Evaluation of a panel of molecular markers for the diagnosis of malignant serous effusions

mRNA markers associated with malignant pleural effusion

Malignant pleural effusions (MPE) commonly result from malignant tumors and represent advanced-stage cancers. Thus, in clinical practice, early recognition of MPE is valuable. However, the current diagnosis of MPE is based on pleural fluid cytology or histologic analysis of pleural biopsies with a low diagnostic rate. This research aimed to assess the diagnostic ability of eight previously identified Non-Small Cell Lung Cancer (NSCLC)-associated genes for MPE. In the study, eighty-two individuals with pleural effusion were recruited. There were thirty-three patients with MPE and forty-nine patients with benign transudate. mRNA was isolated from the pleural effusion and amplified by Quantitative real-time PCR. The logistic models were further applied to evaluate the diagnostic performance of those genes. Four significant MPE-associated genes were discovered in our study, including Dual-specificity phosphatase 6 (DUSP6), MDM2 proto-oncogene (MDM2), Ring finger protein 4 (RNF4), and WEE1 G2 Checkpoint Kinase (WEE1). Pleural effusion with higher expression levels of MDM2 and WEE1 and lower expression levels of RNF4 and DUSP6 had a higher possibility of being MPE. The four-gene model had an excellent performance distinguishing MPE and benign pleural effusion, especially for pathologically negative effusions. Therefore, the gene combination is a suitable candidate for MPE screening in patients with pleural effusion. We also identified three survival-associated genes, WEE1, Neurofibromin 1 (NF1), and DNA polymerase delta interacting protein 2 (POLDIP2), which could predict the overall survival of patients with MPE.

Molecular testing on serous effusion: An update

Cytological examination of the effusion fluid provides valuable information regarding the presence of malignancy. At times, it is challenging to diagnose malignant cells in serous effusion. The various ancillary techniques are available to solve the problem including immunocytochemistry, DNA ploidy, and multicolored flow cytometry. At present, the molecular tests on the effusion sample are of growing interest. The effusion sample is rich in cells and cell-free fluid that contains free DNA, cytokines, and extracellular vesicles. Molecular tests in effusion sample not only provide a diagnosis of malignancy but can also give valuable information that may be essential for the individualized therapy, management, and prognostic assessment. In this paper, we reviewed the application of the different molecular tests in the effusion sample.

Selection of DNA Aptamers Recognizing EpCAM-Positive Prostate Cancer by Cell-SELEX for in vitro and in vivo MR Imaging

Background

The sensitive and specific detection of pathogenic cells is important in tumor diagnosis at an early stage. Aptamers are short single-stranded oligonucleotides evolved from systematic evolution of ligands by exponential enrichment (SELEX). It has been proved that aptamers can interact with cognate target molecules with high affinity and specificity and have great potential in the development of medical imaging at molecular level.

Purpose

To select epithelial cell adhesion molecule (EpCAM) specific aptamers targeting prostate cancer and further to conjugate aptamers with GoldMag nanoparticles (a typical iron oxide core/gold shell structure) to construct magnetic molecular probes for medical imaging.

Methods

EpCAM-specific aptamers were selected by Cell-SELEX. The enrichment of specific aptamer candidates was monitored by flow cytometric analysis. Aptamers were further conjugated with GoldMag nanoparticles to construct magnetic molecular probes. The affinity and specificity of aptamer candidates and aptamer-conjugated GoldMag nanoparticles were evaluated. The MR imaging of aptamer-conjugated GoldMag nanoparticles to prostate cancer was further explored in vitro and in vivo.

Results

After 12 rounds of selection, aptamer candidates Eppc6 and Eppc14 could specifically target three types of prostate cancer cells, revealing a high affinity of Eppc6 and Eppc14. Moreover, aptamer-conjugated GoldMag nanoparticles not only exhibited good affinity to different prostate cancer cells but also produced strong T2WI signal intensity reduction distinguished from peritumoral tissue in MRI, indicating that the molecular probes possess both the affinity properties of EpCAM-specific aptamer and the superparamagnetic features of iron oxide.

Conclusion

Our study indicates that aptamer Eppc6 and Eppc14 can recognize prostate cancer cells and tissues. The aptamer-conjugated GoldMag nanoparticles constructed in the study can be used as a molecular imaging agent for detection of PCa in MRI.

Diagnosis of malignant versus tuberculous ascites using tumor markers and globulin ratios in serum and ascites: A Fisher discriminant model

BACKGROUND AND STUDY AIMS

This study was conducted to investigate the significance of tumor and biochemical markers in serum and ascitic fluid in the differential diagnosis of tuberculous and malignant ascites.

PATIENTS AND METHODS

Based on findings from natural orifice transluminal endoscopic surgery and postoperative pathology or cytology of 63 patients, they were divided into the malignant group (31 patients) and the tuberculous group (32 patients). Levels of tumor markers, albumin, globulin, and lactate dehydrogenase were measured simultaneously. Data were statistically analyzed, and a Fisher discriminant model was established. The receiver operating characteristic curve was constructed to confirm the discriminant value.

RESULTS

The levels of carcinoembryonic antigen (CEA), cancer antigen 125 (CA125), cancer antigen 19-9 (CA 19-9), and globulin in serum and ascitic fluid were different between the tuberculous and malignant ascites groups (P < .05). The ratios of ascites-to-serum levels of CEA, CA125, and CA 19-9, as well as the ratio of serum-to-ascites of globulin levels, were different between the two groups (P < .05). The Fisher discriminant model was established based on the ascites-to-serum ratios of CEA, CA125, and CA 19-9 levels and the serum-to-ascites ratio of globulin levels. The area under the curve was 0.908, the sensitivity was 0.838 (26/31), and the specificity was 0.875 (28/32).

CONCLUSION

A Fisher discriminant model can be established using serum and ascites tumor markers and globulin ratios, which is valuable in the differential diagnosis of tuberculous versus malignant ascites.

Current applications of molecular testing on body cavity fluids

INTRODUCTION

Effusion cytology has a high sensitivity for the diagnosis of malignancy and provides abundant material for molecular testing. Effusion draining is a minimally invasive procedure with few complications.

MATERIALS AND METHODS

We performed a review of publications regarding the use of molecular testing in serous effusions.

RESULTS

In diagnostics, BAP-1 IHC and CDKN2A FISH are powerful tools for the diagnosis of malignant mesothelioma. FISH, PCR, and EBER-ISH work well in lymphomas. RT-PCR may enhance the diagnosis of secondary epithelial malignancies. In theranostics, molecular testing on serous effusions is widely reported for the detection of alterations in genes related to lung carcinomas, such as EGFR, ALK, ROS1, and BRAF. PD-L1 expression testing by immunohistochemistry (IHC) also seems to be viable in this type of sample. HER2 FISH and IHC provide actionable results in the context of breast malignancies. Results in serous effusions seem to be equivalent to tissue biopsies for most applications and across different molecular techniques. The most interesting technology is next-generation sequencing (NGS), given its ability to sequence multiple genes on a single sample and the decreasing costs that have closely followed increasing throughputs. Cell-free DNA from effusion supernatants might be the most promising area for future research, showing superiority to serum and even to cell-block samples in limited studies.

CONCLUSIONS

Molecular tests are viable in serous effusion specimens when sufficient material is available. Given the rising importance of molecular testing we expect this to be an active field of research in the near future.

