Osimertinib-induced Cutaneous Vasculitis Responsive to Low Dose Dapsone Without Interruption of Anticancer Therapy: A Case Report and Review of the Literature

A 45-year-old woman with a history of lung adenocarcinoma treated with osimertinib developed purpuric plaques and vesicles on the lower extremities after 5 months of therapy. Skin biopsy revealed leukocytoclastic vasculitis (LCV). A workup for systemic involvement was unremarkable. The patient was treated with oral dapsone while continuing osimertinib without interruption. Skin lesions cleared within 2 weeks of therapy with no recurrence after titrating off dapsone. To the best of our knowledge, this is the first reported case of LCV induced by a small-molecule EGFR inhibitor in which therapy was not interrupted. This is also the first reported case treated with dapsone rather than systemic corticosteroids. We suggest consideration of dapsone to treat skin-limited LCV induced by EGFR inhibitors in patients with lung cancer without features of systemic vasculitis. In addition, this case highlights that it may not be necessary to stop EGFR inhibitor therapy in the absence of severe features such as ulceration, bullae, necrosis, or severe pain. Dapsone is an effective targeted therapy for cutaneous LCV that does not globally impair the immune system and may allow for uninterrupted treatment of the underlying malignancy.

A woman presenting with an unusual cause of fulminant liver failure and sepsis

We present the case of a 61-year-old woman who presented with acutely worsening right upper quadrant pain and was found to be in acute liver failure with Klebsiella pneumoniae bacteremia. Despite aggressive intensive care management, the patient ultimately died of refractory shock attributed to sepsis and fulminant liver failure. On autopsy, she was found unexpectedly to have diffuse intrahepatic cholangiocarcinoma with metastases to regional lymph nodes and intravascular spread to the lungs. The case highlights a rare instance where intrahepatic cholangiocarcinoma presents with acute liver failure and discusses key intensive care management principles of this clinical syndrome.

Understanding the impact of chemotherapy on the immune landscape of high-grade serous ovarian cancer

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Neoadjuvant chemotherapy induces heterogeneous changes in the tumor microenvironment.

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Macrophages are a significant component of the TME PD-L1 expression enriched in a subset of patients.

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Alteration in T cell ratios after chemotherapy indicate patient subsets favorable to checkpoint modulation in the recurrent setting.

Objectives

We quantitatively characterized the change in temporospatial expression of repressive and stimulatory checkpoints across immune cell populations in the tumor microenvironment in a cohort of high grade serous ovarian carcinomas (HGSOC) using matched samples before and after neoadjuvant platinum-based chemotherapy.

Methods

Using retrospectively collected matched tissue samples from 9 patients, cell populations were assessed using multiplex immunofluorescence using the Vectra Multispectral Imaging System (Perkin Elmer). We used multiple panels to assess: tumor (AE1/AE3), T cells (CD3, CD8, FOXP3), macrophages (CD68) as well as immune checkpoints (C3aR, PD-1, PD-L1, LAG3, IDO, ICOS, GITR). IHC staining was performed for folate receptor status. Changes in immune cell populations as well as intensities of associated repressive and stimulatory proteins were assessed pre- to post-treatment.

Results

We observed a consistently high pre-treatment stromal macrophage population which is reduced post-chemotherapy with post-treatment enrichment in macrophage PD-L1 expression. While inhibitory checkpoint expression on T cells was heterogeneous post-chemotherapy, we observed a change in the T_hICOS+:T_reg ratio which resulted in T_hICOS+ cells outnumbering T_reg cells post-treatment. Spatial analysis revealed the proximity of T_reg cells to T_hICOS+ T cells decreased post-treatment. We also observed upward shifts in T_eff:T_reg T cell ratios with retention of immune checkpoints PD-1, LAG3 and GITR.

Conclusions

In this unique dataset of pre and post matched chemotherapy treated HGSOC patients, we observed changes in immune cell subsets expressing repressive or stimulatory proteins resulting in immune compositions more favorable to checkpoint modulations, suggesting novel therapeutic strategies in the recurrent setting.

