Copy number architectures define treatment-mediated selection of lethal prostate cancer clones

Despite initial responses to hormone treatment, metastatic prostate cancer invariably evolves to a lethal state. To characterize the intra-patient evolutionary relationships of metastases that evade treatment, we perform genome-wide copy number profiling and bespoke approaches targeting the androgen receptor (AR) on 167 metastatic regions from 11 organs harvested post-mortem from 10 men who died from prostate cancer. We identify diverse and patient-unique alterations clustering around the AR in metastases from every patient with evidence of independent acquisition of related genomic changes within an individual and, in some patients, the co-existence of AR-neutral clones. Using the genomic boundaries of pan-autosome copy number changes, we confirm a common clone of origin across metastases and diagnostic biopsies, and identified in individual patients, clusters of metastases occupied by dominant clones with diverged autosomal copy number alterations. These autosome-defined clusters are characterized by cluster-specific AR gene architectures, and in two index cases are topologically more congruent than by chance (p-values 3.07 × 10-8 and 6.4 × 10-4). Integration with anatomical sites suggests patterns of spread and points of genomic divergence. Here, we show that copy number boundaries identify treatment-selected clones with putatively distinct lethal trajectories.

An interactive web application for processing, correcting, and visualizing genome-wide pooled CRISPR-Cas9 screens

A limitation of pooled CRISPR-Cas9 screens is the high false-positive rate in detecting essential genes arising from copy-number-amplified genomics regions. To solve this issue, we previously developed CRISPRcleanR: a computational method implemented as R/python package and in a dockerized version. CRISPRcleanR detects and corrects biased responses to CRISPR-Cas9 targeting in an unsupervised fashion, accurately reducing false-positive signals while maintaining sensitivity in identifying relevant genetic dependencies. Here, we present CRISPRcleanR WebApp , a web application enabling access to CRISPRcleanR through an intuitive interface. CRISPRcleanR WebApp removes the complexity of R/python language user interactions; provides user-friendly access to a complete analytical pipeline, not requiring any data pre-processing and generating gene-level summaries of essentiality with associated statistical scores; and offers a range of interactively explorable plots while supporting a more comprehensive range of CRISPR guide RNAs' libraries than the original package. CRISPRcleanR WebApp is available at https://crisprcleanr-webapp.fht.org/.

Accumulation of copy number alterations and clinical progression across advanced prostate cancer

BACKGROUND

Genomic copy number alterations commonly occur in prostate cancer and are one measure of genomic instability. The clinical implication of copy number change in advanced prostate cancer, which defines a wide spectrum of disease from high-risk localised to metastatic, is unknown.

METHODS

We performed copy number profiling on 688 tumour regions from 300 patients, who presented with advanced prostate cancer prior to the start of long-term androgen deprivation therapy (ADT), in the control arm of the prospective randomised STAMPEDE trial. Patients were categorised into metastatic states as follows; high-risk non-metastatic with or without local lymph node involvement, or metastatic low/high volume. We followed up patients for a median of 7 years. Univariable and multivariable Cox survival models were fitted to estimate the association between the burden of copy number alteration as a continuous variable and the hazard of death or disease progression.

RESULTS

The burden of copy number alterations positively associated with radiologically evident distant metastases at diagnosis (P=0.00006) and showed a non-linear relationship with clinical outcome on univariable and multivariable analysis, characterised by a sharp increase in the relative risk of progression (P=0.003) and death (P=0.045) for each unit increase, stabilising into more modest increases with higher copy number burdens. This association between copy number burden and outcome was similar in each metastatic state. Copy number loss occurred significantly more frequently than gain at the lowest copy number burden quartile (q=4.1 × 10-6). Loss of segments in chromosome 5q21-22 and gains at 8q21-24, respectively including CHD1 and cMYC occurred more frequently in cases with higher copy number alteration (for either region: Kolmogorov-Smirnov distance, 0.5; adjusted P<0.0001). Copy number alterations showed variability across tumour regions in the same prostate. This variance associated with increased risk of distant metastases (Kruskal-Wallis test P=0.037).

CONCLUSIONS

Copy number alteration in advanced prostate cancer associates with increased risk of metastases at diagnosis. Accumulation of a limited number of copy number alterations associates with most of the increased risk of disease progression and death. The increased likelihood of involvement of specific segments in high copy number alteration burden cancers may suggest an order underlying the accumulation of copy number changes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00268476 , registered on December 22, 2005. EudraCT  2004-000193-31 , registered on October 4, 2004.

