Staging and clean room: Constructs designed to facilitate transparency and reduce bias in comparative analyses of real-world data

PURPOSE

We describe constructs designed to protect the integrity of the results from comparative analyses using real-world data (RWD): staging and clean room.

METHODS

Staging involves performing sequential preliminary analyses and evaluating the population size available and potential bias before conducting comparative analyses. A clean room involves restricted access to data and preliminary results, policies governing exploratory analyses and protocol deviations, and audit trail. These constructs are intended to allow decisions about protocol deviations, such as changes to design or model specification, to be made without knowledge of how they might affect subsequent analyses. We describe an example for implementing staging with a clean room.

RESULTS

Stage 1 may involve selecting a data source, developing and registering a protocol, establishing a clean room, and applying inclusion/exclusion criteria. Stage 2 may involve attempting to achieve covariate balance, often through propensity score models. Stage 3 may involve evaluating the presence of residual confounding using negative control outcomes. After each stage, check points may be implemented when a team of statisticians, epidemiologists and clinicians masked to how their decisions may affect study outcomes, reviews the results. This review team may be tasked with making recommendations for protocol deviations to address study precision or bias. They may recommend proceeding to the next stage, conducting additional analyses to address bias, or terminating the study. Stage 4 may involve conducting the comparative analyses.

CONCLUSIONS

The staging and clean room constructs are intended to protect the integrity and enhance confidence in the results of analyses of RWD.

Brain tumor risk according to germ-line variation in the MLLT10 locus

Genome-wide association studies have recently identified a cancer susceptibility locus at 10p12 mapping to MLLT10 associated with the onset of diverse tumors. We genotyped two tightly linked single-nucleotide polymorphisms (SNPs) at MLLT10 associated with meningioma (rs12770228) or ovarian cancer (rs1243180), and tested for associations among 295 meningioma cases, 606 glioma cases and 646 noncancer controls, all of European descent. The variant 'A' allele in MLLT10 rs12770228 was associated with an increased risk of meningioma (per allele odds ratio: 1.25; 95% confidence interval: 1.02, 1.53; P=0.031). Similar associations were observed for rs1243180. MLLT10 variants were unrelated to glioma. Functional investigation identified 22 candidate functional SNPs mapping to this region. The present study further validates 10p12 as a meningioma risk locus.

Circadian pathway genes in relation to glioma risk and outcome

PURPOSE

There is growing evidence that circadian disruption may alter risk and aggressiveness of cancer. We evaluated common genetic variants in the circadian gene pathway for associations with glioma risk and patient outcome in a US clinic-based case-control study.

METHODS

Subjects were genotyped for 17 candidate single nucleotide polymorphisms in ARNTL, CRY1, CRY2, CSNK1E, KLHL30, NPAS2, PER1, PER3, CLOCK, and MYRIP. Unconditional logistic regression was used to estimate age and gender-adjusted odds ratios (OR) and 95 % confidence intervals (CI) for glioma risk under three inheritance models (additive, dominant, and recessive). Proportional hazards regression was used to estimate hazard ratios for glioma-related death among 441 patients with high-grade tumors. Survival associations were validated using The Cancer Genome Atlas (TCGA) dataset.

RESULTS

A variant in PER1 (rs2289591) was significantly associated with overall glioma risk (per variant allele OR 0.80; 95 % CI 0.66-0.97; p trend = 0.027). The variant allele for CLOCK rs11133391 under a recessive model increased risk of oligodendroglioma (OR 2.41; 95 % CI 1.31-4.42; p = 0.005), though not other glioma subtypes (p for heterogeneity = 0.0033). The association remained significant after false discovery rate adjustment (p = 0.008). Differential associations by gender were observed for MYRIP rs6599077 and CSNK1E rs1534891 though differences were not significant after adjustment for multiple testing. No consistent mortality associations were identified. Several of the examined genes exhibited differential expression in glioblastoma multiforme versus normal brain in TCGA data (MYRIP, ARNTL, CRY1, KLHL30, PER1, CLOCK, and PER3), and expression of NPAS2 was significantly associated with a poor patient outcome in TCGA patients.

CONCLUSION

This exploratory analysis provides some evidence supporting a role for circadian genes in the onset of glioma and possibly the outcome of glioma.

Toenail iron, genetic determinants of iron status, and the risk of glioma

PURPOSE

Iron is essential for oxygen transport and oxidative metabolism; however, elevated iron stores can trigger overproduction of reactive oxygen species and induce DNA damage. Little is known about the association between body iron stores and glioma risk. This study examined the associations of iron levels measured in toenails and genetic variants linked to body iron stores with risk of glioma in a clinic-based case-control study.

METHODS

Samples were collected a median of 24 days following glioma diagnosis in the cases (10th-90th percentile, range: 10-44 days). Nail iron levels were measured in 300 cases and 300 controls using neutron activation analysis. A total of 24 genetic variants associated with iron status were genotyped in 622 cases and 628 controls. Logistic regression was used to estimate odds ratios (OR) and 95 % confidence intervals (CI) for glioma risk according to toenail iron and the examined genotypes.

RESULTS

No association was observed between toenail iron and glioma risk when restricting to cases with nails collected within ~3 weeks of diagnosis (OR = 0.93; 95 % CI 0.46, 1.87 comparing those with high (≥14 μg/g) vs. low (<6 μg/g) iron levels). In contrast, an inverse association with increasing iron was observed after restricting to cases with a delay of 3 weeks or greater (OR = 0.42; 95 % CI 0.19, 0.95), reflecting potentially insidious effects of advancing disease on iron levels among the cases. No associations were observed for any of the examined genetic variants.

CONCLUSION

The results do not support a role for body iron stores as a determinant of glioma risk.

Early life exposures and the risk of adult glioma

Exposure to common infections in early life may stimulate immune development and reduce the risk for developing cancer. Birth order and family size are proxies for the timing of exposure to childhood infections with several studies showing a reduced risk of glioma associated with a higher order of birth (and presumed younger age at infection). The aim of this study was to examine whether birth order, family size, and other early life exposures are associated with the risk of glioma in adults using data collected in a large clinic-based US case-control study including 889 glioma cases and 903 community controls. A structured interviewer-administered questionnaire was used to collect information on family structure, childhood exposures and other potential risk factors. Logistic regression was used to calculate odds ratios (OR) and corresponding 95% confidence intervals (CI) for the association between early life factors and glioma risk. Persons having any siblings were at significantly lower risk for glioma when compared to those reporting no siblings (OR=0.64; 95% CI 0.44-0.93; p=0.020). Compared to first-borns, individuals with older siblings had a significantly lower risk (OR=0.75; 95% CI 0.61-0.91; p=0.004). Birth weight, having been breast fed in infancy, and season of birth were not associated with glioma risk. The current findings lend further support to a growing body of evidence that early exposure to childhood infections reduces the risk of glioma onset in children and adults.

