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Bansal R, Park H, Taborda CC, Gordillo C, Mapara MY, Assal A, Uhlemann AC, Reshef R. Antibiotic Exposure, Not Alloreactivity, Is the Major Driver of Microbiome Changes in Hematopoietic Cell Transplantation. Transplant Cell Ther 2022; 28:135-144. [PMID: 34958974 PMCID: PMC8923982 DOI: 10.1016/j.jtct.2021.12.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 12/17/2021] [Accepted: 12/19/2021] [Indexed: 12/31/2022]
Abstract
Both autologous hematopoietic cell transplantation (auto-HCT) and allogeneic hematopoietic cell transplantation (allo-HCT) are associated with significant alterations in the intestinal microbiome. The relative contributions of antibiotic use and alloreactivity to microbiome dynamics have not yet been elucidated, however. There is a lack of data on the kinetics of microbiome changes beyond 30 days post-transplantation and how they might differ between different transplantation modalities. A direct comparison of the differential effects of auto-HCT and allo-HCT on the microbiome may shed light on these dynamics. This study was conducted to compare intestinal microbial diversity between auto-HCT recipients and allo-HCT recipients from pre-transplantation to 100 days post-transplantation, and to examine the effect of antibiotics, transplant type (auto versus allo), and conditioning regimens on the dynamics of microbiome recovery. We conducted a longitudinal analysis of changes in the intestinal microbiome in 35 patients undergoing HCT (17 auto-HCT, 18 allo-HCT) at 4 time points: pre-conditioning and 14, 28, and 100 days post-transplantation. Granular data on antibiotic exposure from day -30 pre-transplantation to day +100 post-transplantation were collected. Pre-transplantation, allo-HCT recipients had lower α-diversity in the intestinal microbiome compared with auto-HCT recipients, which correlated with greater pre-transplantation antibiotic use in allo-HCT recipients. The microbiome diversity declined at days +14 and +28 post-transplantation in both cohorts but generally returned to baseline by day +100. Conditioning regimen intensity did not significantly affect post-transplantation α-diversity. Through differential abundance analysis, we show that commensal bacterial taxa involved with maintenance of gut epithelial integrity and production of short-chain fatty acids were depleted after both auto-HCT and allo-HCT. In our dataset, antibiotic exposure was the major driver of post-transplantation microbiome changes rather than alloreactivity, conditioning intensity, or immunosuppression. Our findings also suggest that interventions to limit microbiome injury, such as limiting the use of broad-spectrum antibiotics, should target the pre-transplantation period and not only the peri-transplantation period.
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Affiliation(s)
- Rajat Bansal
- Blood and Marrow Transplantation and Cell Therapy Program,
Columbia University Irving Medical Center,Division of Hematologic Malignancies and Cellular
Therapeutics, University of Kansas Medical Center
| | - Heekuk Park
- Division of Infectious Diseases, Columbia University Irving
Medical Center
| | - Cristian C Taborda
- Columbia Center for Translational Immunology, Columbia
University Irving Medical Center
| | - Christian Gordillo
- Blood and Marrow Transplantation and Cell Therapy Program,
Columbia University Irving Medical Center,Columbia Center for Translational Immunology, Columbia
University Irving Medical Center
| | - Markus Y Mapara
- Blood and Marrow Transplantation and Cell Therapy Program,
Columbia University Irving Medical Center,Columbia Center for Translational Immunology, Columbia
University Irving Medical Center
| | - Amer Assal
- Blood and Marrow Transplantation and Cell Therapy Program,
Columbia University Irving Medical Center
| | | | - Ran Reshef
- Blood and Marrow Transplantation and Cell Therapy Program, Columbia University Irving Medical Center, New York, New York; Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, New York.
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Hultcrantz M, Richter J, Rosenbaum CA, Patel D, Smith EL, Korde N, Lu SX, Mailankody S, Shah UA, Lesokhin AM, Hassoun H, Tan C, Maura F, Derkach A, Diamond B, Rossi A, Pearse R, Madduri D, Chari A, Kaminetzky D, Braunstein MJ, Gordillo C, Reshef R, Taur Y, Davies FE, Jagannath S, Niesvizky R, Lentzsch S, Morgan GJ, Landgren O. Correction: COVID-19 Infections and Outcomes in Patients with Multiple Myeloma in New York City: A Cohort Study from Five Academic Centers. Blood Cancer Discov 2020; 1:290. [PMID: 34661147 PMCID: PMC8510790 DOI: 10.1158/2643-3230.bcd-20-0160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
[This corrects the article DOI: 10.1158/2643-3230.BCD-20-0102.].