Are we ready to develop a tiered scheme for the effusion cytology? A comprehensive review and analysis of the literature

BACKGROUND

Cytology is widely utilized in the initial evaluation of fluid accumulation in the body cavities. The aim of this study was to determine the accuracy of cytology in distinguishing between benign and malignant (MAL) effusions.

METHODS

A comprehensive and systematic review of the literature was conducted to evaluate the accuracy of serous effusion cytology (SEC) against tissue biopsy/resection histology, imaging, or clinical follow-up as the reference test. Risk of publication bias and level of heterogeneity in the included studies was assessed. Meta-regression was performed to assess the effect of various variables on the accuracy of SEC.

RESULTS

Eighty studies met the inclusion criteria for meta-analysis comprising of 34 941 samples; of which 52 (0.2%), 22 202 (72.7%), 194 (0.6%), 711 (2.3%), and 6507 (21.3%) could be reclassified as nondiagnostic (ND), negative for malignancy (NFM), atypical (atypia of uncertain significance-AUS), suspicious for malignancy (SFM), and malignant (MAL), respectively. On follow-up, the mean risk of malignancy for ND, NFM, AUS, SFM, MAL was 17.4%, 20.7%, 65.9%, 81.8%, and 98.9%, respectively. A total of 73 studies were included in estimating the diagnostic accuracy of SEC. The bivariate mixed-effect model estimated the SEC sensitivity, specificity, diagnostic odds ratio, positive likelihood ratio, and negative likelihood ratio as 73.1%, 99.9%, 7850.6%, 2112.2%, and 0.27%, respectively.

CONCLUSION

Serous effusion cytology shows high specificity and moderate sensitivity in the evaluation of serous effusions. A tiered classification scheme can improve the consistency of terminology for reporting SEC results, thus improving communication between the pathologists and clinical team, and quality of patient care.

Epithelial cell adhesion molecule (EpCAM) from pleural fluid cell lysates is a highly accurate diagnostic biomarker of adenocarcinomatous effusions

BACKGROUND AND OBJECTIVE

The discovery of highly accurate pleural fluid (PF) biomarkers of malignancy remains elusive. We assessed the operating characteristics of the PF epithelial cell adhesion molecule (EpCAM), claudin 4 (CL4) and human epididymis protein 4 (HE4) as potential markers of epithelial malignancies.

METHODS

The three markers were quantified by immunoassays in the supernatants (s) and cell lysates (cl) of 175 PF samples. The cut-off values with 100% specificity were selected for malignant-benign discrimination. An immunocytochemical staining index score for each marker was also evaluated on PF cell blocks. The resulting best biomarker was further validated in two independent populations of 73 and 48 patients with pleural effusions (PE).

RESULTS

An EpCAM(cl) >98 pg/g total lysate protein yielded 75% sensitivity, 100% specificity, negative likelihood ratio of 0.25 and area under the curve of 0.94 for labelling adenocarcinomatous effusions. Sensitivity reached 88% if EpCAM(cl) was combined with EpCAM immunostaining. One-third or more of the malignant effusions exhibiting a false-negative cytological fluid examination were correctly classified by EpCAM(cl) concentrations. Immunoassays for CL4 and HE4 were diagnostically useless.

CONCLUSION

EpCAM(cl) is a new biomarker of adenocarcinomatous PE with meaningful discriminating properties.

A preliminary study on treatment of human breast cancer xenografts with a cocktail of paclitaxel, doxorubicin, and 131I-anti-epithelial cell adhesion molecule (9C4)

Triple-negative breast cancer often has devastating outcomes and treatment options remain limited. Therefore, different treatment combinations are worthy of testing. The efficacy of a cocktail of paclitaxel, doxorubicin, and ¹³¹I-anti-epithelial cell adhesion molecule (EpCAM) (9C4) to treat breast cancer was tested. Efficacy was tested with an MDA-MB-231 human breast cancer xenograft model. Anti-EpCAM (9C4) was demonstrated to bind to MDA-MB-231 human adenocarcinoma cells in vitro. Subsequently, mice-bearing MDA-MB-231× enografts were treated with either ¹³¹I-anti-EpCAM (9C4), unlabeled anti-EpCAM (9C4), paclitaxel, doxorubicin, or a cocktail of all of the agents. Tumor volume was measured for up to 70-day postinjection. Exponential regression was performed on tumor growth curves for each of the therapy groups. Statistical comparison of the growth constants λ of the regression models for each of the treatment groups with that of the cold antibody and control groups was done using extra sum-of-square F-tests. Biexponential clearance of ¹³¹I-anti-EpCAM (9C4) was observed with biological clearance half-times of 1.14 and 17.6 days for the first and second components, respectively. The mean growth rate of the tumors in animals treated with a cocktail of all of the agents was slower than in those treated with unlabeled anti-EpCAM (9C4) (P = 0.022). These preliminary data suggest that a cocktail of ¹³¹I-anti-EpCAM (9C4), paclitaxel, and doxorubicin may be suitable for treating breast cancers with high expression of EpCAM.

Clinical Relevance of Human Mammaglobin mRNA in Pleural Effusion from Patients Undergoing Thoracoscopy: A Pilot Study

Background

human mammaglobin (hMAM) expression has been reported in pleural effusions (PE). The aim of this study was to assess the clinical relevance of hMAM mRNA in PE from patients who underwent thoracoscopy.

Material and methods

A total of 288 patients with PE were studied, 155 of which were diagnosed with malignant and 133 with non-malignant diseases by thoracoscopy. Cells from PE were analyzed by nested hMAM RT-PCR. Statistical analyses were performed to evaluate the diagnostic performance parameters (DPP), the association between hMAM expression and benign or malignant status and the relative risk of cancer for patients with negative thoracoscopy showing hMAM positivity.

Results

hMAM mRNA was found in 68/288 (23.6%) PE samples of which 51 were from the 155 patients diagnosed with malignant diseases and 17 were from the 133 patients diagnosed with non-malignant diseases. A significant correlation between hMAM expression and malignancy was found (OR=3.04) and the DPP were as follows: sensitivity=32.9%, specificity=87.2%, accuracy=58.0%, positive predictive value=75.0% and negative predictive value=52.7%. Among the patients with negative thoracoscopy (n=133), 5/17 (29.4%) hMAM-positive patients had or developed a tumor during the 18-month follow up period, as compared to 10/116 (8.6%) hMAM-negative patients (relative risk of 4.6 for developing a malignancy).

Conclusion

These findings suggest a possible application of hMAM RT-PCR detection in PE as to identify a false-negative thoracoscopy in non-specific pleuritis.