Prediagnostic body weight and survival in high grade glioma

Greater adiposity has been linked to an increased risk and/or poorer survival in a variety of cancers. We examined whether prediagnostic body weight 1-5 years prior to diagnosis is associated with survival in patients with high grade glioma. The analysis was based on a series of patients with high-grade glioma (N = 853) enrolled in a US-based multicenter case-control study. Subjects reported height and weight 1-5 years prior to interview and at age 21. BMI was categorized according to WHO criteria as underweight (BMI <18.5 kg/m(2)), normal weight (BMI 18.5-24.9 kg/m(2)), overweight (BMI 25-29.9 kg/m(2)) and obese (BMI ≥30 kg/m(2)). Proportional hazards regression was used to estimate hazard ratios (HR) and 95 % confidence intervals (CIs) for glioma-related death according to body mass index (BMI, kg/m(2)). Overall survival was reduced among patients underweight (median survival: 12.0 months) or obese (median: 13.6 months) when compared to patients of normal weight (median: 17.5 months) prior to glioma diagnosis (p = 0.004). In a multivariate model controlling for other prognostic factors, an excess mortality was observed in patients reporting obese body weights 1-5 years prior to study interview when compared to patients with a normal BMI (HR = 1.32; 95 % CI 1.04-1.68). Consistent patterns of association with excess body weight were observed in men and women, and all findings were similar regardless of treatment for glioma. A lower than optimal body weight was associated with a nonsignificant excess mortality in multivariate analysis. Premorbid obesity was significantly associated with a poor patient outcome independent of treatment and established prognostic factors. Excess body weight may be an adverse prognostic factor in glioma, a relationship observed across a spectrum of cancer types. The current findings linking prediagnostic body weight with mortality in high-grade glioma warrant further research.

Anthropometric factors in relation to risk of glioma

INTRODUCTION

Increased height and greater adiposity have been linked to an increased risk of many cancer types, though few large studies have examined these associations in glioma. We examined body weight and height as potential risk factors for glioma in a large US-based case-control study.

METHODS

The analysis included 1,111 glioma cases and 1,096 community controls. In a structured interview, participants reported their height and weight at 21 years of age, lowest and highest weight in adulthood, and weight 1-5 years in the past.

RESULTS

Being underweight at age 21 (BMI < 18.5 kg/m(2)) was inversely associated with the risk of glioma development. This protective association was observed in both men and women, but reached statistical significance in women only (multivariate OR 0.68; 95 % CI 0.48, 0.96). When BMI at age 21 was assessed as a continuous variate, a small but significant increase in risk was observed per unit increase in kg/m(2) (OR 1.04; 95 % CI 1.02, 1.07). Adult height, recent body weight, and weight change in adulthood were not associated with glioma risk. All results were similar among never smokers and were consistent after stratifying by glioma subtype.

CONCLUSION

The present data suggest that a low body weight in early adulthood is associated with a reduced risk of glioma later in life. Results are consistent with previous studies in showing no material association of glioma risk with usual adult body weight. The present study does not support any association of adult stature with glioma risk.

Abstract 104: Toenail iron, genetic variation in iron status, and the risk and outcome of glioma

Elevated iron stores can trigger overproduction of reactive oxygen species and induce oxidative DNA damage. To our knowledge, no studies have investigated the association of body iron stores with the risk of glioma. In this investigation, we examined single nucleotide polymorphisms (SNPs) identified as markers of iron status in genome-wide association studies, and also measured iron stores in toenail samples in a clinic-based case-control study conducted at medical centers in the southeastern US. Genotyping was performed in 622 newly diagnosed, nonrecurrent glioma cases (including 341 WHO grade IV glioblastomas (GBM); 146 WHO grade II or III astrocytomas, 94 mixed oligoastrocytomas (MOAs) and oligodendrogliomas, and 41 gliomas with unspecified histology) and 628 healthy controls with no history of brain tumors. Illumina GoldenGate and Taqman OpenArray assays were used to genotype oral DNA samples. A total of 24 SNPs associated with markers of iron status were genotyped. Iron levels in toenail samples were measured in 200 glioma cases and 200 controls using neutron-activation analysis. Logistic regression was used to estimate age and gender-adjusted odds ratios (OR) and 95% confidence intervals (CI) for glioma risk according to examined genotypes and toenail iron levels. Proportional hazards regression was used to estimate age and gender-adjusted hazard ratios (HR) for glioma-related death among 320 patients with GBM or high grade astrocytomas all treated with the current standard of care for high grade glioma (eg. surgery, radiation and temozolomide) (248 deaths; median Kaplan-Meier survival: 15.0 months). We observed no overall association with glioma risk or patient outcome for SNPs in ARSB, BTN1A1, C7ORF10, FLJ43390, GHR, GTSCR1, HFE, HIST1H2BJ, KRT18P33, LRRC16, SCGN, SLC17A1, TOPBP1, and WTAP. Among non-GBM astrocytomas, borderline risk associations were observed for rs236918 in PCSK7 (G&gt;C; minor allele frequency (MAF) = 0.11) (per variant allele OR = 0.50; 95% CI: 0.29 to 0.88; p for trend = 0.01) and with rs1049296 in TF (C&gt;T; MAF = 0.17) (recessive model OR = 3.03; 95% CI: 1.11 to 8.27; p = 0.03). Among oligodendrogliomas/MOAs, risk associations were observed for rs4820268 in TMPRSS6 (A&gt;G; MAF = 0.43) (recessive model OR = 1.91; 95% CI: 1.14 to 3.22; p = 0.01) and rs12216125 in TRIM38 (C&gt;T; MAF = 0.35) (dominant model OR = 1.67; 95% CI: 1.03 to 2.72; p = 0.04). No SNPs were associated with the risk of GBM. One SNP, rs972275 in RSPO3 (G&gt;C; MAF = 0.38), was associated with shorter patient survival (dominant model HR = 1.40; 95% CI: 1.06, 1.87; p=0.02). Increasing levels of toenail iron was associated with a non-significant decrease in glioma risk (OR = 0.88; 95% CI: 0.77 to 1.02; p = 0.08). Iron levels were not associated with survival. To our knowledge this is the first report suggesting that genetically determined variation in iron status may affect glioma risk and patient outcome. Further studies are needed to confirm these results.