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Hultcrantz M, Richter J, Rosenbaum CA, Patel D, Smith EL, Korde N, Lu SX, Mailankody S, Shah UA, Lesokhin AM, Hassoun H, Tan C, Maura F, Derkach A, Diamond B, Rossi A, Pearse RN, Madduri D, Chari A, Kaminetzky D, Braunstein MJ, Gordillo C, Reshef R, Taur Y, Davies FE, Jagannath S, Niesvizky R, Lentzsch S, Morgan GJ, Landgren O. COVID-19 Infections and Clinical Outcomes in Patients with Multiple Myeloma in New York City: A Cohort Study from Five Academic Centers. Blood Cancer Discov 2020; 1:234-243. [PMID: 34651141 PMCID: PMC7668224 DOI: 10.1158/2643-3230.bcd-20-0102] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/15/2020] [Accepted: 07/27/2020] [Indexed: 01/08/2023] Open
Abstract
Patients with multiple myeloma have a compromised immune system, due to both the disease and antimyeloma therapies, and may therefore be particularly susceptible to COVID-19. Here, we report outcomes and risk factors for serious disease in patients with multiple myeloma treated at five large academic centers in New York City in the spring of 2020, during which it was a global epicenter of the SARS-CoV-2 pandemic. Of 100 patients with multiple myeloma (male 58%; median age 68) diagnosed with COVID-19, 75 were admitted; of these, 13 patients (17%) were placed on invasive mechanical ventilation, and 22 patients (29%) expired. Of the 25 nonadmitted patients, 4 were asymptomatic. There was a higher risk of adverse outcome (intensive care unit admission, mechanical ventilation, or death) in Hispanics/Latinos (n = 21), OR = 4.7 (95% confidence interval, 1.3-16.7), and African American Blacks (n = 33), OR = 3.5 (1.1-11.5), as compared with White patients (n = 36). Patients who met the adverse combined endpoint had overall higher levels of inflammatory markers and cytokine activation. None of the other studied risk factors were significantly associated (P > 0.05) with adverse outcome: hypertension (n = 56), OR = 2.2 (0.9-5.4); diabetes (n = 18), OR = 0.9 (0.3-2.9); age >65 years (n = 63), OR = 1.8 (0.7-4.6); high-dose melphalan with autologous stem cell transplant <12 months (n = 7), OR = 0.9 (0.2-5.4); and immunoglobulin G <650 mg/dL (n = 42), OR = 0.9 (0.3-2.2). In this largest cohort to date of patients with multiple myeloma and COVID-19, we found the case fatality rate to be 29% among hospitalized patients and that race/ethnicity was the most significant risk factor for adverse outcome. Significance Patients with multiple myeloma are immunocompromised, raising the question whether they are at higher risk of severe COVID-19 disease. In this large case series on COVID-19 in patients with multiple myeloma, we report 29% mortality rates among hospitalized patients and identify race/ethnicity as the most significant risk factor for severe outcome.See related commentary by Munshi and Anderson, p. 218. This article is highlighted in the In This Issue feature, p. 215.