Abstract 401: Single-cell transcriptome and chromatin sequencing uncover gene expression and gene regulatory patterns associated with enzalutamide resistance

Resistance to androgen receptor-targeted therapy due to tumor heterogeneity and clonal evolution is a key challenge for improving prostate cancer outcomes. Despite this, the transcriptomic and chromatin accessibility changes contributing to the emergence of resistance remain incompletely understood at the level of individual cells. Using single-cell assays for transposase-accessible chromatin (ATAC) and RNA sequencing in models of early treatment response and resistance to enzalutamide, we previously identified pre-existing and persistent cell subpopulations that possess regenerative potential when subjected to treatment. Here we analyze the chromatin and transcriptomes of these single cells to characterize their gene regulation and gene expression trajectories. We present evidence of a model of enzalutamide resistance emergence in which the pre-existing and treatment-persistent cells regenerate the bulk of resistant cells. This process is underpinned by chromatin reprogramming that increases the overall relaxation of chromatin upon resistance. We show that the reprogramming of the chromatin further differentially contributes to transcription factor-mediated transcriptional reprogramming via DNA motif exposure in different cell subpopulations. For example, in the treatment-persistent cells, we identify chromatin configurations characterized by the exposure of DNA motifs for GATA2, RELA (a NFkB subunit), CREB1, and E2F1. Pre-existing and treatment-persistent cells consistently display transcriptional features of high developmental potential and RNA velocity analysis identifies them as precursors of cell populations that arise from enzalutamide treatment. We also analyze the pre-existing and treatment-persistent cells in spatial transcriptomics of prostate cancer patient specimens based on their characteristic gene expression profiles. We find these cells to be enriched in cancerous regions of the tissue but also detect them within apparent benign regions, which has potential implications for treatment choice. In summary, we show patterns of gene expression regulation in preclinical models and patient samples that uncover mechanisms of resistance to androgen receptor-targeted therapy in prostate cancer.

Citation Format: Sinja Taavitsainen, Nikolai Engedal, Shaolong Cao, Florian Handle, Andrew Erickson, Stefan Prekovic, Daniel Wetterskog, Teemu Tolonen, Elisa M. Vuorinen, Antti Kiviaho, Reetta Nätkin, Tomi Häkkinen, Wout Devlies, Sallamari Henttinen, Roosa Kaarijärvi, Mari Lahnalampi, Heidi Kaljunen, Karolina Nowakowska, Heimo Syvälä, Merja Bläuer, Paolo Cremaschi, Frank Claessens, Tapio Visakorpi, Teuvo L. Tammela, Teemu Murtola, Kirsi J. Granberg, Alastair D. Lamb, Kirsi Ketola, Ian G. Mills, Gerhardt Attard, Wenyi Wang, Matti Nykter, Alfonso Urbanucci. Single-cell transcriptome and chromatin sequencing uncover gene expression and gene regulatory patterns associated with enzalutamide resistance [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 401.

Single-cell ATAC and RNA sequencing reveal pre-existing and persistent cells associated with prostate cancer relapse

Prostate cancer is heterogeneous and patients would benefit from methods that stratify those who are likely to respond to systemic therapy. Here, we employ single-cell assays for transposase-accessible chromatin (ATAC) and RNA sequencing in models of early treatment response and resistance to enzalutamide. In doing so, we identify pre-existing and treatment-persistent cell subpopulations that possess regenerative potential when subjected to treatment. We find distinct chromatin landscapes associated with enzalutamide treatment and resistance that are linked to alternative transcriptional programs. Transcriptional profiles characteristic of persistent cells are able to stratify the treatment response of patients. Ultimately, we show that defining changes in chromatin and gene expression in single-cell populations from pre-clinical models can reveal as yet unrecognized molecular predictors of treatment response. This suggests that the application of single-cell methods with high analytical resolution in pre-clinical models may powerfully inform clinical decision-making.

Copy number profiles of primary tumors for risk stratification of advanced prostate cancer: A biomarker study embedded in the multicenter STAMPEDE trial

