Mexiletine effectively prevented refractory Torsades de Pointes and ventricular fibrillation in a patient with congenital type 2 long QT syndrome

We report a 28-year-old female patient with congenital type 2 long QT syndrome (LQTS) in which mexiletine shortened QTc and effectively prevented refractory Torsade de Pointes (TdP) and ventricular fibrillation (VF). She developed TdP and VF, and was subsequently diagnosed as congenital type 2 LQTS type 2. She had refractory TdP and VF every day despite medical therapy including β-blocker. They were completely suppressed after the initiation of mexiletine with shorting of QTc interval. This article is protected by copyright. All rights reserved.

Abstract P3-08-08: SOX11 is a potential prognostic marker of high-risk breast ductal carcinoma in situ

Ductal carcinoma in situ (DCIS) comprises 20-25% of screen-detected breast cancers and, like invasive ductal carcinoma (IDC), is heterogenous in terms of the underlying biology, presentation, and outcome. While there are limited potential biomarkers of outcome for DCIS, estrogen receptor (ER)- positive, progesterone receptor (PR)- positive, and HER2- negative DCIS appears to have a better prognosis compared to ER- negative, PR- negative, and HER2- positive DCIS. The aim of this study was to identify additional clinically relevant markers to stratify DCIS according to risk of relapse or progression to invasive disease. In order to determine the driver genes involved in DCIS evolution, we utilized transcriptional data sets (GSE788, GSE16873), containing data from both normal mammary glands (NMG) and DCIS. Upon performing class comparison (NMG vs DCIS), we identified 297 over-expressed genes and 187 under-expressed genes. The over-expressed genes represented mitotic and proliferative features annotated as mitotic spindle and condensed chromosomes, while the under-expressed genes were associated with loss of epithelial features annotated as epithelial cell differentiation and development. The 484 differentially expressed genes were further correlated with recurrence events using Kessler's breast cancer data set to identify genes contributing to the aggressive features across IDC and subsequently associated with DCIS. Genes correlating with recurrence events were selected. Of the 484 genes, 99 genes were found to be significantly associated with recurrence events of IDC (with P<0.003). Among these 99 genes, component genes of the Oncotype DCIS score and genes reported as relevant to DCIS biology were included for Nanostring transcriptomic analysis. The final number of genes-of-interest were 58, including 5 housekeeping genes. 40 DCIS lesions and 8 NMG tissue were macro- dissected from formalin- fix paraffin- embedded blocks (FFPE) and extracted transcripts were subjected for Nanostring analysis. Gene expression data was clustered in an unsupervised manner using R software. Two sample clusters were identified: an ER/PR- negative cluster and an ER/PR- positive cluster. Over-expression of transcription factor SOX11, along with HER2, was exclusively seen in the ER/PR- negative cluster. This cluster was further categorized into HER2-low/SOX11+ and HER2-high/SOX11+ groups. These RNA expression findings are undergoing confirmation by immunohistochemistry (IHC) of the FFPE tumor sections. An independent series of 15 DCIS cases that have recurred as DCIS or progressed to IDC were analyzed by IHC, revealing SOX11 expression only present in cases displaying a high proportion of HER2+ expression. SOX11 is exclusively expressed in ER/PR-negative DCIS and is a candidate clinical marker for recurrence of DCIS or progression to IDC.

Citation Format: Ladha FA, Kai K, Lu W, Yang F, Tang X, Wistuba II, Sen S, Thompson A. SOX11 is a potential prognostic marker of high-risk breast ductal carcinoma in situ [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-08-08.

Abstract P1-05-05: eEF1A2 facilitates PTEN-GSK3β mediated Aurora-A protein degradation during S-G2 phase inactivated in PTEN-deficient breast cancer

The AURKA gene, encoding Aurora kinase-A (Aurora-A), is frequently amplified and overexpressed across multiple cancer types correlating with poor prognosis. Although the AURKA gene is frequently amplified in human cancers, underlying mechanism(s) for Aurora-A protein stability through different phases of cell cycle are not well elucidated. Inhibiting the kinase activity and promoting protein degradation are two well-validated conceptual strategies for targeting protein kinases in cancers. Here, we demonstrate that Eukaryotic Elongation Factor 1 Alpha 2 (eEF1A2) facilitates PTEN-GSK3β mediated Aurora-A protein degradation through the SCF complex (SKP1-Cul1-FBXW7) during the S/G2 phase of proliferating cells. In contrast, this mechanism is inactivated in cancer cells accompanying PTEN-GSK3β pathway deficiency. Mechanistically, eEF1A2 interacts with Aurora-A, GSK3β, FBXW7 and Cul1-E3 ligase, as the SCF complex, to facilitate Aurora-A polyubiquitination for 26S proteasomal degradation. eEF1A2 promotes PTEN phosphorylation at T366 and stability, inactivates AKT and activates GSK3β which in turn phosphorylates Aurora-A at S283, S284 and S342. The phosphorylation of Aurora-A at S342 is detected during S/G2 phase of cell mitosis in parallel with eEF1A2-SCF complex formation with active form of GSK3β and neddylated Cul1. Conversely, genetic ablation of EEF1A2 and PTEN, activation of AKT, inhibition of GSK3β, expression of Aurora-A phosphodeficient-mutant attenuates the Aurora-A protein degradation which is corroborated in Aurora-A overexpressing mouse mammary carcinomas and human breast carcinomas. This study identifies a novel mechanism of Aurora-A protein degradation mediated eEF1A2-PTEN-GSK3β pathway and provides a framework for the discovery of Aurora-A therapeutic targets in breast cancer that harbors deficiency of PTEN tumor suppressor pathway.

Citation Format: Treekitkarnmongkol W, Solis LM, Kai K, Thompson AM, Tian W, Wistuba II, Sasai K, Jltsumori Y, Sahin AA, Hawke DH, Lee JM, Qin L, Bawa-Khalfe T, Rad R, Wong KK, Abbott CM, Katayama H, Sen S. eEF1A2 facilitates PTEN-GSK3β mediated Aurora-A protein degradation during S-G2 phase inactivated in PTEN-deficient breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-05-05.

Abstract P4-14-02: CSF1/CSF1R axis reprograms epithelial-to-mesenchymal phenotypes in inflammatory breast cancer

