Harmonizing Definitions for Diagnostic Criteria and Prognostic Assessment of Transplantation-Associated Thrombotic Microangiopathy: A Report on Behalf of the European Society for Blood and Marrow Transplantation, American Society for Transplantation and Cellular Therapy, Asia-Pacific Blood and Marrow Transplantation Group, and Center for International Blood and Marrow Transplant Research

Transplantation-associated thrombotic microangiopathy (TA-TMA) is an increasingly recognized complication of hematopoietic cell transplantation (HCT) associated with significant morbidity and mortality. However, TA-TMA is a clinical diagnosis, and multiple criteria have been proposed without universal application. Although some patients have a self-resolving disease, others progress to multiorgan failure and/or death. Poor prognostic features also are not uniformly accepted. The lack of harmonization of diagnostic and prognostic markers has precluded multi-institutional studies to better understand incidence and outcomes. Even current interventional trials use different criteria, making it challenging to interpret the data. To address this urgent need, the American Society for Transplantation and Cellular Therapy, Center for International Bone Marrow Transplant Research, Asia-Pacific Blood and Marrow Transplantation, and European Society for Blood and Marrow Transplantation nominated representatives for an expert panel tasked with reaching consensus on diagnostic and prognostic criteria. The panel reviewed literature, generated consensus statements regarding diagnostic and prognostic features of TA-TMA using the Delphi method, and identified future directions of investigation. Consensus was reached on 4 key concepts: (1) TA-TMA can be diagnosed using clinical and laboratory criteria or tissue biopsy of kidney or gastrointestinal tissue; however, biopsy is not required; (2) consensus diagnostic criteria are proposed using the modified Jodele criteria with additional definitions of anemia and thrombocytopenia. TA-TMA is diagnosed when ≥4 of the following 7 features occur twice within 14 days: anemia, defined as failure to achieve transfusion independence despite neutrophil engraftment; hemoglobin decline by ≥1 g/dL or new-onset transfusion dependence; thrombocytopenia, defined as failure to achieve platelet engraftment, higher-than-expected transfusion needs, refractory to platelet transfusions, or ≥50% reduction in baseline platelet count after full platelet engraftment; lactate dehydrogenase (LDH) exceeding the upper limit of normal (ULN); schistocytes; hypertension; soluble C5b-9 (sC5b-9) exceeding the ULN; and proteinuria (≥1 mg/mg random urine protein-to-creatinine ratio [rUPCR]); (3) patients with any of the following features are at increased risk of nonrelapse mortality and should be stratified as high-risk TA-TMA: elevated sC5b-9, LDH ≥2 times the ULN, rUPCR ≥1 mg/mg, multiorgan dysfunction, concurrent grade II-IV acute graft-versus-host disease (GVHD), or infection (bacterial or viral); and (4) all allogeneic and pediatric autologous HCT recipients with neuroblastoma should be screened weekly for TA-TMA during the first 100 days post-HCT. Patients diagnosed with TA-TMA should be risk-stratified, and those with high-risk disease should be offered participation in a clinical trial for TA-TMA-directed therapy if available. We propose that these criteria and risk stratification features be used in data registries, prospective studies, and clinical practice across international settings. This harmonization will facilitate the investigation of TA-TMA across populations diverse in race, ethnicity, age, disease indications, and transplantation characteristics. As these criteria are widely used, we expect continued refinement as necessary. Efforts to identify more specific diagnostic and prognostic biomarkers are a top priority of the field. Finally, an investigation of the impact of TA-TMA-directed treatment, particularly in the setting of concurrent highly morbid complications, such as steroid-refractory GVHD and infection, is critically needed.

Massive pneumatosis without necrosis: A case report of Clostridium perfringens sepsis in an extremely low birth weight infant

Pneumatosis intestinalis and free intraperitoneal air on abdominal radiographs are considered pathognomonic signs of necrotizing enterocolitis (NEC). We report a unique case of late-onset fulminant sepsis due to Clostridium perfringens presenting with shock, extensive pneumatosis intestinalis and free intraperitoneal air in an extremely low birth weight infant without histopathological evidence of bowel necrosis or NEC.

Advantages of a high-throughput measure of hair fiber torsional properties

While the tensile response of fibers of human hair is the most extensively studied mode of mechanical deformation, the properties of hair in different deformation modes remain of interest and can provide valuable insight into the effects of chemical treatments. Previously reported methods for the measurement of fibers in torsional deformation have inherent systematic errors, are low-throughput, and are operator-intensive. This paper presents a new method for the measurement of fiber torsional properties developed to reduce these errors and to improve the efficiency of the technique. This method was designed to be fully automated, requiring no operator input during an experiment, and affording higher sample throughput while improving the ease of use in variable climatic conditions. The new method is compared to a conventional torsional pendulum method for measuring fiber shear modulus, and an evaluation of experimental reproducibility is made using hair and nylon fibers. It was found that the new method provides absolute values for shear modulus similar to those of the pendulum technique, with reduced run-to-run variability between fibers, while enabling larger sample numbers to be explored in shorter times.

OT2-05-02: ACRIN 6691 Monitoring and Predicting Breast Cancer Neoadjuvant Chemotherapy Response Using Diffuse Optical Spectroscopic Imaging (DOSI)

Background

Imaging technologies monitoring and predicting breast cancer response to neoadjuvant chemotherapy (NAC) are of increasing interest. The utility of conventional imaging approaches varies and identifies the need for alternate functional imaging strategies. The use of model-based photon migration methods to quantitatively separate light absorption from scattering in multiply-scattering tissues is a type of near-infrared spectroscopy (NIRS) broadly referred to as diffuse optical spectroscopy (DOS) [Bevilacqua, et al. Applied Optics, 2000; Jakubowski, et al., J of Applied Optics, 2009]. DOSI is a promising experimental technology that allows patients undergoing NAC to be followed with a “no significant risk” device meeting Food and Drug Administration criteria for exempt status. The current design is a mobile device which offers increased accessibility and is relatively simple to perform and interpret, as compared to mammography, magnetic resonance imaging, and positron emission tomography. Due to its size and portability, DOSI is a low barrier-to-access technology, creating new opportunities for patients to receive personalized treatment and for physicians to gain new insight into response mechanisms. The long-term goal is to provide oncologists with a relatively simple, risk-free bedside tool that can be used to help inform medical decisions on chemotherapy regimen, duration, and timing of surgery, thereby maximizing therapeutic response and minimizing unnecessary toxicity.