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Background: Men with advanced hormone-sensitive prostate cancer (HSPC) starting long term androgen deprivation therapy (ADT) follow a highly variable clinical course. Treatment intensification with docetaxel or AR targeted therapies improves outcomes but there is a risk of overtreatment, especially in non-metastatic (M0) or metastatic (M1) low volume disease. We established a framework for biomarker evaluation in the STAMPEDE trial. We aimed to evaluate the feasibility and clinical utility of assessing the burden of copy number (CN) aberrations in newly diagnosed advanced HSPC. We hypothesised that increased percentage genome altered (PGA) would associate with higher disease burden and worse prognosis. Methods: We implemented a scalable strategy using low coverage whole genome sequencing (lpWGS) of formalin fixed paraffin embedded (FFPE) diagnostic core biopsies from STAMPEDE participants randomised to the standard of care ADT arm, between 2005 and 2016. Tissue was retrieved from 136 trial sites. 315 cases were randomly selected, aiming for a biomarker population of 300, anticipating an assay failure rate ̃5%. We defined 40% as the minimum histopathologically determined tumor cellularity (TC) for inclusion. We performed a survival analysis investigating PGA at diagnosis as a continuous measure with fractional polynomial specification in Cox models adjusting for disease burden, Gleason grade, pre-ADT PSA (log-transformed), age at randomisation and TC. We pre-specified that all hypothesis tests required evidence at the 5% significance level to consider rejecting the null hypothesis. Results: We successfully CN profiled 300/315 cases. There were no significantly different baseline clinico-pathological features between the full trial comparison n = 3106 and final biomarker population n = 300, 290/300 cases were de novo presentations. PGA in the core with highest Gleason grade and TC was median 18% (range 0%-75%; n = 300). PGA was significantly higher in M1 (n = 169) compared to M0 (n = 131) cases (median: 21% vs 14%; p = 0.00006). 284/300 were subclassified by disease burden into M0 node negative and node positive, and M1 low and high volume. PGA was significantly associated with increased disease burden (p = 0.00002). Increased PGA was significantly and non-linearly associated with an increased hazard of failure-free survival (p = 0.004), progression-free survival (p = 0.002), metastatic progression-free survival (p = 0.003), overall survival (p = 0.045) and prostate cancer-specific survival (p = 0.011). Conclusions: Evaluation of the burden of CN aberrations in archival, poor quality FFPE diagnostic tissue from men randomised in the STAMPEDE trial is feasible using lpWGS and has potential clinical utility to identify better prognosis advanced HSPC patients, who may not require treatment intensification.

Genome-wide plasma DNA methylation features of metastatic prostate cancer

Tumor DNA circulates in the plasma of cancer patients admixed with DNA from noncancerous cells. The genomic landscape of plasma DNA has been characterized in metastatic castration-resistant prostate cancer (mCRPC) but the plasma methylome has not been extensively explored. Here, we performed next-generation sequencing (NGS) on plasma DNA with and without bisulfite treatment from mCRPC patients receiving either abiraterone or enzalutamide in the pre- or post-chemotherapy setting. Principal component analysis on the mCRPC plasma methylome indicated that the main contributor to methylation variance (principal component one, or PC1) was strongly correlated with genomically determined tumor fraction (r = -0.96; P < 10-8) and characterized by hypermethylation of targets of the polycomb repressor complex 2 components. Further deconvolution of the PC1 top-correlated segments revealed that these segments are comprised of methylation patterns specific to either prostate cancer or prostate normal epithelium. To extract information specific to an individual's cancer, we then focused on an orthogonal methylation signature, which revealed enrichment for androgen receptor binding sequences and hypomethylation of these segments associated with AR copy number gain. Individuals harboring this methylation pattern had a more aggressive clinical course. Plasma methylome analysis can accurately quantitate tumor fraction and identify distinct biologically relevant mCRPC phenotypes.

Chronic Replication Problems Impact Cell Morphology and Adhesion of DNA Ligase I Defective Cells

Moderate DNA damage resulting from metabolic activities or sub-lethal doses of exogenous insults may eventually lead to cancer onset. Human 46BR.1G1 cells bear a mutation in replicative DNA ligase I (LigI) which results in low levels of replication-dependent DNA damage. This replication stress elicits a constitutive phosphorylation of the ataxia telangiectasia mutated (ATM) checkpoint kinase that fails to arrest cell cycle progression or to activate apoptosis or cell senescence. Stable transfection of wild type LigI, as in 7A3 cells, prevents DNA damage and ATM activation. Here we show that parental 46BR.1G1 and 7A3 cells differ in important features such as cell morphology, adhesion and migration. Comparison of gene expression profiles in the two cell lines detects Bio-Functional categories consistent with the morphological and migration properties of LigI deficient cells. Interestingly, ATM inhibition makes 46BR.1G1 more similar to 7A3 cells for what concerns morphology, adhesion and expression of cell-cell adhesion receptors. These observations extend the influence of the DNA damage response checkpoint pathways and unveil a role for ATM kinase activity in modulating cell biology parameters relevant to cancer progression.