Inflammatory breast cancer (IBC) accounts for 2% of breast cancers but 10% of breast cancer-related deaths in the US. Clinical hallmarks of IBC are tumor cell emboli in lymphatic vessels and overexpression of E-cadherin, which promotes cell clustering. Given these hallmarks, IBC is thought to spread via collective invasion and cell clusters. However, we showed that IBC cells underwent epithelial-to-mesenchymal transition (EMT) and metastasized through EMT. Thus, there are two contradictory theories of IBC metastasis. The objectives of this study were 1) to propose a model that reconciles these two models, and 2) to identify target molecules for inhibition of IBC metastasis. Methods: We previously showed that Matrigel culture induced EMT-like changes in SUM149 IBC cells. To test if this transformation from epithelial (E) to mesenchymal (M) in Matrigel culture is unique to IBC cells, a panel of breast cancer cells was cultured in both monolayer and Matrigel-coated plates. The cells were IBC (SUM149, SUM190, KPL4, IBC3), triple-negative breast cancer (TNBC) (MDA-MB-231, MDA-MB-468), and ER+ (MCF7) cells. Phenotypic changes in morphology and expression of EMT markers (E-cadherin, vimentin) were captured with bright field and immunofluorescent (IF) images, respectively. For genome-wide and targeted transcriptional analysis, SUM149 cells cultured in monolayer and Matrigel were processed using DNA microarrays and Taqman qRT-PCR. To correlate the Matrigel gene signature with M features in human breast cancer, a human breast cancer data set was hierarchically clustered with the Matrigel gene signature. Results: SUM149 cells showed a remarkable phenotypic change from E in monolayer culture to M in Matrigel. IF analysis confirmed induction of vimentin expression in Matrigel but stable expression of E-cadherin (thus, we refer to this state as E/M hybrid). This trend was also observed with SUM190 cells. Using qRT-PCR, we confirmed downregulation of E-cadherin and upregulation of M markers (vimentin, Twist1, Snail1, ZEB2) in Matrigel-cultured SUM149 and SUM190 cells compared to monolayer-cultured cells. DNA microarray transcriptional analysis confirmed this trend in SUM149 cells. TNBC has more M-like features than other breast cancer subtypes. Given this evidence, we clustered human breast cancer data using overexpressed genes in Matrigel-cultured SUM149 cells. We identified a cluster of 20 genes in TNBC samples and, assuming that these genes are drivers of E to E/M transition, chose the inflammation-related gene CSF1 as a candidate. The CSF1/CSF1R axis was inhibited by a CSF1R inhibitor, BLZ945; moreover, treatment with BLZ945 reversed the EMT changes in cells in Matrigel culture. Treatment with 5 μM BLZ945 re-induced E-cadherin expression and suppressed Snail1 and Twist1 expression in Matrigel-cultured SUM149 cells. Conclusion: IBC cells are more prone to undergo transition from E to E/M phenotype in Matrigel culture than are cells of other breast cancer subtypes. The CSF1/CSF1R axis plays a role in this E to E/M transition, thus warranting testing its significance using an in vivo IBC model. Phenotypic transition and reversion between E and E/M phenotypes could be a new paradigm that reconciles two contradictory models of IBC metastasis.

Citation Format: Kai K, Iwamoto T, Zhang D, Rao AUK, Thompson A, Sen S, Ueno NT. CSF1/CSF1R axis reprograms epithelial-to-mesenchymal phenotypes in inflammatory breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-14-02.

Comprehensive Evaluation of (+)-Usnic Acid–induced Cardiotoxicity in Rats by Sequential Cross-omics Analysis

Two-week administration of (+)-usnic acid (UA) induces mitochondrial swelling of cardiomyocytes, and toxicogenomic analysis of the heart revealed upregulation of oxidative stress, amino acid limitation, and endoplasmic reticulum stress–related genes in rats. To analyze the pathogenesis, UA was orally administrated to rats for 1, 4, 7, and 14 days, and sequential histopathological, genomic, and metabolomic analyses were performed on the heart, liver, and plasma. As a result, mitochondrial swelling of cardiomyocytes was observed on day 15 preceded by genomic upregulation on days 5 and 8. Of the focused gene groups, amino acid limitation–related genes represented by Mthfd2 showed numerically higher values or upregulation from day 5, which was sustained through the experimental period. On the contrary, oxidative stress–related genes were upregulated temporally on day 5. In metabolomic analysis, amino acids such as taurocholate and their metabolites fluctuated in concert with the upregulation of amino acid limitation–related genes in the heart, liver, and plasma. Moreover, accumulations of bile acids were manifested in all the tested tissues, while no histopathological change was seen in the liver. Increased bile acids might have an indirect effect on the myocardium; however, more detailed analysis is required. In conclusion, amino acid limitation was suggested as the pivotal toxic trigger of UA-induced cardiotoxicity.

Abstract P1-08-09: Aurora kinase-A protein stability is negatively regulated by eEF1α2 and PTEN in breast cancer: Prognostic and therapeutic implications

Background: The AURKA gene encoding Aurora kinase-A (Aurora-A) protein is localized on chromosome 20q13 that is frequently amplified and overexpressed across multiple cancer types correlating with patient prognosis. Aurora-A plays a pivotal role in faithful segregation of chromosomes and normal progression of mitosis, peaking at G2/M followed by degradation at the end of mitosis by APC/C (Cdh1). However, regulation of Aurora-A protein stability in human cancer cells is not well elucidated. Here, we show that Aurora-A is targeted for ubiquitination and degradation by SCF complex involving eEF1α2 and PTEN in human breast cancer cells. Methods: Using a panel of breast cancer cell lines, as in vitro models, the eEF1α2 was knocked down or ectopically expressed to test the stability of Aurora-A protein. For in vivo models, tissue micro arrays of human breast cancer were immunostained for Aurora-A and eEF1α2 expression and categorized values were statistically tested by Chi-squared test. In addition, the public breast cancer dataset (Transbig) was used to predict breast cancer prognosis by Kaplan-Meier survival analysis. Results: In breast cancer cell lines and patient samples, an eEF1α2 non-expressing group showed a trend of higher Aurora-A expression than eEF1α2 expressing group, whose trend was significant in patient samples (P<0.05). Knocking down of eEF1α2 enhanced Aurora-A protein stability. In contrast, ectopic expression of eEF1α2 dramatically decreased Aurora-A protein stability. Inhibition of proteasome activity by MG132 could restore the Aurora-A protein in eEF1α2 expressing cells. Biochemical assays showed the direct binding between eEF1α2 and Aurora-A, and eEF1α2 dependent ubiquitination of Aurora-A. Inverse correlation of the expression levels of the two proteins was also observed throug the cell cycle, with eEF1α2 levels being high from G1 through G2 phases while Aurora-A expression peaked from G2/M phase through cytokinesis. Taken together, these findings highlight eEF1α2 as a novel negative regulator destabilizing Aurora-A through ubiquitin-proteasome proteolytic pathway. Further, mechanistic studies revealed that eEF1α2 enhanced the interaction of SCF E3 ubiquitin ligase complex protein; FBXW7 and Cul1, with Aurora-A. In line with this scenario, knocking down of Cul1 increased Aurora-A level. Since PTEN loss was reported to stabilize Aurora-A through inhibiting SCF complex, we tested the significance of PTEN loss in our model. Knocking down of PTEN further stabilized Aurora-A suggesting an independent role of PTEN from eEF1α2 in destabilizing Aurora-A. When eEF1α2 expressing cells were treated with AKT inhibitor, Aurora-A was destabilized with enhanced bindings between Aurora-A and FBXW7/Cul1. Lastly, low PTEN expression correlated with poor prognosis of Aurora-A over expressing breast cancer patients (P<0.01). Conclusions: Aurora-A overexpression in human breast cancer cells may be associated with loss of eEF1α2 and PTEN due to reduced interaction of SCF with Aurora-A. Findings indicate significant prognostic and therapeutic implications of altered expression of eEF1α2/PTEN/Aurora-A pathways among Aurora-A subset of breast cancer patients.

Citation Format: Treekitkarnmongkol W, Kai K, Katayama H, Tian W, Rodriguez-Canales J, Sahin AA, Sen S. Aurora kinase-A protein stability is negatively regulated by eEF1α2 and PTEN in breast cancer: Prognostic and therapeutic implications [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-08-09.

Changes in standing body sway of pregnant women after long-term bed rest

Pregnant women tend to fall and increased body postural instability, namely body sway, may be one of the causative factors. We had a clinical impression that pregnant women after long-term bed rest tend to fall. We hypothesised that such women may show increased body sway, which we attempted to determine. Pregnant women (n = 161) were divided into three groups: (i) women with preterm labour after 2-week bed rest, (ii) those after 4-week bed rest, and (iii) those without bed rest or preterm labour. Body sway was analysed using stabilometry, that is, computed analysis of movement of the centre of gravity. The 3 groups fundamentally showed the same stabilometric measurements. Women with oedema showed greater medial-lateral sway than those without it. Factors other than oedema yielded no differences in stabilometric parameters. Long-term bed rest fundamentally did not increase body sway to the extent that stabilometry could reveal it. It may be prudent to consider that pregnant women with oedema tend to fall.

