Autologous regulatory T-cell transfer in refractory ulcerative colitis with concomitant primary sclerosing cholangitis

OBJECTIVE

Ulcerative colitis (UC) is a chronic, debilitating immune-mediated disease driven by disturbed mucosal homeostasis, with an excess of intestinal effector T cells and an insufficient expansion of mucosal regulatory T cells (Tregs). We here report on the successful adoptive transfer of autologous, ex vivo expanded Tregs in a patient with refractory UC and associated primary sclerosing cholangitis (PSC), for which effective therapy is currently not available.

DESIGN

The patient received a single infusion of 1×10⁶ autologous, ex vivo expanded, polyclonal Tregs per kilogram of body weight, and the clinical, biochemical, endoscopic and histological responses were assessed 4 and 12 weeks after adoptive Treg transfer.

RESULTS

The patient showed clinical, biochemical, endoscopic and histological signs of response until week 12 after adoptive Treg transfer, which was associated with an enrichment of intestinal CD3⁺/FoxP3⁺ and CD3⁺/IL-10⁺ T cells and increased mucosal transforming growth factor beta and amphiregulin levels. Moreover, there was marked improvement of PSC with reduction of liver enzymes. This pronounced effect lasted for 4 weeks before values started to increase again.

CONCLUSION

These findings suggest that adoptive Treg therapy might be effective in refractory UC and might open new avenues for clinical trials in PSC.

TRIAL REGISTRATION NUMBER

NCT04691232.

Safety and tolerability of a single infusion of autologous ex vivo expanded regulatory T cells in adults with ulcerative colitis (ER-TREG 01): protocol of a phase 1, open-label, fast-track dose-escalation clinical trial

INTRODUCTION

Accumulating evidence suggests that the adoptive transfer of ex vivo expanded regulatory T cells (Treg) may overcome colitogenic immune responses in patients with inflammatory bowel diseases. The objective of the ER-TREG 01 trial is to assess safety and tolerability of a single infusion of autologous ex vivo expanded Treg in adults with ulcerative colitis.

METHODS AND ANALYSIS

The study is designed as a single-arm, fast-track dose-escalation trial. The study will include 10 patients with ulcerative colitis. The study intervention consists of (1) a baseline visit; (2) a second visit that includes a leukapheresis to generate the investigational medicinal product, (3) a third visit to infuse the investigational medicinal product and (4) five subsequent follow-up visits within the next 26 weeks to assess safety and tolerability. Patients will intravenously receive a single dose of 0.5×10⁶, 1×10⁶, 2×10⁶, 5×10⁶ or 10×10⁶ autologous Treg/kg body weight. The primary objective is to define the maximum tolerable dose of a single infusion of autologous ex vivo expanded Treg. Secondary objectives include the evaluation of safety of one single infusion of autologous ex vivo expanded Treg, efficacy assessment and accompanying immunomonitoring to measure Treg function in the peripheral blood and intestinal mucosa.

ETHICS AND DISSEMINATION

The study protocol was approved by the Ethics Committee of the Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (number 417_19 Az). In addition, the study was approved by the Paul-Ehrlich Institute, Federal Institute for Vaccines and Biomedicines, Langen, Germany (number 3652/01). The study is funded by the German Research Foundation (DFG, KFO 257 project 08 and SFB/TransRegio 241 project C04). The trial will be conducted in compliance with this study protocol, the Declaration of Helsinki, Good Clinical Practice and Good Manufacturing Practice. The results will be published in peer-reviewed scientific journals and disseminated in scientific conferences and media.

TRIAL REGISTRATION NUMBER

NCT04691232.

Management of meningeal solitary fibrous tumors/hemangiopericytoma; surgery alone or surgery plus postoperative radiotherapy?

INTRODUCTION

A meningeal solitary fibrous tumor (SFT), also called hemangiopericytoma, is a rare mesenchymal malignancy. Due to anatomic constrains, even after macroscopic complete surgery with curative intent, the local relapse risk is still relatively high, thus increasing the risk of dedifferentiation and metastatic spread. This study aims to better define the role of postoperative radiotherapy (RT) in meningeal SFTs.

PATIENTS AND METHODS

A retrospective study was performed across seven sarcoma centers. Clinical information was retrieved from all adult patients with meningeal primary localized SFT treated between 1990 and 2018 with surgery alone (S) compared to those that also received postoperative RT (S + RT). Differences in treatment characteristics between subgroups were tested using independent samples t-test for continuous variables and chi-square tests for proportions. Local control (LC) and overall survival (OS) rates were calculated as time from start of treatment until progression or death from any cause. LC and OS in groups receiving S or S + RT were compared using Kaplan-Meier survival curves.

RESULTS

Among a total of 48 patients, 7 (15%) underwent S and 41 (85%) underwent S + RT. Median FU was 65 months. LC was significantly associated with treatment. LC after S at 60 months was 60% versus 90% after S + RT (p = 0.052). Furthermore, R1 resection status was significantly associated with worse LC (HR 4.08, p = 0.038). OS was predominantly associated with the mitotic count (HR 3.10, p = 0.011).

CONCLUSION

This retrospective study, investigating postoperative RT in primary localized meningeal SFT patients, suggests that combining RT to surgery in the management of this patient population may reduce the risk for local failures.

Surgical Outcome and Oncological Survival of Osteofibrous Dysplasia-Like and Classic Adamantinomas: An International Multicenter Study of 318 Cases

BACKGROUND

Osteofibrous dysplasia-like adamantinoma (OFD-AD) and classic adamantinoma (AD) are rare, neoplastic diseases with only limited data supporting current treatment protocols. We believe that our retrospective multicenter cohort study is the largest analysis of patients with adamantinoma to date. The primary purpose of this study was to describe the disease characteristics and evaluate the oncological outcomes. The secondary purpose was to identify risk factors for local recurrence after surgical treatment and propose treatment guidelines.