CorrelaGenes: a new tool for the interpretation of the human transcriptome

Background

The amount of gene expression data available in public repositories has grown exponentially in the last years, now requiring new data mining tools to transform them in information easily accessible to biologists.

Results

By exploiting expression data publicly available in the Gene Expression Omnibus (GEO) database, we developed a new bioinformatics tool aimed at the identification of genes whose expression appeared simultaneously altered in different experimental conditions, thus suggesting co-regulation or coordinated action in the same biological process. To accomplish this task, we used the 978 human GEO Curated DataSets and we manually performed the selection of 2,109 pair-wise comparisons based on their biological rationale. The lists of differentially expressed genes, obtained from the selected comparisons, were stored in a PostgreSQL database and used as data source for the CorrelaGenes tool. Our application uses a customized Association Rule Mining (ARM) algorithm to identify sets of genes showing expression profiles correlated with a gene of interest. The significance of the correlation is measured coupling the Lift, a well-known standard ARM index, and the χ² p value. The manually curated selection of the comparisons and the developed algorithm constitute a new approach in the field of gene expression profiling studies. Simulation performed on 100 randomly selected target genes allowed us to evaluate the efficiency of the procedure and to obtain preliminary data demonstrating the consistency of the results.

Conclusions

The preliminary results of the simulation showed how CorrelaGenes could contribute to the characterization of molecular pathways and biological processes integrating data obtained from other applications and available in public repositories.

[Longitudinal bronchotomy on the pars membranacea for endoscopic foreign body extraction]

Purpose of this paper is to report a case of foreign body obstructing the middle lobe bronchial origin, surgically removed through a longitudinal bronchotomy on the pars membranacea, reached by passing posteriorly to the lung. Anatomical considerations suggest that longitudinal bronchotomy on the pars membranacea of the main bronchial axis (stem bronchi, intermedius br (right), and lower lobar bronchus) gives direct visualization from inside also of foreign bodies sited into the lobar bronchi (sup, middle and lingula), allowing an easy bronchotomy repair, without lumen distortion or stenosis. Since the pulmonary artery is not in contact with this pars membranacea, broncho-arterial fistula in case of suture line dehiscence is quite improbable.

Effects of interleukin-2 for the treatment of malignant mesothelioma

The hematological profile, and clinical parameters in mesothelioma affected patients undergoing a clinical trial to evaluate the efficacy of IL-2 treatment were investigated. Six patients were monitored for 6 weeks following therapy. Blood cell count, morphological and immunophenotypical analysis were performed, as well as clinical evaluations of the patients before and after therapy. Activation of the immune system (increase in lymphocytes, monocytes, eosinophils and HMS lymphocytes) induced by IL-2 was observed. The treatment was well tolerated: our patients had only mild adverse reactions controlled by symptomatic therapy. Eosinophilia represented the most evident negative effect. A slight decrease in CD4-positive subset of lymphocytes was observed after rIL-2 treatment. The therapy did not induce significant changes in the progression of the disease. In one patient necrosis at the tumoral site was observed after loco-regional rIL-2 administration.

Pulmonary sclerosing hemangioma in a woman with multiple uterine fibromas, cysts to thyroid and kidney

Pulmonary sclerosing hemangioma (PSH) is a relatively rare, homogeneous solitary tumor. Its complex histology may suggest a number of malignancies. We report one case diagnosed in a 62-years-old woman with a tendency to benign tumors (uterine fibromas) and cystes (thyroide, kidney). Bronchoscopy was normal. Pulmonary scintiscan was not done. Chest X-ray showed a 2 x 2 cm solitary, dense, homogeneous, delimited nodule of the LLL. The intraoperatory diagnosis of adenocarcinoma led to lobectomy. The final diagnosis of PSH was done on fixed and stained samples. She is in good condition after 13 months of follow-up.

The role of functional respiratory tests in predicting pneumothorax during lung needle biopsy

In 243 of 945 patients having lung percutaneous needle biopsy, we retrospectively evaluated 10 independent variables that potentially influence the incidence of pneumothorax (PNX): age, sex, lesion size, number of needle passes, needle intrapulmonary route, distance of the lesion from the chest wall, FEV1, FVC, residual volume, and total lung capacity percent predicted. The subjects considered (mean age, 61 years; 192 men and 51 women) performed respiratory function tests within 1 year of the procedure. The sample was also subdivided into four functional groups: restricted patients, obstructed ones, obstructed with alveolar hyperinflation patients, and normal subjects. The variables significantly correlated to PNX were the length of the needle intraparenchymal route (p<0.05) and the distance of the lesion from chest wall greater than 0 cm (p<0.01). None of the functional parameters was determinant in predicting PNX occurrence. Bronchial obstruction was not significantly associated with a higher risk of PNX. Nevertheless, when alveolar hyperinflation was associated with bronchial obstruction, the risk increased significantly (odds ratio, 2.38).

