and Brassica oleracea for the different genes involved in the aliphatic glucosinolate biosynthesis, candidate genes were amplified and sequenced from high to low glucosinolate Brassica juncea lines Varuna and Heera, respectively. Of the 20 paralogues identified, 17 paralogues belonging to six gene families were mapped to 12 of the 18 linkage groups of B. juncea genome. Co-mapping of candidate genes with glucosinolate QTL revealed that the candidate gene BjuA.GSL-ELONG.a mapped to the QTL interval of J2Gsl1, BjuA.GSL-ELONG.c, BjuA.GSL-ELONG.d and BjuA.Myb28.a mapped to the QTL interval of J3Gsl2, BjuA.GSL-ALK.a mapped to the QTL interval of J3Gsl6 and BjuB.Myb28.a mapped to the QTL interval of J17Gsl5. The QTL J9Gsl3 and J16Gsl4 did not correspond to any of the mapped candidate genes. The functionality and contribution of different candidate genes/QTL was assessed by allelic variation study using phenotypic data of 785 BC(4)DH lines. It was observed that BjuA.Myb28.a and J9Gsl3 contributed significantly to the base level glucosinolate production while J16Gsl4, probably GSL-PRO, BjuA.GSL-ELONG.a and BjuA.GSL-ELONG.c contributed to the C3, C4 and C5 elongation pathways, respectively. Three A genome QTL: J2Gsl1harbouring BjuA.GSL-ELONG.a, J3Gsl2 harbouring both BjuA.GSL-ELONG.c and BjuA.Myb28.a and J9Gsl3, possibly the 'Bronowski genes', were identified as most important loci for breeding low glucosinolate B. juncea. We observed two-step genetic control of seed glucosinolate in B. juncea mainly effected by these three A genome QTL. This study, therefore, provides clues to the genetic mechanism of 'Bronowski genes' controlling the glucosinolate trait and also provides efficient markers for marker-assisted introgression of low glucosinolate trait in B. juncea.

Targeting of Sp1 transcription factor: a novel therapeutic approach for keloids, an in vitro analysis

Keloid scars are fibroproliferative disorders characterized by the accumulation of extracellular matrix (ECM) components resulting in a fibrotic condition. Several ECM promoters are regulated by Sp1. Thus, our aim was to investigate the role of Sp1 in keloid pathogenesis and investigate the antiproliferative and antifibrotic effects of Wp631 and mitoxantrone, potent inhibitors of Sp1-activated transcription. An elevated level of Sp1 was observed in tissue extracts obtained from keloid tissue. Serum stimulation elevated Sp1 levels in keloid fibroblasts (KF). Under coculture conditions Sp1 seemed to be downregulated. Wp631 and mitoxanthrone in serum growth factors resulted in a reduced expression of ECM components in KF. Both Wp631 and mitoxanthrone were also able to inhibit the proliferation of normal and keloid keratinocytes and fibroblasts significantly. As Wp631 seems to be potent in downregulating the ECM components in KF and also inhibiting the proliferation of these cells it could be explored as a possible therapeutic agent in the treatment of keloids.

QTL analysis reveals context-dependent loci for seed glucosinolate trait in the oilseed Brassica juncea: importance of recurrent selection backcross scheme for the identification of 'true' QTL

Seed glucosinolate content in Brassica juncea is a complex quantitative trait. A recurrent selection backcross (RSB) method with a doubled haploid (DH) generation interspersing backcross generations was used for the introgression of low glucosinolate alleles from an east European gene pool B. juncea line, Heera into an Indian gene pool variety, Varuna. Phenotypic comparisons among the DH populations derived from early to advanced backcrosses revealed a shift in the mean values for various glucosinolates with the advancement of backcrossing, indicating a change in the selective values of the alleles with change in the genetic background due to the existence of epistasis and context dependencies. QTL mapping for various seed glucosinolates from early (F(1)DH) and advanced generation (BC(4)DH) populations confirmed the presence of epistasis and context dependency. The common QTL detected in both F(1)DH and BC(4)DH changed their R (2) values from the former to the later generation. Some of the QTL detected in the F(1)DH became irrelevant in the BC(4)DH population. Further, new QTL were detected in the BC(4)DH population for various glucosinolates. A validation study on a population of low glucosinolate DH lines derived from all the backcross generations of the RSB breeding programme revealed that the QTL detected in BC(4)DH were the 'true' QTL. Using glucosinolate as an example, the study provides strong evidence for the importance of the RSB method for the identification of the 'true' QTL which would be significant for marker assisted introgression of a complex quantitative trait whose expression is influenced by epistatic interactions.