METHODS

Three hundred and eighteen confirmed cases of OFD-AD and AD for which primary treatment was carried out between 1985 and 2015 were submitted by 22 tertiary bone tumor centers. Proposed clinical risk factors for local recurrence such as size, type, and margins were analyzed using univariable and multivariate Cox regression analysis.

RESULTS

Of the 318 cases, 128 were OFD-AD and 190 were AD. The mean age at diagnosis was 17 years (median, 14.5 years) for OFD-AD and 32 years (median, 28 years) for AD; 53% of the patients were female. The mean tumor size in the OFD-AD and AD groups combined was 7.8 cm, measured histologically. Sixteen percent of the patients sustained a pathological fracture prior to treatment. Local recurrence was recorded in 22% of the OFD-AD cases and 24% of the AD cases. None of the recurrences in the OFD-AD group progressed to AD. Metastatic disease was found in 18% of the AD cases and fatal disease, in 11% of the AD cases. No metastatic or fatal disease was reported in the OFD-AD group. Multivariate Cox regression analysis demonstrated that uncontaminated resection margins (hazard ratio [HR] = 0.164, 95% confidence interval [CI] = 0.092 to 0.290, p < 0.001), pathological fracture (HR = 1.968, 95% CI = 1.076 to 3.600, p = 0.028), and sex (female versus male: HR = 0.535, 95% CI = 0.300 to 0.952, p = 0.033) impacted the risk of local recurrence.

CONCLUSIONS

OFD-AD and AD are parts of a disease spectrum but should be regarded as different entities. Our results support reclassification of OFD-AD into the intermediate locally aggressive category, based on the local recurrence rate of 22% and absence of metastases. In our study, metastatic disease was restricted to the AD group (an 18% rate). We advocate wide resection with uncontaminated margins including bone and involved periosteum for both OFD-AD and AD.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The inter-rater reliability of the diagnosis of surgical site infection in the context of a clinical trial

OBJECTIVES

The diagnosis of surgical site infection following endoprosthetic reconstruction for bone tumours is frequently a subjective diagnosis. Large clinical trials use blinded Central Adjudication Committees (CACs) to minimise the variability and bias associated with assessing a clinical outcome. The aim of this study was to determine the level of inter-rater and intra-rater agreement in the diagnosis of surgical site infection in the context of a clinical trial.

MATERIALS AND METHODS

The Prophylactic Antibiotic Regimens in Tumour Surgery (PARITY) trial CAC adjudicated 29 non-PARITY cases of lower extremity endoprosthetic reconstruction. The CAC members classified each case according to the Centers for Disease Control (CDC) criteria for surgical site infection (superficial, deep, or organ space). Combinatorial analysis was used to calculate the smallest CAC panel size required to maximise agreement. A final meeting was held to establish a consensus.

RESULTS

Full or near consensus was reached in 20 of the 29 cases. The Fleiss kappa value was calculated as 0.44 (95% confidence interval (CI) 0.35 to 0.53), or moderate agreement. The greatest statistical agreement was observed in the outcome of no infection, 0.61 (95% CI 0.49 to 0.72, substantial agreement). Panelists reached a full consensus in 12 of 29 cases and near consensus in five of 29 cases when CDC criteria were used (superficial, deep or organ space). A stable maximum Fleiss kappa of 0.46 (95% CI 0.50 to 0.35) at CAC sizes greater than three members was obtained.

CONCLUSIONS

There is substantial agreement among the members of the PARITY CAC regarding the presence or absence of surgical site infection. Agreement on the level of infection, however, is more challenging. Additional clinical information routinely collected by the prospective PARITY trial may improve the discriminatory capacity of the CAC in the parent study for the diagnosis of infection.Cite this article: J. Nuttall, N. Evaniew, P. Thornley, A. Griffin, B. Deheshi, T. O'Shea, J. Wunder, P. Ferguson, R. L. Randall, R. Turcotte, P. Schneider, P. McKay, M. Bhandari, M. Ghert. The inter-rater reliability of the diagnosis of surgical site infection in the context of a clinical trial. Bone Joint Res 2016;5:347-352. DOI: 10.1302/2046-3758.58.BJR-2016-0036.R1.

MRI characteristics of nodular fasciitis of the musculoskeletal system

OBJECTIVE

To evaluate MRI imaging appearances of nodular fasciitis in a pathologic-proven series of 29 patients.

MATERIALS AND METHODS

Review of the orthopedic oncology and pathology databases yielded 51 cases of histologically proven nodular fasciitis. MR imaging was available in 29 patients. Three musculoskeletal radiologists retrospectively reviewed all cases in consensus. Imaging features evaluated included location in the body, size, compartmental localization, relationship to fascia, signal characteristics, enhancement pattern, transcompartmental extension, and osseous and intra-articular involvement.

RESULTS

There were 15 male and 14 female patients. Mean age was 33 years (range, 16-59 years). Lesions ranged in size from 1.6 to 9 cm with 84 % of lesions measuring less than 4 cm. Twenty-three lesions were located in the upper arm or shoulder girdle. Nine lesions were subcutaneous in location, nine were intra-muscular, and 11 were inter-muscular. Lesions were consistently ovoid in shape with broad fascial contact. They exhibited internal homogenous low T1 and heterogeneous intermediate T2 signal with surrounding edema and slightly inhomogeneous enhancement. Twelve lesions exhibited central non-enhancing areas. Trans-compartmental spread was demonstrated in nine lesions. Osseous changes were seen in five cases and included extrinsic cortical saucerization, medullary edema, and transcortical osseous invasion. Two lesions demonstrated intra-articular extension.

CONCLUSIONS

MR imaging features of nodular fasciitis are generally non-specific and can be mistaken for a soft tissue sarcoma. This series, the largest MRI series of musculoskeletal cases in the literature, confirms the predilection of nodular fasciitis for the upper extremity in young adults but also demonstrates that aggressive imaging features such as transcompartmental spread, and osseous and intra-articular involvement may be seen in association with this benign soft tissue lesion.