Citation Format: Gabriella M. Anic, Reid C. Thompson, L. Burton Nabors, Jeffrey J. Olson, Melissa H. Madden, James E. Browning, John D. Brockman, Peter A. Forsyth, Kathleen M. Egan. Toenail iron, genetic variation in iron status, and the risk and outcome of glioma . [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 104. doi:10.1158/1538-7445.AM2013-104

SWI/SNF gene variants and glioma risk and outcome

BACKGROUND

The human SWItch/Sucrose Non-Fermentable (SWI/SNF) chromatin remodeling complex plays essential roles in a variety of cellular processes and has been implicated in human cancer. However, the role of germline genetic variants in this complex in relation to cancer risk is not well studied.

METHODS

We assessed the association of 16 variants in the catalytic subunits (SMARCA2 and SMARCA4) of the SWI/SNF complex with the risk of glioma subtypes (lower grade astrocytoma, oligodendroglioma and glioblastoma [GBM]) and with mortality from high-grade tumors (GBM) in a multicenter US case-control study that included 561 cases and 574 controls. Associations were estimated with odds ratios (OR, for risk) or hazards ratios (HR, for mortality) with 95% confidence intervals (CI). False discovery rate (FDR-q) was used to control for multiple testing in risk associations.

RESULTS

None of the investigated SNPs was associated with overall glioma risk. However, analyses according to histological subtypes revealed a statistically significant increased risk of oligodendroglioma in association with SMARCA2 rs2296212 (OR = 4.05, 95% CI = 1.11-14.80, P = 0.030, q = 0.08) and rs4741651 (OR = 4.68, 95% CI = 1.43-15.30, P = 0.011, q = 0.08) and SMARCA4 rs11672232 (OR = 1.90, 95% CI = 1.01-3.58, P = 0.048, q = 0.08) and rs12232780 (OR = 2.14, 95% CI = 1.06-4.33, P = 0.035, q = 0.08). No significant risk associations were observed for GBM or lower grade astrocytoma. Suggestive associations with GBM mortality were not validated in the Cancer Genome Atlas.

CONCLUSION

Our findings suggest that genetic variants in SMARCA2 and SMARCA4 influence the risk of oligodendroglioma. Further research is warranted on the SWI/SNF complex genes and epigenetic mechanisms more generally in the development of glioma in adults.

An exploratory analysis of common genetic variants in the vitamin D pathway including genome-wide associated variants in relation to glioma risk and outcome

PURPOSE

Experimental and epidemiological evidence shows a beneficial role of vitamin D in cancer. In vitro evidence is consistent with a similar protective function in glioma; however, no study has yet examined the potential role of vitamin D in glioma.

METHODS

We evaluated the association between common genetic variants in the vitamin D pathway and glioma risk and patient outcome in 622 newly diagnosed glioma cases and 628 healthy controls enrolled in a clinic-based case-control study. Subjects were genotyped for 7 candidate and tagging single nucleotide polymorphisms in the vitamin D receptor and 8 additional variants in NADSYN1, GC, CYP24A1, CYP2R1, and C10ORF88 linked in genome-wide association studies to serum concentrations of vitamin D. Unconditional logistic regression was used to estimate age- and gender-adjusted odds ratios and 95 % confidence intervals for glioma risk according to vitamin D genotypes. Proportional hazards regression was used to estimate hazard ratios for glioma-related death among 320 patients diagnosed with high-grade tumors. P values were uncorrected for multiple comparisons.

RESULTS

Risk of astrocytic tumors was associated with variant alleles in rs3829251 (NADSYN1), rs10741657 (CYP2R1), rs2228570 (Fok1, VDR), and rs731236 (Taq1, VDR). No risk associations were found among oligodendroglial tumors. Survival associations were observed according to variant status for rs1544410 (Bsm1, VDR) and rs6013897 (CYP24A1).

CONCLUSION

This exploratory analysis provides limited evidence of a role for genetic variation in vitamin D pathway genes with glioma risk and survival.

Rare TP53 genetic variant associated with glioma risk and outcome

Validation of a recent finding linking a rare variant in TP53 to the risk of glioma, the most common primary brain tumour, is reported here. This study genotyped the single nucleotide polymorphism (SNP) rs78378222 in 566 glioma cases and 603 controls. The variant 'C' allele (with an allelic frequency of 1.1% in controls) was associated with a 3.5-fold excess in glioma risk (odds ratio 3.54; p=0.0001). Variant carriers had significantly improved survival (hazard ratio 0.52; p=0.009) when compared to non-carriers. The rs78378222 SNP is the first confirmed rare susceptibility variant in glioma. Results may shed light on the aetiology and progression of these tumours.

SSBP2 variants are associated with survival in glioblastoma patients

PURPOSE

Glioblastoma is a devastating, incurable disease with few known prognostic factors. Here, we present the first genome-wide survival and validation study for glioblastoma.

EXPERIMENTAL DESIGN

Cox regressions for survival with 314,635 inherited autosomal single-nucleotide polymorphisms (SNP) among 315 San Francisco Adult Glioma Study patients for discovery and three independent validation data sets [87 Mayo Clinic, 232 glioma patients recruited from several medical centers in Southeastern United States (GliomaSE), and 115 The Cancer Genome Atlas patients] were used to identify SNPs associated with overall survival for Caucasian glioblastoma patients treated with the current standard of care, resection, radiation, and temozolomide (total n = 749). Tumor expression of the gene that contained the identified prognostic SNP was examined in three separate data sets (total n = 619). Genotype imputation was used to estimate hazard ratios (HR) for SNPs that had not been directly genotyped.

RESULTS

From the discovery and validation analyses, we identified a variant in single-stranded DNA-binding protein 2 (SSBP2) on 5q14.1 associated with overall survival in combined analyses (HR, 1.64; P = 1.3 × 10(-6)). Expression of SSBP2 in tumors from three independent data sets also was significantly related to patient survival (P = 5.3 × 10(-4)). Using genotype imputation, the SSBP2 SNP rs17296479 had the strongest statistically significant genome-wide association with poorer overall patient survival (HR, 1.79; 95% CI, 1.45-2.22; P = 1.0 × 10(-7)).