Trial design: In this phase I/II prospective single arm study, patients will receive SOC NAC at five (5) NCI Network for Translational Research in Optical Imaging (NTROI) clinical sites with identical DOSI instruments and procedures. Patients will receive four DOSI exams: at baseline before chemotherapy, at early therapy 5–10 days after NAC initiation, at mid therapy, and at post therapy prior to surgery. The protocol will evaluate a harmonized DOSI technology platform that has been standardized for NAC monitoring.

Eligibility: Women who have been diagnosed with breast cancer, have had confirmation by pre-treatment biopsy, and are scheduled to receive NAC followed by surgery are eligible for this trial.

Specific aims: The primary aim of this clinical trial is to determine whether the baseline to mid-therapy changes in the DOSI measurement of the quantitative tumor tissue optical index can predict final pathologic complete response in patients with breast cancer undergoing NAC. The secondary aims investigate the correlation between additional DOSI quantitative measurements of tumor biochemical composition obtained at other timepoints, the full range of pathologic response (i.e. complete, partial, and non-response), and any corresponding imaging measurements.

Statistical methods: Logistic regression models will be used to study the relationships between pathological complete response and percent change in tissue optical index tumor to normal ratio at different imaging time points.

Study size: A total of sixty (60) patients will be enrolled in this imaging study. Currently, one patient has accrued.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT2-05-02.

Abstract P5-01-10: Tumor Optic Properties Measured Using Diffuse Optic Spectroscopy Imaging Correlate with Proliferation and Glucose Metabolism in Breast Cancer Patients

(Background) Diffuse Optic Spectroscopy Imaging (DOSI) is non-invasive imaging technology that employs near-infrared (NIR) light to quantitatively characterize the hemodynamic and metabolic properties of breast cancer tumors.

(Methods) We utilized DOSI to measure baseline tumor concentrations of oxy-hemoglobin (ctO2Hb), deoxy-hemoglobin (ctHHb), total hemoglobin (ctTHb), oxygen saturation (stO2), as well as water and lipid content of tumors from sixteen patients with primary breast cancer prior to neoadjuvant chemotherapy. Core-needle biopsy specimens were also collected from these patients and analyzed for Ki67, Glut-1, and Fatty acid synthese (FAS), biomarkers of cancer proliferation, glucose metabolism and fatty acid metabolism, respectively. These optic and biological biomarkers were statistically compared to each other and to overall therapy response. (Results) Ki67 score was positively correlated with baseline levels of ctO2Hb (µM) (r = 0.51, p = 0.04), ctTHb (µM) (r = 0.51, p = 0.05), and stO2 (%) (r = 0.57, p = 0.02), and negatively correlated with lipid content (%) (r = -0.52, p = 0.04). Tumors with positive Glut-1 status (n=8) showed significantly higher baseline levels of ctO2Hb (26.2±12.5 v.s 19.9±10.1, p = 0.04), ctTHb (41±13.3 v.s 27.5±11.7, p = 0.05), and stO2 (81.1±6.6 v.s 70.2±9.9, p = 0.02) and lower baseline levels of lipid (49±17.1 v.s 66.2±10.4, p = 0.03) compared to those with negative Glut-1 status (n = 8). There were no correlation between FAS and the optic properties. Five (31.3%) of 16 tumors achieved pathologic complete response (pCR) after completion of chemotherapy followed by surgery. Tumors with pCR showed higher stO2, higher Ki67 score and higher likelihood of Glut-1 expression than those with non-pCR (p = 0.009, 0.01, 0.03, respectively).

Only p-values with statistical significance were described.

(Conclusion) Higher tumoral expression levels of Ki67 and Glut-1 were correlated with higher oxygenation and lower lipid concentration and associated with a pathologic complete response to chemotherapy. Non-invasive optic properties measured using DOSI are potential surrogate markers for tumor proliferation and glucose metabolism.

Abstract P2-02-11: Evaluation of Tumor Response Using 3T Breast MRI Following Neoadjuvant Albumin-Bound Paclitaxel and Carboplatin with Bevacizumab or Trastuzumab

PURPOSE: MRI is known as the most accurate imaging modality for evaluating the extent of residual disease following neoadjuvant chemotherapy (NAC). Although in general breast MRI is done at 1.5T, 3T can provide a better signal-to-noise ratio and may be more sensitive to detect residual disease. In this study the diagnostic performance of 3T MRI for NAC response was investigated.

METHODS AND MATERIALS: In a period of 30 months, 42 NAC patients (29-83 y/o, mean 50 y/o) who received at least three MRI scans before, during and after therapy, and had surgery after completing NAC were analyzed in this study. The NAC protocol included albumin-bound paclitaxel, carboplatin and trastuzumab for HER-2 positive patients (N= 15), or bevacizumab for HER-2 negative patients (N=27). Some patients received doxorubicin and cyclophosphamide, bi-weekly for 4 cycles, as clinically indicated. Twenty-eight lesions were mass types and 14 showed non-mass-like enhancements. The residual tumor size was determined using the RECIST criteria, by measuring the longest dimension shown on MRI. When there was no enhancement (or, with a faint enhancement equal to the background normal tissue enhancement), the case was determined as complete clinical response (CCR). Pathological complete response (pCR) was defined as no residual invasive cancer cells, with or without DCIS. In cases with residual invasive cancer, the pathological size was determined as the longest dimension, either the longest dimension on H&E-stained slide or from the number of blocks (each 5 mm) where the malignant invasive tumor was detected, whichever was greater. For residual tumor showing as scattered cancer cells/nests, the longest dimension was estimated from the involved blocks.