Genetic variants of mucins: unexplored conundrum

Alternative gene splicing, occurring ubiquitously in multicellular organisms can produce several protein isoforms with putatively different functions. The enormously extended genomic structure of mucin genes characterized by the presence of multiple exons encoding various domains may result in functionally diverse repertoire of mucin proteins due to alternative splicing. Splice variants (Svs) and mutations in mucin genes have been observed in various cancers and shown to participate in cancer progression and metastasis. Although several mucin Svs have been identified, their potential functions remain largely unexplored with the exception of the Svs of MUC1 and MUC4. A few studies have examined the expression of MUC1 and MUC4 Svs in cancer and indicated their potential involvement in promoting cancer cell proliferation, invasion, migration, angiogenesis and inflammation. Herein we review the current understanding of mucin Svs in cancer and inflammation and discuss the potential impact of splicing in generating a functionally diverse repertoire of mucin gene products. We also performed mutational analysis of mucin genes across five major cancer types in International Cancer Genome Consortium database and found unequal mutational rates across the panel of cancer-associated mucins. Although the functional role of mucins in the pathobiology of various malignancies and their utility as diagnostic and therapeutic targets remain undisputed, these attributes need to be reevaluated in light of the potentially unique functions of disease-specific genetic variants of mucins. Thus, the expressional and functional characterization of the genetic variants of mucins may provide avenues to fully exploit their potential as novel biomarkers and therapeutic targets.

Detection of EpCAM-positive microparticles in pleural fluid: A new approach to mini-invasively identify patients with malignant pleural effusions

Pleural biomarkers allowing to mini-invasively discriminate benign from malignant pleural effusions are needed. Among potential candidates, microparticles (MPs) are extracellular vesicles that vectorize antigen derived from the parent cell. We hypothesized that tumor-derived MPs could be present in the pleural liquid and help to identify patients with malignant pleural effusions. Using highly sensitive flow cytometry and cryo-electron microscopy, we showed that large amounts of MPs from hematopoïetic and vascular origin could be detectable in pleural fluids. Their level did not differ between benign (n = 14) and malignant (n = 71) pleural effusions. Analysis of selected tumoral associated antigens (podoplanin, mucin 1 and EpCAM, epithelial-cell-adhesion-molecule) evidenced for the first time the presence of tumor-derived MPs expressing EpCAM in malignant pleural fluids only (Specificity = 93%, Sensitivity = 49% and 45% for flow cytometry and ELISA, respectively). The detection of EpCAM-positive-MPs (EpCAM + MPs) by flow cytometry showed a better specificity and sensitivity than ELISA to distinguish between pleural carcinoma and the others malignant pleural effusions (MPE; Sp: 96% vs 89%; Se: 79% vs 66%). Combining EpCAM+ MPs and cytology improved the diagnosis of MPE compared to cytology alone. This study establishes the basis for using EpCAM+ MPs as a promising new biomarker that could be added to the armamentarium to mini-invasively identify patients with malignant pleural effusions.

Value of measurement of gradient and ratio of ascites-serum tumor markers in differential diagnosis of tuberculous ascites and malignant ascites

AIM

To assess the value of measurement of the gradient and ratio of ascites-serum tumor markers in the differential diagnosis of tuberculous ascites and malignancy-related ascites.

METHODS

Sixty patients with ascites were divided into two groups, namely, 31 cases of malignant ascites and 31 cases of tuberculous ascites. Tumor markers in serum and ascites were simultaneously detected to calculate and compare the gradient and ratio of serum-ascites tumor markers between the two groups.

RESULTS

The positive rates of CEA and CA199 in the malignant group were significantly higher than those of the tuberculosis group (P < 0.01). The positive rates of CA125 and α-fetoprotein (AFP) showed no significant difference between the two groups (P > 0.05). Ratio analysis of tumor markers in ascites and serum revealed that CA125, CA199, and CEA ratios were statistically significant between the two groups, with CA125 ratio having the most significant difference (P < 0.01). Ascites-serum gradient analysis showed that CA125, CEA, and CA199 gradients were significantly different between the two groups (P < 0.01). The ratio and gradient of AFP were not significantly different between the two groups (P > 0.05).

CONCLUSION

At the cutoff values of CA125 ratio > 2.16, CA125 gradient > 264.05 ng/mL, CEA ratio > 4.8, CEA gradient > 23.05 ng/mL, CA199 ratio > 0.96, and CEA gradient > -0.20 ng/mL, the diagnostic value of combining the gradients and ratios of the three tumor markers are more helpful to distinguish tuberculous ascites and non-liver cancer ascites than any of the three markers alone.

Taking up Cancer Immunotherapy Challenges: Bispecific Antibodies, the Path Forward?

As evidenced by the recent approvals of Removab (EU, Trion Pharma) in 2009 and of Blincyto (US, Amgen) in 2014, the high potential of bispecific antibodies in the field of immuno-oncology is eliciting a renewed interest from pharmaceutical companies. Supported by rapid advances in antibody engineering and the development of several technological platforms such as Triomab or bispecific T cell engagers (BiTEs), the “bispecifics” market has increased significantly over the past decade and may occupy a pivotal space in the future. Over 30 bispecific molecules are currently in different stages of clinical trials and more than 70 in preclinical phase. This review focuses on the clinical potential of bispecific antibodies as immune effector cell engagers in the onco-immunotherapy field. We summarize current strategies targeting various immune cells and their clinical interests. Furthermore, perspectives of bispecific antibodies in future clinical developments are addressed.

Effective recovery of highly purified CD326(+) tumor cells from lavage fluid of patients treated with a novel cell-free and concentrated ascites reinfusion therapy (KM-CART)

For the production of tumor-specific vaccines, including dendritic cell (DC) vaccines, the tumor cells themselves are an ideal source. Floating tumor cells in the ascites fluid from patients with malignant ascites are a good candidate source, but it is not easy to obtain pure tumor cells from ascites because of various types of cell contamination as well as protein aggregates. We here report an effective method to recover pure tumor cells from malignant ascites. We used lavage fluid from 13 patients with malignant ascites who were treated with modified cell-free and concentrated ascites reinfusion therapy (KM-CART). Cellular components were separated from the lavage fluid by centrifugation, enzymatic digestion and hemolysis. Tumor cells were purified by depleting CD45⁺ leukocytes with antibody-conjugated magnetic beads. The tumor cell lysate was extracted by freeze-and-thaw cycles. The mean obtained total cell number was 7.50 × 10⁷ cells (range 4.40 × 10⁶–2.48 × 10⁸ cells). From this fraction, 6.39 × 10⁶ (range 3.23 × 10⁵–2.53 × 10⁷) CD45⁻ cells were collected, and the tumor cell purity was over 80 % defined as CD45⁻CD326⁺. A sufficient amount of tumor lysate, average  = 2416 μg (range 25–8743 μg), was extracted from CD45⁻CD326⁺ tumor cells. We here established an effective method to produce highly purified tumor cells from KM-CART lavage fluid. The clinical feasibility of this simple preparation method for generating tumor lysate should be examined in clinical studies of DC vaccines.

Catumaxomab for the treatment of malignant ascites in patients with chemotherapy-refractory ovarian cancer: a phase II study

OBJECTIVE

The aim of this study was to investigate the efficacy and safety of intraperitoneal catumaxomab in heavily pretreated patients with chemotherapy-refractory ovarian cancer and recurrent symptomatic malignant ascites.

METHODS

The study is a single-arm open-label multicenter US phase II study. Patients received 4 three-hour intraperitoneal catumaxomab infusions (10, 20, 50, and 150 μg within 10 days). The primary end point was the percentage of patients with at least a 4-fold increase in the puncture-free interval (PuFI) relative to the pretreatment interval. The main secondary end points were puncture-free survival, overall survival, ascites symptoms, and safety. Time to first therapeutic puncture (TTPu) was analyzed post hoc.

