The Importance of Multi-Parametric MRI, PET/CT, and Biopsy for Identifying and Delineating the Extent of Locally Radiorecurrent Prostate Cancer: A Multi-institutional Analysis of the F-SHARP Clinical Trial

PURPOSE/OBJECTIVE(S)

Up to 50% of clinical recurrences after curative-intent radiation are intraprostatic local radiorecurrences (LRR), with improved detection through the recent incorporation of multi-parametric MRI and PET/CT in workup. Salvage local therapy (SLT) is increasingly being offered, particularly focal SLT to try to reduce toxicity due to prior radiation. Limited data exist on the incremental value of each imaging modality and biopsy in defining LRR. The objective of this study is to compare the findings of MRI, PET/CT and biopsy in patients with LRR prostate cancer, and the impact each modality has on identifying recurrence and defining the extent of prostate involvement.

MATERIALS/METHODS

This is a secondary analysis of 58 patients enrolled on the ongoing F-SHARP phase I/II clinical trial of salvage HDR brachytherapy from 3 institutions who underwent PSMA or fluciclovine PET/CT, MRI, and biopsy prior to enrollment. Recurrent tumor was delineated on each imaging modality and by inclusion of involved regions on biopsy. Descriptive statistics were used to compare the imaging-defined tumor with biopsy findings to assess the congruence between the imaging modalities and generate the percentage of patients with disease involvement on biopsy outside of the image-defined targets.

RESULTS

Initial therapy was conventional/moderately hypofractionated photons in 35 patients, LDR in 13, proton therapy in 7, SBRT in 2, and neutrons in 1. Recurrence Gleason grade groups included 1 (n = 3), 2 (17), 3 (12), 4 (8), 5 (9), and uninterpretable (9). MRI/TRUS sextant + fusion biopsy was performed in 40 patients, TRUS saturation biopsy in 4, and TRUS systematic biopsy in 14. The median number of cores involved and obtained were 6 and 14. The median number of discrete lesions on biopsy in different quadrants of the prostate was 3 (1-6). The median number of discrete lesions seen on MRI was 1 (0-4). MRI did not identity a discrete lesion in 4 patients. The sensitivity of MRI for detection of the LRR was 92.8%. The false negative rate for not detecting the focus of LRR on MRI was 7.2%. 68.4% of patients had biopsy-proven cancer outside of the MRI-defined target. Fluciclovine PET/CT was used in 45 patients, and 13 had PSMA PET/CT. The median number of lesions on PET/CT was 1 (0-2). PET/CT did not identify a discrete lesion in 8 patients. The pooled sensitivity of PET/CT in detecting the focus of LRR was 86.2% (Fluciclovine: 82.2%, PSMA: 100%). PET/CT false negative rate of PET/CT for not detecting the focus of LRR was 13.8% (Fluciclovine: 17.8%, PSMA 0%). 72.41% of patients had biopsy-proven cancer outside of the PET/CT-defined target (Fluciclovine: 77.8%, PSMA: 53.8%).

CONCLUSION

Although mpMRI and PET/CT are valuable tools for identifying LRR and delineating the extent of prostate/SV involvement, a thorough biopsy is mandatory if pursuing focal SLT. Such treatment should optimally be performed on a clinical trial with robust integration of all imaging and histopathologic data.

Surgical Treatment of Pediatric Scoliosis: Historical Origins and Review of Current Techniques

The treatment of scoliosis has been explored and debated in medicine since the first recorded texts. Scoliosis treatment has shifted over time from external modalities, such as traction and bracing, to internal stabilization techniques that leverage surgical advances. Surgical fixation constructs can generally be separated into two different modalities: dynamic vs. static constructs. For skeletally immature individuals with progressive deformities, surgical options range from traditional or magnetically controlled growing rods to vertebral body staples or tethering. For individuals who have reached skeletal maturity, many devices have been developed that provide static length constructs. Understanding the surgical options available is critical for the appropriate management of this varied patient population. With this article, we sought to provide a summary of past and present techniques and devices used in the treatment of scoliosis.

PROMIS Utilization in Pediatric Orthopaedics: A Scoping Review

BACKGROUND

The lack of a common patient-reported outcome metric used among the orthopaedic population is a problem that has been previously identified by the American Academy of Orthopaedic Surgeons. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed by the National Institute of Health with the goal of creating a precise and efficient measurement tool for patient-reported symptoms, functioning, and health-related quality of life to be used in clinical research. A study summarizing its use in the pediatric orthopaedic population has not been previously performed.