RESULTS: MRI diagnosed 12 complete clinical response and 30 cases with residual cancers. In pathological examination, 12 were pCR (29%). Overall, comparing MRI diagnosis to pCR diagnosis, there were 27 true positive, 9 true negative, 3 false negative, and 3 false positive. The three false positive cases all had residual DCIS-so although MRI did not predict pCR it correctly diagnosed residual DCIS. The three false negative cases were all non-mass lesions, in which pathology showed scattered small cancer foci in 3, 14, and 14 cm areas, respectively. The sensitivity, specificity, and accuracy of MRI were 90%, 75%, and 86%. Overall, the correlation between MRI and pathologic size was higher for mass lesions than for non-mass-like lesions (r=0.80 vs. r=0.67), and similar between Her-2 positive and negative lesions (r=0.82 vs. r=0.84). The discrepancy between MRI and pathological size was larger for non-mass lesions than for mass lesions (0.6-14 cm vs. 0-3 cm).

CONCLUSIONS: Similar to 1.5T, high resolution 3T MRI has limitations for the non-mass-like lesions that break into small foci and scattered cells. This might be due to that small tumor foci have lowered angiogenic activity, limiting MR contrast agent uptake, thus lowering the detection rate. For mass lesions, MR residual tumor size was highly correlated with pathological size. Understanding the accuracy and limitations of 3T MRI for NAC patients may aid in designing an improved NAC protocol and a better surgical planning.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-02-11.

Safety and potential efficacy of low-dose methotrexate for treatment of chronic graft-versus-host disease

Low-dose methotrexate (MTX) is widely used in autoimmune diseases because of its anti-inflammatory activity. We report here the results of a retrospective study to review the outcomes of low-dose MTX used for treatment of refractory chronic graft-versus-host disease GVHD, with the goal of reducing the amount of prednisone needed to control the disease. In all, 14 patients with refractory chronic GVHD received MTX at a dose of 7.5 mg/m(2)/weekly for 3--0 weeks. Also, 11 patients had skin involvement, often with scleroderma or fasciitis. The median duration of chronic GVHD at the start of MTX was 38 (range 1--35) months. In this retrospective review, we found no grade 3-- toxicities, and none of the patients needed blood transfusion or growth factors. In 10 patients (71%), GVHD could be adequately controlled with prednisone at doses below 1 mg/kg every other day without the addition of other agents. Four patients decreased the amount of concomitant immunosuppressive treatment, five continued with the same regimen, four required an increase in immunosuppressive treatment, and one decided to discontinue all treatment. From this preliminary analysis, MTX appears to be a well-tolerated, inexpensive and possibly steroid-sparing agent that is worthy of further evaluation in prospective trials for treatment of chronic GVHD.

Thrombophilia and venous thromboembolism. International consensus statement. Guidelines according to scientific evidence

Thrombophilia is the term now used to describe predisposition to increased risk of venous and occasionally arterial thromboembolism due to hematological abnormalities. It can be a multifactorial disorder where congenital defects of anticoagulant or procoagulant factors may be combined with acquired hematological abnormalities. It should be considered in patients with a documented unexplained thrombotic episode or a positive family history. The aim of this document is to provide guidelines for investigation and management of patients with thrombophilia in the presence or absence of venous thromboembolism (VTE).

Serious graft-versus-host disease after hematopoietic cell transplantation following nonmyeloablative conditioning

The efficacy of allogeneic hematopoietic cell transplantation (HCT) after nonmyeloablative conditioning depends on the balance between the desirable antineoplastic effects of donor cells weighed against the undesirable morbidity of graft-versus-host disease (GVHD). Development of serious acute or chronic GVHD was analyzed retrospectively in 171 consecutive patients, who had related or unrelated nonmyeloablative HCT for hematologic malignancies. GVHD was defined as serious when it resulted in (1) death, (2) disability, (3) three or more major infections in 1 year, (4) prolonged hospitalization or (5) suicide or hospitalization for suicidal ideation. According to this definition, 43 of 171 (25%) patients developed serious GVHD with a median follow-up of 30 (range, 12-65) months. The incidence of serious GVHD was similar after related and unrelated HCT. Among the 43 patients with serious GVHD, 20 had grade III-IV acute GVHD, and 30 had extensive chronic GVHD. Among the 171 patients, seven had grade III acute GVHD and 84 had extensive chronic GVHD that did not meet criteria for serious GVHD. Assessment of serious GVHD provides additional useful information to acute GVHD grades and classification of limited and extensive chronic GVHD in describing the overall risk and impact complications caused by donor cells.

