Tumor marker determination after orthotopic heart transplantation

Cardiac transplant rejection assessment with 18F-FDG PET-CT: initial single-centre experience for diagnosis and management

BACKGROUND

Rejection is a major cause of mortality and morbidity in heart transplant (HTx) recipients. Current methods for diagnosing rejection have limitations. Imaging methods to map the entire left ventricle and reliably identify potential sites of rejection is lacking. Animal studies suggest FDG PET-CT (FDG PET) could have potential application in human HTx recipients.

METHODS

Between December 2020 and February 2022, all HTx recipients at Harefield Hospital, London, with definite or suspected rejection underwent FDG PET in addition to routine work-up.

RESULTS

Thirty HTx recipients (12 with definite and 18 with suspected rejection) underwent FDG PET scans. Overall, 12 of the 30 patients had FDG PET with increased myocardial avidity, of whom 2 died (17%). Eighteen patients of the 30 patients had FDG PET with no myocardial avidity and all are alive (100%, p = 0.15). All patients with definite rejection, scanned within 2 weeks of starting anti-rejection treatment, showed increased myocardial avidity. In 5 cases, FDG PET showed myocardial avidity beyond 6 weeks despite pulsed steroid treatment, suggesting unresolved myocardial rejection.

CONCLUSION

Preliminary findings suggest FDG PET may have a role in diagnosing cardiac transplant rejection. Future blinded studies are needed to help further validate this.

CA125--a test with a change of heart

CA125 is well known as a tumour marker for ovarian cancer. Like all tumour markers it is not specific for a specific tumour and may be elevated in benign disease. Even in ovarian cancer it seems that CA125 is derived from mesothelial production rather than from the cancer cells. CA125 is a natural product of serosal epithelial cells and present in most serosal fluids whether malignant or benign. Benign causes of CA125 elevation include liver cirrhosis, peritoneal infection, abdominal surgery or the congestion of cardiac failure. Elevated CA125 levels are found in ascitic, pleural or pericardial fluid of patients with cardiac failure and the serum levels correlate with the clinical staging of cardiac failure. Whilst CA125 levels might be useful for diagnosis of cardiac failure, it has an equally impressive ability for defining prognosis in that condition, especially when combined with measuring natriuretic peptides. The CA125 assay is not standardised and different methods, such as new CA125II assays, often give differing results. Furthermore, as CA125 levels fall at the menopause, and may rise in the elderly, reference limits appropriate for age and gender need to be refined in order for CA125 to fulfil any of its potential as a marker of cardiac failure in these age groups.

JC virus T-Antigen DNA in gastrointestinal mucosa of immunosuppressed patients: a prospective, controlled study

BACKGROUND

JC virus (JCV), a polyoma virus, is the etiological agent of progressive multifocal leukoencephalopathy in immunosuppressed patients. JCV T-Ag has proven oncogenic potential and is expressed in colonic polyps and carcinomas. We proposed that the prevalence of JCV T-Ag DNA is higher in the normal gastrointestinal (GI) mucosa of immunosuppressed patients compared with their immunocompetent counterparts.

AIMS

To look for JCV T-Ag DNA in the normal gastrointestinal mucosa of immunosuppressed patients compared with immunocompetent controls.

METHODS

Macroscopically normal samples of upper and lower GI mucosa were obtained from 38 immunosuppressed patients. A control group included samples from 19 immunocompetent inflammatory bowel disease (IBD) and 29 non-IBD cases. DNA was extracted and polymerase chain reaction (PCR) was performed using primers specific for T-Ag.

RESULTS

JCV T-Ag DNA was found in nine of the immunosuppressed patients (23.7%) and in three of the controls (6.3%; P = 0.02). Transplant recipients had a particularly high prevalence of JCV T-Ag DNA (35.3%). Patients with IBD receiving immunosuppressive drugs had a higher prevalence of JCV T-Ag DNA in comparison with IBD patients who did not receive immunosuppression (22.2% versus 10.5%, respectively), but this difference was not statistically significant (P = 0.574).

CONCLUSION

JCV T-Ag DNA is more prevalent in the upper and lower GI mucosa of immunosuppressed patients, possibly indicating that the virus resides in these patients. This may account for the higher prevalence of GI carcinomas in immunosuppressed patients.

JC virus infection in colorectal neoplasia that develops after liver transplantation

PURPOSE

Liver transplant recepients (LTRs) have an increased risk of colorectal neoplasia. The mechanism responsible for this is unknown. JCV encodes for TAg and has been implicated in colorectal carcinogenesis. We hypothesized that the use of immunosuppression in LTRs facilitates activation of JCV and is responsible for the increased risk of neoplasia.

EXPERIMENTAL DESIGN

JCV TAg DNA and protein expression were determined in normal colonic epithelium (n = 15) and adenomatous polyps (n = 26) from LTRs and compared with tissue samples from control patients (normal colon, n = 21; adenomas, n = 40). Apoptosis and proliferation were determined by M30 and Ki-67 immunoreactivity, respectively.

RESULTS

JCV TAg DNA was found in 10 of 15 (67%) of normal colonic mucosa from LTRs compared with 5 of 21 (24%) of control normal mucosa (P = 0.025). JCV TAg DNA was detected in 16 of 26 (62%) of the adenomas from LTRs and in 20 of 40 (50%) of control adenomas. JCV TAg protein was expressed in 13 of 26 (50%) adenomas from LTRs versus 2 of 40 (5%) of adenomas from controls (P < 0.001). In adenomas from LTRs, the mean proliferative activity was higher compared with controls (60.3 +/- 3.2% versus 42.7 +/- 2.8%, P < 0.001), whereas mean apoptotic indices were lower in LTRs (0.29 +/- 0.08% versus 0.39 +/- 0.06%, P = 0.05).