METHODS

We performed a literature search of Ovid Medline, Embase, Scopus, and the Cochrane Central Register of Controlled Trials from 2010 to August 2021. There were 1961 unique citations included after the removal of 1756 duplicates. After initial screening, 183 studies were screened under full-text review leaving a final number of 51 studies included in this scoping review.

RESULTS

Pediatric PROMIS studies were grouped by body part or sub-speciality: "Hand and Upper Extremity" (25.5%, n=13), "Sports" (23.5%, n=12), "Spine" (13.7%, n=7), "Trauma" (13.7%, n=7), "General Pediatric Orthopaedics" (11.8%, n=6), "Lower Extremity" (9.8%, n=5), and "Orthopaedic Oncology" (2%, n=1). An increase in studies utilizing PROMIS was seen throughout the study period with only 3 studies published from 2013 to 2016 to 39 in 2020 and 2021 alone. The 3 most frequently used pediatric PROMIS domains were Pain Interference (76.5%, n=39/51), Mobility (60.8%, n=31/51), and Upper Extremity (54.9%, n=28/51). 64.3% (n=9/14) of the included studies which reported on the floor effects of Pain Interference exhibited a significant floor effect. In all, 77.8% (n=7/9) of the included studies which reported on ceiling effects of Upper Extremity exhibited a significant ceiling effect.

CONCLUSION

The use of PROMIS increased significantly since the first publication in 2013 suggesting orthopaedic providers have increasingly utilized PROMIS in their day-to-day practice as an outcome measure. Ceiling and floor effects were prominent in several of the included domains (Pain Interference and Upper Extremity). Overall, PROMIS measures are efficient, reliable, and effective to use.

LEVEL OF EVIDENCE

IV.

Meniscal Repair Outcomes at Greater Than 5 Years: A Systematic Review and Meta-Analysis

BACKGROUND

The utilization of meniscal repair techniques continues to evolve in an effort to maximize the rate of healing. Meniscal repair outcomes at a minimum of 5 years postoperatively appear to better represent the true failure rates. Thus, a systematic review and meta-analysis of the current literature was conducted to assess the rate of failure at a minimum of 5 years after meniscal repair.

METHODS

We performed a systematic review of studies reporting the outcomes of meniscal repair at a minimum of 5 years postoperatively. A standardized search and review strategy was utilized. Failure was defined as recurrent clinical symptoms or a meniscal reintervention to repair or resect the meniscus in any capacity, as defined by the study. When reported, outcomes were assessed relative to anterior cruciate ligament (ACL) status, sex, age, and postoperative rehabilitation protocol. Meta-analyses were performed with a random-effects model.

RESULTS

A total of 27 studies of 1,612 patients and 1,630 meniscal repairs were included in this review and meta-analysis. The pooled overall failure rate was 22.6%, while the failure rate of modern repairs (excluding early-generation all-inside devices) was 19.5%. Medial repairs were significantly more likely to fail compared with lateral repairs (23.9% versus 12.6%, p = 0.04). Failure rates were similar for inside-out (14.2%) and modern all-inside repairs (15.8%). Early-generation all-inside devices had a significantly higher failure rate (30.2%) compared with modern all-inside devices (15.8%, p = 0.01). There was no significant difference in meniscal failure rate between repairs with concomitant ACL reconstruction (21.2%) and repairs in ACL-intact knees (23.3%, p = 0.54).

CONCLUSIONS

Modern meniscal repair had an overall failure rate of 19.5% at a minimum of 5 years postoperatively. Modern all-inside techniques appear to have improved the success rate of meniscal repair compared with use of early-generation all-inside devices. Lateral repairs were significantly more likely to be successful compared with medial repairs, while no difference was seen between patients undergoing meniscal repair with and without concomitant ACL reconstruction.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatment Trends in Meniscal Pathology in the Setting of Concomitant ACL Injuries in Pediatric and Young Adult Patients: An Insurance Database Study

BACKGROUND

Meniscal pathology is commonly encountered in the setting of anterior cruciate ligament (ACL) rupture and is increasingly common in the pediatric and adolescent population. Studies have shown that over half of individuals presenting with ACL rupture will have concurrent meniscal pathology.

PURPOSE

To define trends in the utilization of meniscal procedures (ie, meniscus repair vs partial meniscectomy) and short-term complications in pediatric and young adult patients with meniscal pathology in the setting of a concurrent ACL reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The IBM MarketScan Commercial Database was utilized to identify ACL reconstruction procedures performed between 2006 and 2018 for individuals aged 5 to 30 years. Annual proportions of meniscectomy and meniscal repair were analyzed, and short-term complications were compared between pediatric/adolescent patients (aged 5-17 years) and young adults (aged 18-30 years).