Clinical features, treatment, and outcome in 108 patients with localized, high-grade synovial sarcoma (SS)

10584

Background: There remains ongoing controversy in the treatment of localized SS, with no clear consensus on routine use of chemotherapy. Methods: Between 1986 and 2007, 93 adult (AP) and 15 pediatric (PP) patients were diagnosed with high grade, localized SS at 2 centres in Toronto. Clinical records and pathology reports were examined. Survival distribution functions were estimated by Kaplan-meier and compared using Log-rank test. Results: Median age for AP and PP was 36 (range 14–76) and 14 (range 0.4–18) years, respectively. Sixty-six (61%) patients had large tumours (> 5 cm), 7 (6.5%) had neuro-vascular invasion, and 10 (9.3%) had bone invasion. 76 (82%) AP and 8 (53%) PP received radiation (RT). 16 (17%) AP and 13 (87%) PP received chemotherapy. All patients underwent definitive surgery with gross total resection; 9 patients (8 PP) had positive margins. Some patients received neoadjuvant chemotherapy, and response was evaluable in 15 patients: 10 SD, 2 PR, 1 CR, 1 PD. Relapse occurred in 32 patients: 28 distant, 3 local only, 1 local + distant. With a median follow-up of 5.6 years, EFS and OS was 72 ± 4.6% and 82 ± 4.2%, respectively and was similar for AP and PP. Patients with tumours > 5 cm had significantly worse EFS (63 ± 6.5%) compared to patients with small tumours (88 ± 5.4%, p=0.02), as did those with bone invasion (47 ± 18 vs.75 ± 4.9, p=0.05). The effect of chemotherapy was assessed in the entire cohort. Of 29 who received chemotherapy, 9 (31%) relapsed, and of 79 who did not receive chemotherapy, 23 (29%) relapsed. In patients with tumours >5 cm, relapse occurred in 41% (7/17) of those who received chemotherapy compared to 37% (18/49) in those that received no chemotherapy. Conclusions: Patients with SS < 5 cm have an excellent chance of cure with surgery and RT. Large tumours and those with evidence of bone invasion have a poor outlook. It is unlikely that chemotherapy contributes to an improvement in survival in SS.

No significant financial relationships to disclose.

Multifocality and multifocal postradiation sarcomas

Hypothetically, any site in a radiation portal has potential for late malignant transformation. Secondary malignant neoplasms may occur after almost any index cancer has been treated with radiation and/or chemotherapy. The incidence of secondary malignant neoplasms, histopathology, time delay, radiation dose, cytotoxic agents, age and type of initial malignancy, and outcome all negatively impact cancer survivors. We highlight the new concept of multifocality, defined as greater than two noncontiguous second malignant neoplasms that develop in a prior radiation port. We identified 48 patients with postradiation sarcomas from three prospectively collected databases. Fifteen of these patients (31%) had evidence of multifocal postradiation sarcomas. Five of 10 women had multifocal postradiation sarcomas after breast-conserving surgery for carcinoma. The longer the time interval between the index cancer and post-radiation sarcoma, the greater the likelihood of multifocal malignant transformation occurring.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Cyclin D1 and p21 is elevated in the giant cells of giant cell tumors

Alterations of cell cycle regulatory proteins, especially those that regulate G1 to S transition, have been implicated in the pathogenesis of a wide variety of human tumors. In previous studies we showed that that there is overexpression of cyclin D1 protein predominately in the giant cell component of giant cell tumors of bone. The purpose of this study was to investigate the mechanisms that may be responsible for cyclin D1 accumulation in giant cell tumors. Giant cell tumors have high levels of cyclin D1 mRNA and the giant cell-enriched population of these tumors have significantly more mRNA and protein expression of cyclin D1 than the mononuclear cell population. The giant cells also expressed higher levels of p21 protein and more p21 bound to cyclin D1 than the mononuclear cells. It is possible that p21 may be contributing to the cyclin D1 accumulation that occurs in the giant cells and perhaps even giant cell formation in these tumors. Additional studies are required to confirm the role of p21 in the pathogenesis of these tumors.

A reconsideration of the domestication geography of tetraploid wheats

The domestication of tetraploid wheats started from their wild progenitor Triticum dicoccoides. In this paper, the geographical distribution of this progenitor is revised to include more sampling locations. The paper is based on a collection of wild and domesticated lines (226 accessions in total) analyzed by AFLP at 169 polymorphic loci. The collection includes the 69 wild lines considered by Mori et al. (2003) in their study on chloroplast DNA haplotypes of T. dicoccoides. The goal of the experiment was to reconsider which location thought to have generated the domesticated germplasm has the highest chance of being the actual site from which wild progenitors were sampled during domestication. Phylogenetic analysis of the nuclear AFLP databases indicates that two different genetic taxa of T. dicoccoides exist, the western one, colonizing Israel, Syria, Lebanon and Jordan, and the central-eastern one, which has been frequently sampled in Turkey and rarely in Iran and Iraq. It is the central-eastern race that played the role of the progenitor of the domesticated germplasm. This is supported by the cumulative results of the AFLP data from the collections of Ozkan et al. (2002) and of Mori et al. (2003), which indicate that the Turkish Karacadag population, intermixed with some Iraq-Iran lines, has a tree topology consistent with that of the progenitor of domesticated genotypes. The Turkish Kartal population belongs genetically to the central-eastern T. dicoccoides race but at the nuclear DNA level is less related to the domesticated gene pool. A general agreement between published work on tetraploid wheat domestication emerges from these results. A disagreement is nevertheless evident at the local geographical scale; the chloroplast DNA data indicate the Kartal mountains while AFLP fingerprinting points to the Karacadag Range as the putative site of tetraploid wheat domestication.