RESULTS

Forty patients were screened, and 32 patients (80%) were treated. Seven patients (23%) achieved the primary end point. The median PuFI was prolonged 2-fold from 12 to 27.5 days. The median TTPu was prolonged 4-fold from 12 to 52 days. The median puncture-free survival and overall survival were 29.5 and 111 days, respectively. Nineteen patients (59%) required puncture after catumaxomab treatment. Ascites symptoms improved in most of the 13 predefined categories. At study end, most symptoms were still improved compared with screening. The most frequent treatment-related adverse events were related to cytokine release (vomiting, nausea, pyrexia, fatigue, and chills) or intraperitoneal administration (abdominal pain). Transient increases in liver parameters and transient decreases in blood lymphocytes were regularly observed but were generally without clinical relevance.

CONCLUSIONS

Catumaxomab prolonged PuFI and TTPu had a beneficial effect on quality of life, as shown by the improvement in ascites symptoms, and had an acceptable safety profile, which is consistent with its mode of action.

Diagnostic value of MUC1 and EpCAM mRNA as tumor markers in differentiating benign from malignant pleural effusion

BACKGROUND

The sensitivity of conventional cytology for the detection of tumor cells in pleural effusion (PE) is inadequate. Mucine 1 (MUC1) and epithelial cell adhesion molecule (EpCAM) are two frequently and intensely expressed tumor-associated antigens in malignancies of epithelial origin.

OBJECTIVE

To evaluate the diagnostic value of pleural fluid MUC1 and EpCAM mRNA in differentiating benign and malignant PE.

METHOD

Fifty-eight patients with malignant PE and 40 patients with benign PE were included in this study. Pleural fluid MUC1 and EpCAM mRNA levels were measured by quantitative real-time PCR. Carcinoembryonic antigen (CEA) and cytokeratin 19 fragment (Cyfra21-1) were also detected simultaneously. The receiver operating characteristic (ROC) curves were constructed to assess diagnostic performance of the four tumor markers in PE.

RESULTS

For the diagnosis of malignant PE, MUC1 and EpCAM mRNA had larger area under ROC curves (0.916 and 0.922) and higher sensitivity (67.2 and 70.7%) with the same specificity, when compared with CEA and Cyfra21-1 (0.821 and 0.780; 48.3 and 44.8%, respectively). By combining cytology with MUC and EpCAM, a positive result indicating the presence of malignancy was achieved in 87.9%, with a good specificity of 95%.

CONCLUSIONS

Compared with CEA and Cyfra21-1, the performance of MUC1 and EpCAM mRNA in malignant PE diagnosis was better. MUC1 and EpCAM mRNA in combination with cytology is a highly sensitive and specific diagnostic tool for detecting malignancy in PE.

Re-challenge with catumaxomab in patients with malignant ascites: results from the SECIMAS study

Malignant ascites is a common phenomenon in cancer patients. It poses a great challenge to the clinician, because of limited treatment options and strong impairment of the quality of life of the often palliative patients. The SECIMAS study investigated the feasibility of a re-challenge with four catumaxomab intraperitoneal infusions in patients who had already received a first cycle of four infusions in the phase III CASIMAS study, which compared catumaxomab with and without prednisolone premedication. The primary endpoint was the proportion of patients who received at least three catumaxomab infusions. Secondary endpoints included a composite safety score (CSS) summarising the worst grades for the main catumaxomab-related adverse events (pyrexia, nausea, vomiting and abdominal pain), safety, efficacy and the occurrence of anti-drug antibodies (ADAs). Eight of nine screened patients received a second catumaxomab cycle. Compliance with a catumaxomab re-challenge was high: all eight patients (100%) received all four infusions. The median CSS was 3.0 versus 3.4 in CASIMAS. The tolerability profile of the second catumaxomab cycle was comparable to that of the first cycle. Median puncture-free survival (48 days) and overall survival (407 days) were longer than in CASIMAS (35 and 103 days, respectively), although median time to next puncture was shorter (60 vs. 97 days). Of six patients sampled, all were ADA positive at screening and remained ADA positive until the end of the study. The presence of ADAs did not affect catumaxomab's safety or efficacy. The CSS and tolerability profile for catumaxomab in SECIMAS were comparable to those in CASIMAS. The majority of patients benefitted from a second cycle of catumaxomab. A re-challenge seems to be feasible and safe for selected patients with recurrent malignant ascites due to carcinoma after a first cycle of catumaxomab.

Immunological screening for tumor cells in serous body fluids has added value with the CELL-DYN Sapphire

BACKGROUND

Conventional cytological examination has limited sensitivity for detecting tumor cells in serous body cavity effusions and therefore, adjuvant techniques are necessary for a reliable diagnosis. Flow cytometry has proven benefit in these circumstances. The aim of our study was to explore the feasibility of CELL-DYN Sapphire, an advanced hematology analyzer with flow cytometric capabilities, for detecting tumor cells in serous body fluids, using CD326 monoclonal antibodies, which are directed against the epithelial marker EpCAM.

METHODS

One hundred and five serous fluids (39 peritoneal and 66 pleural effusions) were analyzed by the CELL-DYN Sapphire using monoclonal antibody combinations CD3/CD19 and CD45/CD326. Of all samples a cytospin preparation was made and microscopically examined; the pathology findings served as a reference.

RESULTS

Using a threshold of 1% CD326+ cells, CELL-DYN Sapphire identified nine out of 12 cases with tumor cells in the serous effusions (sensitivity 75%), whereas routine cytology found eight cases (sensitivity 67%). The combination of immunophenotyping and cytology identified all 12 cases with tumor cells in the effusion fluid (sensitivity 100%). The specificities were 92% and 100%, respectively.

CONCLUSIONS

We demonstrated that it is feasible to run an immunophenotypic assay on CELL-DYN Sapphire for detecting tumor cells in serous body fluids. In addition, this study confirmed that a combination of conventional cytology and flow cytometry had a very high diagnostic yield in cases of carcinomatous effusions.

Catumaxomab with and without prednisolone premedication for the treatment of malignant ascites due to epithelial cancer: results of the randomised phase IIIb CASIMAS study

This two-arm, randomised, multicentre, open-label, phase IIIb study investigated the safety and efficacy of a 3-h catumaxomab infusion with/without prednisolone premedication to reduce catumaxomab-related adverse events. Patients with malignant ascites due to epithelial cancer received four 3-h intraperitoneal catumaxomab infusions with/without intravenous prednisolone (25 mg) premedication before each infusion. The primary safety endpoint was a composite safety score calculated from the incidence and intensity of the most frequent catumaxomab-related adverse events (pyrexia, nausea, vomiting and abdominal pain). Puncture-free survival (PuFS) was a co-primary endpoint. Time to next puncture (TTPu) and overall survival (OS) were secondary endpoints. Prednisolone premedication did not result in a significant reduction in the main catumaxomab-related adverse events. The mean composite safety score was comparable in both arms (catumaxomab plus prednisolone, 4.1; catumaxomab, 3.8; p = 0.383). Median PuFS (30 vs. 37 days) and TTPu (78 vs. 102 days) were shorter in the catumaxomab plus prednisolone arm than in the catumaxomab arm, but the differences were not statistically significant (p = 0.402 and 0.599, respectively). Median OS was longer in the catumaxomab plus prednisolone arm than in the catumaxomab arm (124 vs. 86 days), but the difference was not statistically significant (p = 0.186). The superiority of catumaxomab plus prednisolone versus catumaxomab alone could not be proven for the primary endpoint. Prednisolone did not result in a significant reduction in the main catumaxomab-related adverse events. The study confirms the safety and efficacy of catumaxomab administered as four 3-h intraperitoneal infusions for the treatment of malignant ascites.