RESULTS

An overall 40,736 records of individuals <18 years old with ACL tears were included. The pediatric/adolescent population had a significantly lower proportion of concomitant meniscal procedures (56.8%; 23,149/40,736) than the young adult population (59.7%; 33,764/56,515; P < .01). From 2006 to 2018, utilization of meniscal repair in the setting of ACL reconstruction steadily increased (20.1% to 35.1% [+15 percentage points], P < .01), while the proportion with meniscectomy decreased (34.4% to 21.3% [-13.1 percentage points], P < .01). There was no difference in rate of reoperation for repeat meniscal repair or meniscectomy in the pediatric/adolescent population for those undergoing meniscal repair versus meniscectomy within 180 days of primary surgery (1.7% [188/10,766] vs 1.5% [186/12,383]; P = .14).

CONCLUSION

From 2006 to 2018, the proportion of patients receiving ACL reconstruction with concomitant meniscal repair increased (20.1% to 35.1%) while the proportion with meniscectomy decreased (34.4% to 21.3%) in the pediatric/adolescent population. Meniscal repair was not associated with a higher 180-day rate of reoperation for repeat meniscal repair or meniscectomy than meniscectomy in the setting of ACL reconstruction.

Rates of Infection After ACL Reconstruction in Pediatric and Adolescent Patients: A MarketScan Database Study of 44,501 Patients

BACKGROUND

Numerous studies have demonstrated an increase in the number of anterior cruciate ligament (ACL) reconstruction procedures performed in pediatric patients. Despite this, most knowledge of surgical site infection rates after these procedures are based on adult studies and data is currently limited in pediatric patients. The purpose of this study was to describe and analyze the rates of infection after ACL reconstruction among pediatric patients and adolescent patients (compared with young adult patients) utilizing the MarketScan Commercial Claims and Encounters Database.

METHODS

The Truven Health Analytics MarketScan Commercial Claims and Encounters database was assessed to access health care utilization data for privately insured individuals aged 5 to 30 years old. ACL reconstruction records performed between 2006 and 2018 were identified using Current Procedures Terminology (CPT) codes. International Classification of Diseases Ninth Revision (ICD-9), Tenth (ICD-10) codes and CPT codes were used to identify patients requiring treatment for infection. All patients had at least 180 days of insurance coverage after intervention.

RESULTS

A total of 44,501 individuals aged below 18 years old and 63,495 individuals aged 18 to 30 years old that underwent arthroscopic ACL reconstruction were identified. There were no differences in infection rates between those below 18 years old (0.52%) and those above 18 years old (0.46%, P=0.227). However, among patients below 18 years old, patients below 15 years old had a significantly lower rate of infection at 0.37% compared with adolescents (15 to 17 y old) at 0.55% (P=0.039). Among young adults, males had higher rates of infection than females (0.52% vs. 0.37%), while no difference was observed in the pediatric and adolescent population (0.58% vs. 0.47%, P=0.109).

CONCLUSION

Utilizing an insurance database, this study demonstrated that rates of infection after ACL Reconstruction in a pediatric/adolescent population are low (0.52%) and similar to rates in young adults. Infection rates after ACLR reconstruction appear to be slightly lower in patients under 15 years of age (0.37%).

LEVEL OF EVIDENCE

Level III-Retrospective comparative study.

Utility of the Merchant View Radiograph for Assessment of Tibial Tubercle-Trochlear Groove Distance: A Comparison to MRI in Pediatric and Adolescent Patients

BACKGROUND

Plain radiographic evaluation remains the standard initial assessment of patellar instability, while 3-dimensional imaging is obtained in some patients. Merchant radiographs can demonstrate the tibial tubercle relative to the trochlear groove (TT-TG), but the determination of the TT-TG from these radiographs has been abandoned since its original description. The purpose of this study is to evaluate the utility of the TT-TG measured on Merchant radiographs for the assessment of patellar instability.

METHODS

A prospective cohort study was performed of pediatric and adolescent patients aged 10 to 18 who underwent standardized Merchant radiographs, including a total of 98 knees (in 57 patients). Merchant TT-TG was measured as the distance between the center of the trochlear groove and the tibial tubercle, with both lines perpendicular to the anterior femoral condylar axis. In Part 1, the Merchant TT-TG measured by the tibial tubercle radiographic appearance was compared with the measurement utilizing a radiographic marker. In Part 2, the Merchant TT-TG was compared with the magnetic resonance imaging (MRI) TT-TG distance using bivariate linear regression analysis. TT-TG measurements were compared in patients with and without patellar instability with receiver operating characteristic curve analysis.