CONCLUSION

The minor allele of SSBP2 SNP rs17296479 and the increased tumor expression of SSBP2 were statistically significantly associated with poorer overall survival among glioblastoma patients. With further confirmation, previously unrecognized inherited variations influencing survival may warrant inclusion in clinical trials to improve randomization. Unaccounted for genetic influence on survival could produce unwanted bias in such studies.

Abstract 644: Premorbid body weight and survival in high grade glioma

Introduction: Greater adiposity has been linked to an increased risk and/or poorer survival in a variety of cancers. However, the relationship of body fat mass to glioma outcome is not well studied. In the present analysis, we examined whether premorbid body weight determined 1 to 5 years prior to diagnosis is associated with glioma patient survival. Methods: The analysis was based on 619 patients with high grade glioma (84% glioblastoma multiforme (GBM) and16% anaplastic astrocytoma (AA)) enrolled in a US-based multicenter case-control study between December 2004 and March 2011. In a structured interview, subjects provided information on height at age 21, weight at age 21 and weight 5 years prior to the study interview (1 year during the pilot study phase; N=95). Subjects were interviewed a median of 1.2 months following glioma diagnosis (interquartile range: 3 weeks to 2.5 months). A total of 408 deaths occurred, all glioma-related, 2 months to 4.8 years following diagnosis (median: 9.4 months). Proportional hazards regression was used to estimate Hazard Ratios (HR) and 95% Confidence Intervals (CIs) for glioma-related death according to categories of body mass index (BMI) (kg/m2) defining obesity (BMI &gt;=30; N=178), overweight (BMI 25-29.9; N=254), normal weight (BMI 18.5-24.9; N=179) and underweight (BMI &lt;18.5; N=8). All results were adjusted for age, gender and glioma subtype (GBM versus AA). Results: Patients with a premorbid BMI of 30 or greater had an elevated rate of glioma-related death when compared to patients with a normal BMI (HR=1.39; 95% CI: 1.07-1.82) whereas no significant excess mortality was observed in patients defined as overweight (HR=1.15; 95% CI: 0.89-1.49). Patients underweight 1-5 years prior to diagnosis had significantly poorer outcomes when compared to patients of normal weight (HR=2.43; 95% CI: 1.06-5.57), and weight loss of 10 pounds or greater between age 21 and 1-5 years prior to diagnosis (N=27) was significantly associated with a worse outcome (HR=1.92; 95% CI: 1.18-3.13) when compared to stable weight (within 10 pounds). All results were consistent in men and women, and were unchanged in analysis restricted to patients treated with the current standard of care including surgery, radiation and temozolomide (not shown). Conclusions: In this large well-characterized patient series, premorbid obesity was significantly associated with poorer survival following glioma diagnosis. Low body weight was also associated with a poorer outcome possibly reflecting effects of preclinical disease-associated changes on body weight. Findings for obesity support the hypothesis that elevated pre-diagnostic body weight is detrimental to glioma survival and suggest a role for insulin resistance, aberrant IGF signaling, and/or low-level chronic inflammation in the progression of high grade tumors.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 644. doi:1538-7445.AM2012-644

Abstract 877: Genetic variation in podoplanin in relation to glioma risk and outcome

Gliomas are highly invasive tumors that invariably disseminate throughout the brain. The mechanisms of glioma cell migration are still poorly understood. Human PDPN (eg. podoplanin) is a novel transmembrane glycoprotein and a lymphatic endothelial marker thought to play a role in wound healing and frequently upregulated in human neoplasia. Although its physiologic function is still unknown, the recent observation of restricted expression at the leading invasive edge of solid tumors in experimental systems has raised the possibility that PDPN plays a role in tumor cell migration and invasion. Microarray-based gene expression analysis has recently identified PDPN as a novel candidate gene in glioma pathogenesis (Clin Cancer Res. 2009 15:6541-50). In this study, we examined whether polymorphisms in the gene encoding PDPN (located at 1p36.21) are associated with glioma risk and outcome in a clinic-based case-control study encompassing 563 newly diagnosed (eg. nonrecurrent) glioma cases (including 324 WHO grade IV glioblastomas (GBM); 145 WHO grade II or III astrocytomas and 94 oligoastrocytomas and oligodendrogliomas) and 629 healthy controls with no history of brain cancer. DNA was isolated from saliva samples. A total of 22 candidate and haplotype tagging SNPs in PDPN including the 5’ and 3’ UTR region of PDPN were genotyped using the Illumina Goldengate assay. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for glioma risk in relation to individual SNPs adjusting for age and gender. Proportional hazards regression was used to estimate age- and gender-adjusted hazard ratios (HR) for GBM-related death (203 deaths; median follow up: 11.2 months) according to PDPN genotypes. No consistent associations were observed for any examined PDPN variant with glioma risk, overall, or according to glioma histological subtype. In contrast, 3 intronic SNPs (rs92406, rs2487643 and rs4391657) in moderately high linkage disequilibrium (r2: 0.57-0.96) residing in a haplotype block spanning 8kb were significantly associated with GBM mortality with the strongest signal observed in rs4391657 (NT_004610.19:g.617369T&gt;C) (per variant “T” allele HR: 1.62; 95% CI: 1.28-2.05; P=0.00006; allele frequency: 0.20). The magnitude of association was similar for deaths occurring within 12 months (per variant allele HR: 1.51; 95% CI: 1.13-2.02; P=0.005) and greater than 12 months (per variant allele HR: 1.84; 95% CI: 1.21-2.80; P=0.004) following GBM diagnosis. The median survival times were 14.4, 11.4 and 8.9 months in those carrying 0, 1, or 2 at-risk “T” alleles in PDPN rs4391657 (log rank P value 0.0018), irrespective of therapy. To our knowledge this is the first report of an association of a PDPN genetic variant predicting survival times in malignancy. Further studies are needed to confirm this observation and to identify the putative causal variant.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 877. doi:10.1158/1538-7445.AM2011-877

Abstract 876: Genetic variation in the voltage-gated chloride channel family members CLCN2 and CLCN3 in relation to glioma risk and outcome