Evaluation of tumor markers for the differential diagnosis of benign and malignant ascites

INTRODUCTION

The diagnosis of malignant ascites is a challenging problem in clinical practice, non-invasive techniques should be developed to improve diagnostic accuracy. The diagnostic performances of tumor markers in malignant ascites remained unsettled. Our aim was to evaluate diagnostic performance of tumor markers in differential diagnosis of benign and malignant ascites.

MATERIAL AND METHODS

A total of 437 patients were enrolled, and the relevant parameters of the patients were analyzed for the differentiation of benign ascites from malignant ascites.

RESULTS

At the predetermined cutoff values of tumor makers, tumor markers in ascitic fluid showed better diagnostic performance than those in serum. Combined use of tumor markers and the cytology increased the diagnostic yield of the latter by 37%. In cytologically negative malignant ascites, tumor markers provided assistance in differentiating malignant ascites from benign ascites, and the combination of ascitic tumor markers yielded 86% sensitivity, 97% specificity.

CONCLUSION

Use of a panel of tumor markers exhibited excellent diagnostic performance in diagnosing malignant ascites, which indicated the detection of tumor markers may represent a beneficial adjunct to cytology, thus guiding the selection of patients who might benefit from further invasive procedures.

Expression and significance of cyclooxygenase-2 mRNA in benign and malignant ascites

AIM: To investigate the mRNA expression of cyclooxygensae-2 (COX-2) in benign and malignant ascites, and to explore the difference in COX-2 mRNA expression among different diseases.

METHODS: A total of 36 samples were collected from the Fifth Affiliated Hospital of Sun Yat-Sen University and divided into two experimental groups: benign ascites (n = 21) and malignant ascites (n = 15). Benign ascites included cirrhotic ascites (n = 10) and tuberculous ascites (n = 5). Malignant ascites included oophoroma (n = 7), cancer of colon (n = 5), cancer of the liver (n = 6), gastric cancer (n = 2), and bladder carcinoma (n = 1). The mRNA expression of COX-2 in ascites was examined with reverse transcriptase polymerase chain reaction (RT-PCR) technology, and the positive rate of COX-2 mRNA was compared between different diseases.

RESULTS: The positive rate of COX-2 mRNA in malignant ascites was 42.9% (9/21), which was significantly higher than in benign ascites, 6.7% (1/15), difference being significant between these two groups (χ² = 4.051, P = 0.044). The proportion of the positive rate in the malignant ascites was as follows: ovarian cancers 57.1% (4/7), colon cancer 40.0% (2/5), liver cancer 33.3% (2/6), gastric cancer 50.0% (1/2), and bladder cancer 0.00% (0/1). However, there was no significant difference in COX-2 mRNA expression among various tumors with malignant ascites (χ² = 1.614, P = 0.806). Among the benign ascites, COX-2 mRNA levels were different between the tuberculous ascites (0/5) and cirrhotic ascites (1/10), but there was no significant difference (P = 1.000).

CONCLUSION: COX-2 mRNA, detected by RT-PCR, is useful in the differential diagnosis of benign and malignant ascites, which also has potential value in the clinical diagnosis of tumors.

Diagnostic usefulness of MUC1 and MUC4 for distinguishing between metastatic adenocarcinoma cells and reactive mesothelial cells in effusion cell blocks

OBJECTIVE

The aim of our study was to determine the diagnostic value of MUC1 and MUC4 for distinguishing between metastatic adenocarcinoma cells (MAC) and reactive mesothelial cells (RMC) in effusion fluids.

STUDY DESIGN

A total of 237 cell block specimens from pleural and peritoneal effusions, including 196 malignant effusions with MAC and 41 benign effusions with RMC, were stained with antibodies against MUC1 and MUC4. Membranous staining with or without cytoplasmic staining was considered to be positive.

RESULTS

MUC1 immunoreactivity was observed in 194 (99.0%) of 196 cases of MAC and in 20 (48.8%) of 41 cases of RMC. MUC4 immunoreactivity was observed in 174 (88.8%) of 196 cases of MAC and in 4 (9.8%) of 41 cases of RMC. For distinguishing MAC from RMC, the MUC1 reactivity was found to be 99.0% sensitive and 51.2% specific with a positive predictive value of 90.7% and a negative predictive value of 91.3%. The sensitivity of MUC4 for MAC was 88.8%, the specificity was 90.2%, the negative predictive value was 62.7%, and the positive predictive value was 97.8%.

CONCLUSION

Our data suggest that MUC4 appears to be a sensitive and specific marker for differentiating between MAC and RMC.

High expression of epithelial cellular adhesion molecule in peritoneal metastasis of gastric cancer

Intraperitoneally administrated epithelial cellular adhesion molecule (EpCAM) monoclonal antibody is a therapeutic agent in patients with malignant effusion in several types of carcinoma. However, the role of EpCAM in peritoneal metastasis (PM) lesions and primary lesions of gastric cancer (GC) is still unclear. Therefore, in this study, we investigated EpCAM expression in GC patients with PM. We investigated the expression of EpCAM in 35PM lesions and 104 biopsy samples as primary lesions. Immunohistochemical staining was performed using the Ventana Benchmark XT (Roche Diagnostics) system. EpCAM expression was evaluated by calculating the total immunostaining score, which is the product of the proportion score and the intensity score. Overexpression was defined as a total score greater than 4. All PM specimens showed overexpression of EpCAM, and GC cells in both the surface layer and the deep layer of the PM showed a high expression of EpCAM. Meanwhile, in the biopsy sample, the expression of EpCAM ranged from none to strong. The EpCAM score results for PM specimens and biopsy samples were 11.0 ± 2.0 and 6.9 ± 3.9, respectively. The difference between the scores was statistically significant (P < 0.05). The intraperitoneally administrated EpCAM antibody might have a anti-cancer effect in PM lesions of GC. Additionally, it can be assumed that only GC cells which express a high level of EpCAM might metastasize to the peritoneum.

Intraperitoneal catumaxomab therapy in a cirrhotic patient with malignant ascites due to urethelial carcinoma: a case report

BACKGROUND

Refractory malignant ascites is a common complication in tumor patients. To date, chemotherapy and paracentesis represent the most widely used methods to relieve the symptoms. Lately, intraperitoneal therapy with catumaxomab, a trifunctional hybrid antibody, has been introduced for the treatment of malignant ascites, and its utility has been demonstrated in patients with distinct abdominal malignancies.

CASE REPORT

We report the first case of successful catumaxomab treatment of malignant ascites in a patient with advanced carcinoma of the urinary bladder and liver cirrhosis. Although at admission a large volume paracentesis was needed every other day, paracentesis was no longer necessary after catumaxomab therapy.

CONCLUSION

Catumaxomab might represent a safe treatment option for malignant ascites in the course of metastatic urothelial carcinoma, also in the setting of liver cirrhosis.

