SPOP the mutation

Prostate cancers with mutations to a protein called SPOP use an error-prone method to repair broken DNA strands.

Coordinate loss of MAP3K7 and CHD1 promotes aggressive prostate cancer

Prostate cancer subtypes are poorly defined and functional validation of drivers of ETS rearrangement-negative prostate cancer has not been conducted. Here, we identified an ETS(-) subtype of aggressive prostate cancer (ERG(-)MAP3K7(del)CHD1(del)) and used a novel developmental model and a cell line xenograft model to show that cosuppression of MAP3K7 and CHD1 expression promotes aggressive disease. Analyses of publicly available prostate cancer datasets revealed that MAP3K7 and CHD1 were significantly codeleted in 10% to 20% of localized tumors and combined loss correlated with poor disease-free survival. To evaluate the functional impact of dual MAP3K7-CHD1 loss, we suppressed Map3k7 and/or Chd1 expression in mouse prostate epithelial progenitor/stem cells (PrP/SC) and performed tissue recombination experiments in vivo. Dual shMap3k7-shChd1 PrP/SC recombinants displayed massive glandular atypia with regions of prostatic intraepithelial neoplasia and carcinoma apparent. Combined Map3k7-Chd1 suppression greatly disrupted normal prostatic lineage differentiation; dual recombinants displayed significant androgen receptor loss, increased neuroendocrine differentiation, and increased neural differentiation. Clinical samples with dual MAP3K7-CHD1 loss also displayed neuroendocrine and neural characteristics. In addition, dual Map3k7-Chd1 suppression promoted E-cadherin loss and mucin production in recombinants. MAP3K7 and CHD1 protein loss also correlated with Gleason grade and E-cadherin loss in clinical samples. To further validate the phenotype observed in the PrP/SC model, we suppressed MAP3K7 and/or CHD1 expression in LNCaP prostate cancer cells. Dual shMAP3K7-shCHD1 LNCaP xenografts displayed increased tumor growth and decreased survival compared with shControl, shMAP3K7, and shCHD1 xenografts. Collectively, these data identify coordinate loss of MAP3K7 and CHD1 as a unique driver of aggressive prostate cancer development.

Abstract 445: Coordinate loss of CHD1 and MAP3K7 promotes aggressive prostate cancer

The genomic complexity of prostate cancer contributes to disease progression, resistance to therapy, and development of metastases. The genes CHD1 and MAP3K7 are signficantly co-deleted in 10-15% of primary tumors and combined loss of CHD1 and MAP3K7 expression is associated with poor disease-free survival. We recently validated MAP3K7 as a prostate tumor suppressor, but CHD1's role in prostate tumorigenesis has not been evaluated. In this study, we used a mouse prostate epithelial stem cell (PrP/SC) model and a human prostate cancer cell line (LNCaP) model to investigate how loss of CHD1 alone or in combination with MAP3K7 suppression affects prostate tumorigenesis. Suppression of Map3k7 increased proliferation of PrP/SCs. Chd1 suppression decreased growth of wildtype PrP/SCs but not PrP/SCs already deficient in Map3k7 expression. Similarly, suppression of CHD1 in LNCaP cells decreased proliferation when MAP3K7 expression was present, but not when MAP3K7 was suppressed. These data suggest that loss of CHD1 alone is deleterious to growth, but that MAP3K7 suppression can compensate for this growth inhibition. Chd1 and Map3k7-deficient PrP/SCs were then evaluated in vivo using tissue recombination. When Chd1-deficient PrP/SCs were recombined with fetal rat urogenital mesenchyme (rUGM) and implanted under the renal capsules of immunocompromised mice, grafts contained mostly benign glandular tissue with focal areas of mild hyperplasia/prostatic intraepithelial neoplasia (PIN). A few nuclear abnormalities were observed. Map3k7-deficient recombinants generated a mixture of benign tissue, PIN, and adenocarcinoma (consistent with our previous findings). The nuclear morphology of these grafts was unremarkable. Strikingly, dual Chd1-Map3k7 knockdown recombinants displayed massive glandular atypia with glands completely filled with AR-negative and p63-negative cells. These cells had large nuclei, prominent nucleoli, and abundant cytoplasm. Tumorigenicity of CHD1 and/or MAP3K7-deficient LNCaP cells was also assessed by subcutaneous implantation of cells into immunocompromised mice. Mice implanted with CHD1-deficient xenografts formed smaller tumors and had increased survival relative to mice injected with control LNCaP cells (p=0.0083). MAP3K7-deficient xenografts were similar in size and in survival rate compared to control LNCAP cells. Dual CHD1-MAP3K7 deficient xenografts, in contrast, showed increased tumor growth and decreased survival relative to control (p=0.0242), MAP3K7 alone (p=0.0462) and CHD1 alone (p=0.0002). Collectively, these data suggest that loss of CHD1 alone is anti-tumorigenic but that combined loss of CHD1 and MAP3K7 drives aggressive prostate cancer development.

