Successful Pregnancy and Cancer Outcomes With Ipilimumab and Nivolumab for Metastatic Renal Cell Carcinoma: Case Report and Review of the Literature

Pregnancy and cancer share CTLA-4 and PD-1/PD-L1 as some of the immunomodulatory pathways that reshape the immune system from a destructive response to a state of tolerance to the fetus and the tumor, respectively. Ipilimumab (anti-CTLA-4 inhibitor) and nivolumab (anti-PD-1 inhibitor) are used in combination for the treatment of metastatic renal cell carcinoma, and their use could theoretically result in an immune response against the fetus. Furthermore, these immune checkpoint inhibitors are immunoglobulin G antibodies that transfer from the mother to the fetus and may cause a direct toxicity. We present the first report of a metastatic renal cell carcinoma patient in which ipilimumab and nivolumab were successfully used starting in her first trimester of pregnancy, with sufficient follow-up to show favorable outcomes for both the mother and the child. We describe our management of this challenging case and we review the available evidence, coming from Developmental and Reproductive Toxicology Studies and case reports of metastatic melanoma patients.

Co-occurrence of neurofibromatosis type 1 and optic nerve gliomas with autosomal dominant polycystic kidney disease type 2

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD) and neurofibromatosis type 1 (NF1) are both autosomal dominant disorders with a high rate of novel mutations. However, the two disorders have distinct and well-delineated genetic, biochemical, and clinical findings. Only a few cases of coexistence of ADPKD and NF1 in a single individual have been reported, but the possible implications of this association are unknown.

METHODS

We report an ADPKD male belonging to a family of several affected members in three generations associated with NF1 and optic pathway gliomas. The clinical diagnosis of ADPKD and NF1 was performed by several image techniques.

RESULTS

Linkage analysis of ADPKD family was consistent to the PKD2 locus by a nonsense mutation, yielding a truncated polycystin-2 by means of next-generation sequencing. The diagnosis of NF1 was confirmed by mutational analysis of this gene showing a 4-bp deletion, resulting in a truncated neurofibromin, as well. The impact of this association was investigated by analyzing putative genetic interactions and by comparing the evolution of renal size and function in the proband with his older brother with ADPKD without NF1 and with ADPKD cohorts.

CONCLUSION

Despite the presence of both conditions there was not additive effect of NF1 and PKD2 in terms of the severity of tumor development and/or ADPKD progression.

Polyvinyl alcohol cryogel phantoms of biological tissues for wideband operation at microwave frequencies

The aim of this work is to provide a methodology to model the dielectric properties of human tissues based on phantoms prepared with an aqueous solution, in a semi-solid form, by using off-the-shelf components. Polyvinyl alcohol cryogel (PVA-C) has been employed as a novel gelling agent in the fabrication of phantoms for microwave applications in a wide frequency range, from 500 MHz to 20 GHz. Agar-based and deionized water phantoms have also been manufactured for comparison purposes. Mathematical models dependent on frequency and sucrose concentration are proposed to obtain the complex permittivity of the desired mimicked tissues. These models have been validated in the referred bandwidth showing a good agreement to experimental data for different sucrose concentrations. The PVA-C model provides a great performance as compared to agar, increasing the shelf-life of the phantoms and improving their consistency for contact-required devices. In addition, the feasibility of fabricating a multilayer phantom has been demonstrated with a two-layer phantom that exhibits a clear interface between each layer and its properties. Thus, the use of PVA-C extends the option for producing complex multilayer and multimodal phantoms.

Spanish survey on follow-up programmes for children born very preterm

AIM

To describe variations in practice between follow-up programmes for very preterm children born at less than 32 weeks' gestation or with very low birth weight of less than 1,500 g.

METHODS

A survey on follow-up practices was electronically distributed to level II and III units among hospitals of the Spanish National Health Service in 2016. The survey included 70 questions covering issues such as follow-up organisation and resources, routine assessments, relationships with other services and families, information management and training.

RESULTS

The response rate was 91.5% (141/154). Among respondents, 70.9% (100/141) reported that they do provide follow-up and 42% do so up to six years of age. Routine neurological and ophthalmological follow-up is not performed in 60% and 37% of hospitals, respectively, and a second hearing assessment is not given in 62%. Just 38% of units have psychologist. In 41% of hospitals, training in follow-up skills is not included in Paediatric Residency training programme.

CONCLUSION

Although Spain has a nationwide health system that provides universal health coverage, we found that follow-up care for children born very preterm/very low birth weight is not equitable. Nearly half of paediatric residents receive no training in follow-up for this high-risk population.