Evaluation of pleural fluid survivin and XIAP for the diagnosis of malignant pleural effusion

Survivin and X-linked inhibitor of apoptosis (XIAP) are two inhibitors of apoptosis that are expressed highly in most malignancies and may be diagnostic markers of cancer. The aim of this study was to assess the diagnostic value of survivin and XIAP as tumor markers in malignant pleural effusion. Ninety-eight consecutive patients (including 56 malignant effusions and 42 benign effusions) with pleural effusion were enrolled in the study. Levels of survivin and XIAP mRNA in pleural fluid were measured by reverse transcription polymerase chain reaction. Carcinoembryonic antigen (CEA) was also detected simultaneously. Results showed that levels of survivin and XIAP mRNA were significantly higher in malignant than in benign effusion (P < 0.001 and P = 0.002, respectively). In the diagnosis of malignant pleural effusion, survivin achieved the highest sensitivity (89.3 %) and specificity (95.2 %), as compared with XIAP (66.1 % sensitivity and 85.7 % specificity), or CEA (71.4 % sensitivity and 80.9 % specificity). The combination of survivin and CEA reached 94.6 % sensitivity, with 90.5 % specificity, whereas the combined analysis of survivin and XIAP yielded the highest specificity (95.2 %) and a very good sensitivity (91.1 %). In conclusion, survivin mRNA assay is a useful tumor marker for discriminating malignant from benign pleural effusion. XIAP may be a good candidate for molecular detection of malignant effusion. The combination of survivin and CEA, or XIAP, can increase diagnostic performance.

The association of PI3 kinase signaling and chemoresistance in advanced ovarian cancer

Evidence that the phosphoinositide 3-kinase (PI3K) pathway is deregulated in ovarian cancer is largely based on the analysis of surgical specimens sampled at diagnosis and may not reflect the biology of advanced ovarian cancer. We aimed to investigate PI3K signaling in cancer cells isolated from patients with advanced ovarian cancer. Ascites samples were analyzed from 88 patients, of whom 61 received further treatment. Cancer cells were immunomagnetically separated from ascites, and the signaling output of the PI3K pathway was studied by quantifying p-AKT, p-p70S6K, and p-GSK3β by ELISA. Relevant oncogenes, such as PIK3CA and AKT, were sequenced by PCR-amplified mass spectroscopy detection methods. In addition, PIK3CA and AKT2 amplifications and PTEN deletions were analyzed by FISH. p-p70S6K levels were significantly higher in cells from 37 of 61 patients who did not respond to subsequent chemotherapy (0.7184 vs. 0.3496; P = 0.0100), and this difference was greater in patients who had not received previous chemotherapy. PIK3CA and AKT mutations were present in 5% and 0% of samples, respectively. Amplification of PIK3CA and AKT2 and deletion of PTEN was seen in 10%, 10%, and 27% of samples, respectively. Mutations of PIK3CA and amplification of PIK3CA/AKT2 or deletion of PTEN did not correlate with levels of p-AKT, p-p70S6K, and p-GSK3β. In patients with advanced ovarian cancer, there is an association between levels of p-p70S6K and response to subsequent chemotherapy. There is no clear evidence that this is driven specifically by PIK3CA or AKT mutations or by amplifications or deletion of PTEN.

The association of PI3 kinase signaling and chemoresistance in advanced ovarian cancer

Evidence that the phosphoinositide 3-kinase (PI3K) pathway is deregulated in ovarian cancer is largely based on the analysis of surgical specimens sampled at diagnosis and may not reflect the biology of advanced ovarian cancer. We aimed to investigate PI3K signaling in cancer cells isolated from patients with advanced ovarian cancer. Ascites samples were analyzed from 88 patients, of whom 61 received further treatment. Cancer cells were immunomagnetically separated from ascites, and the signaling output of the PI3K pathway was studied by quantifying p-AKT, p-p70S6K, and p-GSK3β by ELISA. Relevant oncogenes, such as PIK3CA and AKT, were sequenced by PCR-amplified mass spectroscopy detection methods. In addition, PIK3CA and AKT2 amplifications and PTEN deletions were analyzed by FISH. p-p70S6K levels were significantly higher in cells from 37 of 61 patients who did not respond to subsequent chemotherapy (0.7184 vs. 0.3496; P = 0.0100), and this difference was greater in patients who had not received previous chemotherapy. PIK3CA and AKT mutations were present in 5% and 0% of samples, respectively. Amplification of PIK3CA and AKT2 and deletion of PTEN was seen in 10%, 10%, and 27% of samples, respectively. Mutations of PIK3CA and amplification of PIK3CA/AKT2 or deletion of PTEN did not correlate with levels of p-AKT, p-p70S6K, and p-GSK3β. In patients with advanced ovarian cancer, there is an association between levels of p-p70S6K and response to subsequent chemotherapy. There is no clear evidence that this is driven specifically by PIK3CA or AKT mutations or by amplifications or deletion of PTEN.

Novel monoclonal antibodies for cancer treatment: the trifunctional antibody catumaxomab (removab)

The trifunctional antibody (trAb) catumaxomab is characterized by a unique ability to bind three different cell types: tumor cells; T-cells; and accessory cells. It binds to epithelial cell adhesion molecule (EpCAM) on tumor cells, the CD3 antigen on T-cells, and to type I, IIa, and III Fcγ receptors (FcγRs) on accessory cells (e.g. natural killer cells, dendritic cells, and macrophages). Catumaxomab exerts its anti-tumor effects via T-cell-mediated lysis, antibody-dependent, cell-mediated cytotoxicity, and phagocytosis via activation of FcγR-positive accessory cells. Catumaxomab represents a self-supporting system, as no additional immune cell activation is required for tumor eradication. The efficacy and safety of catumaxomab have been demonstrated in a pivotal phase II/III study in malignant ascites (MA) and supporting phase I/II studies. It is administered as four intraperitoneal (i.p.) infusions of 10, 20, 50, and 150 µg on days 0, 3, 7, and 10, respectively. Catumaxomab was approved for the i.p. treatment of MA in patients with EpCAM-positive carcinomas where standard therapy is not available or no longer feasible in the European Union in April 2009. It is the first trAb and the first drug in the world approved specifically for the treatment of MA. Catumaxomab was awarded the Galen of Pergamon Prize, which recognizes pharmacological research for developing new and innovative drugs and diagnostics, in the specialist care category in 2010. The use of catumaxomab in other indications and additional routes of administration are currently being investigated to further exploit its therapeutic potential in EpCAM-positive carcinomas.

Epithelial cell adhesion molecule expression (CD326) in cancer: a short review

Epithelial cell adhesion molecule (EpCAM, CD326) is a pleiotropic molecule that potentially offers therapeutic applications in cancer treatment. Initially described as a dominant surface antigen on human colon carcinoma, it is a transmembrane glycoprotein mediating epithelial-specific intercellular cell-adhesion. Recent data suggest that EpCAM is also involved in cell signaling, migration, proliferation and differentiation. Since EpCAM is expressed exclusively in epithelia and epithelial-derived neoplasms, EpCAM can be used as diagnostic marker. Testing for EpCAM is based on morphology and phenotypical staining and can be performed with primary carcinoma tissue and cells harvested from malignant effusions. Stable or highly expressed EpCAM has been detected in most adenocarcinomas and has also been found in metastases, malignant effusions, and cancer stem cells. EpCAM may thus be an ideal tumor antigen candidate to detect circulating and metastasizing cancer cells by microchip technologies. In certain tumor types overexpression was linked to advanced stage of disease and worse overall survival, suggesting EpCAM as a potential prognostic marker. In addition to its diagnostic and prognostic role, EpCAM's broad expression and apparent involvement in tumorigenesis and metastasis point to its potential as a target for immunotherapeutic strategies. The first EpCAM targeting, trifunctional antibody catumaxomab (Removab®) has shown clear clinical benefits in treatment of malignant ascites associated with EpCAM positive carcinomas. Further research and clinical studies should unravel EpCAM's complex role in oncological processes, and expand potential therapeutic applications of EpCAM targeted strategies.