Citation Format: Lindsey Ulkus, Leah Rider, Cera Nieto, Lina Romero, Haitao Chen, Massimo Loda, Wennuan Liu, Jianfeng Xu, Scott Cramer. Coordinate loss of CHD1 and MAP3K7 promotes aggressive prostate cancer. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 445. doi:10.1158/1538-7445.AM2014-445

Lipid catabolism via CPT1 as a therapeutic target for prostate cancer

Prostate cancer is the most commonly diagnosed malignancy among Western men and accounts for the second leading cause of cancer-related deaths. Prostate cancer tends to grow slowly and recent studies suggest that it relies on lipid fuel more than on aerobic glycolysis. However, the biochemical mechanisms governing the relationships between lipid synthesis, lipid utilization, and cancer growth remain unknown. To address the role of lipid metabolism in prostate cancer, we have used etomoxir and orlistat, clinically safe drugs that block lipid oxidation and lipid synthesis/lipolysis, respectively. Etomoxir is an irreversible inhibitor of the carnitine palmitoyltransferase (CPT1) enzyme that decreases β oxidation in the mitochondria. Combinatorial treatments using etomoxir and orlistat resulted in synergistic decreased viability in LNCaP, VCaP, and patient-derived benign and prostate cancer cells. These effects were associated with decreased androgen receptor expression, decreased mTOR signaling, and increased caspase-3 activation. Knockdown of CPT1A enzyme in LNCaP cells resulted in decreased palmitate oxidation but increased sensitivity to etomoxir, with inactivation of AKT kinase and activation of caspase-3. Systemic treatment with etomoxir in nude mice resulted in decreased xenograft growth over 21 days, underscoring the therapeutic potential of blocking lipid catabolism to decrease prostate cancer tumor growth.

PAK1 regulates breast cancer cell invasion through secretion of matrix metalloproteinases in response to prolactin and three-dimensional collagen IV

p21-Activated serine-threonine kinase (PAK1) is implicated in breast cancer. We have shown previously that PAK1 is tyrosyl phosphorylated by prolactin (PRL)-activated Janus tyrosine kinase (JAK2). Although a role for both PRL and PAK1 in breast cancer is widely acknowledged, the mechanism remains poorly understood. In the present study, PRL-activated PAK1 stimulates the invasion of TMX2-28 human breast cancer cells through Matrigel. Three-dimensional (3D) collagen IV stimulates the secretion of the matrix proteases, metalloproteinase (MMP)-1 and -3 that is further enhanced by the PRL-dependent tyrosyl phosphorylation of PAK1. 3D collagen IV also stimulates the expression and secretion of MMP-2, but in contrast to MMP-1 and -3, PRL/PAK1 signaling down-regulates MMP-2 expression and secretion. In contrast, MMP-9 expression and secretion are stimulated by 3D collagen I, not collagen IV, and are not affected by PRL but are down-regulated by PAK1. MMP-1 and -3 are required and MMP-2 contributes to PRL-dependent invasion. ERK1/2 signaling appears to be required for the enhanced expression and secretion of MMP-1 and -3 and enhanced PRL-dependent invasion. p38 MAPK and c-Jun N-terminal kinase 1/2 pathways participate in production of MMP-1 and -3 as well as in PRL/PAK1-dependent cell invasion. Together, these data illustrate the complex interaction between the substratum and PRL/PAK1 signaling in human breast cancer cells and suggest a pivotal role for PRL-dependent PAK1 tyrosyl phosphorylation in MMP secretion.