Mapping of yield influencing QTL in Brassica juncea: implications for breeding of a major oilseed crop of dryland areas

Quantitative trait loci (QTL) analysis of yield influencing traits was carried out in Brassica juncea (AABB) using a doubled haploid (DH) mapping population of 123 lines derived from a cross between Varuna (a line representing the Indian gene pool) and Heera (representing the east European gene pool) to identify potentially useful alleles from both the parents. The existing AFLP based map of B. juncea was further saturated with RFLP and SSR markers which led to the identification of the linkage groups belonging to the A (B. rapa) and B (B. nigra) genome components of B. juncea. For QTL dissection, the DH lines were evaluated at three different environments and phenotyped for 12 quantitative traits. A total of 65 QTL spread over 13 linkage groups (LG) were identified from the three environments. QTL analysis showed that the A genome has contributed more than the B genome to productivity (68% of the total QTL detected) suggesting a more prominent role of the A genome towards domestication of this crop. The east European line, Heera, carried favorable alleles for 42% of the detected QTL and the remaining 58% were in the Indian gene pool line, Varuna. We observed clustering of major QTL in a few linkage groups, particularly in J7 and J10 of the A genome, with QTL of different traits having agronomically antagonistic allelic effects co-mapping to the same genetic interval. QTL analysis also identified some well-separated QTL which could be readily transferred between the two pools. Based on the QTL analysis, we propose that improvement in yield could be achieved more readily by heterosis breeding rather than by pure line breeding.

Alloantigen recognition is critical for CD8 T cell-mediated graft anti-tumor activity against murine BCL1 lymphoma after myeloablative bone marrow transplantation

The goal of the current study was to determine whether whole bone marrow cells or splenic CD8(+) T cells from C57BL/6 (H-2(b)) donor mice, which are tolerant to BALB/c (H-2(d)) alloantigens, are capable of mediating graft anti-tumor activity against a BALB/c B-cell lymphoma after injection into irradiated BALB/c hosts. The experimental results show that high doses of splenic CD8(+) T cells mixed with T cell-depleted bone marrow cells from C57BL/6 non-tolerant (normal) donors eliminate the BCL(1) B-cell lymphoma cells and induce lethal graft-versus-host disease (GVHD). CD8(+) T cells from tolerant donors simultaneously lose both their ability to induce GVHD and their anti-tumor activity. Whole bone marrow cell transplants from normal donors eliminated BCL(1) tumor cells without inducing GVHD, and bone marrow cells from tolerant donors failed to eliminate the tumor cells. The infused BCL(1) tumor cells expressed an immunogenic tumor-specific idiotype antigen disparate from host alloantigens, indicating that recognition of the tumor-specific antigen alone was insufficient to elicit graft anti-tumor activity from unimmunized allotolerant donor splenic CD8(+) T cells or whole bone marrow cells. We conclude that CD8(+) T cells from unimmunized normal donor mice require alloantigen recognition to mediate their anti-tumor activity following allogeneic BMT.

Combination of gemcite and cisplatin chemotherapy in unresectables gall bladder cancer

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Background: Adenocarcinoma of the gall bladder accounts for approximately 4% of all malignant neoplasm of the gastro- intestinal tract. Though surgical resection is the treatment of choice, majority of the cases are unresectable. Different chemotherapeutic agents including 5Flurouracil, Mytomycin C, Cisplatin, Methotrexate, Etoposide and Doxorubicin have been tried single or in combination. Partial response lasting from weeks to several months have been observed only in about 10% - 20 % of the cases and the median survival for patients with gall bladder cancer is approximately 4 months. Gemcitabine has shown strong anti tumour activity in a variety of solid tumours. Cisplatin has synergistic activity with Gemcitabine. The aim of our study was to determine the response rate of Gemcitabine and Cisplatin combination in unresectable gall bladder cancer and to see the tolerability in Indian-Asian pollution. Methods: During period from November 2002 to December 2006 we selected 84 consecutive patients with histologicaly proven unresectable measurable, gall bladder cancer. The inclusion criteria were performance status more than 60% (Kornofsky) and normal liver (bilirubin < 2) and kidney function ( creatinine <2) function . All patient received Gemcitabine (1000mg/m2 intravenously over 30 minute) on day 1 and day 8 and Cisplatin total (100mg/m2 divided D1 to D3) every 21days. Response assessment was done by CT Scan after 3 cycles of chemotherapy. All 84 patients are eligible for efficacy and toxicity analysis. Results: There were 15 (17.8%) complete responders, 27 (32%) partial responders, 22 (26.1%) with stable disease and 20 (23.8%) shows disease progression. The median time to progression was 22 weeks (range 12- 30 weeks). The median duration of response was 16 weeks (range 5.6 - 60 weeks). The median over all survival was 24 weeks (range 11–32 weeks) with 1year survival rate of 20.2%. WHO grade III or IV anaemia was seen in 23 (18.63%) patients respectively. Sixteen (13.44%) patients experienced grade III or IV neutropenia while grade III or IV thompocytopenia was seen in 8 patients (6.72%). Conclusions: The present study showed the Gemcitabin & Cisplatine combination was very useful in advanced unresectable gall bladder cancer. It was well tolerated by the patients.