Comment on "AFLP data and the origins of domesticated crops"

We review some concepts and methods of handling and using DNA fingerprinting in phylogenetic analyses related to crop domestication. Particular reference is made to AFLP markers and mode and place of einkorn, barley, and tetraploid wheat domestication in the Neolithic by human communities in the Fertile Crescent. The reconsideration of AFLP databases of domesticated and wild lines demonstrates that phylogenetic tree topologies, originally described for the three species, match closely the new results obtained by principle coordinate analyse.

Analysis of eggplant ( Solanum melongena)-related germplasm: morphological and AFLP data contribute to phylogenetic interpretations and germplasm utilization

A total of 94 Solanum accessions, including eggplants and related species, were morphologically characterized based on greenhouse observations, and molecularly analysed by the AFLP technique. Morphological parameters were helpful in assessing similarities or differences among accessions, and molecular data were used to support morphological conclusions. A dendrogram was computed based on the Dice genetic distances using the neighbour-joining method. The analysis was efficient in the assignment of a species name for eight out of nine accessions that were not previously classified, and revealed that 14 further accessions were misnamed in the collection originally received. The results indicate that the taxonomy of Solanum sections and subgenera including several species should be reconsidered. The AFLP technique was revealed as an efficient tool in determining genetic relationships among species. In general, morphological observations were consistent with molecular data, indicating that both approaches complemented to define the phylogenetic status of a large genus like Solanum. In terms of eggplant breeding, the molecular analysis of the Melongena complex, and of the other sections of the subgenus Leptostemonum, establishes useful germplasm relationships in the gene pool available for the genetic improvement of the cultivated species. The results we have provided highlight an urgent necessity to include molecular parameters in handling and characterizing the genebank-deposited germplasm related to cultivated crops.

Preoperative radiotherapy is effective in the treatment of fibromatosis

The use of preoperative radiation is well-established for soft tissue sarcoma, but its use in fibromatosis is not well-characterized. The purpose of this study was to examine the impact of preoperative radiotherapy on the local control of fibromatosis and to assess treatment-related morbidity in this setting. In particular we assessed complication rates in comparison with soft tissue sarcoma treatment. All patients with fibromatosis referred to this unit who received preoperative radiotherapy (50 Gy in 25 fractions) from 1988 to 2000 and who had at least 2 years of followup were included in this study. The rate of recurrence in this group was ascertained. Similarly constructed datasets from all patients with soft tissue sarcomas of the extremities who received preoperative radiation from 1986 to 1997 also were analyzed. The rates of complications in the two groups were compared. Fifty-eight patients were treated with preoperative radiation for fibromatosis and the median followup was 69 months. There were 11 local recurrences (19%). Major wound complications manifested in two patients (3.4%). Wound-related complications arose in 89 of 265 patients with soft tissue sarcomas (33.5%). There was a significant difference in the rate of major wound complications observed in the two groups. The use of radiotherapy before surgery is effective in the combined treatment of fibromatosis.

Periosteal chondroid tumors: radiologic evaluation with pathologic correlation

OBJECTIVE

The purpose of this study was to determine whether the imaging features of periosteal chondroid tumors correlate with histopathology.

MATERIALS AND METHODS

Twenty-two patients (nine women and 13 men; mean age, 33 years) with pathologically proven periosteal chondroid lesions were retrospectively reviewed. The imaging modalities included conventional radiography (n = 17), CT (n = 10), and MR imaging (n = 14). The images were reviewed by two osteoradiologists, with agreement by consensus. Evaluation criteria included lesion location, mineralization, and size; periosteal reaction; and cortical response. Intramedullary extension, adjacent intramedullary edema, soft-tissue edema, and intrinsic characteristics were also evaluated on MR imaging. After the evaluation, a radiologic diagnosis of chondroma or chondrosarcoma was obtained. An experienced osteopathologist who was unaware of the patient's medical history and radiologic findings reviewed all histopathology. Agreement between the radiologic and the histopathologic diagnosis was tested using the kappa analysis. Imaging features were correlated with the pathologic findings, and a statistical analysis was performed.

RESULTS

Using strict pathologic criteria, we diagnosed 11 chondromas and 11 chondrosarcomas (nine, grade I; two, grade II). Moderate agreement was reached between the radiologic and the pathologic diagnosis (kappa = 0.55). The size of periosteal chondrosarcomas (range, 3-14 cm; median, 4 cm) was considerably larger than the size of the chondromas (range, 1-6.5 cm; median, 2.5 cm; p < 0.05). Other imaging features did not significantly correlate with benign versus malignant disease at pathology (all p > 0.05).

CONCLUSION

A variable overlap existed in the imaging appearances of benign and malignant periosteal chondroid lesions, with size being the most reliable indicator in distinguishing the two lesions. This and the fact that histologic differentiation of the entities can be difficult, suggests that surgical wide excision may be the most appropriate procedure in treating patients with lesions greater than 3 cm.

Functional evaluation in distal femoral endoprosthetic replacement for bone sarcoma

A multicenter study of successfully treated patients (mean age, 36.7 years) with a minimum 1-year followup (average, 35.4 months) after distal femoral endoprosthetic replacement for bone sarcoma was done using the 1987 and 1993 versions of the Musculoskeletal Tumor Society, the Short Form-36, and the Toronto Extremity Salvage Score functional evaluation criteria. Fifty-six patients (28 women and 28 men) fulfilled the criteria. Thirty-one Kotz prostheses (fixed hinge, uncemented) and 25 Modular Replacement System Prostheses (rotating hinge, cemented) were used. Thirty-five patients walked without aids, 19 used a cane, and two used crutches or a walker. The Musculoskeletal Tumor Society 1987 mean score was 28.1. The Musculoskeletal Tumor Society 1993 mean score was 80.4. The Toronto Extremity Salvage Score mean was 81.6. The Short Form-36 Physical Component Score had a mean of 43.2 and Mental Component Score mean of 54.2. The two groups of implants were comparable, except for the length of bone resection. Multivariate regression analysis revealed that patient age, existence of a pathologic fracture, and type of prosthesis all significantly accounted for differences in functional outcome as measured by the Musculoskeletal Tumor Society 1993, the Toronto Extremity Salvage Score, and the Short Form-36 Physical Component Score scales. Although both implants provided satisfactory function, the Musculoskeletal Tumor Society 1993 and the Toronto Extremity Salvage Score results were significantly better with the Modular Replacement System prosthesis. The effect of possible differences among surgeons or institutions was not addressed.