RESULTS

The tibial tubercle was identified on Merchant radiograph in 81.7% (67/82) of knees, and there was an excellent correlation (Pearson correlation coefficient=0.85) between the Merchant TT-TG and the measurement based on marker placement. Merchant TT-TG was on average 4.5 mm less than MRI TT-TG (12.8±4.4 vs. 8.4±7.7 mm, P<0.001) and was moderately correlated (Pearson correlation coefficient=0.58, P<0.01). TT-TG distance was increased in patients with patellar instability compared with those without patellar instability on the Merchant view (10.5±6.9 vs. 2.0±5.5 mm, P<0.001) and MRI (13.9±4.4 vs. 10.5±2.9 mm, P=0.012). Merchant TT-TG also demonstrated a higher area under the curve than MRI TT-TG (0.872 vs. 0.775) in differentiating patients with and without patellar instability.

CONCLUSIONS

Standardized Merchant radiographs allow for reliable assessment of the Merchant TT-TG distance when the tibial tubercle is visualized and moderately correlate with MRI TT-TG (with Merchant TT-TG on average 4.5 mm less than MRI).

LEVEL OF EVIDENCE

Level III.

Normative PROMIS Scores in Healthy Collegiate Athletes: Establishing a Target for Return to Function in the Young Adult Athlete

Background

The Patient-Reported Outcomes Measurement Information System (PROMIS) computer-adaptive testing (CAT) has been shown to be a valid and reliable means of assessing patient-reported outcomes. However, normal scores and distributions for a subset of a healthy young athletic population have not been established.

Purpose

To establish normative PROMIS scores for the domains of Physical Function (PF-CAT), Mobility (M-CAT), Upper Extremity Function (UE-CAT), and Pain Interference (PI-CAT) and determine the frequency of floor and ceiling effects in a population of healthy collegiate athletes.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Healthy collegiate athletes (18-23 years of age) were prospectively enrolled to complete the 4 PROMIS CAT domains. Additionally, the athletes provided information regarding their age, sex, and sport(s). Mean scores (±SD) and identification of ceiling or floor effects were calculated. Ceiling and floor effects were considered significant if >15% of the participants obtained the highest or lowest possible score on a domain.

Results

A total of 194 healthy athletes (mean age, 19.1 years) were included in the study: 118 (60.8%) men and 76 (39.2%) women. Mean scores were 62.9 ± 6.7 for PF-CAT, 58.2 ± 4.1 for M-CAT, 57.4 ± 5.8 for UE-CAT, and 43.2 ± 6.2 for PI-CAT. Distributions of scores for M-CAT and UE-CAT indicated strong ceiling effects by 77.3% and 66.0% of the participants, respectively. In healthy athletes, the PF-CAT differed most from the expected population-based mean score (50), with the mean being >1 SD above (62.9), without a ceiling effect observed. There were no significant sex- or age-based differences on any of the PROMIS domain scores.

Conclusion

Healthy collegiate athletes scored nearly 1 SD from population-based means for all of the domains tested. M-CAT and UE-CAT demonstrated ceiling effects in more than two-thirds of healthy athletes, which may limit their utility in this population. The PF-CAT did not demonstrate floor or ceiling effects and demonstrated differences in a young adult athletic population from the population mean. The mean PF-CAT score of 62.9 can represent a target for return of function in injured athletes.

Insurance Coverage Criteria for Femoroacetabular Impingement Surgery: Are They Responding to Improving Evidence?

BACKGROUND

With the rapidly growing body of FAI literature in the last decade, improved evidence exists to support FAI surgery. However, it remains unclear how well third-party insurance company's FAI policies have adapted over time to improved evidence. The purpose of this study was (1) to compare the 2020 FAI surgery criteria of four major insurance companies utilizing a multi-center cohort of FAI patients undergoing surgery to identify rates and causes of ineligibility, and (2) to compare the rates of approval based on changes in policy from 2012 to 2020.

METHODS

Four major insurance companies' coverage policies with specific criteria for the surgical treatment of FAI were applied to this population at two time points (2012 and 2020). The policies listed various combinations of age, symptom duration, radiographic signs of FAI, radiographic signs of osteoarthritis, and physical exam findings. A prospective, multi-center cohort of 712 patients (including 45.5% males and 54.5% females with a mean age of 28.7 years) undergoing surgical treatment of FAI was utilized for analysis of insurance policies.