CONCLUSIONS

The presence of JCV in the colorectal mucosa and adenomas from LTRs, in concert with the use of immunosuppressive agents, suggests that JCV may undergo reactivation, and the subsequent TAg protein expression might explain the increased risk of colorectal neoplasia in LTRs.

Serum carbohydrate antigen 125 levels in advanced heart failure: relation to B-type natriuretic peptide and left atrial volume

AIMS

To assess the relation between serum levels of carbohydrate antigen 125 (CA 125) and parameters of left ventricular (LV) filling pressure in patients with advanced heart failure (AHF).

METHODS

Forty-nine patients (mean age 67+/-10 years) with LV ejection fraction (EF) < or =0.35 and New York Heart Association (NYHA) class III or IV symptoms of heart failure were enrolled. Left atrial volume indexed to body surface area (LAVI) and the ratio of mitral inflow early diastolic velocity to annulus velocity (E/e) were evaluated with pulsed wave and tissue Doppler. Plasma B-type natriuretic peptide (BNP) was also measured.

RESULTS

The median overall CA 125 value was 44.0 (17.7-140) U/ml. CA 125 above the normal value (<35 U/ml) was found in 28 of the 49 patients (57%). Compared to patients with normal CA 125 levels, those with elevated CA 125 had a higher NYHA class and increased serum BNP levels, LAVI and E/e. In multivariate analysis, serum CA 125 levels were significantly associated with BNP (standardized beta coefficient=0.58, p<0.001) and LAVI (standardized beta coefficient 0.34, p<0.005).

CONCLUSION

Our study demonstrates that elevated serum CA 125 levels are associated with increased LAVI in parallel to increased neurohormonal activation in patients with AHF.

Carbohydrate antigen 125: an emerging prognostic risk factor in acute heart failure?

OBJECTIVE

To assess whether circulating levels of carbohydrate antigen 125 (CA125) predict subsequent 6-month all-cause mortality in patients after the index hospitalisation for acute heart failure (HF).

DESIGN AND SETTING

Prospective cohort study at a single teaching centre in Spain.

METHODS

529 consecutive patients with acute HF admitted in a single university centre were analysed. In addition to the traditional clinical information, CA125 (U/ml) was measured during the early course of hospitalisation. The independent association between baseline CA125 and mortality was assessed with Cox regression analysis. The follow-up was limited to 6 months.

RESULTS

349 (66%) patients showed serum levels of CA125 >35 U/ml (established cut-off point value). At a 6-month follow-up, 89 (16.8%) deaths were identified. A positive trend between mortality and CA125 quartiles was observed; 3.8%, 15.2%, 22% and 26.5% of deaths occurred from quartile 1 to 4 of CA125 (p<0.001). Likewise, a monotonic, ascending trend in the risk ratios was estimated from the multivariable Cox model. Compared with the first quartile of CA125, the HRs (95% CI) for the second, third and fourth quartiles were 3.25 (1.20 to 8.79), 4.91 (1.88 to 12.85) and 8.41 (3.24 to 21.79), respectively.

CONCLUSIONS

Serum levels of CA125 obtained in patients admitted with a diagnosis of acute HF was shown to be an independent predictor of mortality up to the 6-month follow-up.

Elevation of serum and ascites CA125 levels in liver cirrhosis

AIM

To evaluate the range of serum and ascitic cancer antigen(CA) 125 levels in patients with liver cirrhosis and to explore possible factors associated with CA 125 elevation.

METHODS

A total of 70 patients were studied. Group I consisted of 30 patients with liver cirrhosis with or without ascites. Group II consisted of 30 patients with digestive malignant tumors with or without asictes. And group III consisted of 10 patients with benign (but not cirrhotic) ascites. CA 125 levels were measured in sera of all the patients and also simultaneously in ascitic fluids of 15 patients.

RESULTS

Serum CA125 levels in 87% patients from group I were elevated, especially in those with ascites (95% vs 38% in patients without ascites, P<0.01) irrespective of the etiology of cirrhosis. Serum CA 125 levels were correlated with Child-Pugh scores (r = 0.38) but it was marginally significant (P = 0.06). All the patients with ascites from group II and group III had elevated serum CA 125 levels. There was no difference in serum CA 125 levels among patients with ascites from group I (275±175 kU/L), group II (368±190 kU/L) and group III (396±287 kU/L), neither did ascitic CA 125 levels (P>0.05), but serum CA 125 levels were significantly higher than those of patients without ascites from group I (72±83 kU/L) and group II (83±42 kU/L). The levels of serum CA 125 were lower than, but correlated with that of ascites CA 125 (198±108 kU/L vs 460±234 kU/L, r = 0.58, P = 0.026). The elevation of serum CA 125 in malignant ascites was more often accompanied with abnormalities of other tumor markers compared with that in benign ascites(90% vs 6%, P<0.01). Among the 38 patients with only serum CA125 elevation but not accompanied with a rise of other tumor markers, 36 (95%) were diagnosed as benign ascites.

CONCLUSION

The elevation of serum CA 125 is common in liver cirrhosis patients. It is correlated with the amount of ascites, and possibly insufficiency of liver function. Serum CA 125 probably derives from ascites. It usually predicts benign disease if the elevation of serum or ascites CA 125 is not accompanied with a rise of other tumor markers.