Enhanced miR-210 expression promotes the pathogenesis of endometriosis through activation of signal transducer and activator of transcription 3

STUDY QUESTION

What are the roles of the microRNA miR-210-an miRNA that is up-regulated in endometriotic cyst stromal cells (ECSCs)-in the pathogenesis of endometriosis?

SUMMARY ANSWER

Up-regulated miR-210 expression in ECSCs is involved in their proliferation, resistance to apoptosis and angiogenesis through signal transducer and activator of transcription (STAT) 3.

WHAT IS KNOWN ALREADY

In the pathogenesis of endometriosis, a number of roles for microRNAs (miRNAs) are becoming apparent.

STUDY DESIGN, SIZE, DURATION

ECSCs and normal endometrial stromal cells (NESCs) were isolated from ovarian endometriotic tissues (patients aged 24-40 years undergoing salpingo-oophorectomy or evisceration for the treatment of ovarian endometriotic cysts, n = 10) and the eutopic endometrial tissues without endometriosis (premenopausal patients aged 35-45 years undergoing hysterectomies for subserousal leiomyoma, n = 13), respectively.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We used a global gene expression microarray technique to identify downstream targets of miR-210, and we assessed the functions of miR-210 in the pathogenesis of endometriosis by using the miR-210-transfected NESCs.

MAIN RESULTS AND THE ROLE OF CHANCE

Gene expression microarray analysis revealed that one of the key target molecules of miR-210 is STAT3. In the NESCs, in comparison to the control, miR-210 transfection resulted in the induction of cell proliferation (P < 0.0005), the production of vascular endothelial cell growth factor (VEGF) (P < 0.0005) and the inhibition of apoptosis (P < 0.05) through STAT3 activation [increased levels of mRNA (P < 0.0005), and protein (P < 0.005)]. In the ECSCs, inhibitors of STAT3 inhibited the cell proliferation and VEGF production (P < 0.05), and induced the apoptosis of these cells (P < 0.05).

LIMITATIONS, REASONS FOR CAUTION

The roles of aberrant miR-210 expression were investigated only in the stromal component of ectopic and eutopic endometrium. Control endometrial tissues were obtained from premenopausal patients who had subserosal leiomyoma and NESC gene expression patterns may be altered in these women. Furthermore, the effects of STAT3 inhibitors were evaluated only in ECSCs and not in NESCs.

WIDER IMPLICATIONS OF THE FINDINGS

The present findings indicate that miR-210 induces NESCs to differentiate into the endometriotic phenotype and we speculate that up-regulated miR-210 expression in ECSCs is involved in the creation of the endometriosis-specific cellular dysfunctions through epigenetic mechanisms. The data indicate that STAT3 inhibitors may be promising candidates for the treatment of endometriosis.

STUDY FUNDING/COMPETING INTERESTS

This work was supported in part by Grants-in-Aid for Scientific Research from the Japan Society for the Promotion of Science (no. 13237327 to K.N., no. 25861500 to Y.K. and no. 23592407 to H.N.). There are no conflicts of interest to declare.

Abstract P2-09-04: Development of novel combination therapy of IGF-1R/InsR and MEK inhibitors in triple-negative breast cancer (TNBC)

Recent studies found that TNBC had a highly activated profile in the insulin-like growth factor 1 receptor (IGF-1R)/insulin receptor (InsR) pathway. Patients in whom the IGF-1R/InsR pathway was activated had a worse prognosis than did those in whom the pathway was not activated. We also previously found that the tumor-initiating cells in mouse TNBCs had a highly activated IGF-1R pathway. On the basis of these findings, we tested an IGF-1R/InsR dual kinase inhibitor, KW-2450, in TNBC. Results: To investigate the antitumor effects of KW-2450 in TNBC, we first confirmed the high IGF-1R and low InsR expression in TNBC cell lines (e.g., SUM149, MDA-MB-231, MDA-MB-468). An in vitro growth inhibition assay revealed that KW-2450 inhibited cell growth (all IC50 &lt;0.5 μM), and an agar assay for colony formation confirmed this antitumor effect in TNBC cells. We also tested KW-2450's inhibitory effect against cancer stem cell (CSC) activity. With KW-2450 treatment of SUM149 and MDA-MB-231 cells, proportions of CSCs, profiled as CD44+CD24−, were significantly reduced in a dose-dependent manner. Indeed, KW-2450 dose-dependently inhibited mammosphere-forming, a hallmark of CSC activity. Cell cycle analysis revealed that KW-2450 induced mitotic accumulation and apoptosis in TNBC cells. Interestingly, MDA-MB-468 cells were the most susceptible to death, and their sensitivity to KW-2450 was associated with the high activation level of the mitotic checkpoint, the levels of which were determined by accumulation of cyclin B1 (on Western blot) and of phospho-histone H3–positive cells, a mitosis marker (on FACS). In contrast, SUM149 and MDA-MB-231 cells, which are relatively unsusceptible to death from KW-2450, exited from mitosis (as indicated by an accumulation of 8N; octaploidy) without significant cell death. This variable sensitivity to KW-2450 was also observed in in vivo studies. We confirmed that MDA-MB-468 tumors that were treated with 80 mg/kg of KW-2450 in vivo were stable and had many more mitotic cells than did those treated with vehicle control, which suggests that mitotic accumulation is a key process for this antitumor effect. Since it is known that any of the MAPKs (e.g., JNKs, p38 kinase, ERKs) become activated at the mitotic phase in mammalian cells, we next investigated whether the activation levels of MAPKs play critical roles in either mitotic progression or mitotic death in TNBC. Western blot analysis revealed that KW-2450 activated ERKs, but not JNKs or p38 kinase, in KW-2450–insensitive MDA-MB-231 and SUM149 cells, suggesting that ERK activation may promote mitotic progression but not mitotic death. Indeed, the combination of a MEK inhibitor (AZD6244), which inhibits ERK activation, and KW-2450 significantly reduced the 8N fraction and increased cell death in SUM149 and MDA-MB-231 cells. Conclusion: KW-2450 had significant antitumor effects in vitro and in vivo in TNBC cells. KW-2450–induced cell death, accompanied by mitotic accumulation, depended on mitotic checkpoint activity. TNBC cells refractory to KW-2450 were sensitized to KW-2450 by the addition of a MEK inhibitor. This novel combination therapy targeting IGF-1R/InsR and MEK in TNBCs, whose mitotic checkpoints are commonly abrogated, needs to be developed.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-09-04.

Ink4a/Arf(-/-) and HRAS(G12V) transform mouse mammary cells into triple-negative breast cancer containing tumorigenic CD49f(-) quiescent cells

Intratumoral heterogeneity within individual breast tumors is a well-known phenomenon that may contribute to drug resistance. This heterogeneity is dependent on several factors, such as types of oncogenic drivers and tumor precursor cells. The purpose of our study was to engineer a mouse mammary tumor model with intratumoral heterogeneity by using defined genetic perturbations. To achieve this, we used mice with knockout (−/−) of Ink4a/Arf, a tumor suppressor locus; these mice are known to be susceptible to non-mammary tumors such as fibrosarcoma. To induce mammary tumors, we retrovirally introduced an oncogene, HRAS(G12V), into Ink4a/Arf^−/− mammary cells in vitro, and those cells were inoculated into syngeneic mice mammary fat pads. We observed 100% tumorigenesis. The tumors formed were negative for estrogen receptor, progesterone receptor, and HER2. Further, they had pathological features similar to those of human triple-negative breast cancer (e.g. pushing borders, central necrosis). The tumors were found to be heterogeneous and included two subpopulations: CD49f⁻ quiescent cells and CD49f⁺ cells. Contrary to our expectation, CD49f⁻ quiescent cells had high tumor-initiating potential and CD49f⁺ cells had relatively low tumor-initiating potential. Gene expression analysis revealed that CD49f⁻ quiescent cells overexpressed epithelial-to-mesenchymal transition-driving genes, reminiscent of tumor-initiating cells and claudin-low breast cancer. Our animal model with intratumoral heterogeneity, derived from defined genetic perturbations, allows us to test novel molecular targeted drugs in a setting that mimics the intratumoral heterogeneity of human triple-negative breast cancer.