Tyrosyl phosphorylated PAK1 regulates breast cancer cell motility in response to prolactin through filamin A

The p21-activated serine-threonine kinase (PAK1) is activated by small GTPase-dependent and -independent mechanisms and regulates cell motility. Both PAK1 and the hormone prolactin (PRL) have been implicated in breast cancer by numerous studies. We have previously shown that the PRL-activated tyrosine kinase JAK2 (Janus tyrosine kinase 2) phosphorylates PAK1 in vivo and identified tyrosines (Tyr) 153, 201, and 285 in the PAK1 molecule as sites of JAK2 tyrosyl phosphorylation. Here, we have used human breast cancer T47D cells stably overexpressing PAK1 wild type or PAK1 Y3F mutant in which Tyr(s) 153, 201, and 285 were mutated to phenylalanines to demonstrate that phosphorylation of these three tyrosines are required for maximal PRL-dependent ruffling. In addition, phosphorylation of these three tyrosines is required for increased migration of T47D cells in response to PRL as assessed by two independent motility assays. Finally, we show that PAK1 phosphorylates serine (Ser) 2152 of the actin-binding protein filamin A to a greater extent when PAK1 is tyrosyl phosphorylated by JAK2. Down-regulation of PAK1 or filamin A abolishes the effect of PRL on cell migration. Thus, our data presented here bring some insight into the mechanism of PRL-stimulated motility of breast cancer cells.

PAK1-Nck regulates cyclin D1 promoter activity in response to prolactin

Prolactin (PRL) is critical for alveolar proliferation and differentiation in normal mammary development and is also implicated in breast cancer. PRL influences cell proliferation and growth by altering the expression of cyclin D1. Cyclin D1 expression is directly regulated by PRL through the Janus kinase 2 (JAK2)/signal transducer and activator of transcription 5-mediated transcriptional activation of the cyclin D1 promoter. A p21-activated serine-threonine kinase (PAK)1 has also been implicated in the regulation of cyclin D1 gene expression. We have previously demonstrated that JAK2 directly phosphorylates PAK1 and extend these data here to demonstrate that PAK1 activates the cyclin D1 promoter in response to PRL. We show that mutation of PAK1 Tyr 153, 201, and 285 (sites of JAK2 phosphorylation; PAK1 Y3F) decreases both PAK1 nuclear translocation in response to PRL and PRL-induced cyclin D1 promoter activity by 55%. Mutation of the PAK1 nuclear localization signals decreases PRL-induced cyclin D1 promoter activity by 46%. A PAK1 Y3F mutant lacking functional nuclear localization signals decreases PRL-induced cyclin D1 activity by 68%, suggesting that there is another PAK1-dependent mechanism to activate the cyclin D1 promoter. We have found that adapter protein Nck sequesters PAK1 in the cytoplasm and that coexpression of both PAK1 and Nck inhibits the amplifying effect of PRL-induced PAK1 on cyclin D1 promoter activity (95% inhibition). This inhibition is partially abolished by disruption of PAK1-Nck binding. We propose two PAK1-dependent mechanisms to activate cyclin D1 promoter activity in response to PRL: via nuclear translocation of tyrosyl-phosphorylated PAK1 and via formation of a Nck-PAK1 complex that sequesters PAK1 in the cytoplasm.

Adapter protein SH2B1beta binds filamin A to regulate prolactin-dependent cytoskeletal reorganization and cell motility

Prolactin (PRL) regulates cytoskeletal rearrangement and cell motility. PRL-activated Janus tyrosine kinase 2 (JAK2) phosphorylates the p21-activated serine-threonine kinase (PAK)1 and the Src homology 2 (SH2) domain-containing adapter protein SH2B1β. SH2B1β is an actin-binding protein that cross-links actin filaments, whereas PAK1 regulates the actin cytoskeleton by different mechanisms, including direct phosphorylation of the actin-binding protein filamin A (FLNa). Here, we have used a FLNa-deficient human melanoma cell line (M2) and its derivative line (A7) that stably expresses FLNa to demonstrate that SH2B1β and FLNa are required for maximal PRL-dependent cell ruffling. We have found that in addition to two actin-binding domains, SH2B1β has a FLNa-binding domain (amino acids 200-260) that binds directly to repeats 17-23 of FLNa. The SH2B1β-FLNa interaction participates in PRL-dependent actin rearrangement. We also show that phosphorylation of the three tyrosines of PAK1 by JAK2, as well as the presence of FLNa, play a role in PRL-dependent cell ruffling. Finally, we show that the actin- and FLNa-binding-deficient mutant of SH2B1β (SH2B1β 3Δ) abolished PRL-dependent ruffling and PRL-dependent cell migration when expressed along with PAK1 Y3F (JAK2 tyrosyl-phosphorylation-deficient mutant). Together, these data provide insight into a novel mechanism of PRL-stimulated regulation of the actin cytoskeleton and cell motility via JAK2 signaling through FLNa, PAK1, and SH2B1β. We propose a model for PRL-dependent regulation of the actin cytoskeleton that integrates our findings with previous studies.