The expression of Met/hepatocyte growth factor receptor gene in giant cell tumors of bone and other benign musculoskeletal tumors

Overexpression of the hepatocyte growth factor receptor (Met/HGF receptor), a transmembrane tyrosine kinase encoded by the MET proto-oncogene, is involved in transformation and invasive behavior of human carcinomas and sarcomas. We have previously found that bone sarcomas express high levels of Met/HGF receptor while in some cases the ligand HGF is co-expressed with the receptor, activating an autocrine loop. In this study, we analyzed 40 biopsy samples of a collection of giant cell tumors and other rare benign tumors of bone for expression of the MET proto-oncogene. These included nonossifying fibromas, osteoblastomas, desmoplastic fibromas of bone, chondroblastomas, and giant cell tumors of bone. Snap frozen samples were tested for the MET and HGF gene expression by immuno-histochemistry and Western blotting with anti-MET antibodies and RT-PCR. Over 50% of all cases scored positive for MET expression being constantly positive in recurrent or locally aggressive lesions. Sporadic co-expression of the Met/HGF receptor and ligand is also demonstrated. Met/HGF receptor expression in benign bone neoplasms suggests its early involvement in sarcomagenesis.

MET oncogene aberrant expression in canine osteosarcoma

The objective of this study was to investigate the role of the MET oncogene in canine osteosarcoma. Seven large-breed dogs affected by spontaneous skeletal osteosarcoma underwent en bloc tumor excision. Total RNA was extracted from frozen tumor samples and assessed for expression of the MET oncogene by Northern blot analysis. Five of seven biopsy samples expressed high levels of the MET oncogene; its expression in the primary tumors was comparable with that previously identified in primary osteosarcomas in humans. A lung metastasis from one of the dogs expressed MET at a higher level than did its primary tumor. Spontaneously arising osteosarcoma in dogs clinically and pathologically mimics the corresponding disease in humans. We previously demonstrated that the MET oncogene was aberrantly expressed in a high percentage of human osteosarcomas. The results of the current study also provide a molecular parallel between the tumors in dogs and humans. This in vivo model may be helpful in evaluating new strategies for therapy against osteosarcoma.

The local management of soft tissue sarcoma

Soft tissue sarcomas (STS) are rare tumors arising from the connective tissues. STS can arise at any anatomic site, can demonstrate varied behavior and prognosis, and therefore present a formidable challenge in management. The local treatment of STS demands technical complexity in the application of diagnostic tools, including pathology and imaging, as well as treatment approaches, including surgical ablation and reconstruction, radiotherapy, and, in defined cases, chemotherapy. The understanding of the management of these lesions is profoundly dependent on the multidisciplinary setting, where experience has been gained and skills are available to increase the likelihood of a successful result. Several proven options are available for optimal local management, and the choice of approach depends on the prevailing practice and resource profile of the treating center. With modern approaches, the local control rate can be expected to be at least 90% for extremity lesions, which constitute the most common STS. The experience in other anatomic sites is less favorable as a result of a combination of late diagnosis, technically difficult access sites, and possibly less familiarity with these less common presentations. The disappointing results make it all the more important for patients to be referred to a multidisciplinary setting with experience in sarcoma management to maximize the chance of successful local outcome.

Molecular alterations in bone and soft-tissue sarcoma

Understanding the molecular alterations evident in human cancer offers the potential for more meaningful diagnosis and more accurate prediction of cancer risk as well as the hope of developing novel therapies. In this review, several of the molecular abnormalities identified in both bone and soft-tissue sarcoma are outlined. Some sarcomas exhibit consistent gene translocations, which produce a unique oncoprotein that can serve as a molecular fingerprint for the sarcoma subtype. Mutations in tumour suppressor genes result in cell proliferation that is not regulated by normal cell cycle control genes. Amplification (multiple copies) of genes that act as positive controls on cell division have a similar effect on increasing cell proliferation. Finally, the understanding of drug resistance and sarcoma response to signalling systems such as IGF ligand and receptors may help in designing new therapies based on molecular changes in the cancer.

EWS-FLI1 fusion transcript structure is an independent determinant of prognosis in Ewing's sarcoma

PURPOSE

More than 90% of Ewing's sarcomas (ES) contain a fusion of the EWS and FLI1 genes, due to the t(11;22)(q24;q12) translocation. At the molecular level, the EWS-FLI1 rearrangements show great diversity. Specifically, many different combinations of exons from EWS and FLI1 encode in-frame fusion transcripts and result in differences in the length and composition of the chimeric protein, which functions as an oncogenic aberrant transcription factor. In the most common fusion type (type 1), EWS exon 7 is linked in frame with exon 6 of FLI1. As the fundamental pathogenetic lesion in ES, the molecular heterogeneity of these fusion transcripts may have functional and clinical significance.

PATIENTS AND METHODS

We performed a clinical and pathologic analysis of 112 patients with ES in which EWS-FLI1 fusion transcripts were identified by reverse-transcriptase polymerase chain reaction (RT-PCR). Adequate treatment and follow-up data were available in 99 patients treated with curative intent. Median follow-up in these 99 patients was 26 months (range, 1 to 140 months). Univariate and multivariate survival analyses were performed that included other prognostic factors, such as age, tumor location, size, and stage.

RESULTS

Among the 99 patients suitable for survival analysis, the tumors in 64 patients contained the type 1 fusion and in 35 patients contained less common fusion types. Stage at presentation was localized in 74 patients and metastatic in 25. Metastases (relative risk [RR] = 2.6; P = .008), and type 1 EWS-FLI1 fusion (RR = 0.37; P = .014) were, respectively, independent negative and positive prognostic factors for overall survival by multivariate analysis. Among 74 patients with localized tumors, the type 1 EWS-FLI1 fusion was also a significant positive predictor of overall survival (RR = 0.32; P = .034) by multivariate analysis.