Extramammary Paget disease shows differential expression of B7 family members B7-H3, B7-H4, PD-L1, PD-L2 and cancer/testis antigens NY-ESO-1 and MAGE-A

Extramammary Paget disease (EMPD) is a rare cutaneous adenocarcinoma of the anogenital region most commonly treated with surgical excision. Surgical margin clearance is often problematic and recurrence rates remain high indicating the need for additional therapeutic options. Topical immunomodulators have been used with reported success suggesting EMPD may respond to other immunotherapies. This study investigates EMPD protein expression of targetable B7 family members and cancer/testis antigens (CTAs) B7-H3, B7-H4, PD-L1, PD-L2, MAGE-A, and NY-ESO-1 and components of antigen presenting machinery B2M and MHC-I. Fifty-seven specimens from 48 patients (31 female and 17 male), representing in situ, invasive, and metastatic disease of primary and secondary origin were stained and scored (627 total slides). The percentage of cases expressing each immune regulatory molecule in the in situ followed by invasive tumor components was: B7-H3 (94, 90), B7-H4 (82, 78), PD-L1 (6, 10), MAGE-A (39, 50), NY-ESO-1 (16, 20), B2M (100, 89), and MHC-I (78, 79). PD-L2 was negative in all cases. There was high correlation between marker expression within the in situ and invasive tumor components of the same case. B7-H4 was preferentially expressed in primary cutaneous EMPD. Co-expression of B7 family members B7-H3 and B7-H4 was found within the in situ and invasive tumor components of 74% and 48% of cases, respectively. These findings provide an initial characterization of EMPD tumor cell expression of B7-H3, B7-H4, PD-L1, PD-L2, MAGE-A, and NY-ESO-1 and indicate the potential for new immunotherapeutic options for patients with EMPD.

Differentiation of Patients with Balance Insufficiency (Vestibular Hypofunction) versus Normal Subjects Using a Low-Cost Small Wireless Wearable Gait Sensor

Balance disorders present a significant healthcare burden due to the potential for hospitalization or complications for the patient, especially among the elderly population when considering intangible losses such as quality of life, morbidities, and mortalities. This work is a continuation of our earlier works where we now examine feature extraction methodology on Dynamic Gait Index (DGI) tests and machine learning classifiers to differentiate patients with balance problems versus normal subjects on an expanded cohort of 60 patients. All data was obtained using our custom designed low-cost wireless gait analysis sensor (WGAS) containing a basic inertial measurement unit (IMU) worn by each subject during the DGI tests. The raw gait data is wirelessly transmitted from the WGAS for real-time gait data collection and analysis. Here we demonstrate predictive classifiers that achieve high accuracy, sensitivity, and specificity in distinguishing abnormal from normal gaits. These results show that gait data collected from our very low-cost wearable wireless gait sensor can effectively differentiate patients with balance disorders from normal subjects in real-time using various classifiers. Our ultimate goal is to be able to use a remote sensor such as the WGAS to accurately stratify an individual's risk for falls.

Genitourinary Tract Infection Due to Mycobacterium avium intracellulare Complex Infection in Pretransplant Setting With Recurrence Following Transplant: A Case Report

Genitourinary (GU) tract infection with Mycobacterium avium intracellulare complex (MAI) is very rare and, to our knowledge, has never been reported in the solid organ transplant literature. CASE DESCRIPTION: A 61-year-old Somali-born woman had a history of liver cirrhosis due to chronic hepatitis C infection. She was diagnosed as having and treated for latent tuberculosis infection and GU tract infection due to MAI. She received a total of 17 months antimycobacterial therapy consisting of azithromycin, ethambutol, and moxifloxacin. Within 5 months of the initiation of antimicrobial therapy, there was documented sterilization of urine mycobacterial cultures. Liver and kidney transplant was performed 3 months after finishing the treatment course. One year following transplant, GU tract infection due to MAI recurred. She declined further diagnostic testing as well as mycobacterial therapy. She died 15 months following transplant for reasons not related to infections. CONCLUSION: The treatment of MAI infection in solid organ transplant candidates and recipients is challenging, and the duration of therapy in this population is not known. The recurrence of infection following transplant in this case may argue in favor of a duration that extends beyond the date of transplant. The combination of a fluoroquinolone and ethambutol may successfully prevent reactivation of tuberculosis in patients with history of latent tuberculosis infection and deserves further evaluation.