Adapter protein SH2B1beta cross-links actin filaments and regulates actin cytoskeleton

The Src homology 2 (SH2) domain-containing adapter protein SH2B1beta plays a role in severe obesity, leptin and insulin resistance, and infertility. SH2B1beta was initially identified as a Janus tyrosine kinase 2 (JAK2) substrate, and it has been implicated in cell motility and regulation of the actin rearrangement in response to GH and platelet-derived growth factor. SH2B1beta is also required for maximal actin-based motility of Listeria. Here we have used a low-speed pelleting assay and electron microscopy to demonstrate that SH2B1beta has two actin-binding sites and that it cross-links actin filaments in vitro. Wild-type SH2B1beta localized to cell ruffles and along filopodia, but deletion of amino acids 150-200 (the first actin-binding site) led to mislocalization of the protein to filopodia tip complexes where it colocalized with vasodilator-stimulated phosphoprotein (VASP). Based on studies performed in VASP-deficient MVD7(-/-) cells, with or without green fluorescent protein-VASP reconstitution, we concluded that the proper intracellular localization of native SH2B1beta required the presence of the first SH2B1beta actin-binding site and VASP. Finally, we found that both SH2B1beta actin-binding domains were required for maximal GH- and prolactin-induced cell ruffling. Together, these results suggest that SH2B1beta functions as an adapter protein that cross-links actin filaments, leading to modulation of cellular responses in response to JAK2 activation.

JAK2 Tyrosine Kinase Phosphorylates PAK1 and Regulates PAK1 Activity and Functions

The serine-threonine kinase PAK1 is activated by small GTPase-dependent and -independent mechanisms and promotes cell survival. However, the role of tyrosyl phosphorylation in the regulation of PAK1 function is poorly understood. In this study, we have shown that the prolactin-activated tyrosine kinase JAK2 phosphorylates PAK1 in vivo. Wild type, but not kinase-dead, JAK2 directly phosphorylates PAK1 in cells and in an in vitro kinase assay. PAK1 tyrosines 153, 201, and 285 were identified as sites of JAK2 tyrosyl phosphorylation by mass spectrometry and two-dimensional peptide mapping. Mutation of PAK1 tyrosines 153, 201, and 285 to phenylalanines individually or in combination implicated these PAK1 tyrosines in the regulation of PAK1 kinase activity. Tyrosyl phosphorylation by JAK2 significantly increases PAK1 kinase activity, whereas similar phosphorylation of the PAK1 Y153F,Y201F,Y285F mutant has no effect on PAK1 activity. Tyrosyl phosphorylation of wild type PAK1 decreases apoptosis induced by serum deprivation and staurosporine treatment and increases cell motility. In contrast, these parameters are unaltered in the PAK1 Y153F,Y201F,Y285F mutant. Our findings indicate that JAK2 phosphorylates PAK1 at these specific tyrosines and that this phosphorylation plays an important role in cell survival and motility.

International consensus outcome measures for patients with idiopathic inflammatory myopathies. Development and initial validation of myositis activity and damage indices in patients with adult onset disease

OBJECTIVE

To devise new tools to assess activity and damage in patients with idiopathic myopathies (IIM).

METHODS

An international multidisciplinary consensus effort to standardize the conduct and reporting of the myositis clinical trials has been established. Two tools, known as the myositis intention to treat index (MITAX) and the myositis disease activity assessment visual analogue scale (MYOACT), have been developed to capture activity in patients with IIM. In addition, the myositis damage index (MDI) has been devised to assess the extent and severity of damage developing in different organs and systems. These measures have been reviewed by the myositis experts participating in the International Myositis Assessment and Clinical Studies (IMACS) group and have been found to have good face validity and to be comprehensive. The instruments were assessed in two real patient exercises involving patients with adult dermatomyositis and inclusion body myositis.

RESULTS

The reliability of MITAX, MYOACT and MDI, measured by the intraclass correlation coefficient among the physicians, and the inter-rater reliability, as assessed by variation in the physicians' rating of patients, was fair to good for most aspects of the tools. Reliability and inter-rater agreement improved at the second exercise after the participants had completed additional training.