CONCLUSION

EWS-FLI1 fusion type appears to be prognostically relevant in ES, independent of tumor site, stage, and size. Further studies are needed to clarify the biologic basis of this phenomenon.

Expression of cytochrome P450 aromatase in the channel catfish, Ictalurus punctatus

The cDNA encoding the catfish ovarian aromatase has previously been isolated and described (accession number S75715). As demonstrated previously, the predicted amino acid sequence and enzymatic activity of the encoded protein share a significant degree of similarity to the forms of aromatase found in other vertebrates. Analyses utilizing reverse transcription coupled with the polymerase chain reaction (RT-PCR) demonstrate the expression of aromatase mRNA in catfish brain, testis and ovary. In spite of the evidence provided by Northern blot analysis for a single transcript encoding ovarian aromatase, RT-PCR analysis indicated transcript heterogeneity within the ovary, but not the testis or the brain. Although not characterized, PCR analysis indicated that the transcript complexity of ovarian aromatase was within the encoding region. Until this study, the expression of aromatase and its correlation with the reproductive physiology of fish had not been studied at the molecular level. In the catfish, significant changes in ovarian development were evident following elevation of plasma estradiol titers during October and again in February. Seasonal changes in the expression of ovarian aromatase and 3beta-hydroxysteroid dehydrogenase (3beta-HSD) mRNA was reflected in estradiol plasma titers. Ovarian expression of 3beta-HSD mRNA commenced a month before the message for aromatase was detected. Both transcripts were present from October to April. As the female approached the time of spawning (in May), the abundance of both aromatase and 3beta-HSD transcripts decreased. The aromatase message was not detected in post-spawning females but 3beta-HSD transcripts were evident. These data indicate that the timely synthesis of estradiol in catfish is caused by the regulation of both 3beta-HSD and aromatase.

Soft tissue sarcoma of the extremity. Limb salvage after failure of combined conservative therapy

PURPOSE

To assess the results of salvage therapy using surgery alone or surgery and re-irradiation for patients with locally recurrent extremity soft tissue sarcoma (STS) following conservative surgery and radiotherapy.

MATERIALS AND METHODS

25 patients with locally recurrent STS after conservative surgery and irradiation were assessed between 1990 and 1995. Two patients with concurrent systemic relapse were treated palliatively. Seven patients were not candidates for conservative re-excision and underwent amputation, 11 patients underwent conservative resection without irradiation. Seven of these patients relapsed, and five went on to receive combined conservative surgery and re-irradiation. A further five patients initially received combined retreatment, for a total of ten patients treated with combined conservative surgery and re-irradiation. Six of these ten patients were treated with brachytherapy alone, one with brachytherapy and external beam therapy, and three with external beam therapy alone. The median retreatment dose was 49.5 Gy (range 35-65 Gy), and the median cumulative soft tissue dose was 100 Gy (range 93-120 Gy).

RESULTS

The median follow-up from the most recent treatment is 24 months (range 7-42 months). At the last follow-up 14 patients are alive and disease free; two are alive with local disease and four with systemic disease, and five are dead of disease. Overall local control is 19/23 (91%). The local control for patients treated with conservative excision without irradiation is 4/11 (36%) and for conservative excision with re-irradiation 10/10 (100%). Six (60%) of these patients experienced significant post-irradiation would-healing complications, but three have recovered fully. Functional scores for the entire treated group are significantly lower after treatment, as are those for patients undergoing combined surgery and re-irradiation, but 70% of those treated with conservative surgery and re-irradiation and a good or excellent post-treatment functional score.

CONCLUSIONS

Combined conservative surgery and re-irradiation provided superior local control to local re-excision alone and a functional outcome superior to amputation. Combined treatment with re-irradiation should be considered the primary salvage therapy for patients who fail combined therapy and who are suitable for conservative re-excision. Systemic relapse is a significant problem, and optimal therapy should minimize the risk of local relapse after the initial therapy. Eighteen patients (72%) had a history of intralesional excision as their initial intervention, and suggests that inappropriate initial management is a risk factor for relapse after combined conservative therapy. Improvements in therapy must include the appropriate education of the primary care physicians.

Chordoma: long-term follow-up after radical photon irradiation

PURPOSE

To retrospectively analyze the long term results of treatment and the patterns of failure for patients with chordoma of the sacrum, base of skull and mobile spine treated predominantly with postoperative photon irradiation.

MATERIALS AND METHODS

Forty-eight adult patients with chordoma of the sacrum (23), base of skull (20) or mobile spine (5), were seen between 1958-1992. Forty-four were referred post operatively with overt disease and 31 of these were irradiated with conventionally fractionated radiation to a median dose of 50 Gy/25 fractions/5 weeks (range 25-60 Gy). Eight received a hyperfractionation protocol of 1 Gy, 4 hourly, 4 times a day (median 40 Gy/44 fractions/14 days), two sacral patients were treated with a hypofractionation protocol and three cases with skull base tumours were referred elsewhere for proton therapy. Endpoints measured were survival from diagnosis, objective response rate, symptomatic response rate and clinical or radiological progression-free survival from radiotherapy.

RESULTS

Median survival was 62 months (range 4-240 month) from diagnosis with no difference between clival and non-clival presentations. One complete and no partial responses were identified in 23 assessable patients. A subjective response was recorded for 12/14 (85%) with pain and 10/23 (45%) with neurological signs or symptoms, and the median time to progression for those with overt disease was 35 months (range 5-220 months). There was no survival advantage to patients receiving radiation doses > 50 Gy (median 60 Gy) compared to doses < 50 Gy (median 40 Gy). There was no difference between the conventional or hyperfractionation regimens with respect to the degree or duration of symptomatic response, or in progression-free survival. Fourteen patients who progressed after irradiation were retreated with surgery (6), irradiation (7) or both modalities (1). Median survival after retreatment was 18 months, and the only two symptomatic responses seen were with reirradiation, and after failure of relatively low dose initial therapy. At last follow-up, 35 were dead of or with disease, seven are alive with disease, and two are disease-free. Thirty-eight had local disease persistence as the sole site of failure, and four developed distant metastases initially or subsequently.