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Affiliation(s)
- Malin Hultcrantz
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joshua Richter
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Cara A. Rosenbaum
- Center for Myeloma, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Dhwani Patel
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eric L. Smith
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Neha Korde
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sydney X. Lu
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sham Mailankody
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Urvi A. Shah
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alexander M. Lesokhin
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hani Hassoun
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Carlyn Tan
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Francesco Maura
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andriy Derkach
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Benjamin Diamond
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Adriana Rossi
- Center for Myeloma, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Roger N. Pearse
- Center for Myeloma, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Deepu Madduri
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ajai Chari
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David Kaminetzky
- Department of Medicine, Multiple Myeloma Research Perlmutter Cancer Center, NYU Langone Health, New York, New York
| | - Marc J. Braunstein
- Department of Medicine, Multiple Myeloma Research Perlmutter Cancer Center, NYU Langone Health, New York, New York
| | - Christian Gordillo
- Division of Hematology and Oncology, Columbia University Medical Center, New York, New York
| | - Ran Reshef
- Division of Hematology and Oncology, Columbia University Medical Center, New York, New York
| | - Ying Taur
- Infectious Diseases, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Joan and Sanford Weill Medical College of Cornell University, New York, New York
| | - Faith E. Davies
- Department of Medicine, Multiple Myeloma Research Perlmutter Cancer Center, NYU Langone Health, New York, New York
| | - Sundar Jagannath
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ruben Niesvizky
- Center for Myeloma, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Suzanne Lentzsch
- Division of Hematology and Oncology, Columbia University Medical Center, New York, New York
| | - Gareth J. Morgan
- Department of Medicine, Multiple Myeloma Research Perlmutter Cancer Center, NYU Langone Health, New York, New York
| | - Ola Landgren
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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Hultcrantz M, Richter J, Rosenbaum C, Patel D, Smith E, Korde N, Lu S, Mailankody S, Shah U, Lesokhin A, Hassoun H, Tan C, Maura F, Derkacs A, Diamond B, Rossi A, Pearse RN, Madduri D, Chari A, Kaminetsky D, Braunstein M, Gordillo C, Davies F, Jagannath S, Niesvizky R, Lentzsch S, Morgan G, Landgren O. COVID-19 infections and outcomes in patients with multiple myeloma in New York City: a cohort study from five academic centers. medRxiv 2020:2020.06.09.20126516. [PMID: 32577667 PMCID: PMC7302217 DOI: 10.1101/2020.06.09.20126516] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Importance New York City is a global epicenter for the SARS-CoV-2 outbreak with a significant number of individuals infected by the virus. Patients with multiple myeloma have a compromised immune system, due to both the disease and anti-myeloma therapies, and may therefore be particularly susceptible to coronavirus disease 2019 (COVID-19); however, there is limited information to guide clinical management. Objective To assess risk factors and outcomes of COVID-19 in patients with multiple myeloma. Design Case-series. Setting Five large academic centers in New York City. Participants Patients with multiple myeloma and related plasma cell disorders who were diagnosed with COVID-19 between March 10th, 2020 and April 30th, 2020. Exposures Clinical features and risk factors were analyzed in relation to severity of COVID-19. Main Outcomes and Measures Descriptive statistics as well as logistic regression were used to estimate disease severity reflected in hospital admissions, intensive care unit (ICU) admission, need for mechanical ventilation, or death. Results Of 100 multiple myeloma patients (male 58%; median age 68, range 41-91) diagnosed with COVID-19, 74 (74%) were admitted; of these 13 (18%) patients were placed on mechanical ventilation, and 18 patients (24%) expired. None of the studied risk factors were significantly associated (P>0.05) with adverse outcomes (ICU-admission, mechanical ventilation, or death): hypertension (N=56) odds ratio (OR) 2.3 (95% confidence interval [CI] 0.9-5.9); diabetes (N=18) OR 1.1 (95% CI 0.3-3.2); age >65 years (N=63) OR 2.0 (95% CI 0.8-5.3); high dose melphalan with autologous stem cell transplant <12 months (N=7) OR 1.2 (95% CI 0.2-7.4), IgG<650 mg/dL (N=42) OR=1.2 (95% CI 0.4-3.1). In the entire series of 127 patients with plasma cell disorders, hypertension was significantly associated with the combined end-point (OR 3.4, 95% CI 1.5-8.1). Conclusions and Relevance Although multiple myeloma patients have a compromised immune system due to both the disease and therapy; in this largest disease specific cohort to date of patients with multiple myeloma and COVID-19, compared to the general population, we found risk factors for adverse outcome to be shared and mortality rates to be within the higher range of officially reported mortality rates.