Agreement between a simple dyspnea-guided treatment algorithm for stable COPD and the GOLD guidelines: a pilot study

Introduction

Guidelines recommendations for the treatment of COPD are poorly followed. This could be related to the complexity of classification and treatment algorithms. The purpose of this study was to validate a simpler dyspnea-based treatment algorithm for inhaled pharmacotherapy in stable COPD, comparing its concordance with the current Global Initiative for Obstructive Lung Disease (GOLD) guideline.

Methods

We enrolled patients who had been diagnosed with COPD in three primary care facilities and two tertiary hospitals in Spain. We determined anthropometric data, forced expiratory volume in the 1st second (percent), exacerbations, and dyspnea based on the modified Medical Research Council scale. We evaluated the new algorithm based on dyspnea and exacerbations and calculated the concordance with the current GOLD recommendations.

Results

We enrolled 100 patients in primary care and 150 attending specialized care in a respiratory clinic. There were differences in the sample distribution between cohorts with 41% vs 26% in grade A, 16% vs 12% in grade B, 16% vs 22% in grade C, and 27% vs 40% in grade D for primary and respiratory care, respectively (P=0.005). The coincidence of the algorithm with the GOLD recommendations in primary care was 93% and 91.8% in the respiratory care cohort.

Conclusion

A simple dyspnea-based treatment algorithm for inhaled pharmacotherapy of COPD could be useful in the management of COPD patients and concurs very well with the recommended schema suggested by the GOLD initiative.

A highly sensitive genetic protocol to detect NF1 mutations

Neurofibromatosis type 1 (NF1) is a hereditary disorder caused by mutations in the NF1 gene. Detecting mutation in NF1 is hindered by the gene's large size, the lack of mutation hotspots, the presence of pseudogenes, and the wide variety of possible lesions. We developed a method for detecting germline mutations by combining an original RNA-based cDNA-PCR mutation detection method and denaturing high-performance liquid chromatography (DHPLC) with multiplex ligation-dependent probe amplification (MLPA). The protocol was validated in a cohort of 56 blood samples from NF1 patients who fulfilled NIH diagnostic criteria, identifying the germline mutation in 53 cases (95% sensitivity). The efficiency and reliability of this approach facilitated detection of different types of mutations, including single-base substitutions, deletions or insertions of one to several nucleotides, microdeletions, and changes in intragenic copy number. Because mutational screening for minor lesions was performed using cDNA and the characterization of mutated alleles was performed at both the RNA and genomic DNA level, the analysis provided insight into the nature of the different mutations and their effect on NF1 mRNA splicing. After validation, we implemented the protocol as a routine test. Here we present the overall unbiased spectrum of NF1 mutations identified in 93 patients in a cohort of 105. The results indicate that this protocol is a powerful new tool for the molecular diagnosis of NF1.

Monozygotic twins with Neurofibromatosis type 1, concordant phenotype and synchronous development of MPNST and metastasis

Background

Neurofibromatosis type 1 is a common autosomal dominant disorder with full penetrance and variable expression. The condition predisposes individuals to the development of malignant nervous system tumours, most frequently Malignant Peripheral Nerve Sheath Tumours (MPNSTs). Previous studies indicate that genetic factors other than mutations in NF1 may be responsible for the condition's variable expression.

Case report

Here we present data from a pair of monozygotic twins affected by Neurofibromatosis type 1 resulting from a de novo mutation. Both twins developed a left sciatic plexiform neurofibroma that evolved into MPNST at a similar age and they also developed pulmonary metastasis at the same age. Other concordant traits between the twins were: macrocephaly, psychomotor delay, café-au-lait spots, cutaneous neurofibromas, retroperitoneal, pleural and paraspinal neurofibromas. The main discordant features observed were tibial pseudoarthrosis, pectus carinatum, osteoporosis and thymus hyperplasia.

Conclusions

This is the first report of monozygotic twins with Neurofibromatosis type 1 that develop MPNSTs, the localization and chronological evolution of which, and its metastasis, is concordant in both twins. These cases suggest that the events involved in the transformation of benign plexiform neurofibromas to MPNSTs in Neurofibromatosis type 1, follow a spatiotemporally programme that is influenced by heritable factors other than NF1 mutations.