Abstract P2-04-01: Development of mouse breast cancer models based on induced cancer stem cells (iCSC)

Breast cancer is one of the leading causes of death in women worldwide. To develop novel therapeutic approaches for the refractory cases, the mouse models which recapitulate the tumor tissues biologically and pathologically similar to human breast cancer are required. Although xenograft models of established cell lines in immune-deficient mice are frequently used for preclinical experiments, such xenograft models are not sufficient because the heterogenous structure based on the microenvironment and the intrinsic characteristics of cancer cells is not correctly formed.

In this study, we have established induced cancer stem cells (iCSC) from normal mouse mammary stem/progenitor cells through minimal required genetic manipulations and generated mouse breast cancer models by inoculating the iCSCs in the mammary fat pads. Initially, we established iCSC by introducing the H-RasV12 into Ink4a/Arf-knockout mammary stem/progenitor cells and this iCSC formed tumor similar to human triple negative breast cancer in mouse. This finding suggested that two genetic events, an activation of oncogenic signal and a tumor suppressor inactivation, are required for generating the breast cancer iCSC.

Anaplastic Lymphoma Kinase (ALK) gene, which encodes a receptor tyrosine kinase, was reported to be amplified and/or overexpressed up to 86% of patients in inflammatory breast cancer, and pleiotrophin (PTN), which is a physiological ligand for ALK, was also shown to be highly expressed in about 60% of human breast cancers. Therefore, we hypothesized that ALK pathway is involved in tumorigenesis of breast cancers and, then, attempted to generate iCSC by using ALK gene. Interestingly, we found that one of the naturally occurring mutations of ALK is sufficient for generating iCSC and tumor formation in vivo without any prior tumor suppressor inactivation. The ALK-induced iCSCs developed highly aggressive breast cancers in mice. Furthermore, the tumor formation was significantly suppressed when the ALK-induced iCSCs were generated by using mammary stem/progenitor cells derived from mouse deficient in CD44 which is a CSC marker. We have recently revealed a role of CD44, in particular that of a variant isoform (CD44v), in the protection of CSCs from high levels of oxidative stress derived from both tumor cells and their microenvironment (Cancer Cell 19: 387–400, 2011; Cancer Res 72: 1438–1448, 2012; Nat Commun 3: 883, 2012). We will discuss the underlying mechanism of ALK-induced tumorigenesis and a role of CD44 in the CSC functions.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-04-01.

Abstract PD03-08: Statin use and improved outcome in primary inflammatory breast cancer: retrospective cohort study

Background Inflammatory breast cancer (IBC) is the most aggressive type of breast cancer. HMG-CoA reductase inhibitors (statins) are cholesterol reducing agents with pleiotropic effects, including antitumorigenic and anti-inflammatory properties. We hypothesized that statins reduce the metastatic potential in primary IBC.

Methods We retrospectively reviewed 724 patients diagnosed with and treated for primary IBC at The University of Texas MD Anderson Cancer Center between Jan. 12, 1995 and Jan. 27, 2011. Patients with records indicating statin use at the time of IBC diagnosis on the electronic medical record were compared with those without. We further compared outcomes stratified by statin type (hydrophilic [H] versus lipophilic [L]). We used the Kaplan-Meier method to estimate the median disease-free survival (DFS) after surgery, overall survival (OS), and disease specific survival (DSS), followed by Cox proportional hazards regression model to test statistical significance of several potential prognostic factors.

Results For primary IBC patients who had information on their statin use status at IBC diagnosis, the median DFS time were 4.88 years, 2.47 years and 1.76 years (P= 0.04); the median OS time 5.05 years, 3.79 years and 4.32 years (P= 0.35); and the median DSS time 5.10 years, 3.79 years and 4.52 years (P= 0.37), for patients who took “ H”, “L” and no statin, respectively. In multivariable Cox model stratified by radiation therapy, ER/PR status and HER2 status, statin “H” use was associated with significantly improved DFS compared to no statin use (HR=0.49; 95% CI: 0.28–0.84; p&lt;0.01), adjusted for lymphatic/vascular invasion. Although there is a trend that patients who used statin “H” had a longer time to death compared to patients who did not take statin, it did not reach statistical significance for OS (HR=0.80; 95% CI: 0.43–1.49; p=0.49) and DSS (HR=0.85; 95% CI: 0.46–1.57, p=0.59) after adjustment for lymphatic/vascular invasion, nuclear grade and surgery status within one year.

Conclusions Hydrophilic statin use was associated with improved DFS. There was a trend for reduced HR in OS and DSS among primary IBC patient who used hydrophilic statins. A prospective randomized study to evaluate the potential survival benefits of statins in primary IBC population is warranted.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD03-08.

Abstract P3-10-05: Response to neoadjuvant systemic therapy (NST) in inflammatory breast cancer (IBC) according to estrogen receptor (ER) and HER2 expression

Background: Inflammatory breast cancer (IBC) is the most aggressive form breast cancer. NST, followed by local therapy (surgery and radiation therapy), is considered the current standard therapy for IBC. Among noninflammatory breast cancers, sensitivity to NST differs based on ER and HER2 status. However, whether the sensitivity to NST also differs in primary IBC based on ER status or other prognostic factors has not been studied in a large cohort.

Methods: We retrospectively reviewed 1078 patients (pts) newly diagnosed with IBC from April 1989 to January 2011. Of these, 838 pts met our inclusion criterion of stage III disease at diagnosis, and 713 of these pts had received NST and surgery. Among this population, 545 pts had information available on both ER and HER2 status. We compared pathological complete response (pCR) rates (defined as no evidence of invasive disease in the breast and ipsilateral axillary limph nodes) and clinical characteristics between ER and HER2-status subgroups and analyzed their clinical outcome. We used the Kaplan-Meier method to estimate the median recurrence-free survival (RFS) after surgery and overall survival (OS), and the Cox proportional hazards regression model to test the statistical significance of potential prognostic factors in each group.

Results: Overall 177 pts had ER+HER2− tumors; 75, ER+HER2+; 134, ER-HER2+; and 159, ER-HER2−. NST consisted of anthracycline-based [A] alone, a taxane [T] alone or with A+T; HER2 targeting therapies (H) were administered to 117 patients with HER2-positive breast cancer after 1998. Overall pCR rate was 14.7%. pCR rates are shown by marker subtype and NST received in the table below. pCR rate, nuclear grade, vascular invasion, clinical response to NST, adjuvant treatment, radiation therapy, and adjuvant hormonal therapy differed significantly among subgroups.

The median RFS and OS for all patients was 19.2 and 33.2 months, respectively. In multivariate analysis, BMI, ER status, lymphatic invasion, radiation therapy, and pCR rate were associated with RFS, and ER status, vascular invasion, radiation therapy, and pCR rate were associated with OS. Except in the ER+HER2− group, pCR was associated with better prognosis compared to non-pCR. Adjuvant hormonal therapy improved RFS both in ER+HER2+ and ER+HER2− groups, but did not improve OS in the ER+HER2+ group. Among 209 patients with HER2+ IBC, 134 received HER2 targeting therapies in neoadjuvant or adjuvant chemotherapy, and had a trend to improvement in RFS compared to chemotherapy alone (p = 0.082). The ER-HER2− group showed poorest outcome compared to other subgroups (P &lt; 0.001).