RESULTS

Based on 2020 FAI policies across 4 insurers, 22.5% (range 18.4-28.4%) of FAI patients would be deemed ineligible. In 2012, the average percent exclusion of the four companies was 23.7%. The most likely reason to be excluded was either failure to meet imaging criteria (alpha angle >50° or positive cross-over sign) [13%, n=94]) or the absence of an impingement sign (9%, n=65). Other causes of exclusion were <6-month symptom duration (6%, n=44), age <15 years (4%, n=28), or skeletally immaturity (3%, n=23).

CONCLUSION

Our study shows that despite a six-year span of growing literature and updated policies, nearly 1 in 5 patients diagnosed with FAI would still potentially be denied coverage. This highlights a continued divide between surgeons and insurance companies. There is a major need for improved consensus regarding the diagnosis of FAI and appropriate indications for surgical intervention.Level of Evidence: IV.

PROMIS Physical Function for prediction of postoperative pain, narcotics consumption, and patient-reported outcomes following minimally invasive transforaminal lumbar interbody fusion

OBJECTIVE

This study aimed to determine if the preoperative Patient-Reported Outcomes Measurement Information System, Physical Function (PROMIS PF) score is predictive of immediate postoperative patient pain and narcotics consumption or long-term patient-reported outcomes (PROs) following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

METHODS

A prospectively maintained database was retrospectively reviewed. Patients who underwent primary, single-level MIS TLIF for degenerative pathology were identified and grouped by their preoperative PROMIS PF scores: mild disability (score 40-50), moderate disability (score 30-39.9), and severe disability (score 20-29.9). Postoperative pain was quantified using the visual analog scale (VAS), and narcotics consumption was quantified using Oral Morphine Equivalents. PROMIS PF, Oswestry Disability Index (ODI), 12-Item Short-Form Health Survey, Physical Component Summary (SF-12 PCS), and VAS back and leg pain were collected preoperatively and at 6-week, 3-month, 6-month, and 12-month follow-up. Preoperative PROMIS PF subgroups were tested for an association with demographic and perioperative characteristics using 1-way ANOVA or chi-square analysis. Preoperative PROMIS PF subgroups were tested for an association with immediate postoperative pain and narcotics consumption in addition to improvements in PROMIS PF, ODI, SF-12 PCS, and VAS back and leg pain by using linear regression controlling for statistically different demographic characteristics.

RESULTS

A total of 130 patients were included in this analysis. Patients were grouped by their preoperative PROMIS PF scores: 15.4% had mild disability, 63.8% had moderate disability, and 20.8% had severe disability. There were no significant differences among the subgroups in terms of age, sex, smoking status, and comorbidity burden. Patients with greater disability were more likely to be obese and to have workers' compensation insurance. There were no differences among subgroups in regard to operative levels, operative time, estimated blood loss, and hospital length of stay. Patients with greater disability reported higher VAS pain scores and narcotics consumption for postoperative day 0 and postoperative day 1. Patients with greater preoperative disability demonstrated lower PROMIS PF, ODI, SF-12 PCS, and worse VAS pain scores at each postoperative time point.

CONCLUSIONS

Patients with worse preoperative disability, as assessed by PROMIS PF, experienced increased pain and narcotics consumption, along with less improvement in long-term PROs. The authors conclude that PROMIS PF is an efficient and accurate instrument that can quickly assess patient disability in the preoperative period and predict both short-term and long-term surgical outcomes.

Dose-volume factors to select patient-specific image-guidance action thresholds in prostate cancer

For radiation delivery tracking systems that monitor intrafraction prostate motion, generalized departmental threshold protocols may be used. The purpose of this study is to determine whether predefined action thresholds can be generally applied or if patient-specific action thresholds may be required. Software algorithms were developed in the MatLab (The Mathworks Inc., Natick, MA) software environment to simulate shifts of the patient structure set consisting of prostate, bladder, and rectum. These structures were shifted by 1/2 10 mm in each direction in 1 mm increments to simulate displacements during treatment, without taking into consideration organ deformity. Dose-volume data at each shift were plotted and analyzed. A linear relationship was observed between planning dose-volume parameters and shifted dose-volume parameters. For a 5 mm anterior shift, it was observed that individual rectal V70 values increased by absolute magnitudes of 6-15%, dependent on the planning rectal V70 of each patient. Likewise, for a 5 mm inferior shift, individual bladder V70 values increased by 1-14%, dependent on planning bladder V70. This linear relationship was observed for all levels of shifts up to 10 mm. Since rectum and bladder dose-volume changes due to patient shifts are dependent on dose-volume parameters, this study suggests that patient-specific action thresholds may be necessary.