Multicenter Study Using Desorption-Electrospray-Ionization-Mass-Spectrometry Imaging for Breast-Cancer Diagnosis

The histological and molecular subtypes of breast cancer demand distinct therapeutic approaches. Invasive ductal carcinoma (IDC) is subtyped according to estrogen-receptor (ER), progesterone-receptor (PR), and HER2 status, among other markers. Desorption-electrospray-ionization-mass-spectrometry imaging (DESI-MSI) is an ambient-ionization MS technique that has been previously used to diagnose IDC. Aiming to investigate the robustness of ambient-ionization MS for IDC diagnosis and subtyping over diverse patient populations and interlaboratory use, we report a multicenter study using DESI-MSI to analyze samples from 103 patients independently analyzed in the United States and Brazil. The lipid profiles of IDC and normal breast tissues were consistent across different patient races and were unrelated to country of sample collection. Similar experimental parameters used in both laboratories yielded consistent mass-spectral data in mass-to-charge ratios ( m/ z) above 700, where complex lipids are observed. Statistical classifiers built using data acquired in the United States yielded 97.6% sensitivity, 96.7% specificity, and 97.6% accuracy for cancer diagnosis. Equivalent performance was observed for the intralaboratory validation set (99.2% accuracy) and, most remarkably, for the interlaboratory validation set independently acquired in Brazil (95.3% accuracy). Separate classification models built for ER and PR statuses as well as the status of their combined hormone receptor (HR) provided predictive accuracies (>89.0%), although low classification accuracies were achieved for HER2 status. Altogether, our multicenter study demonstrates that DESI-MSI is a robust and reproducible technology for rapid breast-cancer-tissue diagnosis and therefore is of value for clinical use.

Nondestructive tissue analysis for ex vivo and in vivo cancer diagnosis using a handheld mass spectrometry system

Conventional methods for histopathologic tissue diagnosis are labor- and time-intensive and can delay decision-making during diagnostic and therapeutic procedures. We report the development of an automated and biocompatible handheld mass spectrometry device for rapid and nondestructive diagnosis of human cancer tissues. The device, named MasSpec Pen, enables controlled and automated delivery of a discrete water droplet to a tissue surface for efficient extraction of biomolecules. We used the MasSpec Pen for ex vivo molecular analysis of 20 human cancer thin tissue sections and 253 human patient tissue samples including normal and cancerous tissues from breast, lung, thyroid, and ovary. The mass spectra obtained presented rich molecular profiles characterized by a variety of potential cancer biomarkers identified as metabolites, lipids, and proteins. Statistical classifiers built from the histologically validated molecular database allowed cancer prediction with high sensitivity (96.4%), specificity (96.2%), and overall accuracy (96.3%), as well as prediction of benign and malignant thyroid tumors and different histologic subtypes of lung cancer. Notably, our classifier allowed accurate diagnosis of cancer in marginal tumor regions presenting mixed histologic composition. Last, we demonstrate that the MasSpec Pen is suited for in vivo cancer diagnosis during surgery performed in tumor-bearing mouse models, without causing any observable tissue harm or stress to the animal. Our results provide evidence that the MasSpec Pen could potentially be used as a clinical and intraoperative technology for ex vivo and in vivo cancer diagnosis.

Metabolic Markers and Statistical Prediction of Serous Ovarian Cancer Aggressiveness by Ambient Ionization Mass Spectrometry Imaging

Ovarian high-grade serous carcinoma (HGSC) results in the highest mortality among gynecological cancers, developing rapidly and aggressively. Dissimilarly, serous borderline ovarian tumors (BOT) can progress into low-grade serous carcinomas and have relatively indolent clinical behavior. The underlying biological differences between HGSC and BOT call for accurate diagnostic methodologies and tailored treatment options, and identification of molecular markers of aggressiveness could provide valuable biochemical insights and improve disease management. Here, we used desorption electrospray ionization (DESI) mass spectrometry (MS) to image and chemically characterize the metabolic profiles of HGSC, BOT, and normal ovarian tissue samples. DESI-MS imaging enabled clear visualization of fine papillary branches in serous BOT and allowed for characterization of spatial features of tumor heterogeneity such as adjacent necrosis and stroma in HGSC. Predictive markers of cancer aggressiveness were identified, including various free fatty acids, metabolites, and complex lipids such as ceramides, glycerophosphoglycerols, cardiolipins, and glycerophosphocholines. Classification models built from a total of 89,826 individual pixels, acquired in positive and negative ion modes from 78 different tissue samples, enabled diagnosis and prediction of HGSC and all tumor samples in comparison with normal tissues, with overall agreements of 96.4% and 96.2%, respectively. HGSC and BOT discrimination was achieved with an overall accuracy of 93.0%. Interestingly, our classification model allowed identification of three BOT samples presenting unusual histologic features that could be associated with the development of low-grade carcinomas. Our results suggest DESI-MS as a powerful approach for rapid serous ovarian cancer diagnosis based on altered metabolic signatures. Cancer Res; 77(11); 2903-13. ©2017 AACR.