Human kallikrein 2 (hK2), but not prostate-specific antigen (PSA), rapidly complexes with protease inhibitor 6 (PI-6) released from prostate carcinoma cells

Human kallikrein 2 (hK2) is a secreted, trypsin-like protease that shares 80% amino acid sequence identity with prostate-specific antigen (PSA). hK2 has been shown to be a serum marker for prostate cancer and may also play a role in cancer progression and metastasis. We have previously identified a novel complex between human kallikrein 2 (hK2) and protease inhibitor 6 (PI-6) in prostate cancer tissue. PI-6 is an intracellular serine protease inhibitor with both antitrypsin and antichymotrypsin activity. In the current study we have shown that PI-6 forms a rapid in vitro complex with hK2 but does not complex with PSA. Recombinant mammalian cells expressing both hK2 and PI-6 showed hK2-PI-6 complex in the spent media only after cell death and lysis. Similarly, LNCaP cells expressing endogenous hK2 and PI-6 showed extracellular hK2-PI-6 complex formation concurrently with cell death. Immunostaining of prostate cancer tissues with PI-6 monoclonal antibodies showed a marked preferential staining pattern in cancerous epithelial cells compared with noncancerous tissue. These results indicate that the hK2-PI-6 complex may be a naturally occurring marker of tissue damage and necrosis associated with neoplasia. Both hK2 and PI-6 were shed into the lumen of prostate cancer glands as granular material that appeared to be cellular necrotic debris. The differential staining pattern of PI6 in tissues suggests a complex regulation of PI-6 expression that may play a role in other aspects of neoplastic progression.

C1qR(P), a myeloid cell receptor in blood, is predominantly expressed on endothelial cells in human tissue

C1qR(P) is a type I cell surface glycoprotein that has been shown to enhance ingestion of suboptimally opsonized targets by phagocytes in vitro. In this study, we developed and characterized polyclonal antibodies to study the tissue distribution of this receptor targeted to either the N- or C-terminal portion of the molecule. C1qR(P) was detected in vascular endothelial cells and in a subset of pyramidal neurons in the brain, as well as neutrophils, but it was absent in most tissue macrophages. Analysis of in vitro differentiation of blood monocytes to dendritic cells demonstrated a down-regulation of the receptor as monocytes differentiate to dendritic cells, providing a possible explanation for the lack of reactivity of these cells in tissue. The predominant presence of C1qR(P) in endothelial cells, while compatible with a phagocytic role in host defense and/or clearance of cellular material, suggests other possible novel roles for this receptor.

Human herpesvirus 6 reactivation and encephalitis in allogeneic bone marrow transplant recipients

To determine whether receipt of an investigational anti-CD3 monoclonal antibody (BC3) increased the risk of human herpesvirus 6 (HHV-6) reactivation and development of encephalitis in bone marrow transplant (BMT) recipients, persons who had and had not received BC3 were compared. Odds of HHV-6 reactivation were higher among BC3 recipients than among control patients (odds ratio, 2.5; 95% confidence interval [CI], 1.3-4.7). In addition, BC3 recipients were more likely than control patients to develop encephalitis (risk ratio [RR], 3.5; 95% CI, 1.3-9.5), and this association followed a BC3 dose-dependent relationship (P=.03, by Mantel-Haenszel chi(2) test). In a multivariable model, HHV-6 reactivation and receipt of BC3 were associated with increased risk of encephalitis (RR, 5.4; 95% CI, 1.9-15.3, and RR, 3.3; 95% CI, 1.2-9.1, respectively). In conclusion, both HHV-6 reactivation and receipt of BC3 for prophylaxis of acute graft-versus-host disease independently increased the risk of encephalitis in allogeneic BMT recipients. Prospective studies to better define the relationship between HHV-6 reactivation and encephalitis in allogeneic BMT recipients are warranted.

A truncated precursor form of prostate-specific antigen is a more specific serum marker of prostate cancer

Prostate-specific antigen (PSA) is a widely used serum marker for prostate cancer (PCa) but has limited specificity for distinguishing early PCa from benign prostatic hyperplasia, because both PCa and benign prostatic hyperplasia release PSA into the serum. We have identified previously a truncated form of precursor PSA (pPSA) in prostate tumor extracts consisting of PSA with a serine-arginine pro leader peptide ([-2]pPSA) instead of the normally expressed 7 amino acid pro leader peptide. In the current study we developed monoclonal antibodies to detect [-2]pPSA and other isoforms of pPSA for Western blot analysis. PSA was immunoaffinity purified from 100 to 200 ml of serum from each of five men with biopsy-proven cancer and three biopsy-negative men, all with total PSA levels in the diagnostically relevant range near 10 ng/ml. The truncated [-2]pPSA was estimated to range from 25 to 95% of the free PSA in the five PCa samples but only 6-19% of the free PSA in the biopsy-negative men. Immunohistochemical studies showed positive staining for [-2]pPSA in PCa epithelium and that [-2]pPSA was enriched in cancer cell secretions. In vitro activation studies showed that human kallikrein 2 and trypsin readily activated full-length pPSA but were unable to activate [-2]pPSA to mature PSA. Thus, [-2]pPSA, once formed, is a stable but inactive isoform of PSA. Truncated [-2]pPSA may represent an important new diagnostic marker for the early detection of PCa.

Advances in transplantation tolerance

Immunosuppressive drugs developed in the past two decades have improved the short-term survival of organ allografts, but tolerance has not been achieved and almost all transplant recipients continue to require drugs throughout life. Graft rejection arises from the cognate interaction of T cells with antigen-presenting cells, the recognition of alloantigen through the T-cell receptor, and the delivery of accessory stimulation signals. Once activated by the specific antigen, replicating T cells die if they are re-exposed to the same antigen. Since depletion of antigen-activated T cells is one critical mechanism of transplantation tolerance, drugs such as ciclosporin that interfere with activation-induced T-cell death could inhibit tolerance, whereas drugs such as mycophenolate mofetil, that induce the death of activated T cells, could facilitate tolerance. Other tolerance mechanisms depend on inactivation rather than elimination of allograft reactive T cells. When antigen recognition occurs without costimulation through the CD28 and CD154 accessory receptors, or in absence of cell division, T cells become unresponsive. Thus, inhibitors of CD28 and CD154, and inhibition of T-cell division by rapamycin promotes transplantation tolerance.

