Real-time Doppler ultrasound to identify vessels and guide needle placement for gynecologic interstitial brachytherapy

PURPOSE

Doppler ultrasound (US) gives real-time information regarding anatomy and blood vessel location to guide needle placement for gynecologic interstitial (IS) brachytherapy (BT). We retrospectively assessed Doppler US images for vessel quantity, size, and distribution in cervical cancer patients undergoing high-dose-rate BT at our institution.

METHODS AND MATERIALS

Eleven consecutive patients undergoing IS high-dose-rate BT implants for cervical cancer between 2015 and 2017 were included. Transrectal Doppler US was used for real-time image guidance. US images were retrospectively evaluated. Vessel quantity, size, and distribution at superior and inferior levels of the cervix were recorded. Correlation of vessel quantity with tumor size and International Federation of Gynecology and Obstetrics stage was evaluated.

RESULTS

Average vessel quantity was 4.2 in the inferior cervix and 3.8 in the superior cervix (range 1-11). Median vessel diameter was 2 mm in the inferior cervix and 2 mm in the superior cervix (range 1-6 mm). The most common location was posterolateral (3:00-5:00 and 7:00-9:00), outer third (78% of vessels inferiorly, 64% of vessels superiorly). Vessel quantity was correlated to initial tumor size superiorly (p = 0.04, paired t-test) but not inferiorly (p = 0.31, paired t-test). There was no correlation between vessel quantity and International Federation of Gynecology and Obstetrics stage (p > 0.05, analysis of variance). Doppler US was successfully used to guide needle placement away from visualized blood vessels with no incidents of hemorrhage in these patients.

CONCLUSIONS

Doppler US is a useful tool to guide needle placement for IS BT for cervical cancer. Vessel quantity varied with increased vessel quantity seen higher in the cervix for larger tumors. Vessels were most commonly distributed in the outer third of the posterolateral cervix.

Biased Generation and In Situ Activation of Lung Tissue-Resident Memory CD4 T Cells in the Pathogenesis of Allergic Asthma

Asthma is a chronic inflammatory disease mediated by allergen-specific CD4 T cells that promote lung inflammation through recruitment of cellular effectors into the lung. A subset of lung T cells can persist as tissue-resident memory T cells (TRMs) following infection and allergen induction, although the generation and role of TRM in asthma persistence and pathogenesis remain unclear. In this study, we used a mouse model of chronic exposure to intranasal house dust mite (HDM) extract to dissect how lung TRMs are generated and function in the persistence and pathogenesis of allergic airway disease. We demonstrate that both CD4⁺ and CD8⁺ T cells infiltrate into the lung tissue during acute HDM exposure; however, only CD4⁺ TRMs, and not CD8⁺ TRMs, persist long term following cessation of HDM administration. Lung CD4⁺ TRMs are localized around airways and are rapidly reactivated upon allergen re-exposure accompanied by the rapid induction of airway hyperresponsiveness independent of circulating T cells. Lung CD4⁺ TRM activation to HDM challenge is also accompanied by increased recruitment and activation of dendritic cells in the lungs. Our results indicate that lung CD4⁺ TRMs can perpetuate allergen-specific sensitization and direct early inflammatory signals that promote rapid lung pathology, suggesting that targeting lung CD4⁺ TRMs could have therapeutic benefit in alleviating recurrent asthma episodes.

Breast cancer following ovarian cancer in BRCA mutation carriers

IMPORTANCE

BRCA mutation carriers are at increased risk of developing breast cancer. However, the incidence of breast cancer after a diagnosis of epithelial ovarian cancer (EOC), one of the tubal/peritoneal cancers collectively referred to as pelvic serous carcinomas, is not well known. Optimal breast cancer surveillance and detection for these patients have also not been well characterized.

OBJECTIVES

To determine the incidence of breast cancer after a diagnosis of EOC and to evaluate the need for breast cancer surveillance for these patients.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective database review of 364 patients who underwent BRCA mutation testing for EOC (stages I-IV) between 1998 and 2012 at an academic medical center with gynecologic and breast cancer centers.

MAIN OUTCOMES AND MEASURES

Incidence of breast cancer and methods of surveillance.

RESULTS

Of 364 patients, 135 (37.1%) were found to carry a germline BRCA1 or BRCA2 mutation. The mean age of patients at diagnosis of EOC was 49.5 years (range, 28-89 years). Of the 135 patients, 12 (8.9%) developed breast cancer. The median time from diagnosis of EOC to diagnosis of breast cancer was 50.5 months. Annual mammography was performed for 80 patients (59.3%), with annual magnetic resonance imaging of the breasts performed for 60 patients (44.4%). Thirteen patients (9.6%) underwent a bilateral prophylactic mastectomy at a median of 23 months following EOC diagnosis. Breast cancer was most commonly diagnosed by mammography for 7 of the 12 patients (58.3%), 3 (25.0%) of whom had a palpable mass and 2 (16.7%) of whom had incidental breast cancer detected during a prophylactic mastectomy. Seven patients with breast cancer (58.3%) underwent a bilateral mastectomy. All patients had early-stage breast cancer (stages 0-II). Four patients (33.3%) received adjuvant chemotherapy. At a median follow-up of 6.3 years, 4 of the 12 patients (33.3%) died of recurrent EOC after a diagnosis of breast cancer. The overall 10-year survival rate for the entire cohort of 135 patients was 17.0%.