DISCUSSION

Overt residual chordoma is rarely cured with conventional external beam irradiation, but treatment does provide useful and prolonged palliation of pain for most patients. Chordoma is a disease with low metastatic potential, and better local control may improve survival. Complete resection rates may be improved for patients with sacral disease by using planned excisions in centres experienced in treating this rare disease. Because radiation therapy may prove to be more successful in controlling microscopic disease, it should be considered as a pre- or postoperative adjuvant to a macroscopically complete resection. Patients with skull base disease should also be resected in centres specializing in this surgery, but complete excision is unlikely. These patients will not obtain local control with conventional photon irradiation, and suitable patients should be considered for irradiation with stereotactic photon or particle beam therapy. For patients who progress after irradiation, there is limited symptomatic benefit to retreatment with surgery or reirradiation, and this should be limited to treating life-threatening complications.

Residual disease following unplanned excision of soft-tissue sarcoma of an extremity

Sixty-five patients who had been referred to our unit for additional management after an unplanned excision of a soft-tissue sarcoma of an extremity at another institution were studied retrospectively to determine the prevalence of residual tumor and to identify factors that predict which patients will have a tumor following such an excision. Unplanned excision was defined as excisional biopsy or unplanned resection of the lesion without benefit of preoperative imaging and without regard for the necessity to resect the lesion with a margin of normal tissue. In each patient, histological evaluation of the specimen removed at the unplanned excision had demonstrated positive resection margins, but postoperative physical examination on our unit revealed no gross evidence of residual tumor and no tumor was identified on cross-sectional imaging of the local site. Patients who had evidence of residual disease on physical examination or on imaging were thought to have definite evidence of sarcoma at the site of the operative wound and were therefore excluded from the study. After multidisciplinary consultation, all patients had a repeat resection at our cancer center. Extensive pathological sampling of the specimen from this second procedure was carried out, with sections obtained at mean intervals of 1.2 +/- 0.7 centimeters. Nodules initially thought to indicate disease were identified grossly in twenty-seven (42 percent) of the sixty-five patients, but histological evaluation confirmed the presence of tumor in only sixteen (59 percent). Histological evidence of sarcoma was identified in seven additional patients in whom gross nodules were not apparent in the specimen. Thus, sarcoma was identified in a total of twenty-three (35 percent) of the sixty-five patients. The mean duration of follow-up was forty-six months (range, twenty-four to eighty months; median, thirty-nine months). The margins of the second resection were positive in nine (39 percent) of the twenty-three patients who had residual sarcoma. Five (22 percent) of the twenty-three had a local recurrence. Four of the five patients who had a local recurrence had positive margins on repeat resection. This rate of local recurrence (five of twenty-three patients) was significantly higher than that in the remainder of our patients who had a soft-tissue sarcoma of an extremity (sixteen [7 percent] of 227) (p = 0.03). There was no association between the detection of sarcoma at the second procedure and the initial size or grade of the tumor, the use of irradiation preoperatively, or the interval between the initial, unplanned excision and referral to our cancer center. These data indicate that it is not possible to predict which patients will have residual tumor at the site of the operative wound. Therefore, it is prudent to advise repeat excision for all patients who have had an unplanned excision of a soft-tissue sarcoma of an extremity. Unplanned excision complicates decision-making in the treatment of this disease and should be avoided.

A scale for predicting nonphysiological contributions to pain

BACKGROUND

Waddell and colleagues have identified a series of nonorganic signs which may appear in low back pain patients. The occurrence of these signs helps predict nonphysiological factors in the etiology of the pain. This study describes the development of the Waddell Equivalency Scale (WES) which elicits comparable information from patients with pain at other sites.

METHODS

One hundred fifty patients presenting to a comprehensive pain clinic with low back pain were evaluated by physicians for Waddell signs and by psychologists using the Pain Presentation Inventory (PPI) developed by Psychometric Designs Inc. From three scales of the PPI, correlation, analysis of variance and multiple regression identified a formula which predicted Waddell signs from the PPI. The study was replicated on a new sample of 150 patients with almost identical results. The two samples were combined, again with highly similar results. An interpretive scheme was devised for use of the WES scale.

RESULTS

The WES score derived from three scales of the PPI predicts the number of Waddell signs elicited from low back pain patients. Since it comes from a paper-and-pencil test rather than a physical examination, it can be used with patients whose pain locus is other than the back.

CONCLUSIONS

Behavioral expectations and treatment plans, à la Waddell, can now be applied to patients with other than low back pain. Clinical application of the WES information over a variety of pain populations will be required to determine the parameters of its usefulness.

A Pain Rating Scale and a Pain Behavior Checklist for clinical use: development, norms, and the consistency score

A Pain Rating Scale [PRS] and a Pain Behavior Checklist [PBC] were developed for use during a clinical pain interview. Norms were based on 395 chronic pain patients referred for pain management. The PRS obtained ratings of present pain, and worst and least pain during the previous 30 days. The PBC recorded 16 pain behaviors during the 45- to 60-min interview. Normative data were given for seven measures: (1) worst pain rating, past month; (2) least pain rating, past month; (3) present pain rating; (4) difference between worst and least pain ratings; (5) pain behavior score; (6) total pain score (based on Nos. 1, 2, 3, and 5), and (7) consistency score. The consistency score reflects the agreement (or discrepancy) between the pain behavior and present pain ratings. A moderate overall relationship was found between pain behavior and present pain ratings (r = 0.46, p < 0.001). The frequency of good agreement between pain behavior and present pain ratings was unaffected by sex, race, age, pain site, type of injury, duration of pain, legal representation, and evaluating psychologist; but it varied markedly with conscious symptom magnification. Patients seen as consciously exaggerating pain (n = 127) gave higher pain ratings (all p values < 0.001); and had frequent (64.6%) discrepancies between their pain report and pain behavior compared to others (14.2%). The report of present pain was unrelated to pain behavior for conscious exaggerators (r = 0.04, NS); in contrast there was a moderately high relationship for other patients (r = 0.68, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic course of anxiety disorders in children and adolescents