Conclusions: Sensitivity to NST differs depending on the ER and HER2 status in IBC pts. pCR rates based on these subgroups appear to be low. There is a need more effective treatments in the neoadjuvant and adjuvant therapies for all subgroups of IBC.

Long-term impact of hypertension on renal allografts

OBJECTIVE

We assessed the impact of hypertension on renal transplant function and survival in the past decade after introduction of mycophenolate mofetil and rituximab.

METHODS

We examined the 184 patients who underwent renal transplantation from March 1982 to September 1999 and presented at our outpatient clinic from 2001 to 2011. They were divided into group 1 with mean systolic blood pressure (mSBP) >130 mm Hg and Group 2 with mSBP <130 mm Hg. We compared mean serum creatinine (sCr) levels for 9 years and 12-year actuarial graft survival rates. Risk factors for graft survival were assessed by Cox regression analysis.

RESULTS

There were 75 group 1 and 109 group 2 recipients. The mean sCr level of group 1 was 1.59 ± 0.12 mg/dL and that of group 2 1.54 ± 0.10 mg/dL (P < .0001). Of note was that mean sCr levels of group 1 started to increase about 3 years after transplantation. Although 5-year graft survival rates of both groups were 100%, 9- and 12-year rates among group 1 were 97.3% and 90.5%, respectively, whereas among group 2 they were 99.1% and 98.1%, respectively (P = .0195). Cox univariate and multivariate analyses showed mean SBP to be the only significant risk factor for graft survival (P < .05).

CONCLUSIONS

We concluded that the hypertensive group showed deteriorating renal function from around 3 years after transplantation that lowered graft survival afterward, resulting in a clear distinction from the nonhypertensive group at around 10 years after transplantation. Mean SBP was a significant risk factor for graft survival. Hypertension may be a surrogate for a poor renal graft prognosis in the long run.

Depression and pregnancy-associated death by suicide after spinal cord injury: a case report

PURPOSE OF INVESTIGATION

To report a case of a pregnant woman with traumatic spinal cord injury complicated with a psychiatric disorder.

CASE REPORT

A 24-year-old woman at 18 weeks of gestation was transferred to our hospital with a history of having jumped from a third-floor apartment patio.

RESULT

A trauma survey showed no life-threatening hemorrhage, and fetal wellbeing was confirmed. Neurological examination showed complete loss of motor and sensory function in her lower extremities. Termination of pregnancy was advised and was achieved medically. Surgical intervention was performed to achieve stabilization of the spine and decompression of neural elements. After the operation, she was referred to a psychiatrist, and the administration of paroxetine, etizolam and flunitrazepam was begun. Four months after undergoing the abortion, she choked herself to death on her ward bed.

CONCLUSION

Although it is rare, we should pay special attention to the substantial suicide risk of women who face severe spinal cord injury.

P4-03-04: Identification of Molecular Targets for Cancer-Initiating Cells Using a Triple-Negative Breast Cancer Mouse Model

Background

Triple-negative breast cancer (TNBC), which is negative for estrogen receptor, progesterone receptor, and HER2, cannot be targeted with hormonal or anti-HER2 agents and frequently relapses. Thus, innovative molecular targeted therapies for TNBC are needed. Cancer-initiating cells (CICs) play a crucial role in tumor recurrences. TNBC has a much higher proportion of CICs compared with the other breast cancer subtypes, reflecting TNBC's clinical aggressiveness. However, qualitative or molecular traits of TNBC CICs have not been fully elucidated. We established a TNBC mouse model that successfully recapitulated human-like TNBC in vivo (SABCS 2010 abstract P1-03-02). We here report the phenotypes and molecular features of CICs in our TNBC mouse model.

Methods: We created this animal model by transferring HRAS(G12V) into Ink4a/Arf-knockout (KO) mouse mammary epithelial cells (MECs) in vitro and inducing tumors in mammary fat pads of recipient mice. The induced TNBCs were digested, and single suspended cells were reacted with antibodies to candidate CIC markers CD29, CD24, CD44, Sca1, CD61, and CD49f. Expression patterns of the tumor cells were analyzed by FACS. Tumor cells were sorted according to their expression levels and inoculated into recipient mouse mammary fat pads to determine tumor-initiating activity. To analyze the cell-cycle status of tumor cells, we stained them with Hoechst 33342 (for DNA staining) and pyronin Y (for RNA staining) and analyzed them by FACS. The CICs’ genome-wide molecular profiles were determined by mouse microarray expression analysis.

Results: In FACS and the in vivo tumor-initiating assay, the CD49f expression level was the most significant for defining tumor-initiating activity. That is, CD49f− tumor cells had much higher tumor-initiating activity than did CD49f+ cells at 100-cell inoculations (CD49f−, 5 tumors/8 mice; CD49f+, 0/8). We hypothesized that tumor initiation by CD49f− cells depends on their quiescent profile, which is a trait of CICs. To test this hypothesis, we further fractionated CD49f− cells into CD49f− quiescent (CD49f−q) cells and CD49f− dividing cells and inoculated these fractions into recipient mice. CD49f−q cells had higher tumor-initiating activity than that of CD49f− dividing cells. We thus determined that CD49f−q cells were CICs in our model. Genome-wide expression patterns for CD49f−q cells and CD49f+ cells were compared by paired t test, and over- and underexpressed genes in CD49f−q cells were functionally annotated by Ingenuity pathway analysis. The top-ranked bioprocess of overexpressed genes in CD49f−q cells was hepatic satellite cell activation (HSCA), followed by pantothenale and Coenzyme A biosynthesis, and HER2 signaling in breast cancer. HSCA is known to result in liver fibrosis due to collagen deposits in response to liver damage. In CD49f−q cells in our model, collagen family proteins and the upstream endothelin-A receptor were overexpressed and significantly correlated with HSCA. Conclusion: We identified CICs in a mouse TNBC model and revealed their molecular profile. We plan to analyze expression of HSCA-associated proteins in human TNBC. Our first step is to determine whether endothelin-A receptor is a therapeutic target in human TNBC.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-03-04.

Twelve oxo-eicosatetraenoic acid induces fetal membrane release after delivery in cows

Fetal fibroblast cell culture from cotyledons of bovine placenta and animal experiments close to term were used to elucidate afterbirth release and factors missing in the signal transduction mechanism for retained fetal membranes (RFM) after delivery. In cell culture the addition of arachidonic acid (Ara) to the medium caused rapid release to free floating cell in the culture dish, accompanied by matrix metalloproteinase (MMP) activation, being consistent with previous in vivo observations, where a relation between MMP and fetal membrane release had been shown. Ara-induced cell floating was not inhibited by the addition of cyclooxygenase (COX) inhibitor, and not induced by the addition of PGF2α or PGE2 to replace Ara, while 12-lipoxygenase (12-LOX) metabolite of Ara, 12-oxo-eicosatetraenoic acid (12-oxoETE), strongly induced cell floating. In the animal experiments, 12-oxoETE injection to delivery-induced cows (n = 6) using prostaglandin (PG) and dexamethazone resulted in rapid release of fetal membranes. In cows with natural calf delivery, a 12-oxoETE peak (11.7-16.8 ng/ml) was observed in maternal blood plasma prior to release of fetal membranes. This investigation thus gives new indications for that the mediator for fetal membrane release is 12-oxoETE and not PG.