GCKR and PPP1R3B identified as genome-wide significant loci for plasma lactate: the Atherosclerosis Risk in Communities (ARIC) study

AIM

To investigate the genetic influence of circulating lactate level, a marker of oxidative capacity associated with diabetes.

METHODS

We conducted a genome-wide association study of log-transformed plasma lactate levels in 6901 European-American participants in the Atherosclerosis Risk in Communities study. For regions that achieved genome-wide significance in European-American participants, we conducted candidate region analysis in African-American subjects and tested for interaction between metformin use and the index single nucleotide polymorphisms for plasma lactate in European-American subjects.

RESULTS

The genome-wide association study in European-American subjects identified two genome-wide significant loci, GCKR (rs1260326, T allele β=0.08; P=1.8×10(-47) ) and PPP1R3B/LOC157273 (rs9987289, A allele β=0.06; P=1.6×10(-9) ). The index single nucleotide polymorphisms in these two loci explain 3.3% of the variance in log-transformed plasma lactate levels among the European-American subjects. In the African-American subjects, based on a region-significant threshold, the index single nucleotide polymorphism at GCKR was associated with plasma lactate but that at PPP1R3B/LOC157273 was not. Metformin use appeared to strengthen the association between the index single nucleotide polymorphism at PPP1R3B/LOC157273 and plasma lactate in European-American subjects (P for interaction=0.01).

CONCLUSIONS

We identified GCKR and PPP1R3B/LOC157273 as two genome-wide significant loci of plasma lactate. Both loci are associated with other diabetes-related phenotypes. These findings increase our understanding of the genetic control of lactate metabolism.

Computational discovery of pathway-level genetic vulnerabilities in non-small-cell lung cancer

Motivation: Novel approaches are needed for discovery of targeted therapies for non-small-cell lung cancer (NSCLC) that are specific to certain patients. Whole genome RNAi screening of lung cancer cell lines provides an ideal source for determining candidate drug targets.

Results: Unsupervised learning algorithms uncovered patterns of differential vulnerability across lung cancer cell lines to loss of functionally related genes. Such genetic vulnerabilities represent candidate targets for therapy and are found to be involved in splicing, translation and protein folding. In particular, many NSCLC cell lines were especially sensitive to the loss of components of the LSm2-8 protein complex or the CCT/TRiC chaperonin. Different vulnerabilities were also found for different cell line subgroups. Furthermore, the predicted vulnerability of a single adenocarcinoma cell line to loss of the Wnt pathway was experimentally validated with screening of small-molecule Wnt inhibitors against an extensive cell line panel.

Availability and implementation: The clustering algorithm is implemented in Python and is freely available at https://bitbucket.org/youngjh/nsclc_paper.

Contact:marcotte@icmb.utexas.edu or jon.young@utexas.edu

Supplementary information:Supplementary data are available at Bioinformatics online.

Efforts to make and apply humanized yeast

Despite a billion years of divergent evolution, the baker’s yeast Saccharomyces cerevisiae has long proven to be an invaluable model organism for studying human biology. Given its tractability and ease of genetic manipulation, along with extensive genetic conservation with humans, it is perhaps no surprise that researchers have been able to expand its utility by expressing human proteins in yeast, or by humanizing specific yeast amino acids, proteins or even entire pathways. These methods are increasingly being scaled in throughput, further enabling the detailed investigation of human biology and disease-specific variations of human genes in a simplified model organism.

Combined admixture mapping and association analysis identifies a novel blood pressure genetic locus on 5p13: contributions from the CARe consortium

Admixture mapping based on recently admixed populations is a powerful method to detect disease variants with substantial allele frequency differences in ancestral populations. We performed admixture mapping analysis for systolic blood pressure (SBP) and diastolic blood pressure (DBP), followed by trait-marker association analysis, in 6303 unrelated African-American participants of the Candidate Gene Association Resource (CARe) consortium. We identified five genomic regions (P< 0.001) harboring genetic variants contributing to inter-individual BP variation. In follow-up association analyses, correcting for all tests performed in this study, three loci were significantly associated with SBP and one significantly associated with DBP (P< 10(-5)). Further analyses suggested that six independent single-nucleotide polymorphisms (SNPs) contributed to the phenotypic variation observed in the admixture mapping analysis. These six SNPs were examined for replication in multiple, large, independent studies of African-Americans [Women's Health Initiative (WHI), Maywood, Genetic Epidemiology Network of Arteriopathy (GENOA) and Howard University Family Study (HUFS)] as well as one native African sample (Nigerian study), with a total replication sample size of 11 882. Meta-analysis of the replication set identified a novel variant (rs7726475) on chromosome 5 between the SUB1 and NPR3 genes, as being associated with SBP and DBP (P< 0.0015 for both); in meta-analyses combining the CARe samples with the replication data, we observed P-values of 4.45 × 10(-7) for SBP and 7.52 × 10(-7) for DBP for rs7726475 that were significant after accounting for all the tests performed. Our study highlights that admixture mapping analysis can help identify genetic variants missed by genome-wide association studies because of drastically reduced number of tests in the whole genome.