Gliomas account for the majority of primary brain neoplasias and are among the most lethal human tumors. Tumor cells diffusely infiltrate surrounding brain tissue. The invasion of glioma cells into normal brain is thought to be facilitated by ion channels which dynamically regulate cell volume and the ability of tumor cells to shrink and invade through tortuous extracellular spaces in the brain. To shrink, glioma cells release K+ and Cl- through ion channels, which induce water to leave the cells through aquaporins. Recent evidence suggests that CL- transport in glioma cells is mediated primarily by the voltage-gated chloride channel family members, CLCN2 and CLCN3, making them attractive candidate genes in glioma pathogenesis. In the present study, we tested whether single nucleotide polymorphisms (SNPs) in CLCN2 (3q27) and CLCN3 (4q33) are associated with glioma risk or patient outcome in a clinic-based case-control study conducted at medical centers in the southeastern US. A total of 15 candidate and haplotype tagging SNPs (4 SNPs in CLCN2 and 11 SNPs in CLCN3) were genotyped using the Illumina Goldengate assay in 563 newly diagnosed (eg. nonrecurrent) glioma cases (including 324 WHO grade IV glioblastomas (GBM); 145 WHO grade II or III astrocytomas and 94 oligoastrocytomas and oligodendrogliomas) and 629 healthy controls. DNA was isolated from saliva samples. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for glioma risk in relation to individual genotypes adjusting for age and gender. Proportional hazards regression was used to estimate age and gender-adjusted hazard ratios (HR) for GBM-related death (203 deaths; median follow up: 11.2 months) for each SNP. No consistent associations were observed for any examined variant in CLCN2. In contrast, 6 of the examined SNPs in CLCN3, all in moderate linkage disequilibrium (r2: 0.30-0.80), were significantly associated with glioma risk. Among them, the strongest signal was observed in rs3797040 (NT_016354.19:g.95088578C&gt;T), a SNP located in a putative transcription binding site (per variant “T” allele OR: 1.25; 95% CI:1.05-1.47; p=0.0095; allele frequency: 0.49); the observed excess risk associated with the variant rs3797040 allele was consistent in GBM (per allele OR: 1.23; 95% CI: 1.01-1.51; p=0.042), astrocytomas (per allele OR: 1.15; 95% CI: 0.88-1.49; p=0.312) and oligodendrogliomas (per allele OR: 1.75; 95% CI: 1.23-2.44; p=0.001). The ancestral “C” allele in CLCN3 rs3797040 was associated with increased mortality rates among the patients with GBM (per allele HR: 1.31; 95% CI: 1.06-1.62; p=0.011). To our knowledge this is the first report suggesting that genetic variation in plasma membrane ion channels may be a determinant of glioma risk. Further studies are needed to confirm these observations and identify the putative causal variant.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 876. doi:10.1158/1538-7445.AM2011-876

Abstract 874: Genetic variation in the NOTCH stem cell signaling network in relation to risk of adult-onset glioma

The Notch signaling network is an evolutionarily conserved intercellular signaling pathway that plays a fundamental role during cell-fate specification in the developing mammalian nervous system. Mounting evidence suggest that this signaling network plays a critical oncogenic role in the development and progression of glioma. Stem-like cells in brain tumors require Notch for their survival and growth. Moreover, Notch-1 and its ligands, Delta-like-1 and Jagged-1 are overexpressed in both glioma cell lines and primary human gliomas. Down-regulation of Notch-1, Delta-like-1, or Jagged-1 by RNA interference induces apoptosis and inhibits proliferation in multiple glioma cell lines. Finally, pretreatment of glioma cells with Notch-1 or Delta-like-1 small interfering RNA significantly prolongs survival in experimental models of brain tumors. In the present study, we tested whether single nucleotide polymorphisms (SNPs) in the genes encoding Notch-1 (NOTCH1 at 9q34) and its ligands, Delta-like-1 (DLL1 at 6q27) and Jagged-1 (JAG1 at 20p12-p11) are associated with the risk of glioma onset in a clinic-based case-control study conducted at medical centers in the southeastern US. A total of 29 candidate and haplotype tagging SNPs (10 SNPs in NOTCH1; 2 in DLL1 and 17 in JAG1) were genotyped using the Illumina Goldengate assay in 563 newly diagnosed (eg. nonrecurrent) glioma cases (including 324 WHO grade IV glioblastomas (GBM); 145 WHO grade II or III astrocytomas and 94 oligoastrocytomas and oligodendrogliomas) and 629 healthy controls with no history of brain tumor. DNA was isolated from saliva samples. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for individual SNPs adjusting for age and gender. No consistent associations were observed for either examined variant in DLL1. An intronic SNP (rs3013300) in NOTCH1 located 9.2kb from the start codon was associated with an increased risk of astrocytomas (per variant “T” allele OR: 1.48; 95% CI: 1.12-1.96; p=0.006; MAF: 0.31), though not other glioma subtypes. Another intronic SNP in NOTCH1 (rs11574903) in weak linkage with the rs3013300 variant (r2: 0.10) was significantly associated with risk of oligodendrogliomas (per variant ‘T” allele OR: 1.68; 95% CI: 1.18-2.40; p=0.004; MAF: 0.22). This SNP is located 62bp downstream of a nonsynonymous SNP (rs115563691; V1671I) in NOTCH1. A SNP in the 3’UTR of the NOTCH1 ligand, JAG1 (rs8708), located in a putative micro-RNA binding site, was significantly associated with the risk of GBM (per variant “A” allele OR: 1.30; 95% CI: 1.06-1.59; p=0.010; MAF: 0.45). To our knowledge, this is the first study implicating genetic variants in the Notch stem cell signaling network with cancer risk. Further research is needed to confirm these findings and to elucidate putative causal variants in this pathway.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 874. doi:10.1158/1538-7445.AM2011-874

Abstract 875: Genetic variation in the natural killer cell activating receptor NKG2D and its ligands in relation to glioma risk and outcome