Molecular identification and characterization of novel human and mouse concentrative Na+-nucleoside cotransporter proteins (hCNT3 and mCNT3) broadly selective for purine and pyrimidine nucleosides (system cib)

The human concentrative (Na(+)-linked) plasma membrane transport proteins hCNT1 and hCNT2 are selective for pyrimidine nucleosides (system cit) and purine nucleosides (system cif), respectively. Both have homologs in other mammalian species and belong to a gene family (CNT) that also includes hfCNT, a newly identified broad specificity pyrimidine and purine Na(+)-nucleoside symporter (system cib) from the ancient marine vertebrate, the Pacific hagfish (Eptatretus stouti). We now report the cDNA cloning and characterization of cib homologs of hfCNT from human mammary gland, differentiated human myeloid HL-60 cells, and mouse liver. The 691- and 703-residue human and mouse proteins, designated hCNT3 and mCNT3, respectively, were 79% identical in amino acid sequence and contained 13 putative transmembrane helices. hCNT3 was 48, 47, and 57% identical to hCNT1, hCNT2, and hfCNT, respectively. When produced in Xenopus oocytes, both proteins exhibited Na(+)-dependent cib-type functional activities. hCNT3 was electrogenic, and a sigmoidal dependence of uridine influx on Na(+) concentration indicated a Na(+):uridine coupling ratio of at least 2:1 for both hCNT3 and mCNT3 (cf 1:1 for hCNT1/2). Phorbol myristate acetate-induced differentiation of HL-60 cells led to the parallel appearance of cib-type activity and hCNT3 mRNA. Tissues containing hCNT3 transcripts included pancreas, bone marrow, trachea, mammary gland, liver, prostate, and regions of intestine, brain, and heart. The hCNT3 gene mapped to chromosome 9q22.2 and included an upstream phorbol myristate acetate response element.

Derivation and evaluation of a document-naming nomenclature

OBJECTIVE

The Computerized Patient Record System is deployed at all 173 Veterans Affairs (VA) medical centers. Providers access clinical notes in the system from a note title menu. Following its implementation at the Nashville VA Medical Center, users expressed dissatisfaction with the time required find notes among hundreds of irregularly structured titles. The authors' objective was to develop a document-naming nomenclature (DNN) that creates informative, structured note titles that improve information access.

DESIGN

One thousand ninety-four unique note titles from two VA medical centers were reviewed. A note-naming nomenclature and compositional syntax were derived. Compositional order was determined by user preference survey.

MEASUREMENTS

The DNN was evaluated by modeling note titles from the Salt Lake City VA Medical Center (n=877), Vanderbilt University Medical Center (n=554), and the Mayo Clinic (n=42). A preliminary usability evaluation was conducted on a structured title display and sorting application.

RESULTS

Classes of note title components were found by inspection. Components describe characteristics of the author, the health care event, and the organizational unit providing care. Terms were taken from VA medical center information systems and national standards. The DNN model accurately described 97 to 99 percent of note titles from the test sites. The DNN term coverage varied, depending on component and site. Users found the DNN title format useful and the DNN-based title sorting and note review application easy to learn and quick to use.

CONCLUSION

The DNN accurately models note titles at five medical centers. Preliminary usability data indicate that DNN integration with title parsing and sorting software enhances information access.

Characterization of N-ethyl-N-nitrosourea-induced malignant and benign breast tumors in rats by using three MR contrast agents

A carcinogen (N-ethyl-N-nitrosourea)-induced animal tumor model was established to grow malignant and benign breast tumors. In each tumor the pharmacokinetic characteristics were measured by using three contrast agents, gadolinium-diethylene-triamine-pentaacetic acid (Gd-DTPA; <1 kD), Gadomer-17 (35 kD), and albumin-Gd-DTPA (70-90 kD). Infiltrating ductal carcinomas (IDC) with low, medium, and high Scarf-Bloom-Richardson grades and fibroadenomas (FA) were analyzed. We found that Gd-DTPA could differentiate between FA and malignant tumors, but not between malignant tumors of low and high grades. In contrast, the intermediate size agent Gadomer-17 could differentiate between high-grade and low-grade IDC, but not between low-grade IDC and FA due to their similar enhancement patterns (despite their different origins). The largest agent, albumin-Gd-DTPA, was capable of differentiating both, but the low contrast-to-noise ratio was its major technical concern. The results in this breast tumor model suggest that macromolecular agents provide useful information for differential diagnosis among IDCs of various grades, but they do not provide superior information than Gd-DTPA for differential diagnosis between IDC and FA.

Effects of experimental hemosiderosis on pancreatic tissue iron content and structure

The effects of iron overload on pancreatic iron content and morphology were investigated. Sprague-Dawley rats were randomized into an iron-overloaded group, which received a single subcutaneous injection of 1.2 g/kg elemental iron as iron-dextran complex, and placebo-treated pair-fed controls. Animals were studied after a 10-month observation period. Tissue nonheme iron content was measured, and histologic examination was carried out. Chronic iron-overloaded animals showed significant increases in tissue iron content. There was a statistically significant increase in stainable iron in perivascular, parenchymal, and lymphoid tissue in the iron-overloaded group. Although pancreatic fibrosis was present in the iron-overload group, it was not statistically significant. The iron-overloaded animals showed some islet cell destruction. In contrast, no significant islet cell destruction was seen in the control group. However, the difference was not statistically significant. Moreover, the serum glucose levels were the same in both groups, suggesting that there was no significant impairment of pancreatic endocrine function. Thus, chronic experimental iron overload in rats leads to significant increases in tissue iron content, but no significant morphologic alterations of the pancreas with the dose and route of iron administered in this animal model.

Mammary epithelium-induced motility of MCF-7 cells

BACKGROUND

Cancer cell invasion may be mediated by motility factors elaborated by the surrounding normal host tissue. This study was performed to determine whether normal breast cells induce motility in breast cancer.