[Bronchial injury due to double-lumen endobronchial tube]

A 68-years-old and 148 cm tall female with lung cancer was operated on a left lower lobectomy via posterolateral thoracotomy. A 35 Fr double-lumen endobronchial tube was smoothly inserted and the tip was placed in the left main bronchus whose position was confirmed by fiberoptic bronchoscope. After lobectomy and lymph node dissection were completed, 1-lung ventilation was terminated, the left chest cavity was filled with saline, and an air-leak test was performed. Immediately after the initiation of bilateral lung ventilation, massive air-leak was observed in the left hilar region and the saline in the chest regurgitated into the airway, and she fell into critical ventilatory insufficiency. After sucking the saline in the chest, thorough observation revealed a 3 cm-long rupture of the membranous portion of the left main bronchus. The rupture was manually occluded and ventilatory insufficiency was avoided, then the tip of the endobronchial tube was re-inserted into the right main bronchus and right single lung ventilation was initiated. The rupture was closed by a 4-0 polydioxanone (PDS) running suture with no coverage. The patient was extubated immediately after the operation. Ten days later, she had a tiny bronchial fistula, and it was cured by chest drainage only, and she discharged home on the 48th postoperative day.

Abstract P1-03-02: Development of a Novel Animal Model of Human Triple-Negative Breast Cancer by Retroviral Oncogene Transduction of Mouse Mammary Stem Cells

Background: Triple-negative breast cancer (TNBC), which is negative for estrogen receptor (ER), progesterone receptor (PgR), and HER2 expression, represents approximately 20% of all newly diagnosed breast cancers. Patients with TNBC do not derive benefits from endocrine therapy and HER2-targeted therapy. Although TNBC is known to frequently involve mutations of the p53 gene, reduced expression of Rb, and activation of extracellular signal-regulated kinase (ERK), the molecular mechanisms of TNBC's etiology, and carcinogenesis animal models relevant to human TNBC, have not been established. In this study, we developed a mouse model of human TNBC.

Methods: To induce TNBC in a murine mammary gland, we used 2 critical genetic events, knockout (KO) of Ink4a/Arf and of the activating form of Hras (12V). Ink4a and Arf play tumor suppressive roles upstream of Rb and p53, respectively; thus, KO of this locus is equivalent to abrogation of the Rb and p53 pathways. Meanwhile, Hras is an oncogene upstream of ERK, Akt, and other kinases. Mammary glands from Ink4a/Arf-KO mice were cultured in serum-free floating culture as single cells, which massed together to form mammospheres. Such mammosphere cells have been shown to repopulate mammary duct-alveolar units in vivo and to differentiate to basal or luminal mammary epithelial cells in adherent culture supplemented with serum, indicating that they are mammary stem cells. To these cellular masses, retroviruses carrying Hras(12V) were infected in floating culture. Then, single-digested mammosphere cells, including the retrovirus-infected cells, were inoculated into mammary fat pads of syngeneic mice. Tumors were evaluated for pathological and immunophenotypical findings and for molecular signature by RT-PCR analysis.

Results: Induced tumors showed aggressive features, higher proliferation, dissemination to distant organs, invasiveness to adjacent lesions, and lethality. Pathologically, immature mammary ducts were identified as delineated by positive cells for keratin 14, a marker of basal cells. Immunophenotypically, all induced tumors were negative for ER, PgR, and HER2, although phosphorylation of ERK kinase was strongly and frequently positive. Together, these pathological findings and immune and biological phenotypes are quite similar to those of human TNBC. In addition, the tumors were negative for an epithelial marker, E-cadherin, although the mammospheres were actually derived from mammary epithelial cells. Meanwhile, induced-tumor cells expressed embryonic stem cell-like genes—Oct-3/4, Cripto, and Zfp42, but not Nanog—much more than did Ink4a/Arf-KO or wild-type mammary epithelial cells in RT-PCR analysis. Furthermore, in the induced tumors, we observed heterogeneous expression of CD49f, CD24, and CD44, which are candidate markers of mouse mammary cancer stem cells.

Conclusion: Induced tumors had the biological and molecular essence of human TNBC, epithelial-to-mesenchymal transition, dedifferentiation, and cancer stem cells. Therefore, our genetically induced mouse mammary tumor model can help reveal the etiology of this disease from the comprehensive standpoints of pathology, biology, cellular context, and molecular signature.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-03-02.

Primary mucinous adenocarcinoma of the vagina

PURPOSE

Primary mucinous adenocarcinoma of the vagina is a rare disease which is characterized by aggressiveness and poor prognosis because of its rapid growth and recurrence, its frequent distant metastases, and its relative resistance to conventional treatment modalities including surgery, radiotherapy, and chemotherapy. We report a case of advanced stage primary mucinous adenocarcinoma of the vagina that showed a highly aggressive course and resistance to combination chemotherapy with paclitaxel and carboplatin.

CASE

A 46-year-old multigravid Japanese woman was admitted to our hospital to be treated for Stage IVb primary mucinous adenocarcinoma of the vagina. She had no history of in utero exposure to diethylstilbestrol. She was treated by two courses of neoadjuvant chemotherapy with tri-weekly paclitaxel and carboplatin, which were not effective. Subsequently, total pelvic exenteration with pelvic lymphadenectomy was performed. However, the disease progressed rapidly and the patient died five months after the initial treatment.

CONCLUSION

Because of its rarity, little is known about the behavior of primary mucinous adenocarcinoma of the vagina. Additional data about patients with this rare tumor should be collected and analyzed in an attempt to elucidate its prognostic factors, characteristics, optimal treatment, and outcome.

Hand-assisted laparoscopic splenectomy in ABO-incompatible kidney transplant recipients

OBJECTIVE

We perform living-related ABO-incompatible kidney transplantations to alleviate the organ shortage in our country. Splenectomy has been performed routinely in these recipients, although its clinical significance remains controversial. In this study, we have reported our experience with a hand-assisted laparoscopic splenectomy (HALS) technique.

METHODS

Between April 2000 and December 2006, 50 patients (23 males) underwent ABO-incompatible kidney transplantation with HALS. The mean age and weight of the recipients were 44 +/- 13 years and 56 +/- 12 kg, respectively. All patients underwent preoperative plasmapheresis to reduce isoagglutinin (A and/or B antibody). In 6/50 patients, a hand-assisted device was placed through a peritoneal window in the right lower abdominal skin incision for kidney engraftment. In the remaining 44 patients, a 6-cm upper midline or periumbilical midline incision was made for the hand-assisted device in the lateral position.

RESULTS

An ABO-incompatible procedure was completed successfully in all cases. The average HALS time was 118 +/- 42 minutes, with an average pneumoperitoneum time of 79 +/- 40 minutes and average blood loss of 48 +/- 81 g. There were two conversions to open splenectomy because of intraoperative bleeding and suspected pneumothorax. Two other cases required relaparotomy because of hematoma and perforation of the ileum. Successfully operations were achieved through the previous periumbilical incision.

CONCLUSIONS

Although meticulous, rigorous surgical technique is essential, HALS is safe and feasible for recipients of ABO-incompatible grafts with tissue weakness and a bleeding tendency because of renal failure and preoperative plasmapheresis.