CONCLUSIONS

The MITAX, MYOACT and MDI tools, which are now undergoing validity testing, should enhance the consistency, comprehensiveness and reliability of disease activity and damage assessment in patients with myositis.

International consensus outcome measures for patients with idiopathic inflammatory myopathies. Development and initial validation of myositis activity and damage indices in patients with adult onset disease

OBJECTIVE

To devise new tools to assess activity and damage in patients with idiopathic myopathies (IIM).

METHODS

An international multidisciplinary consensus effort to standardize the conduct and reporting of the myositis clinical trials has been established. Two tools, known as the myositis intention to treat index (MITAX) and the myositis disease activity assessment visual analogue scale (MYOACT), have been developed to capture activity in patients with IIM. In addition, the myositis damage index (MDI) has been devised to assess the extent and severity of damage developing in different organs and systems. These measures have been reviewed by the myositis experts participating in the International Myositis Assessment and Clinical Studies (IMACS) group and have been found to have good face validity and to be comprehensive. The instruments were assessed in two real patient exercises involving patients with adult dermatomyositis and inclusion body myositis.

RESULTS

The reliability of MITAX, MYOACT and MDI, measured by the intraclass correlation coefficient among the physicians, and the inter-rater reliability, as assessed by variation in the physicians' rating of patients, was fair to good for most aspects of the tools. Reliability and inter-rater agreement improved at the second exercise after the participants had completed additional training.

CONCLUSIONS

The MITAX, MYOACT and MDI tools, which are now undergoing validity testing, should enhance the consistency, comprehensiveness and reliability of disease activity and damage assessment in patients with myositis.

Comparing food intake using the Dietary Risk Assessment with multiple 24-hour dietary recalls and the 7-Day Dietary Recall

The Dietary Risk Assessment (DRA) is a brief dietary assessment tool used to identify dietary behaviors associated with cardiovascular disease. Intended for use by physicians and other nondietitians, the DRA identifies healthful and problematic dietary behaviors and alerts the physician to patients who require further nutrition counseling. To determine the relative validity of this tool, we compared it to the 7-Day Dietary Recall (an instrument developed to assess intake of dietary fat) and to the average of 7 telephone-administered 24-hour dietary recalls. Forty-two free-living subjects were recruited into the study. The 7-Day Dietary Recall and DRA were administered to each subject twice, at the beginning and the end of the study period, and the 24-hour recalls were conducted during the intervening time period. Correlation coefficients were computed to compare the food scores derived from the 3 assessment methods. Correlations between the DRA and 7-Day Dietary Recall data were moderate (r = .47, on average, for postmeasures); correlations between the DRA and 24-hour recalls were lower. The ability of the DRA to assess dietary fat consumption and ease of administration make it a clinically useful screening instrument for the physician when counseling patients about dietary fat reduction.

Changing trends in prostatic cancer

OBJECTIVES

To examine the diagnosis and treatment of prostatic cancer in a population-based study, reporting incidence trends and survival, in the decade before the introduction of prostate-specific antigen (PSA) testing, and thus determine whether the overall incidence of prostatic cancer is increasing or not.

PATIENTS AND METHODS

The study included all men registered as having prostatic cancer in the Yorkshire region between 1981 and 1990. The Northern and Yorkshire Cancer Registry and Information Service has an active registration policy and after notification, the information received is validated by histopathology reports and case-note review. Of the patients registered, 68% were over 70 years old at the time of diagnosis (mean age 74 years). Prostatic cancer was often diagnosed incidentally, after prostatectomy for presumed benign disease. Indications for treatment were not recorded, but most patients had treatment which was designed to control outlet bladder symptoms rather than with intent to cure cancer.

RESULTS

In all, 8118 patients with prostatic cancer were registered, of whom 6587 had histological confirmation. There was a 30% increase in the age-standardized incidence of prostatic cancer during the study period (P<0.001). The mortality from prostatic cancer increased by 35% (P<0.001) and the percentage of patients known to have metastases at the time of presentation increased from 18% to 24%. These changes were seen in all age groups. The overall survival was 49% at 5 years and 34% at 10 years.

CONCLUSIONS

There has been a real increase in the incidence of prostatic cancer which pre-dates the use of serum PSA testing. The percentage relative survival of patients with prostatic cancer in Yorkshire during the study period is similar to that seen in other parts of the UK, but compares badly with reported survival in other countries.