MATERIALS AND METHODS

MCF-7 breast carcinoma cells were co-cultured with either normal cultured human mammary epithelial cells (HMEC) or immortalized 184 A1 mammary epithelial cells and observed for evidence of motility. The ability of conditioned medium from mammary epithelial cells to induce motility in MCF-7 was measured with scattering assays, Boyden chamber assays and time-lapse video microscopy.

RESULTS

A soluble factor in the conditioned medium of both 184 A1 and HMEC induced motility in MCF-7. The motility factor was trypsin-sensitive, but activity remained after 5 minutes of boiling or 2 hours at pH 2.

CONCLUSION

Mammary epithelium secretes a protein capable of inducing motility in breast cancer cells, raising the possibility that this effect contributes to the invasive properties of human mammary carcinoma.

Granulocyte-macrophage colony-stimulating factor in association with high-dose chemotherapy (VETOPEC) for childhood solid tumors: a report from the Australia and New Zealand Children's Cancer Study Group

PURPOSE

Combination chemotherapy with vincristine, etoposide, and high-dose, escalating cyclophosphamide (VETOPEC) is an effective regimen in pediatric patients with high-risk solid tumors. The toxicity of the regimen is predominantly haematologic. This study addressed the role of recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF) following each cycle of chemotherapy in decreasing neutropaenia, incidence of fever/ hospitalization, and/or increasing chemotherapy dose-intensity.

PATIENTS AND METHODS

Twenty-nine children with recurrent solid tumors were treated with the VETOPEC regimen. Sequential cohorts of patients received no GM-CSF (Group I), or GM-CSF in a dosage of 5 micrograms/kg/day (Group II) or 10 micrograms/kg/day (Group III) on days 4-18 of each chemotherapy cycle. Up to four cycles of chemotherapy were analysed with respect to haematopoietic recovery, clinical parameters, and dose intensity.

RESULTS

Neutrophil recovery was significantly more rapid in patients treated with GM-CSF. Time to achieving an absolute neutrophil count (ANC) over 0.5 x 10(9)/L in Groups I, II, and III were 21, 18, and 16 days, respectively (P < 0.0001). Time to achieving an absolute neutrophil count (ANC) over 1.0 x 10(9)/L in Groups I, II, and III were 24, 19, and 17 days, respectively (P < 0.0001). There was no significant difference in the incidence of febrile neutropaenia between the three groups. Febrile neutropaenia occurred following 42, 68, and 62% of chemotherapy cycles in Groups I, II, and III, respectively (P = 0.27). Chemotherapy dose intensity was not different between the three groups. GM-CSF was associated with pericarditis and myalgias in one patient, and transient hypoxia/hypotension in another.

CONCLUSION

GM-CSF led to significantly more rapid neutrophil recovery following VETOPEC chemotherapy, but did not lead to any demonstrable clinical benefit, either in reducing febrile events, or in increasing chemotherapy dose intensity.

Lymphocyte and monocyte-induced motility of MCF-7 cells by tumor necrosis factor-alpha

A potentially important tumor-host interaction is increased tumor-cell invasiveness in response to motility factors derived from stromal and lymphoid cells. Conditioned medium of IL-2-stimulated lymphocytes and fractions enriched in either T cells, natural killer (NK) cells, or monocytes induced motility in MCF-7 breast carcinoma cells. ELISA and antibody neutralization studies demonstrated that this effect was due to tumor necrosis factor-alpha (TNF-alpha) secretion by the lymphoid cells or the enriched fractions. Unstimulated leukocytes in direct contact with MCF-7 cells also induced motility that was inhibited by anti-TNF-alpha antiserum. Time-lapse video microscopy of cells exposed to 10 ng/ml TNF-alpha showed that motility was independent of its toxic effects. Immunoperoxidase showed that MCF-7 cells expressed both the 55-kDa and the 75-kDa TNF-alpha receptors (TNFR). Antiserum against the 55-kDa TNFR, like TNF-alpha, induced motility in MCF-7 cells. This was most likely due to cross-linking of the 55-kDa TNFR monomers, since the monomeric F(ab) did not produce this effect. Our results raise the possibility that TNF-alpha-induced motility is one mechanism by which tumor cells overcome the potential anti-tumor immune function of lymphocytes and macrophages in peri-tumoral infiltrates.

Phase II evaluation of clinical coding schemes: completeness, taxonomy, mapping, definitions, and clarity. CPRI Work Group on Codes and Structures

OBJECTIVE

To compare three potential sources of controlled clinical terminology (READ codes version 3.1, SNOMED International, and Unified Medical Language System (UMLS) version 1.6) relative to attributes of completeness, clinical taxonomy, administrative mapping, term definitions and clarity (duplicate coding rate).

METHODS

The authors assembled 1929 source concept records from a variety of clinical information taken from four medical centers across the United States. The source data included medical as well as ample nursing terminology. The source records were coded in each scheme by an investigator and checked by the coding scheme owner. The codings were then scored by an independent panel of clinicians for acceptability. Codes were checked for definitions provided with the scheme. Codes for a random sample of source records were analyzed by an investigator for "parent" and "child" codes within the scheme. Parent and child pairs were scored by an independent panel of medical informatics specialists for clinical acceptability. Administrative and billing code mapping from the published scheme were reviewed for all coded records and analyzed by independent reviewers for accuracy. The investigator for each scheme exhaustively searched a sample of coded records for duplications.

RESULTS

SNOMED was judged to be significantly more complete in coding the source material than the other schemes (SNOMED* 70%; READ 57%; UMLS 50%; *p < .00001). SNOMED also had a richer clinical taxonomy judged by the number of acceptable first-degree relatives per coded concept (SNOMED* 4.56, UMLS 3.17; READ 2.14, *p < .005). Only the UMLS provided any definitions; these were found for 49% of records which had a coding assignment. READ and UMLS had better administrative mappings (composite score: READ* 40.6%; UMLS* 36.1%; SNOMED 20.7%, *p < .00001), and SNOMED had substantially more duplications of coding assignments (duplication rate: READ 0%; UMLS 4.2%; SNOMED* 13.9%, *p < .004) associated with a loss of clarity.