Natural killer (NK) cells play a key role in the immune response to certain infections and neoplasms. A major activating receptor of NK lymphocytes is NKG2D. In cancer, NKG2D ligands on transformed cells transmit danger signals to NKG2D-activated NK T cells culminating in cytolysis of malignant cells. A role for NK host defense in glioma is suggested by the expression of NKG2D ligands on glioma cells though not normal brain and correlation of NKG2D ligand expression with increasing WHO grade of malignancy. Genetic variation in NKG2D and its ligands has been associated with susceptibility to cancer and autoimmune diseases. We examined single nucleotide polymorphisms (SNPs) in genes affecting NK cell-mediated immune response for association with glioma risk and outcome in a case-control study encompassing 563 newly diagnosed glioma cases (including 324 WHO grade IV glioblastomas (GBM); 145 WHO grade II or III astrocytomas and 94 oligoastrocytomas and oligodendrogliomas) and 629 healthy controls with no history of brain cancer. DNA was isolated from saliva samples. A total of 24 candidate SNPs were genotyped using the Illumina Goldengate assay in critical genes linked to NK immunosurveillance including KLRK1 (encoding NKG2D), key NKG2D ligands (MICA, MICB and RAET1E), and genes linked to tumor immunoresistance (IDO1, IDO2). Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for glioma risk in relation to individual SNPs adjusting for age and gender. Proportional hazards regression was used to estimate age and gender-adjusted hazard ratios (HR) for GBM-related death (203 deaths; median follow up: 11.2 months) for each examined SNP. A haplotype associated with low NK activity in peripheral lymphocytes, identified by SNPs in the NK complex gene region on 12p13-p12 and marked by rs1049174 in the 3’UTR of KLRK1 (minor allele frequency (MAF) in controls: 26%), was associated with an increased glioma risk (per variant “C” allele OR: 1.22; 95% CI: 1.02-1.46; p=0.030); associations with this SNP were most prominent among oligodendroglioma patients (per allele OR: 1.69; 95% CI: 1.20-2.38; p=0.0027). A putatively functional nonsynonymous SNP in MICA (rs1051794; Lys196Glu; MAF: 27%) had a borderline association with risk for GBM (per variant “A” allele OR: 1.24; 95% CI: 1.00-1.53; p=0.048) though not other glioma subtypes; the variant rs1051794 allele was associated with increased GBM mortality (per allele HR: 1.31; 95% CI: 1.04-1.65; p=0.020). An intronic SNP in IDO2 (rs2543072) associated with risk of astrocytic tumors (per variant “T” allele OR: 1.65; 95% CI: 1.19-2.30; p=0.003; MAF: 21%) was also associated with GBM mortality (per allele HR: 1.28; 95% CI: 1.00-1.62; p=0.046). These results provide evidence that genetic variation in NK immunosurveillance influences glioma susceptibility and may contribute to GBM aggressiveness.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 875. doi:10.1158/1538-7445.AM2011-875

Cancer susceptibility variants and the risk of adult glioma in a US case-control study

Malignant gliomas are the most common and deadly brain tumors. Although their etiology remains elusive, recent studies have narrowed the search for genetic loci that influence risk. We examined variants implicated in recent cancer genome-wide association studies (GWAS) for associations with glioma risk in a US case-control study. Cases were identified from neurosurgical and neuro-oncology clinics at major academic centers in the Southeastern US. Controls were identified from the community or were friends or other associates of cases. We examined a total of 191 susceptibility variants in genes identified in published cancer GWAS including glioma. A total of 639 glioma cases and 649 controls, all Caucasian, were included in analysis. Cases were enrolled a median of 1 month following diagnosis. Among glioma GWAS-identified variants, we detected associations in CDKN2B, RTEL1, TERT and PHLDB1, whereas we did not find overall associations for CCDC26. Results showed clear heterogeneity according to histologic subtypes of glioma, with TERT and RTEL variants a feature of astrocytic tumors and glioblastoma (GBM), CCDC26 and PHLDB1 variants a feature of astrocytic and oligodendroglial tumors, and CDKN2B variants most prominent in GBM. No examined variant in other cancer GWAS was found to be related to risk after adjustment for multiple comparisons. These results suggest that GWAS-identified SNPs in glioma mark different molecular etiologies in glioma. Stratification by broad histological subgroups may shed light on molecular mechanisms and assist in the discovery of novel loci in future studies of genetic susceptibility variants in glioma.

A missense mutation encoding cys(67) --> gly in neurophysin ii is associated with early onset autosomal dominant neurohypophyseal diabetes insipidus

Autosomal dominant neurohypophyseal diabetes insipidus (ADNDI) is an inherited disorder in which progressive degeneration of magnocellular neurons of the hypothalamus impairs production of arginine vasopressin (AVP). ADNDI is caused by mutations in the arginine vasopressin-neurophysin II (AVP-NPII) gene. These mutations are hypothesized to trigger neurodegeneration via disruption of preproAVP-NPII processing. Affected individuals usually develop diabetes insipidus between 1 and 6 years of age. Here we report a novel mutation of the AVP-NPII gene in a family with unusually early presentation of ADNDI. The index case developed symptoms of diabetes insipidus at 1 month of age, her mother at 9 months of age, and the maternal grandfather in early childhood. Each was found to be heterozygous for the missense mutation 1665T > G encoding the amino acid substitution C67G within NPII. This mutation helps to define two homologous regions of the AVP-NPII precursor bounded by disulfide bridges between C13 and C27 and between C61 and C73 that have structural homology and contain the majority of amino acid substitutions associated with ADNDI. The early onset of symptomatic diabetes insipidus in this family suggests that the C67G substitution may be particularly deleterious to magnocellular neurons and may provide a valuable model for study of dominantly inherited neurodegeneration.

Peripartum cardiomyopathy presenting as lower extremity arterial thromboembolism. A case report

BACKGROUND

Although venous thromboembolism has been associated with peripartum cardiomyopathy, there have been no prior reports of lower extremity arterial thromboembolism complicating cardiac failure.

CASE

A 38-year-old woman, gradiva 5, para 5, presented on postpartum day 9 with left pedal parasthesia. Lower extremity angiography found acute thrombotic emboli in the left popliteal artery, right tibial artery and right peroneal artery. When respiratory decompensation ensued, a transthoracic echocardiogram revealed global hypokinesis and a left ventricular ejection fraction of 30%. The patient had an uneventful recovery after treatment with digoxin, furosemide and intravenous heparin.

CONCLUSION

Lower extremity arterial thromboembolism may be the initial manifestation of peripartum cardiomyopathy.

Bladder rupture associated with uterine rupture. A report of two cases occurring during vaginal birth after cesarean

BACKGROUND

Uterine rupture occurs in < 1% of patients undergoing a trial of labor after cesarean section. Associated injury to adjacent organs within the maternal pelvis has likewise been very rarely reported.