CONCLUSIONS AND RELEVANCE

The risk of metachronous breast cancer is low in patients with known BRCA mutations and EOC. A majority of these cases of breast cancer at an early stage are detected by use of mammography. Despite the small number of patients in our study, these results suggest that optimal breast cancer surveillance for patients with BRCA-associated EOC needs to be reevaluated given the low incidence of breast cancer among these high-risk patients. Confirmation of our findings from larger studies seems to be indicated.

Identifying modifier genes in Autoimmune Lymphoproliferative Syndrome (P4084)

Autoimmune Lymphoproliferative Syndrome (ALPS) is an inherited disorder of defective lymphocyte apoptosis, characterized by chronic lymphadenopathy and/or splenomegaly, autoimmune cytopenias, and the expansion of a unique population of CD4-CD8- α/β T cells. ALPS is predominately caused by mutations in Fas with incomplete penetrance. In order to identify modifier genes and understand the mechanism of incomplete penetrance of disease in ALPS, we performed a linkage study using five large families with multiple ALPS patients and healthy Fas mutation-positive relatives (HMPRs) in each family. We identified a putative modifier locus shared by two of the families and a few potential linkage intervals shared by two of the other families. To screen large numbers of family members for an apoptosis defect, we developed a fast assay for testing lymphocyte Fas-mediated apoptosis susceptibility ex vivo, which we have named the FasT Kill assay. The conventional in vitro apoptosis assay takes over a week to obtain results whereas our assay using multi-parameter flow cytometry to specifically analyze apoptosis of the Fas-sensitive effector memory T cells in PBMCs can yield a diagnosis within a single workday. Using the FasT Kill assay, we could rapidly identify patients with apoptosis defects for the diagnosis of ALPS and compare the severity of apoptosis defects among ALPS patients or HMPRs. The results of these genetic analyses will be discussed.

Common variants at 19p13 are associated with susceptibility to ovarian cancer

Epithelial ovarian cancer (EOC) is the leading cause of death from gynecological malignancy in the developed world, accounting for 4% of the deaths from cancer in women. We performed a three-phase genome-wide association study of EOC survival in 8,951 individuals with EOC (cases) with available survival time data and a parallel association analysis of EOC susceptibility. Two SNPs at 19p13.11, rs8170 and rs2363956, showed evidence of association with survival (overall P = 5 × 10⁻⁴ and P = 6 × 10⁻⁴, respectively), but they did not replicate in phase 3. However, the same two SNPs demonstrated genome-wide significance for risk of serous EOC (P = 3 × 10⁻⁹ and P = 4 × 10⁻¹¹, respectively). Expression analysis of candidate genes at this locus in ovarian tumors supported a role for the BRCA1-interacting gene C19orf62, also known as MERIT40, which contains rs8170, in EOC development.

The photochemical attachment of the O-glucoside of 3-hydroxykynurenine to alpha-crystallin: a model for lenticular aging

The young human lens contains a small metabolite from tryptophan called the O-glucoside of 3-hydroxykynurenine (3-HKG). Its function is to absorb most radiation between 295 and 400 nm, preventing it from reaching the retina. With age the concentration of this component decreases while the lens crystallins acquire covalently attached chromophores. This study investigates the photochemical attachment of 3-HKG to lens alpha-crystallin. Initial studies showed that alpha-crystallin photolyzed in the presence of 3-HKG developed a fluorescence (emission, 440 nm) and UV-visible spectrum similar to that found in aged human lens proteins. Extensive studies were then performed on the tryptic HPLC maps as monitored by photodiode array and fluorescent detection. Numerous photoproducts with either blue (emission, > 400 nm) or green (emission, > 500 nm) fluorescence were formed in addition to nonfluorescent compounds with absorption maxima above 300 nm. Comparisons were made between these model photoproducts and peptide maps from alpha-crystallin isolated from old human lenses. In terms of retention time and UV-visible spectra at least two of the peptides that appear in the model system are also present in the human samples. It is concluded that one of the aging processes in the human lens is the photochemically induced attachment of 3-HKG to lens proteins.

National survey of Korean dentists' knowledge and opinions: dental caries etiology and prevention

OBJECTIVE

Dentists have the potential to influence what their patients know and do regarding dental caries prevention. The practices of dentists and what they tell their patients are influenced, in part, by their own knowledge and opinions. The purposes of this study were to determine the level of knowledge and opinions about caries etiology and prevention among Korean dentists and to describe related factors.

METHODS

A pretested, 27-item questionnaire was mailed to 2,047 dentists, selected by a stratified random sampling allocated proportionately. A postcard reminder was sent to all dentists after one week. Nonrespondents were sent additional complete mailings after three, seven, and nine weeks. The response rate was 83 percent (n = 1,700 dentists).

RESULTS

Analysis of six factors thought to be related to knowledge about caries etiology and prevention showed that recent graduates and dentists who worked in public health centers were likely to be more knowledgeable about caries etiology and prevention than their counterparts (P < .05). In regression analysis of perceived effectiveness of caries-preventive procedures for children, recent graduates, males, and dentists who worked in public health centers tended to rate caries-preventive procedures more effective than other dentists (P < .05). Dentists who had experience with school-based preventive programs and dentists in rural areas were likely to rate caries-preventive procedures for adults more effective than other dentists (P < .05).

CONCLUSIONS

Overall, results of this study suggest that the majority of dentists do not know current information concerning etiology and prevention of dental caries, mechanisms of action of fluoride, and effectiveness of preventive procedures for children and adults. Efforts to enhance the level of knowledge and practices of Korean dentists about caries prevention should focus on strategies to educate older graduates and female dentists, especially those in private practice.