CONCLUSION

No major terminology source can lay claim to being the ideal resource for a computer-based patient record. However, based upon this analysis of releases for April 1995, SNOMED International is considerably more complete, has a compositional nature and a richer taxonomy. Is suffers from less clarity, resulting from a lack of syntax and evolutionary changes in its coding scheme. READ has greater clarity and better mapping to administrative schemes (ICD-10 and OPCS-4), is rapidly changing and is less complete. UMLS is a rich lexical resource, with mappings to many source vocabularies. It provides definitions for many of its terms. However, due to the varying granularities and purposes of its source schemes, it has limitations for representation of clinical concepts within a computer-based patient record.

Radiation-induced CA 125 production by mesothelial cells

CA 125 levels are often falsely elevated in disease-free endometrial cancer patients who have undergone abdominal radiation therapy. Because peritoneal irritation or mediators of inflammation can induce CA 125 production in mesothelium, the possibility that irradiated cultured mesothelial cells secrete CA 125 was investigated. Seven mesothelial cell isolates, an ovarian cell line which does not secrete CA 125, normal mammary epithelium, and normal fibroblasts were exposed to 500 cGy of 6-MV photon irradiation. Irradiated mesothelial cells showed little or no growth, while untreated cells increased in number. Twenty-four-hour CA 125 production was measured in the tissue culture medium on Day 4, and daily for one mesothelial cell isolate. Radiation stimulated CA 125 secretion in mesothelial cells up to 32 times over nonirradiated controls. The time course study showed that CA 125 levels increased rapidly in irradiated cells by Day 3 and remained elevated for the next 3 days. Increased immunoreactivity for p53 in irradiated mesothelial cells confirmed that a protein known to be radiation-inducible could be produced by the same conditions. Normal fibroblasts, mammary epithelium, and the ovarian cell line did not produce CA 125 in either the presence or absence of radiation. Thus, irradiated mesothelial cells are a potential source of serum CA 125 in patients who have received abdominal irradiation.

Novel phosphonium salts display in vitro and in vivo cytotoxic activity against human ovarian cancer cell lines

Phosphonium salts are part of a class of lipophilic cationic molecules that accumulate preferentially in mitochondria and inhibit the growth of human and rodent carcinoma cells in vitro and in animal models. The delocalized cations tested previously such as dequalinium have exhibited considerable cross resistance against multiple drug-resistant cells expressing gp 170. In order to overcome this cross resistance, we have developed two novel phosphonium salts which contain haloalkyl moieties with potential protein alkylating capabilities. 3-Chloropropyltris(4-dimethylaminophenyl)phosphonium chloride (APPCL) and 3-iodopropyltris(4-dimethylaminophenyl)phosphonium iodide (APPI) are more lipophilic than other phosphonium salts described to date. By comparing the 50% inhibitory concentration (IC50) values for the A2780 human ovarian carcinoma parental line to a multiple drug-resistant variant (A2780-DR), the degree of cross resistance (IC50 for A2780-DR/IC50 for A2780 Parental) were found to be 494 for doxorubicin, but only 2.7 for APPCL. Similarly, the degree of cross resistance using a cisplatin-resistant variant (IC50 for A2780-CR/IC50 for A2780 Parental) was 30 for cisplatin, but only 2.2 for APPCL. APPCL is also active in vitro against UCI 101 (IC50 = 80 nM), an ovarian carcinoma line isolated from a patient who had failed chemotherapy with taxol, doxorubicin, and high-dose cisplatin. The cytotoxicity of APPI was comparable to that of APPCL with an IC50 ranging from 16.7 to 83.0 nM for a panel of seven cell lines. When administered intraperitoneally at a total dose of 46 mg/kg over 15 days, APPCL increased the median lifespan of nude mice bearing UCI 101, from a control value of 48.0 to 92.5 days (P < 0.0061). The median survival of the APPI-treated mice was 55 days. A total of 37.5% of the APPCL-treated group and 12.5% of the APPI-treated group were long-term survivors: sacrifice of these mice on Day 180 and subsequent histology showed no evidence of disease. Exposure to APPCL and APPI caused mitochondrial damage to UCI 101 cells at sublethal doses in vitro, as shown by morphological damage observed with transmission electron microscopy. APPCL appears to decrease the uptake of rhodamine 123 by mitochondria, suggesting that mitochondria may be significant targets or initial reservoirs for this agent. In conclusion, APPI and APPCL show promising anticancer activity against a variety of human ovarian carcinoma cell lines warranting further investigation.

Characterization and development of UCI 107, a primary human ovarian carcinoma cell line

We introduce a new epithelial ovarian carcinoma cell line (UCI 107) from a patient with papillary adenocarcinoma of the ovary who had not been previously treated. The growth characteristics, chemosensitivity, tumorgenicity, cytogenetics, antigen expression, and receptor status were examined. A standardized photometric assay was implemented to determine the response to single drug agents including doxorubicin (ADR), cisplatin (CDDP), and Taxol. Tumorgenicity was determined utilizing female athymic mice implanted either subcutaneously (sc) or intraperitoneally (ip) with 1 x 10(7) UCI 107 cells. UCI 107 cells grow rapidly in culture with lag phase of approximately 48 hr, population doubling time of 24-36 hr, and saturation density of 4.8 x 10(5) cells/cm2. The 50% inhibitory concentration values for the chemotherapeutic agents were 0.170, 0.029, and 0.330 microM for ADR, Taxol, and CDDP, respectively. Nude mice produced ip tumors within 15 days, resulting in death from carcinomatosis 40-45 days postimplantation. Subcutaneous tumor nodules (100 mm3) were observed in nude mice 12-13 days post-tumor implantation reaching a maximum tumor volume of approximately 10,000 mm3 by Day 30. The cytogenetic composite karyotype is as follows: 46, X, der (X) t (X;7) (p11;q22), inv dup (1) (q12;q32), t (6;6;11;22) (p21.3;q16;q23.3;q13.3), del (13) (q14.1). The cell line expresses progesterone receptor, increased levels of p53 protein, and cytokeratins. It does not appear to express Her-2/neu protein, estrogen receptor, nor the CA 125 tumor marker. In conclusion, UCI 107 displays unique cellular properties which make it an attractive model for the study of ovarian cancer.