Di-(2-ethylhexyl)phthalate in sewage sludge and post-treated sludge: quantitative determination by HRGC-MS and mass spectral characterization

DEHP was quantified into sewage sludge, thermally dried sludge and compost samples from different areas of Catalonia (North East Spain) using high-resolution gas chromatography (HRGC) coupled to a mass spectrometry (MS). The aim of the work was to determine the evolution of this ubiquitous environmental contaminant along some post-treatment sludge processes, such as composting and thermally drying. DEHP concentration detected in some sludges are above the maximum limit suggested by the EC (100 ppm d.m.) for agricultural use. However, the composting and thermally drying reduce the amount of DEHP in sewage sludge to acceptable level for safe land application. The study was completed with the characterization and long-term observation of DEHP in sewage sludge, composted sludge and thermally dried sludge mixed with two types of soils. In all cases, the percentage of DEHP degraded was higher than 50% after 9 months of incubation.

Dietary fat type (virgin olive vs. sunflower oils) affects age-related changes in DNA double-strand-breaks, antioxidant capacity and blood lipids in rats

This study was designed to investigate the possible effect on DNA double-strand breaks, antioxidant capacity and blood lipids of feeding rats lifelong with two different dietary fat sources: virgin olive oil (rich in the monounsaturated oleic acid) or sunflower oil (rich in the polyunsaturated linoleic acid). No changes in mean or maximal lifespan were observed. Overall, aging led to increased levels of plasma cholesterol, triglycerides, phospholipids, total lipids, polyunsaturated fatty acids and DNA double-strand breaks. All these parameters were higher in animals fed on sunflower oil diet. Aging diminished total antioxidant capacity with both diets, but in a lower extension for virgin olive oil diet. A very good inverse correlation (r= -0.715; P < 0.01, for sunflower oil group and r= -0.535; P < 0.01 for virgin olive oil group) between DNA damage and total antioxidant capacity was found. These results allow to conclude that dietary fat type should be considered in studies on aging, since the intake of oils with different polyunsaturation levels directly modulates total antioxidant capacity of plasma, DNA damage to peripheral blood lymphocytes and lead to important changes at the lipid metabolism level. In the present study best results were found after intake of virgin olive oil, which suggest the possible use of that edible oil to provide a healthier aging.

Neonatal spinal muscular atrophy with multiple contractures, bone fractures, respiratory insufficiency and 5q13 deletion

We present the case of a floppy neonate with marked and generalized weakness, respiratory insufficiency and fetal akinesia deformation sequence. The infant showed multiple joint contractures, two bone fractures and needed mechanical ventilation from birth to death at 16 days of age. Electrophysiological assessment showed electrically unexcitable motor and sensory nerves. Muscle biopsy showed diffuse atrophy of type I and type II fibers. Necropsy confirmed the diagnosis of infantile spinal muscular atrophy (SMA) with severe loss of motor neurons in anterior horns and motor nuclei of brainstem. There were also neuronal loss, gliosis, chromatolysis, ballooned cells, empty cell beds and neuronophagia figures in other brainstem and brain nuclei. Genetic analysis of the patient revealed homozygous deletions of survival motor neuron gene 1 (SMN1) and a single copy of SMN2 in region 5q13. This case confirms that the loss of spinal motor neurons underlies the muscular atrophy in severe cases of 5q SMA. This case also shows that the presence of multiple joint contractures, bone fractures and respiratory insufficiency in SMA in the neonatal period does not necessarily exclude the occurrence of classical deletions in the SMA 5q13 region. Rather, these atypical clinical findings show the extreme severity and prenatal onset of the disease in these SMA cases, which may be related with the occurrence of a single copy of SMN2 gene. More reports of clinically, pathologically and genetically well-documented cases are essential to define the different types of this disease.

Auditory neuropathy in patients carrying mutations in the otoferlin gene (OTOF)

Inherited hearing impairment affects one in 2,000 newborns. Nonsyndromic prelingual forms are inherited mainly as autosomal recessive traits, for which 16 genes are currently known. Mutations in the genes encoding connexins 26 and 30 account for up to 50% of these cases. However, the individual contribution of the remaining genes to the whole remains undetermined. In addition, for most of the genes there is a need for studies on genotype-phenotype correlations, to identify distinctive clinical features which may direct the molecular diagnosis to specific genes. Here we present a mutation analysis and a genotype-phenotype correlation study on the gene encoding otoferlin (OTOF), responsible for the DFNB9 subtype of prelingual hearing impairment. Four novel mutations were identified: c.2122C>T (p.Arg708Ter), c.4275G>A (p.Trp1425Ter), c.4362+2T>G, and c.5860_5862delATC (p.Ile1954del). A total of 37 subjects with mutations in OTOF were studied clinically. They were phenotypically homogeneous, having profound hearing impairment with very early onset, as shown by pure-tone audiometry and auditory brainstem responses. Magnetic resonance imaging and computed tomography did not reveal any inner ear malformation. Unexpectedly, transient evoked otoacoustic emissions (TEOAEs) were present, either bilaterally or unilaterally in 11 subjects. Altogether, clinical data of these subjects met the diagnostic criteria of auditory neuropathy. A total of 10 subjects had been successfully provided with cochlear implants. The results of our study indicate that genetic diagnosis of subjects with auditory neuropathy and profound hearing impairment should be directed to the otoferlin gene. Our data are of concern to universal screening programs which use TEOAEs as the first detection test for hearing impairment in newborns, since this technique may overlook a nonnegligible proportion of cases.