No significant financial relationships to disclose.

Oral chemotherapeutic agents in elderly acute myeloid leukemia (AML) patients, a study from a developing country

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Background: Almost 60% of the patients with Acute Myeloid Leukemia (AML) are over the age of 60 years. Age is one of the strongest adverse prognostic factor for AML, both for induction remission and for survival. Studies have shown that elderly patients have reduced tolerance to aggressive chemotherapy especially the myelosupressive effects. Elderly patients with Leukemia who receive intensive treatment often die as a result of chemotherapy. Aggressive chemotherapy is also costly which the relatives in developing country are reluctant to spend for the elderly patients. The aim of our study was to see the outcome, tolerability and cost effectiveness of oral chemotherapeutic agents. Methods: We selected consecutive 100 patients more than 50 years of age in haemato oncology department of NCRI (Netaji Subhas Chandra Bose Cancer Research Institute) during the period from Jan 2004 to Dec 2006. The mean age of the patients was 65 (range 50 –71) years. There was male preponderance. The inclusion criteria were performance status more than 60% (Kornofsky), Morphological, Cyto-Chemical and Immunophenotyping diagnosis of Acute Myeloid Leukemia (AML), normal liver (billirubine < 2) and kidney function ( Creatinine <2%). After the incent consent all patient were started oral chemotherapeutic agents 6 Mercptopurine (6MP) 75mg/m2. Etoposide 70mg/m2 and Prednisolone 40mg/m2. All agents are given 3 weeks followed by 7 days gap every month and continued for 6 months. Bone Marrow was repeated after 3rd & 6th course of chemotherapy. Results: Fifteen (15%) and thirtyeight patients (38%) had complete hematological response after 3rd & 6th course of chemotherapy. Seven patients (7%) died because of grade III/IV Neutropenia. Median duration of Myelosupression was 18 days (2 to 48 days).12% required hospitalisation. With median follow up of 19 months (range 2–36 months) the disease free survival (DFS) and over all survival (OS) was 18 % and 32 % respectively. Conclusions: The combination of oral chemotherapeutic agents consisting of 6MP, Etoposide & Prednisolone were well tolerated by elderly patients with good induction remission, low mortality and median survival. It was cheaper and well accepted by the patients.

No significant financial relationships to disclose.

mTOR as a potential therapeutic target for treatment of keloids and excessive scars

Keloid is a dermal fibroproliferative disorder characterized by excessive deposition of extracellular matrix (ECM) components such as collagen, glycoproteins and fibronectin. The mammalian target of rapamycin (mTOR) is a serine/theronine kinase which plays an important role in the regulation of metabolic processes and translation rates. Published reports have shown mTOR as regulator of collagen expression and its inhibition induces a decrease in ECM deposition. Our aim was to investigate the role of mTOR in keloid pathogenesis and investigate the effect of rapamycin on proliferating cell nuclear antigen (PCNA), cyclin D1, collagen, fibronectin and alpha-smooth muscle actin (alpha-SMA) expression in normal fibroblasts (NF) and keloid fibroblasts (KF). Tissue extracts obtained from keloid scar demonstrated elevated expression of mTOR, p70KDa S6 kinase (p70S6K) and their activated forms, suggesting an activated state in keloid scars. Serum stimulation highlighted the heightened responsiveness of KF to mitogens and the importance of mTOR and p70S6K during early phase of wound healing. Application of rapamycin to monoculture NF and KF, dose- and time-dependently downregulates the expression of cytoplasmic PCNA, cyclin D1, fibronectin, collagen and alpha-SMA, demonstrating the anti-proliferative effect and therapeutic potential of rapamycin in the treatment of keloid scars. The inhibitory effect of rapamycin was found to be reversible following recovery in the expression of proteins following the removal of rapamycin from the culture media. These results demonstrate the important role of mTOR in the regulation of cell cycle and the expression of ECM proteins: fibronectin, collagen and alpha-SMA.