Potential advantage of studying preoperative sentinel node mapping with three-dimensional images by a hybrid single photon emission CT (SPECT)/CT system for breast cancer

601

Background: Lymph node status is one of the key factors in determining the stage, appropriate therapy and outcome in patients with breast cancer. Accurate identification of sentinel nodes (SNs) has clinical importance for each patients before surgery. The purpose of this study was to assess the role of Single-photon emission computed tomography (SPECT)/CT lymphoscintigraphy in SN identification for patients with breast cancer, and to analyze the impact of such information on estimating metastases to SNs. Methods: Two hundred and twenty-three clinically node-negative patients were underwent SN biopsy between July 2002 and November 2006. CT and SPECT images were obtained after injection of subcutaneal 1mCi (99m)Tc-nanocolloid, allowing identification of SN. Target and non-target structures, including lymph nodes identified by SPECT, were drawn by SPECT/CT combined system, which was comprised of a two-detector SPECT system and a multiple-detector CT at the same platform. We compared the anatomical location of SNs demonstrated on the 3D SPECT/CT images and correlation to SN positivity. Results: SPECT/CT uptake was detected in 221 cases (99.1%). 3D SPECT/CT images visualized accurate localization of SNs in each cases. Total number of biopsied SNs were 315 , and the most frequent locations of SN were trapezoid area in the upper side of axilla. We defined this area as ‘Pectoral area (PA)’. In SN negative (SN-) patients, 228 (98.3%) SNs were found in PA, and 4 (1.7%) SNs were out of this area such as parasternal area. In SN positive (SN+) patients, 65(78.3%) SNs were in the PA, and 18(21.7%)SNs were out of PA ,respectively. Significant differences (p<0.01 ,chi-square test) were found in SNs distribution whether in or out of PA between SN+ and SN- patients. Conclusions: SN biopsy navigated by 3D-SPECT/CT can clarify the preoperative anatomical localization of SNs in patients with breast cancer. Atypical distribution of SNs out of PA may suggest SN positivity as a reflection of the failure of lymphatic drainage systems.

No significant financial relationships to disclose.

Aromatase inhibitor-induced joint symptom in patients with breast cancer

11070

Background: Aromatase inhibitor (AI) are superior to tamoxifen (TAM) for postmenopausal women with estrogen receptor (ER)-positive breast cancer. Toxic profiles are different between AI and TAM. The frequency of bone fracture and joint symptom are high in AI compared with TAM. However, there is little report concerning a detailed joint symptom. Methods: From January 2002 to March 2006, 120 postmenopausal women with ER-positive breast cancer were treated with anastrozole 1mg or exemestane 25mg daily at our hospital. We studied retrospectively the incidence, onset, type, sites, grade, and change of joint symptom. We also investigated the incidence of discontinuation due to joint symptoms and correlation between patient’s characteristics and joint symptoms. Results: Median follow-up time is 590 days and median age is 63 years old. Forty-seven (39.1%) of 120 patients complained of joint symptom. Median onset time of the symptom was 90 days of starting AI. All cases with the symptom complained of joint stiffness and 33 (70.2%) of 47 patients with the symptom have joint pain. In decreasing order, the most commonly affected sites were hand, knee, wrist, ankle, shoulder and elbow. The joint symptom was mostly grade 1/2, and most symptom ware resolved with exercise. Most common feature is morning digital stiffness like initial symptom of rheumatoid arthritis. Some patients experienced severe joint symptom. Subsequently, 15 (12.5%) patients had to discontinue AI because of the severe symptom. Discontinuation of AI led to improvement of symptoms, and patients received TAM in stead of AI also led to resolution of symptoms. AI-induced joint symptom was significantly correlated with young age, prior chemotherapy and switching from TAM to AI. Conclusions: Most AI-induced joint symptom is modest, and this symptom can lead to resolution with exercise. However, some patients lead to discontinue AI because of AI-induced severe joint symptom. We should inform patients treated with AI about AI- induced joint symptom and observe patient’s symptom in detail because severe joint symptom can prevent maintenance of quality of life and compliance.

No significant financial relationships to disclose.

Improved outcomes of renal transplantation from cardiac death donors: a 30-year single center experience

Outcomes of renal transplantation from donation after cardiac death (DCD) donors over 30 years were analyzed. Between 1975 and 2004, 256 renal transplantations from DCD donors were performed. The recipients were divided into four groups according to a time period as follows: 1975-1979 (Group 1; n = 18), 1980-1989 (Group 2; n = 81), 1990-1999 (Group 3; n = 84) and 2000-2004 (Group 4; n = 73). Of the 256 transplanted kidneys from DCD donors, 38 (15%) functioned immediately after transplantation. The incidence of delayed graft function (DGF) was 72%. Warm ischemic time and total ischemic time were 7.4 +/- 9.4 min and 11.9 +/- 5.6 h, respectively. The overall graft survival rates at 1, 5 and 10 years were 80%, 72% and 53%, respectively. Graft survival rates in each group have continually improved over time (5-year graft survival; 23% vs. 64% vs. 74% vs. 91%, respectively). However, there was no significant difference in graft survival rates between the groups of patients who survived with a functioning graft for more than 1 year. A multivariate Cox regression analysis showed acute rejection and donor age to be independently associated with graft outcome. DCD donors are a valuable source of kidneys for transplantation with promising long-term outcomes.

Stability of canine distemper virus (CDV) after 20 passages in Vero-DST cells expressing the receptor protein for CDV

Isolates 007Lm, S124C and Ac96I and a Vero cell-adapted Onderstepoort strain of canine distemper viruses (CDV) were examined for stability after passages in Vero cells expressing the canine signaling lymphocyte activation molecule (dogSLAM, the intrinsic receptor to CDV). These viruses passage once in Vero cells expressing dogSLAM (Vero-DST) cells (original) and after 20 passages (20p) were compared by using sequence analyses and growth characteristics. All four strains of 20p grew well and were slightly better than their originals. The 20p viruses developed a cytopathic effect slightly lower than the original strains. A few changes in amino acids in the H gene were between the 20p and the original viruses, but the sites of changes were not specific. Fragments of P, M and L genes of all strains showed no nucleotide changes after the passages. These results showed that: (1) passages of CDVs in Vero-DST cells induced amino acid changes only in the H gene, not in the P, M and L genes, unlike in a previous study with Vero cells; (2) passages did not markedly affect the growth characteristics of every viral strain. These results indicate that Vero cells expressing canine SLAM allow the isolation and passaging of CDV without major changes in viral genes.

Pathogenesis and phylogenetic analyses of canine distemper virus strain 007Lm, a new isolate in dogs

The pathogenesis of a new isolate of canine distemper virus (CDV), strain 007Lm, was investigated from lymph node tissue by using Vero cells that express canine signalling lymphocyte activation molecules with a tag (Vero-DST) in dogs. Two CDV sero-negative Beagle dogs were inoculated intranasally and intraconjunctively with a virus suspension. Both infected dogs showed clinical signs of severe bloody diarrhea, conjunctivitis, ocular discharge, nasal discharge and coughing, lymphopenia, fever and weight loss. Titers of CDV-IgM and CDV-IgG in the blood were measured. CDV was detected by using reverse transcriptase-PCR and was recovered in swabs from one dog from 9 days and from the other dogs from 10 days after inoculation. Molecular and phylogenetic analyses of H and P genes showed that nucleotide and amino acid sequences of these genes of strain 007Lm after isolation in Vero-DST cells are identical to those of the original virus from fresh tissue and that strain 007Lm joins to the Asia 2 group cluster of CDV strains that is distinct from other clusters. These results indicate that (1) CDV strain 007Lm isolated in Vero-DST cells is virulent, (2) nucleotide and amino acid sequences of H and P genes of strain 007Lm do not change after isolation in Vero-DST cells compared with the original virus from fresh tissue and (3) strain 007Lm isolated from a vaccinated dog belongs to a cluster far from the vaccine strains in the phylogenetic trees of H and P genes.