Ageing-related tissue-specific alterations in mitochondrial composition and function are modulated by dietary fat type in the rat

This study investigated the way in which feeding rats with two fat sources (olive or sunflower oils) affected electron-transport components and function of mitotic (liver) and postmitotic (heart and skeletal muscle) tissues during ageing. Rats adapted the mitochondrial-membrane-lipid profile to dietary fat throughout the study, suggesting that the benefits to eat either of the two fats might be maintained lifelong. Liver was more resistant to dietary changes and ageing than heart and skeletal muscle, which showed higher levels of coenzyme Q, cytochrome b, and cytochrome a + a3 with ageing and lower cytochrome c oxidase and complex IV turnover. Dietary fat differentially modulated the response of tissues during ageing, with sunflower oil leading to the highest levels of coenzyme Q and cytochromes b and a + a3. Since high levels of cytochrome b have been related to increased age, it could be hypothesized that olive oil could lead to less aged mitochondria.

Genetic study of SMA patients without homozygous SMN1 deletions: identification of compound heterozygotes and characterisation of novel intragenic SMN1 mutations

Autosomal recessive spinal muscular atrophy (SMA) is a disease resulting from mutations in the telomeric survival motor neuron gene ( SMN1). In our sample of 150 Spanish SMA families, 87% of patients had homozygous deletions of SMN1. To identify patients who retained a single SMN1 copy, SMN dosage analysis was performed by a fluorescent quantitative PCR assay. In five out of 19 patients tested we detected one SMN1 copy. An extensive SMN gene analysis in these patients led to identification of four intragenic mutations, including two novel ones: a frameshift mutation in exon 6 (773insC) and a splice site mutation in intron 6 (c.867+2T-->G). Two previously described mutations were also found: a deletion in exon 3 (430del4), identified in several Spanish patients, and a frequently occurring mutation in exon 6 (813ins/dup11), reported in several populations. Although the spectrum of intragenic mutations is small, only 27 reported up to now, identification of three mutations found exclusively in the Spanish population indicates that the occurrence of different intragenic mutations depends on the ethnic origin of SMA patients. In the remaining patient, who had a single SMN1 copy and three SMN2 copies, we found that the SMN1 allele was non-functional; the patient did not show any SMN1 transcript. Sequencing of the SMN promoter regions revealed various differences between promoters of the patient's four SMN genes, in particular a change in the length of a polyA run removing a putative YY1 binding site, which may affect the expression of SMN genes.

Characterisation of SMN hybrid genes in Spanish SMA patients: de novo, homozygous and compound heterozygous cases

Autosomal recessive spinal muscular atrophy (SMA) is classified, by age of onset and maximal motor milestones achieved, into type I (severe form), type II (intermediate form) and type III (mild/moderate form). SMA is caused by mutations in the survival motor neuron telomeric gene (SMN1) and a centromeric functional copy of this gene (SMN2) exists, both genes being located at 5q13. Homozygous deletion of exons 7 and 8 of SMN1 has been detected in approx 85% of Spanish SMA patients regardless of their phenotype. Nineteen cases with the sole deletion of exon 7 but not exon 8 (2 cases of type I, 13 cases of type II, four cases of type III) were further analysed for the presence of SMN2-SMN1 hybrid genes. We detected four different hybrid structures. Most of the patients were carriers of a hybrid structure: centromeric intron 6- centromeric exon 7- telomeric exon 8 (CCT), with or without neuronal apoptosis-inhibitor protein (NAIP). In two patients, a different hybrid structure, viz. telomeric intron 6- centromeric exon 7- telomeric exon 8 (TCT), was detected with or without NAIP. A phenotype-genotype correlation comparing the different structures of the hybrid alleles was delineated. Type I cases in our series are attributable to intrachromosomal deletion with a smaller number of SMN2 copies. Most cases with hybrid genes are type II occurring by a combination of a classical deletion in one chromosome and a hybrid gene in the other. Type III cases are closely associated with homozygozity or compound heterozygozity for hybrid genes resulting from two conversion events and have more copies of hybrid genes and SMN2 than type I or II cases.