Diagnostic utility of FLI-1 monoclonal antibody and dual-colour, break-apart probe fluorescence in situ (FISH) analysis in Ewing's sarcoma/primitive neuroectodermal tumour (EWS/PNET). A comparative study with CD99 and FLI-1 polyclonal antibodies

AIMS

To compare the sensitivity and specificity of the recently commercially available FLI-1 monoclonal (FLI-1m) antibody with the currently used antibodies [CD99 and FLI-1 polyclonal (FLI-1p)] in the diagnosis of Ewing's sarcoma/primitive neuroectodermal tumour (EWS/PNET) and to determine the diagnostic value of the EWSR1 (22q12) dual-colour, break-apart rearrangement probe fluorescence in situ hybridization (FISH) technique.

MATERIALS AND METHODS

Forty-three cases of well-documented EWS/PNET and 15 non-EWS/PNET cases were retrieved from the archival files. Immunohistochemistry (IHC) for FLI-1p, FLI-1m and FISH analysis was performed.

RESULTS

The most sensitive and specific test panel for the diagnosis of EWS/PNET is the combination of CD99 and FLI-1p. FISH had a very high specificity (100%) but only a moderate sensitivity (50%).

CONCLUSION

The combination of CD99 and FLI-1p is the method of choice for the diagnosis of EWS/PNET. EWRS1 (22q12) dual-colour, break-apart rearrangement probe FISH should be used as a confirmatory test in addition to CD99 and FLI1-p due to its high specificity.

Truncated STAT proteins are prevalent at relapse of acute myeloid leukemia

Signal transducer and activator of transcription (STAT) proteins are implicated in the control of cell survival, proliferation and differentiation in response to hematopoietic cytokines. C-terminally truncated STAT isoforms (STATbeta), as opposed to the full length form (STATalpha), have a competitive or even transdominant negative effect on gene induction mediated by the STAT pathway. We have previously demonstrated that while constitutively active STAT proteins were detected in ten of 36 (28%) for STAT3 and eight of 36 (22%) for STAT5 in pretreatment samples from newly diagnosed acute myeloid leukemia (AML) patients, a significantly larger fraction of samples [21 of 27 (78%)] expressed STATbeta proteins. To determine whether STATbeta expression was maintained or increased after relapse in AML, we compared STAT activity and isoform expression at diagnosis and at relapse in 17 patients. In this selected group, constitutively active STAT3 was detected in 13 of 17 (76%) AML samples at diagnosis but was detected in only four of these patients at relapse. Constitutively active STAT5 was detected in three of 17 (18%) AML samples at diagnosis; but only two at relapse. In contrast, STATbeta protein expression was observed in 12 of the 17 pretreatment samples (71%) and in 16 of 17 samples at relapse. Only one patient did not express STATbeta at relapse. Our results suggest that STATbeta isoform expression, rather than level of constitutive activity, may be involved in disease progression in AML.

Association of germline p53 mutation with MLL segmental jumping translocation in treatment-related leukemia

Segmental jumping translocations are chromosomal abnormalities in treatment-related leukemias characterized by multiple copies of the ABL and/or MLL oncogenes dispersed throughout the genome and extrachromosomally. Because gene amplification potential accompanies loss of wild-type p53, we examined the p53 gene in a case of treatment-related acute myeloid leukemia (t-AML) with MLL segmental jumping translocation. The child was diagnosed with ganglioneuroma and embryonal rhabdomyosarcoma (ERMS) at 2 years of age. Therapy for ERMS included alkylating agents, DNA topoisomerase I and DNA topoisomerase II inhibitors, and local radiation. t-AML was diagnosed at 4 years of age. The complex karyotype of the t-AML showed structural and numerical abnormalities. Fluorescence in situ hybridization analysis showed multiple copies of the MLL gene, consistent with segmental jumping translocation. A genomic region including CD3, MLL, and a segment of band 11q24 was unrearranged and amplified by Southern blot analysis. There was no family history of a cancer predisposing syndrome, but single-strand conformation polymorphism (SSCP) analysis detected identical band shifts in the leukemia, ganglioneuroma, ERMS, and normal tissues, consistent with a germline p53 mutation, and there was loss of heterozygosity in the ERMS and the t-AML. Sequencing showed a CGA-->TGA nonsense mutation at codon 306 in exon 8. The results of this analysis indicate that loss of wild-type p53 may be associated with genomic instability after DNA-damaging chemotherapy and radiation, manifest as a complex karyotype and gene amplification in some cases of t-AML.