A dietitian-delivered group nutrition program leads to reductions in dietary fat, serum cholesterol, and body weight: the Worcester Area Trial for Counseling in Hyperlipidemia (WATCH)

OBJECTIVE

To assess the effectiveness of a dietitian-based nutrition counseling and education program for patients with hyperlipidemia.

DESIGN

A 4-session program implemented as a complement to a randomized physician-delivered intervention.

SUBJECTS/SETTING

From 12 practice sites of the Fallon Clinic, 1,162 subjects with hyperlipidemia were recruited, 645 of whom had data sufficient for our primary analyses.

INTERVENTION

Two individual and 2 group sessions conducted over 6 weeks.

MAIN OUTCOME MEASURES

Total and saturated fat levels; serum low-density lipoprotein cholesterol levels; and body weight, measured at baseline and after 1 year.

STATISTICAL ANALYSES

Multiple linear regression was used to evaluate changes in outcome measures.

RESULTS

After 1 year, there were significant reductions in outcome measures for subjects attending 3 or 4 nutrition sessions vs subjects attending fewer than 3 sessions or those never referred to a nutrition session. Reductions (mean +/- standard error) in saturated fat (measured as percent of energy) were 2.7 +/- 0.5%, 2.1 +/- 0.5%, and 0.3 +/- 0.1%, respectively. These reductions correspond to roughly a 22% relative change from baseline in those attending 3 or 4 sessions. Corollary reductions were observed for total fat (measured as percent of energy): 8.2 +/- 1.4%, 5.0 +/- 1.4%, and 0.7 +/- 0.4%; low-density lipoprotein cholesterol: 0.48 +/- 0.11 mmol/L, 0.13 +/- 0.11 mmol/L, and 0.02 +/- 0.03 mmol/L; and body weight: 4.5 +/- 0.9 kg, 2.1 +/- 0.8 kg, and 1.1 +/- 0.2 kg. The specified changes were additive to those of the physician-delivered intervention.

APPLICATIONS/CONCLUSIONS

This investigation provides empirical data demonstrating the effectiveness of a dietitian-delivered intervention in the care of patients with hyperlipidemia.

Autoimmune-associated congenital heart block: demographics, mortality, morbidity and recurrence rates obtained from a national neonatal lupus registry

OBJECTIVES

The present study describes the demographics, mortality, morbidity and recurrence rates of autoimmune-associated congenital heart block (CHB) using information from the Research Registry for Neonatal Lupus.

BACKGROUND

Isolated CHB detected at or before birth is strongly associated with maternal autoantibodies to 48-kD SSB/La, 52-kD SSA/Ro and 60-kD SSA/Ro ribonucleoproteins and is a permanent manifestation of the neonatal lupus syndromes (NLS). Available data are limited by the rarity of the disease.

RESULTS

The cohort includes 105 mothers whose sera contain anti-SSA/Ro or anti-SSB/La antibodies, or both, and their 113 infants diagnosed with CHB between 1970 and 1997 (56 boys, 57 girls). Of 87 pregnancies in which sufficient medical records were available, bradyarrhythmia confirmed to be CHB was initially detected before 30 weeks of gestation in 71 (82%) (median time 23 weeks). There were no cases in which major congenital cardiac anatomic defects were considered causal for the development of CHB; in 14 there were minor abnormalities. Twenty-two (19%) of the 113 children died, 16 (73%) within 3 months after birth. Cumulative probability of 3-year survival was 79%. Sixty-seven (63%) of 107 live-born children required pacemakers: 35 within 9 days of life, 15 within 1 year, and 17 after 1 year. Forty-nine of the mothers had subsequent pregnancies: 8 (16%) had another infant with CHB and 3 (6%) had a child with an isolated rash consistent with NLS.

CONCLUSIONS

Data from this large series substantiate that autoantibody-associated CHB is not coincident with major structural abnormalities, is most often identified in the late second trimester, carries a substantial mortality in the neonatal period and frequently requires pacing. The recurrence rate of CHB is at least two- to three-fold higher than the rate for a mother with anti-SSA/Ro-SSB/La antibodies who never had an affected child, supporting close echocardiographic monitoring in all subsequent pregnancies, with heightened surveillance between 18 and 24 weeks of gestation.

High risk of lymphomas in children of Asian origin: ethnicity or confounding by socioeconomic status?