In a naturalistic study that assessed the lifetime psychiatric histories of 275 children ascertained independently of diagnostic or treatment-seeking behavior, 38 (14%) of the children had a history of anxiety disorder. Rates of comorbidity of depression and other psychiatric disorders were high. Life table estimates of the duration of illness indicate a more protracted time to recover than expected, because 46% would be ill for at least 8 years. Moreover, of those who recovered from their first episode of anxiety disorder, many had experienced recurrence before interview. After conducting pooled analyses, investigators performed separate analyses for children with separation disorder and overanxious disorder. Median age of onset of these conditions was surprisingly young: 10 years of age for overanxious disorder and 8 years of age for separation disorders.

The disruptive behavioral disorder in children and adolescents: comorbidity and clinical course

Comorbidity, time to recovery, rate of chronicity, and probability of recurrence following recovery were studied in 51 children diagnosed with attention deficit disorder, conduct disorder, and oppositional defiant disorder. Thirty-three percent of the children had two of the above diagnoses, and one child had all three diagnoses. The mean duration of attention deficit disorder was 8 years up to the time of the interview; the mean duration of oppositional defiant disorder was 4.5 years, and the mean duration of conduct disorder was 3 years. Life-table estimates showed that 14% of the children would not have recovered 15 years after the onset of their disorder. Rates of recurrence were high following recovery from each of these disorders.

Clinical course and outcome of substance abuse disorders in adolescents

Seven percent (19 of 275) of children and adolescents not ascertained for seeking treatment received a DSM-III diagnosis of alcohol or drug use disorder. Their entire families were recruited into a research program designed to study the risk to offspring of parental psychopathology. The ages of those diagnosed were between 12 and 18 years. The drug and alcohol use disorders had a mean duration of 2 years, and the adolescents who remitted had a high likelihood of developing subsequent psychopathology. These adolescents also showed high rates of other psychiatric disorders. A high rate of alcoholism was found among their parents.

Depression in children and adolescents: new data on 'undertreatment' and a literature review on the efficacy of available treatments

This article reports on the treatment received by 38 adolescents during an episode of major depression which had a median duration of 4 months. The one subject who received any pharmacologic treatment was prescribed an antianxiety agent. Sixteen percent received psychotherapy. These results are consistent with evidence from studies of adults indicating that depression is underrecognized and undertreated. An important caveat is that the small sample size limits the generalizability of these findings. Moreover, which medication should be prescribed when a diagnosis of depression is made is not yet known with certainty, as literature reviews indicate that more controlled trials of psychotherapeutic and psychopharmacologic treatments for adolescents with depression are needed to better understand the efficacy of treating depressed adolescents.

Human glomerular mesangial cells inactivate leukotriene B4 by reduction into dihydro-leukotriene B4 metabolites

Due to its potent chemotactic properties leukotriene B4 is an important mediator of inflammatory reactions. Cultured human kidney mesangial cells converted exogenously added leukotriene B4 efficiently into three different more lipophilic metabolites, two of them probably representing dihydro-leukotriene B4 isomers. This represents an alternative metabolic pathway, in contrast to leukotriene B4 omega-oxidation found in human polymorphonuclear leukocytes. Both dihydro-leukotriene B4 isomers had nearly completely lost their ability to induce leukocyte chemotaxis as compared to leukotriene B4.

Multidimensional analysis of peak pain symptoms and experiences

Peak pain symptoms and experiences were explored within a group of 243 intractable pain patients seen consecutively at a pain clinic. Using a 5-point scale, patients rated the frequency with which 99 symptom adjectives occurred when their pain was at its worst. Key cluster analysis identified 11 reliable, conceptually clear symptom clusters: Four affective symptom categories, Angry Depression, Diminished Drive, Intropunitive Depression and Anxiety, describing emotional states concomitant with peak pain; two somatic symptom categories, Ecto-Pain and Endo-Pain, describing surface and deep bodily pain, respectively; and five additional symptom categories including Cognitive Dysfunction, Sleep Disturbance, Fatigue, Withdrawal and Disequilibrium. Among the affective symptom clusters, symptoms of Angry Depression were reported to occur frequently by 32% of the patients while only 11% reported the frequent occurrence of Intropunitive Depression. For the somatic symptom clusters, 25 and 52% reported the frequent occurrence of Ecto-Pain and Endo-Pain, respectively. Pain reports measured by Ecto-Pain and Endo-Pain were nearly independent of all other symptom categories. The results suggest that the experiential context of pain differs widely among intractable pain patients. The study derived a Pain Symptom Checklist to measure each symptom cluster as one way to identify coping styles among chronic pain patients.

Course of major depression in non-referred adolescents: a retrospective study

This article reports on a naturalistic study of the course of illness of 38 children diagnosed as having a current or past episode of major depression out of a sample of 275 children who were selected by a method not related to their psychopathology or treatment-seeking behavior. Assessments of the presence of depression and the course of this disorder were made using structured clinical interviews (DICA and DICA-P) and a criterion-based diagnostic system (DSM-III). Longitudinal methods of data analysis included the use of life tables. The proportion of children depressed for 2 years closely resembles the results found in investigations of children who sought treatment for a psychiatric disorder. The probability of remaining depressed in these children was 21% at 1 year after onset, and 10% at the 2-year point. This parallels the rate of chronicity and the decline in rates of recovery which occur over time in adult depression.