The coming epidemic: hypertension in rural Kyrgyzstan, Central Asia

Eastern Europe is experiencing an epidemic of cardiovascular disease far outpacing rates in Western Europe. This epidemic was heralded by a precipitous rise in hypertension prevalence. The former Soviet states of Central Asia may be facing a similar epidemic. In order to access this threat, we performed a retrospective analysis of data generated during humanitarian medical visits to two villages in Kyrgyzstan, Central Asia. The age-adjusted prevalence of hypertension was 39%. Hypertension was much more common among men than women (46 vs 33%, respectively). In addition, the rise in blood pressure with age was striking, surpassing the experience in Western countries. This epidemic of hypertension may herald a coming epidemic of cardiovascular disease in Central Asia.

The early regulation of figs in the United States

When the Food and Drugs Act became law in 1906, the commercial fig industry in California had just become established. Domestic figs began to compete with imported figs, especially from Turkey and Greece. Fig culture, both in the Near East and the American West, was beset by many threats, especially insect pests. The Bureau of Chemistry in the U.S. Department of Agriculture (USDA), enforcer of the 1906 law, undertook to protect consumers from spoiled figs from overseas and in interstate commerce. Simultaneously the USDA helped both domestic and Turkish growers to counter infestation. Through the State Department, sanitary controls in Smyrna were enhanced. Scientific experts from Agriculture educated American growers and packers in protective techniques. A high point of both legal actions and educational endeavors came in the late 1920s. In the 1930s, the state of California assumed the role of guiding inspection and helping dispose of substandard figs. World War II brought retrogression in fig quality, requiring a new corrective campaign by the Food and Drug Administration, successor to the Bureau of Chemistry, to prevent spoiled figs from reaching the market. By the 1950s, the need for such legal actions was rare.

Testing shelled corn for aflatoxin, Part II: modeling the observed distribution of aflatoxin test results

The suitability of several theoretical distributions to predict the observed distribution of aflatoxin test results in shelled corn was investigated. Fifteen positively skewed theoretical distributions were each fitted to 18 empirical distributions of aflatoxin test results for shelled corn. The compound gamma distribution was selected to model aflatoxin test results for shelled corn. The method of moments technique was chosen to estimate the parameters of the compound gamma distribution. Mathematical expressions were developed to calculate the parameters of the compound gamma distribution for any lot aflatoxin concentration and test procedure. Observed acceptance probabilities were compared to operating characteristic curves predicted from the compound gamma distribution, and all 18 observed acceptance probabilities were found to lie within a 95% confidence band. The parameters of compound gamma were used to calculate the fraction of aflatoxin-contaminated kernels in contaminated lots. At 20 ppb, it was estimated that about 6 in 10,000 kernels are contaminated.

Testing shelled corn for aflatoxin, Part III: evaluating the performance of aflatoxin sampling plans

The effects of changes in sample size and/or sample acceptance level on the performance of aflatoxin sampling plans for shelled corn were investigated. Six sampling plans were evaluated for a range of sample sizes and sample acceptance levels. For a given sample size, decreasing the sample acceptance level decreases the percentage of lots accepted while increasing the percentage of lots rejected at all aflatoxin concentrations, and decreases the average aflatoxin concentration in lots accepted and lots rejected. For a given sample size where the sample acceptance level decreases relative to a fixed regulatory guideline, the number of false positives increases and the number of false negatives decreases. For a given sample size where the sample acceptance level increases relative to a fixed regulatory guideline, the number of false positives decreases and the number of false negatives increases. For a given sample acceptance level, increasing the sample size increases the percentage of lots accepted at concentrations below the regulatory guideline while increasing the percentage of lots rejected at concentrations above the regulatory guideline, and decreases the average aflatoxin concentration in the lots accepted while increasing the average aflatoxin concentration in the rejected lots. For a given sample acceptance level that equals the regulatory guideline, increasing the sample size decreases misclassification of lots, both false positives and false negatives.