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Affiliation(s)
- Malin Hultcrantz
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joshua Richter
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Cara Rosenbaum
- Center for Myeloma, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Dhwani Patel
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eric Smith
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Neha Korde
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sydney Lu
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sham Mailankody
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Urvi Shah
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alexander Lesokhin
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hani Hassoun
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Carlyn Tan
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Francesco Maura
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andriy Derkacs
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Benjamin Diamond
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Adriana Rossi
- Center for Myeloma, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Roger N. Pearse
- Center for Myeloma, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Deepu Madduri
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ajai Chari
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David Kaminetsky
- Dpt. of Medicine, Multiple Myeloma Research Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Marc Braunstein
- Dpt. of Medicine, Multiple Myeloma Research Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Christian Gordillo
- Division of Hematology and Oncology, Columbia University Medical Center, New York, NY, USA
| | - Faith Davies
- Dpt. of Medicine, Multiple Myeloma Research Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Sundar Jagannath
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ruben Niesvizky
- Center for Myeloma, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Suzanne Lentzsch
- Division of Hematology and Oncology, Columbia University Medical Center, New York, NY, USA
| | - Gareth Morgan
- Dpt. of Medicine, Multiple Myeloma Research Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Ola Landgren
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Montes-Torres A, Camarero-Mulas C, de Argila D, Gordillo C, Daudén E. Poroqueratosis pruriginosa diseminada inflamatoria. Buena respuesta a ciclosporina. Actas Dermo-Sifiliográficas 2016; 107:261-2. [DOI: 10.1016/j.ad.2015.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/07/2015] [Accepted: 07/08/2015] [Indexed: 12/29/2022] Open
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Carrascosa R, Godoy A, Gordillo C, de Argila D. Pachydermodactyly in a Patient With Generalized Anxiety Disorder and Tics. Actas Dermo-Sifiliográficas (English Edition) 2014. [DOI: 10.1016/j.adengl.2014.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Carrascosa R, Godoy A, Gordillo C, de Argila D. Pachydermodactyly in a patient with generalized anxiety disorder and tics. Actas Dermosifiliogr 2013; 105:625-6. [PMID: 24238330 DOI: 10.1016/j.ad.2013.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 08/13/2013] [Accepted: 09/17/2013] [Indexed: 11/28/2022] Open
Affiliation(s)
- R Carrascosa
- Servicio de Dermatología, Hospital Universitario La Princesa, Madrid, España.
| | - A Godoy
- Servicio de Dermatología, Hospital Universitario La Princesa, Madrid, España
| | - C Gordillo
- Servicio de Anatomía Patológica, Hospital Universitario La Princesa, Madrid, España
| | - D de Argila
- Servicio de Dermatología, Hospital Universitario La Princesa, Madrid, España
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Johnston CE, Gordillo C, Eales JG. Transition from a hatchery to a laboratory environment induces inner-ring monodeiodination pathways for thyroid hormones in liver of rainbow trout, Oncorhynchus mykiss. CAN J ZOOL 1996. [DOI: 10.1139/z96-246] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In laboratory-acclimated rainbow trout (Oncorhynchus mykiss) the main hepatic deiodination pathway for thyroid hormones is L-thyroxine (T4) outer-ring deiodination (T4ORD), which produces biologically active 3,5,3′-triiodo-L-thyronine (T3); T4 inner-ring deiodination (T4IRD) as well as T3ORD and T3IRD activities are low or undetectable. Surprisingly, trout transported 48 h previously from a local hatchery to the laboratory demonstrated not only low T4ORD activity but also significant T4IRD and T3IRD activities. To test if the transition from hatchery to laboratory environment had induced the unexpected inner-ring deiodinations, we measured hepatic deiodinase activities over the same time frame in trout recently transported to the laboratory and also in trout retained undisturbed at the hatchery. Undisturbed hatchery trout showed typical hepatic deiodinase function: T4ORD activity predominated, while T3IRD, T4IRD, and T3ORD activities were basal. However, after 1–3 days in the laboratory, hepatic T4ORD activity was reduced and T4IRD and T3IRD activities were increased. By 5 days, deiodinase activities of laboratory trout reverted to the levels of hatchery trout. We conclude that physical disturbance can temporarily depress thyroidal status by simultaneously decreasing hepatic production of biologically active T3 and inducing degradation of T4 and T3.
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Ocádiz R, Sauceda R, Salcedo M, Ortega V, Rodríguez H, Gordillo C, Chávez P, Gariglio P. Occurrence of human papillomavirus type 16 DNA sequences and c-myc oncogene alterations in uterine-cervix carcinoma. Arch Invest Med (Mex) 1989; 20:355-62. [PMID: 2562235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Using genetic engineering and molecular biology techniques, we have examined sixteen human carcinomas in the uterine-cervix tumors (the most frequent tumor in México, representing 34% of malignant tumors in women), for the presence of Human Papillomavirus type 16 (HPV-16) DNA sequences and possible alterations of the cellular myc (c-myc) proto-oncogene. In this study we have analyzed cervical carcinomas from patient with clinical stage II. We detected in 31% of these samples, the presence of HPV-16 sequences (2-100 copies). In addition, an elevated amplification (up to 80-fold in one tumor) and/or rearrangement of the c-myc oncogene was detected in most tumors (more than 90% of the samples). These results suggest that either c-myc oncogene and/or HPV-16 could play an important role in the development of uterine-cervix carcinoma.
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Affiliation(s)
- R Ocádiz
- Unidad de Oncología, Hospital General de México, SSA y Centro Médico La Raza-IMSS
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