Pharmacokinetics, immunogenicity and bioactivity of the therapeutic antibody catumaxomab intraperitoneally administered to cancer patients

AIMS

Catumaxomab is the first EMEA approved trifunctional anti-EpCAM×anti-CD3 antibody for the treatment of cancer patients with malignant ascites. A phase II pharmacokinetic study was conducted to determine local and systemic antibody concentrations and anti-drug antibody (ADA) development.

METHODS

Thirteen cancer patients with symptomatic malignant ascites were treated with four ascending doses of 10, 20, 50, and 150 µg catumaxomab intraperitoneally (i.p.) infused on days 0, 3, 6 or 7 and 10. The pharmacokinetics of catumaxomab were studied by implementation of supportive data from a non clinical mouse tumour model. Additionally, ADA development was monitored.

RESULTS

Ten out of 13 patients were evaluable for pharmacokinetic analysis. Catumaxomab became increasingly concentrated in ascites during the course of treatment, attaining effective concentrations in the ng ml⁻¹ range. Catumaxomab remained immunologically active even after several days in the circulation. The observed systemic catumaxomab exposure was low (<1%), with a maximal median plasma concentration (C_max) of 403 pg ml⁻¹. The mean elimination half-life in the plasma was 2.13 days. All patients developed ADA, but not before the last infusion. High observed inter-individual variability and low systemic exposure may be explained by the inverse correlation between tumour burden, effector cell numbers and systemic antibody bioavailability as demonstrated in a defined mouse tumour model.

CONCLUSIONS

Based on the high and effective local concentrations, low systemic exposure and acceptable safety profile, we confirmed that the i.p. application scheme of catumaxomab for the treatment of malignant ascites is appropriate.

Catumaxomab--trifunctional anti-EpCAM antibody used to treat malignant ascites

IMPORTANCE OF THE FIELD

Malignant ascites is a sign of advanced tumour growth and is associated with significant morbidity and a poor prognosis with a median survival time of a few months. Paracentesis is a recommended treatment for malignant ascites, but can cause complications, for example infections, injury of abdominal organs, persistent leakage of ascites, and haematoma/haemorrhage. The European Medicines Agency (EMA) approved the use of a trifunctional bispecific antibody, catumaxomab (Removab), for the intraperitoneal (i.p.) treatment of malignant ascites in April 2009.

AREAS COVERED IN THIS REVIEW

This review describes the tailored preclinical and the clinical development of catumaxomab for the i.p. treatment of malignant ascites from 1998 to 2009.

WHAT THE READER WILL GAIN

Relevant toxicology and pharmacokinetic findings are reported as well as main results of a large international Phase II/III study that was pivotal in the EMA approval of catumaxomab.

TAKE HOME MESSAGE

Catumaxomab i.p. treatment results in a significant and clinically relevant improvement of puncture-free survival time and time to first need for puncture compared with paracentesis alone. The related side effects of catumaxomab treatment are predictable and related to the antibody's mode of action.

The trifunctional antibody catumaxomab for the treatment of malignant ascites due to epithelial cancer: Results of a prospective randomized phase II/III trial

Malignant ascites is a common manifestation of advanced cancers, and treatment options are limited. The trifunctional antibody catumaxomab (anti-epithelial cell-adhesion molecule x anti-CD3) represents a targeted immunotherapy for the intraperitoneal (i.p.) treatment of malignant ascites secondary to epithelial cancers. In this phase II/III trial (EudraCT 2004-000723-15; NCT00836654), cancer patients (n = 258) with recurrent symptomatic malignant ascites resistant to conventional chemotherapy were randomized to paracentesis plus catumaxomab (catumaxomab) or paracentesis alone (control) and stratified by cancer type (129 ovarian and 129 nonovarian). Catumaxomab was administered as an i.p. infusion on Days 0, 3, 7 and 10 at doses of 10, 20, 50 and 150 μg, respectively. The primary efficacy endpoint was puncture-free survival. Secondary efficacy parameters included time to next paracentesis, ascites signs and symptoms and overall survival (OS). Puncture-free survival was significantly longer in the catumaxomab group (median 46 days) than the control group (median 11 days) (hazard ratio = 0.254: p < 0.0001) as was median time to next paracentesis (77 versus 13 days; p < 0.0001). In addition, catumaxomab patients had fewer signs and symptoms of ascites than control patients. OS showed a positive trend for the catumaxomab group and, in a prospectively planned analysis, was significantly prolonged in patients with gastric cancer (n = 66; 71 versus 44 days; p = 0.0313). Although adverse events associated with catumaxomab were frequent, they were manageable, generally reversible and mainly related to its immunologic mode of action. Catumaxomab showed a clear clinical benefit in patients with malignant ascites secondary to epithelial cancers, especially gastric cancer, with an acceptable safety profile.

Significance of a galactose specific plant lectin for the differential diagnosis of adenocarcinoma cells in effusion

Background:

Distinguishing adenocarcinoma cells from reactively proliferated mesothelial cells and macrophages is one of the greatest challenges in the cytodiagnosis of effusions. Aberrant glycosylation of cell surface glycoconjugates is emblematic to malignancy, and lectins being an important class of probes to demonstrate these aberrations, lectin cytochemistry is of great interest to differentiate adenocarcinoma cells from reactive mesothelial cells.

Aim:

The present study analyzed the potential of a plant lectin to distinguish malignant cells from reactive mesothelial cells and macrophages.

Materials and Methods:

Snake gourd lectin (SGL) was isolated, purified and conjugated to horse radish peroxidase (HRP) and incubated with the cells of benign (46) as well as malignant (39) effusions using the standard immunocytochemical method with diaminobenzidine as the chromogen. The lectin-bound areas were quantitatively assessed as mild, moderate and intense binding.

Statistical Analysis:

The mean score for benign and malignant effusions were statistically analyzed. Student's ‘t’-test was performed to assess the significance.

Results:

The lectin HRP complex bind to the cytoplasm of benign and malignant cells as well as macrophages. A significantly higher score for intense binding (P = 0.001) was found to differentiate malignant cells from reactive mesothelial cells. Macrophages showed intense irregular binding.

Conclusions:

SGL binding assay can play a role in the differential diagnosis of metastatic adenocarcinoma in effusions.