CASE

Two cases of posterior bladder wall rupture occurred in association with rupture of low transverse uterine incisions.

CONCLUSION

Bladder rupture may be associated with uterine rupture during attempted vaginal birth after cesarean. The potential for bladder injury should be included in the patient's antepartum counseling.

In vivo transfer of bacterial marker genes results in differing levels of gene expression and tumor progression in immunocompetent and immunodeficient mice

To optimize gene delivery for the treatment of malignant mesothelioma, expression of the beta-galactosidase marker gene was examined in a murine model of intraperitoneal malignant mesothelioma. The beta-galactosidase gene was delivered to the peritoneal cavity of tumor-bearing mice by various plasmid-liposome complexes or by replication-incompetent retrovirus, used alone or complexed to liposomes. In tumor samples from immunodeficient nude mice, moderate levels of gene expression were achieved by liposome-complexed plasmids. Retroviral gene delivery was more effective, and was increased nearly 10-fold by complexing the retrovirus to liposomes. In contrast, in tumor samples from immunocompetent CBA mice treated with the same vectors, no marker gene expression was detected. In immunodeficient mice, tumor growth was not affected by beta-galactosidase gene transfer. However, immunocompetent mice showed a significant decrease in tumor size and increase in survival time after beta-galactosidase delivery. Induction of cytotoxic T cells capable of lysing beta-Gal-transfected tumor cells suggests that tumor cells transduced with the bacterial beta-galactosidase gene may be eliminated in immunocompetent hosts. Our findings also indicate that plasmid-liposome complexes, which achieve a low level of gene expression, and retrovirus-liposome complexes, which result in nearly 100 times higher levels of gene expression in tumor cells in vivo, are similarly effective in inducing an antitumor immune response.

Genomic structure and chromosome location of the murine PDE1B phosphodiesterase gene

Cyclic nucleotide phosphodiesterases (PDEs) catalyze the hydrolysis of cAMP and cGMP, thereby participating in regulation of the intracellular concentrations of these second messengers. The PDE1 family is defined by regulation of activity by calcium and calmodulin. We have cloned and characterized the mouse PDE1B gene, which encodes the 63-kDa calcium/calmodulin-dependent PDE (CaM-PDE), an isozyme that is expressed in the CNS in the olfactory tract, dentate gyrus, and striatum and may participate in learning, memory, and regulation of phosphorylation of DARPP-32 in dopaminergic neurons. We screened an I-129/SvJ mouse genomic library and identified exons 2-13 of the PDE1B gene that span 8.4 kb of genomic DNA. Exons range from 67 to 205 nucleotides and introns from 91 to 2250 nucleotides in length. Exon 1 was not present in the 3 kb of genomic DNA 5' to exon 2 in our clones. The mouse PDE1B gene shares many similar or identical exon boundaries as well as considerable sequence identity with the rat PDE4B and PDE4D genes and the Drosophila dunce cAMP-specific PDE gene dnc, suggesting that these genes all arose from a common ancestor. Using fluorescence in situ hybridization, we localized the PDE1B gene to the distal tip of mouse Chromosome (Chr) 15.

The effects of jet nebulisation on cationic liposome-mediated gene transfer in vitro

Nebulisation is currently the most acceptable and practical delivery system for repeated applications of gene therapy to the lower airways of cystic fibrosis (CF) patients. We have assessed whether this route of administration offers other benefits with regard to respiratory gene transfer. A standard jet nebuliser (Acorn System 22, Medicaid) was used to transfer the reporter gene beta-galactosidase complexed with the cationic liposome DC-Chol/DOPE to three epithelial cell lines in vitro, two non-CF and one CF, using a novel collection system. In all three cell lines, nebulisation resulted in significantly (P < 0.05) improved transfection efficiency compared with instillation. At a constant DNA: liposome ratio of 1:5 (wt:wt), transfection efficiency was inversely related to increasing concentrations of DNA-liposomes before nebulisation. This effect was not related to the amount of DNA delivered and measurements of both zeta potential and mean aerodynamic particle size before and after nebulisation did not show concentration-related differences. The increased transfection efficiency did not relate either to the physical consequences of the nebulisation processes nor the effects of nebulisation on the complexes before instillation. Significantly increased transfection efficiency was seen following nebulisation with 95% O2/5% CO2 in comparison with 21% O2/78% N2 (air); this did not relate to changes in either the pH or temperature of the solution bathing the cells. The data confirm that nebulisation is appropriate for gene delivery to the lower airways in clinical practice and points to factors that may optimise gene transfer efficiency.

The effect of mucolytic agents on gene transfer across a CF sputum barrier in vitro

Trials of gene transfer for cystic fibrosis (CF) are currently underway. However, direct application to the airways may be impeded by the presence of airway secretions. We have therefore assessed the effect of CF sputum on the expression of the reporter gene beta-galactosidase complexed with the cationic liposome DC-Chol/DOPE in a number of cell lines in vitro. Transfection was markedly inhibited in the presence of sputum; the effect was concentration dependent and was only partially ameliorated by removal of sputum with phosphate-buffered saline (PBS) washing before gene transfer. However, treatment of the sputum-covered cells with recombinant human DNase (rhDNase, 50 micrograms/ml) but not with N-acetylcysteine, Nacystelyn, lysine (all 20 mM) or recombinant alginase (0.5 U/ml) significantly (P < 0.005) improved gene transfer. Adenovirus-mediated gene transfer efficiency in the presence of sputum was similarly inhibited, and again, treatment with rhDNase before transfection significantly improved gene transfer (P < 0.005). Transfection of Cos 7 cells in the presence of exogenous genomic DNA alone demonstrated similar inhibition to that observed with sputum and was also ameliorated by pre-treatment of DNA-covered cells with rhDNase. In a separate series of experiments performed in the absence of added sputum or genomic DNA, increasing concentrations of rhDNase resulted in a concentration-related decline in transfection efficiency. However, even at the highest concentration (500 micrograms/ml of rhDNase), transfection efficiency remained more than 50% of control. Thus, pre-treatment of CF airways with rhDNase may be appropriate before liposome or adenovirus-mediated gene therapy.