Testing shelled corn for aflatoxin, Part I: estimation of variance components

The variability associated with testing lots of shelled corn for aflatoxin was investigated. Eighteen lots of shelled corn were tested for aflatoxin contamination. The total variance associated with testing shelled corn was estimated and partitioned into sampling, sample preparation, and analytical variances. All variances increased as aflatoxin concentration increased. With the use of regression analysis, mathematical expressions were developed to model the relationship between aflatoxin concentration and the total, sampling, sample preparation, and analytical variances. The expressions for these relationships were used to estimate the variance for any sample size, subsample size, and number of analyses for a specific aflatoxin concentration. Test results on a lot with 20 parts per billion aflatoxin using a 1.13 kg sample, a Romer mill, 50 g subsamples, and liquid chromatographic analysis showed that the total, sampling, sample preparation, and analytical variances were 274.9 (CV = 82.9%), 214.0 (CV = 73.1 %), 56.3 (CV = 37.5%), and 4.6 (CV = 10.7%), respectively. The percentage of the total variance for sampling, sample preparation, and analytical was 77.8, 20.5, and 1.7, respectively.

Diagnosis and follow-up of acute promyelocytic leukemia by detection of PML-RAR alpha gene rearrangement

BACKGROUND

Rapid and accurate diagnosis of acute promyelocytic leukemia (APL) is essential for management of the disease, as all-trans retinoic acid (ATRA) therapy only induces complete remission in patients whose leukemic cells harbor a t(15;17) translocation, resulting in promyelocytic-retinoic acid receptor alpha (PML-RAR alpha) fusion transcripts. Moreover, a positive reverse transcriptase-polymerase chain reaction (RT-PCR) of PML-RAR alpha is reported to be a sensitive predictor of relapse in APL. This prompted us to use RT-PCR for rapid diagnosis and monitoring of minimal residual disease in APL patients.

METHODS

A nested RT-PCR technique was applied to detect the unique PML-RAR alpha fusion transcript in 13 APL patients. The test was applied to help clarify the diagnosis and monitor minimal residual disease after treatment.

RESULTS

All 13 APL patients had a positive test result: five patients with the S-form, seven patients with the L-form and one patient with the V-form of mRNA fusion transcripts. Minimal residual disease was prospectively monitored using this technique in six patients. Although in clinical remission, all four patients treated with ATRA alone were persistently PCR positive. Of the six patients receiving various forms of consolidation chemotherapy, one was persistently PCR positive while in remission and relapsed four months after the positive PCR test. Five patients were PCR negative. One of the five negative patients relapsed six months after a negative PCR test. The other four patients remained in remission, with a follow-up period of 25 to 46 months after the negative test. PCR was performed in two patients who had been in continuous remission for 3.5 and seven years, respectively. They both had negative PCR tests.

CONCLUSIONS

Nested RT-PCR is valuable for confirming the diagnosis of APL and in monitoring minimal residual disease. However, we found that negative test cannot absolutely exclude the possibility of future relapse.

Bilateral choroidal metastases as the initial presentation of a small breast carcinoma: a case report

Most ocular tumors metastasize from systemic origins in breast carcinoma in females, and bronchial carcinoma in males. Here, we report a case of choroidal carcinoma metastasis from the breast with visual problems being the only initial manifestations. In this case, both eyes were involved at almost the same time, with initial manifestation of blurred vision which progressed to complete visual loss. At first, the patient was diagnosed with malignant melanoma, and enucleation of the right eye was performed in another hospital. However, the tumor had already metastasized rapidly to numerous organs, including the lungs, brain and bone, although it had not affected the liver. Clinical presentations were, therefore, not compatible with those of malignant melanoma, which has usually been reported to metastasize to the liver. Persistent hypercalcemia and raised carcinoembryonic antigen (CEA) concentrations prompted investigations into the possibility of systemic malignancy. A very small breast nodule was finally located by thorough physical examination, and a lumpectomy was performed. A detailed review of the histopathology showed the tumors from the breast and the right eye to have the same origin. Simultaneous bilateral choroidal metastases from other malignancies is not uncommon; however, it is quite rare for breast carcinoma to present with visual problems as a first manifestation. Detailed history taking and physical examination are therefore essential when searching for a primary tumor, so that appropriate therapy can be given earlier.