Serum prorenin levels and diabetic retinopathy in type 2 diabetes: new method to measure serum level of prorenin using antibody activating direct kinetic assay

AIM

To investigate the serum levels of prorenin and its correlation with the severity of diabetic retinopathy (DR).

METHODS

248 patients with diabetes and 108 control subjects were divided into four groups: no-DR (n = 146), no proliferative diabetic retinopathy (no-PDR) (n = 78), PDR (n = 24), and controls (n = 108). Serum levels of prorenin from all subjects were measured using the new antibody activating direct kinetic (AAD-PR) assay. The serum prorenin levels were compared among the groups.

RESULTS

The serum levels of prorenin in the control, no-DR, no-PDR, and PDR groups, respectively, were 109.1 (66.1), 194.6 (160.4), 271.5 (220.3), and 428.4 (358.4) pg/ml (mean (SD)). Prorenin in the PDR group was remarkably high compared with the control and no-DR groups (p<0.0001) and with the no-PDR group (p = 0.002). Serum levels of prorenin increased with increasingly severe retinopathy. No correlation was found between the prorenin level and the duration of disease or HbA(1c).

CONCLUSIONS

The serum levels of prorenin in patients with PDR were found to be markedly high using the AAD-PR assay. Increased levels of prorenin in diabetes may have an important role in the pathogenesis of DR.

An intraoperative fluorescent imaging system in organ transplantation

An intraoperative fluorescent imaging system (SPY system; Novadaq Technologies, Inc, Concord, Ontario, Canada) that enables vascular surgeons to confirm the location and states of the reconstructed vessels during surgery, has been developed in the field of open heart surgery. In this paper, we evaluated the usefulness of the SPY system in kidney and liver transplantation.

PATIENTS AND METHODS

SPY system visualizes arteries and grafts intraoperatively, using indocyanine green (ICG) with a portable imaging device. The modality was evaluated in 15 patients undergoing kidney (n = 13) or liver (n = 2) transplantation with respect to safety, feasibility of use, and image quality. Images were generated and acquired with a portable laser diode/infrared camera device after injection of 10 mL of ICG (2.5 mg/mL) intravenously.

RESULT

There was no complication associated with ICG injection or the imaging device. The SPY system was easily used during transplant surgery and adequately demonstrated reconstructed arteries and patency in all patients.

CONCLUSION

The intraoperative imaging system enables the surgeon to view, record, and replay real-time images of the reconstructed arteries during surgery. The system may provide useful information during surgery such as solid organ transplantation that requires vascular reconstruction.

Efficacy of basiliximab induction therapy in ABO-incompatible kidney transplantation: a rapid steroid withdrawal protocol

INTRODUCTION

We have performed ABO-incompatible (ABO-i) kidney transplantation (KT) to alleviate the severe organ shortage in our country. Induction therapy with basiliximab, a monoclonal anti-interleukin-2 receptor antibody, is known to be effective in reducing the incidence of acute rejection (AR) after ABO-compatible KT. However, the efficacy of basiliximab in ABO-i KT is still unknown. In this study, we evaluated the effect of basiliximab to decrease overall maintenance immunosuppression (a steroid withdrawal protocol) and to improve the outcome of ABO-i KT.

PATIENTS AND METHODS

Between April 2002 and May 2003, 14 adult patients underwent ABO-i KT from living donors with cyclosporine (CsA)-based immunosuppression. There were seven men and seven women of mean age 48 +/- 10 years. Three of the 12 cases were second KT. Three sessions of plasmapheresis were performed to remove anti-AB antibodies before KT. Splenectomy was performed in all patients. Immunosuppression consisted of methylprednisolone (MP), CsA, and mycophenolate mofetil, in addition to antibody induction with basiliximab. MP was completely withdrawn on postoperative day 14.

RESULTS

In 3 of 14 recipients, MP was restarted because of AR or a suspicion of AR. Both patient and graft survivals were 100%. The incidence of biopsy-proven AR was 14% (2/14). There was no adverse effect related to the antibody therapy.

CONCLUSION

The use of basiliximab induction therapy may eliminate the need for steroid maintenance therapy without increasing AR risk, even among ABO-i KT recipients. We conclude that basiliximab provides safe and effective induction immunosuppression in ABO-i KT recipients.

Comparative Study of Clinical Outcome in Kidney Transplantation Between Early Steroid Withdrawal Protocol Using Basiliximab, Calcineurin Inhibitor, and Mycophenolate Mofetil and Triple Regimen Consisting of Calcineurin Inhibitor, Mycophenolate Mofetil, and Steroid

AIMS

Effect of early steroid withdrawal protocol using basiliximab in kidney transplantation (KTx) on the clinical outcomes was investigated as compared with triple regimen.

METHODS

Kidney transplant patients in group 1 (n = 62) were treated with 8 mg/kg of cyclosporine (CsA), 2000 mg of MMF, two bolus IV injections of 20 mg of basiliximab and 500 mg of methylprednisolone (MP) rapidly tapered and withdrawn at 14 postoperative days (POD). Group 2 (n = 56) was treated with same dose of CsA and MMF, and 250 mg of MP tapered and continued. Acute rejection (AR) episodes were treated with MP pulse therapy followed by muromonab CD3 (OKT3) in case of steroid-resistant rejection.

RESULTS

In 46 of 62 cases (74.2%) in group 1, steroid was successfully withdrawn at 13.7 +/- 1.7 POD. Graft survival at 3, 6, and 12 months in group 1 was 100%, 100%, and 98.4% (one death with functioning graft), and 100%, 98.2%, and 96.4% in group 2, respectively. The incidence of AR was 12.9% for group 1 and 42.9% for group 2, among which 21 cases in group 2 were treated with ALG or OKT3; no patient needed ALG or OKT3 in group 1. Fifteen cases in group 1 and 13 cases in group 2 developed CMV antigenemia, among which febrile episode was exhibited in 3 cases (4.8%) in group 1 and 5 cases (8.9%) in group 2.

CONCLUSIONS

Early steroid withdrawal protocol using basiliximab is promising for reducing the incidence of AR (especially steroid-resistant rejection), CMV diseases, and steroid-related complications.

Cyclosporine-Sparing Effect of Basiliximab in Renal Transplant Recipients With Mycophenolate Mofetil

Basiliximab added to a maintenance regimen consisting of cyclosporine microemulsion and mycophenolate mofetil was studied for its effectiveness in allowing early steroid withdrawal in renal transplantation. Furthermore, the cyclosporine-sparing effects between groups with and without basiliximab induction therapy were compared.

PATIENTS

Between September 2001 and June 2003, 90 patients underwent renal transplants with cyclosporine-based immunosuppression, namely, cyclosporine, mycophenolate mofetil, and methylprednisolone, (group 1; n = 25). During the latter half of the study basiliximab was administered during the induction phase (group 2; n = 65). In group 2, steroids were completely withdrawn on postoperative day 14 in 57 patients.

RESULTS

The incidence of acute rejection was significantly higher among group 1 patients (P = .005). The incidence of steroid-resistant rejection in group 1 patients was significantly higher (P = .025). At each time point cyclosporine levels in group 1 patients were significantly higher (P < .01). The incidence of infection was comparable between the groups. Patient and graft survival rates in group 1 were 100% and 100%; in group 2, they were 99% and 99%, respectively. In group 2, steroids were discontinued in 57 patients with permanent withdrawal achieved in 32 patients (56%).

CONCLUSION

The use of basiliximab, together with mycophenolate mofetil allowed for a significant reduction in the cyclosporine dose without increasing the risk of acute rejection. Although further follow-up is necessary to confirm the effect, this regimen may attenuate cyclosporine nephrotoxicity thereby affecting the long-term outcomes of renal transplantation.