A de novo mutation in the coding sequence for neurophysin-II (Pro24-->Leu) is associated with onset and transmission of autosomal dominant neurohypophyseal diabetes insipidus

The molecular basis of autosomal dominant neurohypophyseal diabetes insipidus, a hereditary deficiency of vasopressin, was determined by nucleotide sequence analysis of the arginine vasopressin-neurophysin-II gene. A C-->T mutation at nucleotide 1761 was detected in one allele of this gene in each affected individual in three generations of one family. This mutant gene encodes a normal arginine vasopressin peptide, but predicts a substitution of leucine for proline at amino acid 24 of neurophysin-II, the arginine vasopressin carrier protein. This mutation was not detected 50 control individuals, thus demonstrating that it is not a common silent genetic polymorphism. The disease arose in the second generation of the studied family, and the chromosome 20 carrying this new mutation was identified by polymorphic CA microsatellite haplotype analysis. The first affected individual inherited this chromosome segment from her mother, who had neither the disease nor this mutation in her somatic cell DNA. Third generation individuals who subsequently inherited this mutation were affected. These data demonstrate that this amino acid substitution in neurophysin-II causes the disease. Two possibilities to explain the mechanism by which clinical deficiency of arginine vasopressin develops even in the presence of one normal arginine vasopressin-neurophysin-II allele are discussed.

Mechanically induced pelvic pain and organic dysfunction in a patient without low back pain

Previous reports have identified mechanical disorders of the lumbar spine as a cause of pelvic pain and organic dysfunction (PPOD) in patients with low back pain. Less common however, are reports of mechanically induced pelvic pain and organic dysfunction in patients without accompanying low back pain. This report details the examination findings and treatment response of a patient with pelvic pain, organic dysfunction and clinical evidence of lower sacral nerve root compression (LSNRC) in whom low back pain was not an accompanying finding. Despite the absence of low back pain however, clinical evaluation revealed the characteristic findings of mechanically induced pelvic pain and organic dysfunction secondary to lower sacral nerve root irritation or compression as a result of a mechanical disorder of the low back. As in long standing cases of mechanically induced pelvic pain and organic dysfunction in which low back pain is present, this case also exhibited severe and widespread involvement of the pelvic organs. In spite of numerous failed attempts at treatment directed at the symptomatic component of the patients disorder, complete resolution of symptoms was achieved by manipulative treatment directed at the mechanical disorder of the lumbar spine.

The recognition of mechanically induced pelvic pain and organic dysfunction in the low back pain patient

Mechanical disorders of the lumbar spine have been identified as a cause of pelvic pain and organic dysfunction (PPOD). Categorically, the clinical features indicative of mechanically induced PPOD fall into three areas: the history of the development or onset of pelvic symptomatology attributable to lower sacral nerve root compression (LSNRC), identification of related symptomatology on presentation, and the recognition of clinical findings indicative of mechanically induced PPOD on examination. Characteristic features of each category are presented. The clinical signs that most reliably indicate the presence of PPOD secondary to a mechanical lesion of the low back are of a sensory nature, and the disappearance or lack of improvement of these signs closely parallels the patient's overall response to manipulative treatment. Without a thorough understanding of the salient features of mechanically induced PPOD, the practitioner is likely to overlook this as a diagnostic possibility. As a result, efforts to document chiropractic spinal manipulative therapy in relieving disorders of pelvic organic function may be hampered. The empirical efficacy of chiropractic spinal manipulative therapy for treating disorders of pelvic organic function would be enhanced if more chiropractors were apprised of the salient features indicating the presence of mechanically induced PPOD.

Chiropractic distractive decompression in treating pelvic pain and multiple system pelvic organic dysfunction

No data are available on the incidence of pelvic pain and organic dysfunction (PPOD) in patients suffering from low back pain. PPOD is not an uncommon finding in the low back pain patient. Women appear to be more frequently involved than men. The results of recent electrophysiologic investigations indicate that many patients with urological, bowel or anorectal dysfunction demonstrate evidence of denervation neuropathy in muscles innervated by the branches of the pudendal nerve. Six patients with low back pain meeting predetermined criteria, indicating the presence of PPOD as a result of suspected lower sacral nerve root compression (LSNRC) secondary to a mechanical disorder of the low back were treated with chiropractic distractive decompressive manipulation of the lumbar spine. Symptoms of PPOD, and indicators of LSNRC were assessed prior to the onset, and following the termination of treatment. It appears that selected indicators of LSNRC represent the most sensitive clinical signs of identifying the presence of PPOD which may respond to manipulative treatment, and may also provide the most sensitive measure of overall PPOD response. These findings, although preliminary suggest a possible etiology of PPOD in the low back pain patient with evidence of LSNRC. Further work in this area is encouraged.

Chiropractic distractive decompression in the treatment of pelvic pain and organic dysfunction in patients with evidence of lower sacral nerve root compression

Chiropractic theory postulates that organic dysfunction could be the result of neurological disorganization secondary to mechanical disorders of the spine. Few studies have documented the efficacy of chiropractic manipulative therapy in treating mechanically induced organic dysfunction. Lower sacral nerve root compression (LSNRC) as the result of lumbar disc lesion has been identified as a cause of pelvic pain and organic dysfunction (PPOD). Ten cases of PPOD with accompanying evidence of LSNRC in patients with low back pain as a result of a clinically established lumbar disc lesion are presented with symptomatology prior to and following treatment with distractive decompressive manipulation. A report of one of the cases is detailed. LSNRC is often overlooked as a cause of PPOD. Recognition of associated symptomatology in patients with evidence of LSNRC and confirmation through pain provocation examination is emphasized. Chiropractic distractive decompression may be effective in treating PPOD in patients with evidence of LSNRC as a result of a clinically established lumbar disc lesion.

Pelvic pain and organic dysfunction in a patient with low back pain: response to distractive manipulation: a case presentation

Many patients with low back pain demonstrate pelvic symptomatology attributable to lower sacral nerve root compression. Lower sacral nerve root compression has been identified as a cause of pelvic pain and pelvic organ dysfunction. Pelvic symptomatology secondary to lower sacral nerve root compression is given. Lower sacral nerve root compression is most commonly the result of lumbosacral disc lesion. A case of low back pain accompanied with pelvic symptomatology is presented along with its response to distractive manipulation. chiropractic treatment may be an effective means of treating pelvic disorders secondary to lower sacral nerve root compression provided that the underlying disc lesion is dealt with, although further study is needed.