Malignant lymphomas of sinonasal region, including cases of polymorphic reticulosis: a retrospective clinicopathologic analysis of 34 cases

BACKGROUND

Lymphomas occurring in nasal cavities and paranasal sinuses are uncommon neoplasms in Western, but are reported to be higher in Oriental, countries. A retrospective study was performed to analyze the clinical and pathological characteristics of sinonasal lymphomas/polymorphic reticulosis at Taichung Veterans General Hospital during a 14-year period.

METHODS

At Taichung Veterans General Hospital, 37 patients with sinonasal lymphomas (including three patients with polymorphic reticulosis) were seen from November 1982 through September 1996. Excluding three patients without sufficient data, a total of 34 patients with their clinical records were reviewed. Clinical information regarding characteristics of the tumors, histological studies, treatment modalities and follow-up was collected for analysis.

RESULTS

The 34 patients who underwent review showed a male-to-female ratio of 2.1:1. Median age was 60 years (range 13-83 years). The most common symptoms were nasal obstruction, nasal discharge/rhinorrhea and epistaxis. Median duration of symptoms at the time of diagnosis was two months. The most frequently involved sites were nasal cavities (right more than left side). There were 31 non-Hodgkin's lymphomas and three polymorphic reticuloses. The pathological classifications revealed 13 diffuse large cell lymphomas, 14 diffuse mixed small and large cell lymphomas and four pleomorphic T-cell lymphomas. Of the 21 adequately staged patients, 13 patients were in stage I; four, stage II; two, stage III and two, stage IV. The immunophenotypic study was performed in 20 patients. Eighteen (90%) of them were T-cell lymphomas and only two cases (10%) derived from B-cell. Though approach to therapy and follow-up periods varied during the time period covered by this study, the differences in survival according to treatment modalities were not statistically significant. The follow-up period ranged from 9 days to 130 months. The mean survival was 84.2 months. The overall five-year survival rate was 63%.

CONCLUSIONS

The majority of the cases here were T-cell lymphomas. Most histologic grading by Working formulation belonged to the intermediate grade. Optimal treatment for such a group of patients still has no consensus, but adequate local control is important. If diagnosed and treated early, primary sinonasal lymphomas can be associated with a favorable outcome even with local treatment alone.

Pharmaceutical services in the United States Air Force

The status of pharmaceutical services in the United States Air Force medical service is described. Air Force pharmacy is adopting new programs, staffing standards, inventory methods, and roles for pharmacists and technicians. One of the most visible changes is TRICARE, an interservice program that provides improved access to care. Many Air Force medical treatment facilities have been closed; prescription mail-out programs and networks of community pharmacies are filling the gap. The Air Force pharmacy team consists of more than 1300 pharmacists and technicians. Air Force pharmacists are military officers first. Great emphasis is placed on medical readiness training and continuing education. Some Air Force pharmacies are very small outpatient operations filling fewer than 300 prescriptions per day; others fill well over 4000. Many hospitals are being considered for more outpatient-focused operations. Because of anticipated minor reductions in pharmacist staffing, Air Force pharmacists will have to maximize efficiencies to maintain or improve current levels of service. More and better patient information will be provided and distributive processes streamlined. A greater role for technicians is anticipated. The future includes pharmacists serving in a wide variety of leadership and staff positions, improving the use of computers, and incorporating new technologies. Air Force pharmacy is changing to ensure uninterrupted fulfillment of its responsibilities.

Spontaneous remission in acute myelogenous leukemia: a case report

A 62-year-old woman with hypocellular acute myelogenous leukemia experienced spontaneous remission after repeated episodes of severe infections. Transient surge of profuse blasts in the peripheral blood was observed prior to the occurrence of spontaneous remission. The duration of the spontaneous remission was relatively short, and the disease relapsed five months later. A second complete remission was achieved after chemotherapy with low-dose cytosine arabinoside. The patient finally died of relapsed leukemia after a second remission of three year duration. Possible mechanisms implicated in the occurrence of spontaneous remission in this patient are discussed.

Prenatal and molecular diagnosis of hemophilia B

Prenatal diagnosis was carried out on a woman who had previously given birth to a son with a spontaneous mutation of C-->T transition at nt 31133 of the factor IX (F.IX) gene. The diagnosis was performed on chorionic villi sampling by the method of amplification-created restriction site (ACRS). It revealed a female fetus with a normal F.IX gene, as confirmed by DNA sequencing after delivery. Meanwhile, a survey using the ACRS method to evaluate the inheritance of 63 individuals from 8 hemophilia B families was done. A different single-point mutation in each family was proved by DNA sequencing. One individual had a mutation with a naturally-created restriction site. In each of the remaining patients, we were able to show an enzyme-cutting site in their DNA amplification product for ACRS with the designed mutagenesis primers. All patients and carriers could be diagnosed accurately by comparing ACRS results with clinical and laboratory findings. There were new novel mutations among the patients.