Determination of three anabolic compounds in calf urine by liquid chromatography with photodiode-array detection

A method for the determination of three anabolic hormones (diethylstilbestrol, dienestrol and trenbolone) in calf urine is described. After enzymatic hydrolysis, the samples were cleaned up by C18 solid-phase extraction. Drugs were extracted with hexane and analyzed by isocratic elution on a Discovery RP-Amide C16 5 microns column with photodiode-array detection at 240 and 347 nm. Both retention time and UV spectra were used for identification. Detection limits for the HPLC system were calculated to be 0.3 ng injected for all analytes in the standard mixture. However, for urine samples these limits increased because of the presence of unidentified matrix components. After extraction from urine, the limits of detection for the whole analytical procedure were 5 and 10 ng injected for trenbolone and stilbenes, respectively. The average recoveries of the hormones from spiked samples were in the range 53.1-56.7% with RSD between 11.3 and 14.5% for the whole procedure in the concentration range 25-2.5 ng ml-1.

[Standards for the appropriate use of percutaneous transluminal coronary angioplasty and aortocoronary surgery]

INTRODUCTION AND OBJECTIVES

The large differences in rates of use of clinical procedures among regions, hospitals and physicians raise questions as to whether some population groups are receiving inappropriate procedures or others are not receiving necessary ones. The objective of this study is to develop criteria for the appropriate use of coronary revascularization procedures in Spain.

METHODS

Following the RAND appropriateness method, criteria were developed for the appropriate use of coronary revascularization (percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery) in Spain. A literature review was produced as well as a comprehensive and mutually exclusive list of 1,826 indications for coronary revascularization. A panel of 12 experts (4 interventional cardiologists, 4 non-interventional cardiologists and 4 cardiovascular surgeons) rated the appropriateness of each indication on a scale from 1 (highly inappropriate) to 9 (highly appropriate). The ratings were made twice; anonymously in the first round, and during a 2-day meeting in the second round. In accordance with the panelists' mean rating and level of agreement, each indication was classified as appropriate, uncertain or inappropriate for revascularization, angioplasty and bypass surgery.

RESULTS

Criteria have been developed for the appropriate use of angioplasty and bypass surgery which can be applied to patients with coronary artery disease. The combination of clinical characteristics makes it possible to classify patients with a high degree of specificity.

CONCLUSIONS

These criteria can be used retrospectively, to measure the proportions of appropriate use, or prospectively, as an aid to decision making in order to promote the appropriate use of coronary revascularization.

[The follow-up of the cancer patient: how and when?]

The medical resources devoted to cancer patient follow-up are growing. However, intensive follow-up is not translated to any significant improvement survival in a majority of patients. A few neoplasias have an effective salvage therapy, and are worth having strict follow-up to diagnose earlier the recurrence. In many tumours, as breast cancer, an early diagnosis of recurrence does not imply an improvement on survival. Tumoral markers are able to detect the presence of tumour cells even before being clinically apparent and are routinely used in the follow-up of tumours; however, they do not seem to improve survival. The cost-benefit relation of multiple revision in cancer patients apparently cured is debated. No general consensus is achieved to define the best tests to follow-up cancer patients. The trend is to minimize the diagnostic tests and to recommend a clinical follow-up with anamnesis and physical exploration.

Benzimidazo[1,2-c]quinazolines: a new class of antitumor compounds

A series of substituted benzimidazo[1,2-c]quinazolines have been synthesized. This class of compound has been designed by structural comparison with other intercalator patterns. The determination of in vitro activities has shown high inhibitory values.

[Incidence of anti-HCV and ALT in blood donors]

A study was carried out in 2,000 blood donors aimed to assess the incidence of anti-C hepatitis virus antibodies. Of the total number of samples, 10 cases were found positive (0.5%), a figure lower than the national average. Of these 10 cases, ALT levels were high in 5 (0.2%). The potential risk of post-transfusion C hepatitis increases in accordance with the number of blood units transfused. This incidence of anti-C hepatitis virus antibodies is discussed with regard to previous findings in other countries, the incidence of positive donors being also very low.