UCI-VULV-1, a vulvar squamous carcinoma cell line

Squamous carcinoma of the vulva (SCV) is an uncommon neoplasm of uncertain etiology. There is evidence that there are two subgroups of SCV, one associated with human papilloma virus (HPV) and a second HPV-negative group. The UCI-VULV-1 cell line, obtained from a lymph node metastasis of an SCV, grows with a population doubling time of approximately 60 hr. The saturation density is 10(5) cells/cm2. The cell line does not exhibit anchorage independence and is weakly tumorigenic. The cells range in appearance from an abundant spindle cell to a less common larger, flat cell. All of the cells are immunoreactive for high-molecular-weight keratin, but only the flat cells, which form squamous pearls in vivo, are immunoreactive for low-molecular-weight keratin. The cell line expresses epidermal growth factor (EGF), transforming growth factor-alpha, the EGF receptor, and p53 protein. Polymerase chain reaction revealed no HPV DNA within the cells. Early passage cells exhibited karyotypic heterogeneity with few similarities to previous described SCV karyotypes. The cells display sensitivity to cis-platinum in concentrations toxic to many ovarian and cervical carcinoma lines. UCI-VULV-1 may be helpful for studying the properties of the HPV-negative form of SCV.

A report of two cases of recurrent Paget's disease of the vulva in a split-thickness graft and its possible pathogenesis-labeled "retrodissemination"

Two cases of recurrent noninvasive Paget's disease of the vulva in a split-thickness graft without an underlying adenocarcinoma are presented. This is the third report of recurrence of extramammary Paget's disease in a split-thickness graft, and the second of such an occurrence without an underlying dermal adnexa adenocarcinoma. A hypothesis for the possible pathogenetic mechanism of this unusual biological behavior is suggested.

Trisomy 11 and other nonrandom trisomies in congenital fibrosarcoma

Chromosome studies in a 7-week-old female infant with an intraabdominal malignant fibrosarcoma showed a hyperdiploid karyotype of 50,XX, +der(6)del(6)(p23)add(6)(q11), +8, +10, +11,add(12)(p13). Trisomy 11 appears to be a nonrandom primary cytogenetic abnormality in the congenital or infantile form of this mesenchymal tumor and is also a nonrandom gain in congenital mesoblastic nephroma. A possible developmental link between these two mesenchymal tumors, mediated by a gene or genes on chromosome 11 is postulated.

Presence or absence of trisomy 11 is correlated with histologic subtype in congenital mesoblastic nephroma

Fluorescence in situ hybridization utilizing a probe for the alpha satellite repeat sequence on chromosome 11 was used to detect variations in the number of chromosomes 11 in 24 formalin-fixed, paraffin-embedded congenital mesoblastic nephromas. Evidence of trisomy 11 was found in nearly half of the tumors. More importantly, the presence of trisomy 11 was associated with the cellular histologic variant of this tumor.

Prospective study of prenatal screening for Down's syndrome with free beta human chorionic gonadotrophin

OBJECTIVE

To assess the value and impact of a screening programme for Down's syndrome that uses the two maternal serum markers: alpha fetoprotein and free beta human chorionic gonadotrophin.

DESIGN

All women booked into clinics were screened. Further tests were offered to women with a risk of one in 300 or greater of having an affected baby. Follow up of outcome of all pregnancies.

SETTING

Biochemical screening laboratory serving two health districts.

SUBJECTS

8179 women of all ages with singleton pregnancies screened between 15 and 22 weeks' gestation from 1 April 1991 to 31 March 1992.

MAIN OUTCOME MEASURES

Detection rate of Down's syndrome, false positive rate, uptake of screening, uptake of amniocentesis in women identified as at increased risk, prevalence of Down's syndrome at birth.

RESULTS

Overall 89% (8317/9345) of women underwent screening. The rate of detection of Down's syndrome was 69% (11/16; 95% confidence interval 41 to 89%) with a 5.2% false positive rate (426/179; 4.7 to 5.7%). In women under 30 the detection rate was 50% (four out of eight; 32 to 86%) Uptake of amniocentesis was 89% (389/437), resulting in a reduction of prevalence of Down's syndrome at birth from 1.1 per 1000 in previous years (66/59,696) to 0.4 per 1000 during the screening year (4/9345). Additionally, several other abnormalities were identified.

CONCLUSION

The benefit of a high detection rate with this approach and the additional anomalies identified should encourage others to introduce screening programmes for Down's syndrome that use free beta human chorionic gonadotrophin and alpha fetoprotein.

Unbalanced translocation resulting in the loss of the chromosome 17 short arm in an osteoblastoma

We report results of the first cytogenetic study of an osteoblastoma. Cells from the tumor were characterized by a three-way unbalanced translocation involving chromosomes 15, 17, and 20. As a consequence of the translocation, most of one chromosome 17 short arm appears to have been lost. This loss suggests the possibility that loss of 17p DNA sequences may be involved in early changes leading to neoplastic proliferation of osteoblasts.