Three novel and one C31133T (Arg-338-->Stop) mutations of antihemophilic factor IX gene detected in Taiwan

BACKGROUND

Hemophilia-B is caused by mutation of the coagulation factor IX (F.IX) gene. The gene is about 34 kilobases in length and contains 8 exons ranging from 25 to 548 base pairs. There is no common mutation pattern of this gene in any population as there is in thalassemia. The hope is to localize the mutations in patients for use in making rapid familial surveys and for prenatal diagnoses.

METHODS

Diagnoses for a male patient with a newly-discovered mutation in Taiwan and three others with different novel mutations of F.IX gene were made from the results of prothrombin time (PT), activated partial thromboplastin time (APTT), assay of coagulation factors activity and factor IX antigen (F.IX:Ag) and also by assay of its inhibitor. The polymerase-chain-reaction (PCR)-based direct sequencing method was applied to evaluate all of the 8 exons and their flanking regions of F.IX gene for these patients.

RESULTS

The four male patients are all severe hemophilia-B. In the three patients with novel mutation of F.IX gene, two have a very low F.IX:Ag of less than 1% and one has 73%, but no one has any inhibitor. One of the four mutations is A to C transversion at nucleotide (nt) 10458 resulting in tyrosine (69) to serine change in epidermal growth factor (EGF) type B domain. Although the F.IX:Ag is present, the F.IX activity (F.IX:C) is markedly deficit owing to the change of beta-hydroxylase recognition site. Another two have mutations at the splicing junctions. They are G to C transversion at nt 118, i.e. the first base of IVS-1 splicing donor, and G to T transversion at nt 17668, the last base of IVS-4 splicing recipient. These mutations may cause splicing failure and subsequently result in deficiency of both F.IX activity and antigen. The other mutation that has never previously presented in this country is a C to T transition (arginine-338 to stop) at nt 31133 that results in early termination of translation.

CONCLUSIONS

The G to C mutation at nt 118 creates an Alu I restriction site and the C to T mutation at nt 31133 abolishes a Taq I site. Therefore, familial survey and rapid prenatal diagnosis for these patients by PCR-based direct sequencing method or by the restriction of enzyme cutting method pointing at the known mutation sites are certainly possible to achieve in our patients.

Parameters governing steam sterilization of deadlegs

Use of saturated steam for sterilization-in-place (SIP) is limited by factors effecting displacement of air from deadlegs. Effects of tube diameter, length, orientation and position within a deadleg were quantitatively studied by examining temperature profiles and rates of kill of Bacillus stearothermophilus spores. Tube diameter had the greatest effect on sterilization. For small diameter tubes, 0.4 cm inside diameter (ID), air displacement was minimal and due mainly to diffusion. 8.8 cm long tubes with 0.4 cm IDs could not be sterilized at 121 degrees C. As tube diameter was increased and buoyant driven convective flow became dominant over viscous forces, sterilization was achieved and tube orientation became critical. Sterilization time, as defined by a twelve log reduction in spore population, was 75 minutes in a 19.0 cm long vertical tube with 1.7 cm ID, whereas 167 minutes were required for an 8.8 cm long tube with 1.0 cm ID. For 8.8 cm long tubes, only the 1.7 cm ID tube could be sterilized when orientated 5 degrees above horizontal. Data show that length to diameter ratios, L/Ds, do not provide a general guideline which can be used to predict sterilization. In the absence of steam bleeders, equipment should be designed to assure strong buoyancy driven convective flow to assure adequate air removal. This requires elimination of small diameter deadlegs (0.4 cm ID and less) and vertical positioning of deadlegs.

Isolated extramedullary relapse of acute lymphoblastic leukemia presenting as an intraspinal mass

Leptomeningeal relapse is a common finding in acute lymphoblastic leukemia (ALL), but a solid intraspinal mass with cord compression as the sole site of extramedullary relapse is unusual. We report an adult patient with ALL, after 2 years of complete remission, who developed a spinal cord compression due to an intraspinal mass as a first manifestation of extramedullary relapse. Manifestation of first relapse in ALL presenting as an intraspinal mass is rare and may be added to other unusual extramedullary sites of relapse.