To examine the role of ethnic origin as a risk factor for paediatric lymphoma, a cancer registry-based analysis was undertaken in Yorkshire, UK. Children of Asian ethnic origin were found to have an odds ratio for lymphomas of 1.60 (CI 0.98-2.62), after adjusting for age and sex. After adjusting also for 'super profile group' as an indicator of socioeconomic status, the estimate became 1.99 (CI 1.08-3.68). Hodgkin's disease and non-Hodgkin's lymphomas were analysed separately with similar results. Super profile group is an area-based measure and may not reflect the individual variation in living standards, especially among the Asian immigrants. Our results indicate that socioeconomic status does not confound the relationship between lymphomas and ethnic origin. However, there is a need for studies of ethnicity that include indicators of individual living standards or socioeconomic status.

Does it matter where you live? Treatment variation for breast cancer in Yorkshire. The Yorkshire Breast Cancer Group

Over 27,000 patients with breast cancer were identified from cancer registry data from 1978 to 1992 and differences in treatment practice across the 16 districts of Yorkshire studied. A total of 50 surgeons treated more than an average of ten cases a year. Surgeons who expressed an interest in breast cancer were more likely to treat a greater number of patients than those who had no special interest in the disease and offered patients chemotherapy, hormone therapy and radiotherapy more often. The average regional mastectomy rate fell from 70% to 44% over this period, but the rate varied between districts from 13% to 87%, with those at the extremes occupying these positions year on year. The rate of uptake of radiotherapy varied between districts from 13% to 58% over the period 1978-92. The use of adjuvant chemotherapy increased from 5% to 19% and hormone therapy from 19% to 80% over this time period. An audit of the facilities available within each district carried out in early 1994 also showed considerable variation, although all districts now have access to a nurse specialist. There were wide variations in treatment offered to patients with breast cancer. Patients in some districts were denied access to chemo- and and radiotherapy despite published guidelines showing these modalities to be useful. It is recommended that patients are referred to units with an interest in breast cancer rather than to general surgical out-patients.

Influence of clinician workload and patterns of treatment on survival from breast cancer

Chemotherapy and hormone therapy prolong disease-free and overall survival for patients with breast cancer in the clinical-trial setting, but it is not clear if this translates into a benefit on a population basis. It is also not clear if surgical caseload has any influence on survival. We used cancer-registry data from 12,861 patients with breast cancer treated in Yorkshire, UK, between 1979 and 1988, and found that patients of surgeons with higher rates of usage of chemotherapy and hormone therapy (regional mean usage 9.3%, range 0-46%) had prolonged survival. There was considerable variation in survival of breast cancer patients between surgeons, but their rate of use of chemotherapy and hormone therapy explained about 26% of this survival variation. Had the practice of the surgeons with the better outcomes been used by all treating clinicians, 5-year survival would have increased by about 4-5%. Examination of differences in survival as a function of consultant caseload demonstrated poorer results amongst those surgeons treating less than 30 new cases of breast cancer per year (risk ratio [95% CI] for treating > 30 compared with < 10 = 0.85 [0.77-0.93]). We recommend that patients with breast cancer be dealt with only by clinicians who see more than 30 new cases per year and who have a full range of treatment options available within a multidisciplinary setting.

Modes of action of aspirin-like drugs

Current dogma holds that nonsteroidal anti-inflammatory drugs (NSAIDs) act by inhibition of the synthesis and release of prostaglandins. However, NSAIDs also inhibit the activation of neutrophils, which provoke inflammation by releasing products other than prostaglandins. We now report that NSAIDs (e.g., indomethacin, piroxicam) inhibit activation of neutrophils by inflammatory stimuli, such as C5-derived peptides and leukotriene B4, even when cyclooxygenase products generated in suspensions of stimulated neutrophils (prostaglandin E and thromboxanes) are present. Sodium salicylate (3 mM) greatly inhibited aggregation of neutrophils but had no effect on aggregation of platelets or production of thromboxane induced by arachidonate. Sodium salicylate and other NSAIDs also inhibit calcium movements (45Ca uptake, changes in fluorescence of chlortetracycline and quin-2). Aspirin, sodium salicylate, indomethacin, and piroxicam also enhanced the poststimulation increase in intracellular cyclic AMP. NSAIDs therefore inhibit early steps in neutrophil activation as reflected by their capacity to inhibit movements of Ca and to enhance intracellular levels of cyclic AMP.