Persistence of the AML1/ETO fusion transcript in patients treated with allogeneic bone marrow transplantation for t(8;21) leukemia

The AML1/ETO fusion transcript is expressed in virtually all patients with t(8;21) (q22;q22) acute myeloid leukemia (AML). The fusion transcript can be detected by reverse transcription-polymerase chain reaction (RT-PCR) in most of these patients in long-term complete remission (CR) following conventional chemotherapy or autologous bone marrow transplantation (BMT). However, AML1/ETO expression has not been analyzed in a series of patients following allogeneic BMT. We examined CR bone marrow (BM) samples and, in some cases, blood samples from 10 patients with t(8;21) leukemia who underwent allogeneic BMT in either first or second remission or first or second relapse. A variety of myeloablative regimens were used. Eight patients received non-T-cell depleted BM from matched sibling donors, one patient received a T-cell depleted haploidentical BM, and one patient received a non-T-cell depleted BM from a matched unrelated donor (MUD). Five patients developed acute and/ or chronic graft versus host disease (GVHD). The furthest time points analyzed for the AML1/ETO transcript in the 10 patients in CR following allogeneic BMT ranged from 7.5 to 83.0 months. Sufficient RNA was extracted from the most recent BM or BM and blood samples from nine patients to assay for presence or absence of the AML1/ETO fusion transcript by RT-PCR. The fusion transcript was detected by RT-PCR in all nine of these patient samples; eight were positive in BM and one was negative in BM, but positive in blood. The fusion transcript could not be detected in a BM sample from the tenth patient obtained 7.5 months after BMT, but the amount of RNA available was suboptimal. Hematopoietic chimerism could be demonstrated in sorted CD34+ BM cells from two of four patient CR BM samples with RT-PCR evidence of the fusion transcript. Additionally, in one of the two cases with chimerism, we demonstrated an abnormal clonal population of recipient cells in the CR BM sample by fluorescence in situ hybridization. One patient died of complications from GVHD, while the other nine patients remain alive without evidence of relapse, with a median follow-up time of 27 (range, 7.5 to 87) months post-BMT. These data suggest that allogeneic BMT, like conventional chemotherapy and autologous BMT, is not sufficient to eradicate cells expressing AML1/ETO, and that a positive RT-PCR for the fusion transcript post allogeneic BMT is compatible with continued CR.

Establishment and characterization of the tumors of chronic lymphocytic leukemia cell line in nude and SCID mice

A new cell line, designated MO1043, was established from the peripheral blood (PB) of a patient with B-cell chronic lymphocytic leukemia (CLL). Both the PB leukemia cells and MO1043 were found to have an abnormal cytogenetic marker of trisomy 12, the most common cytogenetic abnormality in CLL. In addition, both the PB cells and MO1043 expressed a cell surface phenotype of typical B-CLLs. The MO1043 was efficiently transplanted into X-irradiated athymic nude mice by i.p. inoculation after it was subjected to serial passages in new born (1 week old) and irradiated adult nude mice. The tumor of a CLL cell line (termed CLL tumor) was also generated in the nude mice by s.c. inoculation of the cells. The MO1043 was inoculated i.p. into mice with severe combined immunodeficiency (SCID) which had not been subject to any preconditionings. The CLL tumor in the non-conditioned SCID mice was disseminated to various tissues in a manner more analogous to CLL tumors in patients as compared with nude mice, where the CLL tumors were not as widely disseminated. At each of four different tumor doses, i.e. 2 x 10(6), 6 x 10(6), 1.8 x 10(7) and 5.4 +/- 10(7) cells of MO1043, the transplantability was 100%. Titration experiments revealed a reciprocal relationship between survival and the number of tumor cells inoculated. FACS analysis showed that several cell surface markers of the parental MO1043 were maintained in CLL tumors from nude and SCID mice. Fluorescence in situ hybridization with novel DNA probes demonstrated that CLL tumors of both nude and SCID mice maintained trisomy 12. The CLL tumor models developed here, particularly the SCID mouse model, may be very useful for therapeutic studies of CLL.