The membrane mucin Muc4 inhibits apoptosis induced by multiple insults via ErbB2-dependent and ErbB2-independent mechanisms

The aberrant expression of membrane mucins such as Muc1 and Muc4 by tumor cells has been shown to engage signaling pathways that promote cellular properties associated with tumor progression. Our previous studies have shown that Muc4 interacts with and potentiates signaling by the ErbB2 (HER2) receptor tyrosine kinase through an epidermal growth factor-like domain in its extracellular region. Here, we show that expression of Muc4 in human A375 melanoma cells and MCF7 breast cancer cells confers resistance to apoptosis induced by a variety of stimuli, including chemotherapeutic agents, the absence of serum factors, and the loss of cellular adhesion. Mapping experiments revealed that the O-glycosylation and cytosolic domains of Muc4 are dispensable for its antiapoptotic activity, and are also dispensable for the potentiation of signaling by ErbB2. Knockdown of endogenous Muc4 in JIMT-1 breast cancer cells sensitizes cells to apoptotic stimuli, and this can be rescued by Muc4 forms lacking the O-glycosylation or cytosolic domains. Surprisingly, however, the molecular mechanisms underlying Muc4 antiapoptotic activity vary among cell lines. Although Muc4 in JIMT-1 cells engages ErbB2 to promote cell survival, its antiapoptotic mechanism in MCF7 and A375 cells seems to be independent of ErbB2. However, Muc4 expression in all cell lines culminates in the phosphorylation and inactivation of the proapoptotic protein Bad and the elevation of the prosurvival protein Bcl-xL. Our observations suggest that tumor cells can exploit the versatile antiapoptotic activities of Muc4 to acquire resistance to therapeutic agents, and augment cell survival after the loss of adhesion and microenvironment-derived survival factors.

The evolving role of interventional pulmonary in the interdisciplinary approach to the staging and management of lung cancer. Part III: diagnosis and management of malignant pleural effusions

The diagnosis and management of a malignant pleural effusion can be one of the most vexing problems faced by physicians and their patients. Lung cancer is the most common primary tumor of origin with a prognosis that is limited, but variable and correlated with performance status (PS). Therefore, with a poor PS and known advanced lung cancer, establishing whether or not an effusion is malignant might not be necessary. Conversely, identifiable subsets of patients will have a much better survival, and establishing a definitive diagnosis could be of critical importance. In the great majority of cases, a diagnosis can be determined by serial thoracenteses with or without closed pleural biopsy. However, thoracoscopy is increasingly being utilized and can expedite the workup by obviating the need for repeated thoracenteses and/or closed pleural biopsy, while in the same setting providing definitive palliative treatment. Although studies comparing diagnostic and treatment strategies are limited, we will present the available data with the intention of providing the practicing oncologist with a practical strategy for the diagnosis and management of malignant pleural effusions due to lung cancer. The interventional pulmonologist can play an important role from diagnosis to palliation, greatly facilitating the care of patients with malignant pleural effusions.

MN/CA9: a potential gene marker for detection of malignant cells in effusions

Many cancers cause malignant effusions. The presence of malignant cells in effusions has implications in diagnosis, tumour staging and prognosis. The detection of malignant cells currently presents a challenge for cytopathologists. New adjunctive methods are needed. Although the effusions provide excellent materials for molecular assay, the available molecular markers are extremely limited, which hinders its clinical application. MN/CA9 has proved to be a valuable marker in many cancers such as lung, breast, colon, kidney, etc. The present study was to evaluate MN/CA9 as a new molecular marker for the detection of cancer cells in pleural effusions. Seventy-one pleural effusions including 59 malignant effusions from patients with cancer, and 12 patients with benign diseases as a control, were subjected to RT-PCR for detection of MN/CA9 gene expression. MN/CA9 gene expression was detected in 53/59 (89.8%) pleural effusions from cancer patients (15/16 for breast cancers, 10/11 for lung cancers, 4/4 for ovary cancers, 2/3 for colon-rectal cancers, 5/6 for cancers of unknown site, 7/8 for mesothelioma and 10/11 for other cancers). Furthermore, MN/CA9 was positive in 13/18 (72.2%) of cytologically negative effusions of cancer patients. MN/CA9 was detected in only 1/12 (8.3%) effusions from the control patients (p < 0.01). The sensitivity and specificity of MN/CA9 gene expression were, respectively, 89.8% and 91.7%. Our preliminary results suggest that MN/CA9 could be a potential marker for the detection of malignant cells in effusions. A large-scale study is needed to confirm these results.

Cytopathological diagnosis in a cancer registry: a useful diagnostic tool?

BACKGROUND

To assess the role of cytology in tumor diagnosis and to explore the potential of this technique to improve tumor registry quality, the authors investigated the role of cytology as a diagnostic tool in registry databases.

METHODS

Through the Italian Network of Cancer Registry (AIRTum) archive, the authors retrieved tumors diagnosed during the years 1983-2002 from several registries, Varese, Torino, Ragusa, Ferrara, Genova, and the Tuscan Cancer Registry. The authors then analyzed the amount of morphological confirmation by topographic code, distinguishing cytological from histological diagnosis. The authors analyzed, only for the Tuscan Cancer Registry, the amount of morphological confirmation by both histological and cytological diagnosis and demonstrated the variation of cytological confirmation with stage of tumor.

RESULTS

The better morphological modality for diagnosis was rarely cytology, particularly among lung and pleural tumors; when considered together with histological analysis, cytology examination was often reported in cervical uterine and breast tumors. The usefulness of cytology increases with tumor stage, particularly in sites where biopsy is performed with difficulty.

CONCLUSIONS

Cytology may be useful to improve tumoral characterization in advanced stages or in sites inaccessible for histology; moreover, cytology is useful as an initial detector of pathology, prior to histology. A prospect of improvement in diagnostic cytopathology and the use of ancillary techniques, such as molecular biology, could help clinicians and could increase the accuracy of cancer registration.

Detection of mRNAs of GA733 genes by RT-PCR in exfoliated cells of pleural and peritoneal effusions and its clinical values

OBJECTIVE

To evaluate the diagnostic values of the detection of mRNAs of GA733 gene family in exfoliated cells of pleural and peritoneal effusions.

METHODS

Sixty specimens of pleural and peritoneal fluids from 60 patients were collected. GA733-1 and GA733-2 mRNA in the exfoliated cells were detected by qualitative RT-PCR, and their diagnostic values were assessed. Patients Sixty patients with pleural or peritoneal effusions, from May 2003 and August 2004, aged 23-85 (average 56.5 years).

RESULTS

GA733-1 and GA733-2 mRNA were positive in 5 (13.9%) and 27 (75.0%) of 36 malignant specimens, and in 1 and 7 of 11 cause-unknown specimens, respectively, but both of them were negative in all 13 benign specimens, and the difference of GA733-2 mRNA positive rates among the three groups was significant (P<0.005), but that of GA733-1 mRNA was not (P>0.05). GA733-1 and GA733-2 mRNA were positive in 4 (15.4%) and 22 (84.6%) of 26 cytological positive specimens, and in 1 and 6 of 6 suspicious specimens, and in 1 (3.5%) and 6 (21.4%) of 28 negative specimens, respectively and the difference of GA733-2 mRNA positive rates among the three groups was significant (P<0.005), but that of GA733-1 mRNA was not (P>0.05). Sensitivity, specificity and accuracy of detection for GA733-2 mRNA for diagnosis of malignant effusions were 75.0%, 100% and 81.6%, respectively.

CONCLUSIONS

The detection of GA733-2 mRNA by qualitative RT-PCR is sensitive and highly specific for the diagnosis of malignant pleural and peritoneal effusions, while the diagnostic value of GA733-1 mRNA needs to be further investigated.