Cloning of the t(11;14)(q13;q32) translocation breakpoints from two human leukemia cell lines

The t(11;14)(q13;q32) translocation has been associated with several subtypes of human leukemia and lymphoma. It has been proposed that this translocation activates a proto-oncogene designated BCL1. In an effort to better understand the mechanism by which this translocation leads to malignancy, we have studied this translocation in two human cell lines. MO1094 and MO2058 were derived from patients with prolymphocytic variants of chronic lymphocytic leukemia. Southern blotting of the MO2058 cell line documented that the translocation linked the Jh region in the immunoglobulin heavy chain gene to the previously described BCL1 major translocation cluster (MTC). Using the polymerase chain reaction, we cloned this translocation and showed that the chromosome 11 breakpoint was within 7 bp of two other samples reported previously. Southern blotting of the MO1094 cell line suggested that the translocation in this cell line might link Jh sequences to a new region in the BCL1 locus on chromosome 11. Therefore, the MO1094 breakpoint was cloned from a genomic library. Comparison with normal cloned DNA from the BCL1 locus showed that the chromosome 11 breakpoint occurred 24 kb telomeric of the MTC. This work reinforces the concept that translocation breakpoints in the BCL1 locus are scattered over at least 63 kb.

Expression of the multidrug resistance gene in myeloid leukemias

The human multidrug-resistance gene (MDR1) encodes an energy-dependent multidrug efflux protein responsible for the cross-resistance of cultured cells to natural product chemotherapeutic agents such as the anthracyclines and vinca alkaloids. RNA transcript levels were measured in leukemia cells obtained from 15 adult acute nonlymphocytic leukemia (ANLL) cases and 15 cases of chronic myelogenous leukemia (CML). Expression of MDR1 RNA was common in ANLL, and appears to be most frequent in leukemic cells of patients with the poorest response to chemotherapy. Expression of the MDR1 gene was not detectable in the peripheral white blood cells of any of the CML cases during the chronic phase, but was detectable in the immature cells present during this phase of the disease. The cells of the three blastic crisis patients contained detectable levels of MDR1 RNA. These studies support the idea that expression of the MDR1 gene contributes to drug resistance in ANLL, and may play a role in some instances in the drug-resistance of CML in blastic crisis. In contrast, studies of the level of expression of anionic glutathione transferase and DNA polymerase B failed to show any relationship between the RNA transcript levels of these enzymes and responsiveness to chemotherapy.

Sister chromatid exchange and chromosome abnormalities in uremic patients

Chronic renal failure heightens the risk of malignancy. We therefore examined lymphocytes from 44 uremic patients and 24 normal controls for chromosome abnormalities and sister chromatid exchange (SCE) rate. This is the first report of SCE in uremia. Uremia was found to increase structurally abnormal chromosomes and elevate the rate of SCE. These cytogenetic changes in uremia may play a role in the heightened risk of cancer.

Sexual dysfunction of the male with diabetes mellitus

The literature states that 40 to 60 percent of males with diabetes will at some time become impotent. Nursing awareness and intervention in this problem can make a positive impact on the sexual functioning of males with diabetes. This article supplies suggestions for nursing care of males with diabetes mellitus and autonomic neuropathic impotence. Included is a description of the problem, including incidence, clinical morphology, description of normal male sexual functioning, pathogenesis, differential diagnosis, psychotherapeutic and surgical interventions. Nursing intervention includes a section on counseling by the nurse practitioner.

Effect of dispersing agents on the angular dependence of light scattered from polystyrene sphere/water sols

The particles in nearly monodisperse sols of polystyrene in water need small amounts of adsorbed emulsifier to combat aggregation tendencies. These sols are used in the calibration of many different types of instrument including instruments capable of measuring angular light scattering functions. Using an IBM 360-40 computer with extended precision on all variables and on machine functions, a calculation has been made of the range of observable effects attributable to an adsorbed layer of emulsifier on the sol particles in water suspension. The calculation of the polarization ratio as a function of angle was based on the formal solution of Maxwell's equations by Aden and Kerker [A. L. Aden and M. Kerker, J. Appl. Phys. 22, 1242 (1951)]. Two model sols were treated for three different commonly used wavelengths of incident light 436 nm, 546 nm, and 632.8 nm. The calculation made use of constituent functions up to the eleventh order. The effect of an adsorbed layer on the light-scattering angular functions was negligible unless the adsorbed layer differed from the medium by about 5% with respect to refractive index. If the layer was not at least 1% of the radius of the particle in thickness there was no observable change in the angular position of the maxima and/or minima of the polarization ratio angular function. For layers thicker than 1% of the particle radius and having a refractive index different from both medium or particle, interesting new maxima and minima are predicted.