Surveillance transbronchial biopsy in the diagnosis of acute lung rejection in heart and lung and lung transplant recipients

From March 1991 to December 1993, 30 patients underwent transbronchial biopsy (TBB) after lung transplantation (16 with a heart lung transplant, 7 with a single lung transplant, and 7 with a double lung transplant). The now standard TBB technique was used. Initially, TBB was performed only when clinically indicated, i.e. when there were sound reasons to suspect the existence of acute rejection (AR) or pulmonary infection. From 1992, all the patients were entered into a prospective study, the protocol of which called for serial "surveillance" TBB to be performed, in addition to those for clinical indications, 15 days, 2, 3, 6, 9 and 12 months after the transplant, and then annually. One hundred and twenty nine transbronchial biopsies were performed in 2.5 yrs. Of the 121 successful TBBs, 54 (45%) were positive, i.e. showed signs of acute rejection. Sixty six of 129 (51%) of the TBBs were performed because of clinical indications, 45 of them (68%) within the first 3 months following the transplant. The other 63 were surveillance biopsies. About two thirds of the clinically indicated TBBs and more than a quarter of the surveillance TBBs, yielding adequate samples, were positive for AR > or = A2 (mild rejection). The sensitivity and specificity of the method in detecting AR were 91 and 100%, respectively. The overall incidence of complications was 10.8% (pneumothorax in 9% of cases). There were no deaths correlated to the procedure. Our results confirm the decisive role of TBB in the diagnosis of acute lung rejection. The high incidence of mild acute rejection, and the occasional finding of moderate acute rejection in stable asymptomatic patients, support the use of surveillance TBB in the first 6 months.

Coexpression of aspartic proteinases and human leukocyte antigen-DR in human transplanted lung

Aspartic proteinases have recently been shown to be implicated in antigen processing. We explored the expression of two aspartic proteinases, cathepsins E and D, and of human leukocyte antigen-DR (HLA-DR) molecules in a consecutive series of 80 transbronchial biopsies from transplanted lungs. For controls, we studied five normal donor lungs (not suitable for transplantation on account of thoracic trauma) and macroscopically normal areas of three cancer-affected lungs. Two of the five unsuitable donor lungs showed minimal inflammatory changes. Macroscopically normal samples from the three cancerous lungs showed mild and focal inflammatory infiltrates. In histologically normal lungs, HLA-DR expression was limited to professional antigen-presenting cells. Macroscopically normal lung samples with minimal inflammatory changes from both donor and cancer lungs showed variable HLA-DR expression by alveolar and bronchial epithelial cells and by endothelial cells. All transplanted lung biopsies showed HLA-DR expression by epithelial (alveolar and bronchial) and endothelial cells, with a trend for increased positivity in acute rejection. Cathepsin E was restricted to Clara and to rare bronchus-associated lymphoid tissue-related epithelial cells in histologically normal lung samples, whereas minimal de novo cathepsin E expression by rare alveolar pneumocytes was noted in control lung samples exhibiting minimal inflammatory changes. In all transplanted lung biopsies, cathepsin E was diffusely expressed de novo by hyperplastic alveolar epithelial cells, regardless of the presence or degree of rejection. Cathepsin D was expressed only by alveolar macrophages and by ciliated bronchial cells of normal, minimally inflamed, and transplanted lungs. In transplanted lung, Clara cells and several hyperplastic alveolar pneumocytes coexpressed HLA-DR and cathepsin E, whereas all alveolar macrophages and a few ciliated cells coexpressed cathepsin D and HLA-DR. The present investigation suggests that the de novo expression of cathepsin E and HLA-DR by hyperplastic alveolar pneumocytes of transplanted lung may be crucial for antigen processing and presentation to recipient competent T cells, and thus for the triggering of the immune-inflammatory cascade that leads to rejection.

Correlation between ultrastructural and histochemical parameters in lymphokine-activated killer (LAK) cells reacting with target cells in vitro

Ultrastructural and fluorescence data allowed us to study the most important moments of the interaction between lymphokine-activated killer (LAK) cells against target cells (Chang) in vitro. The LAK cells, maintained at low doses of recombinant interleukin-2, were able to recognize, bind and destroy the tumoral cells. Before the attack, the LAK cells were characterized by a cytoplasm with a high ribosomes content; after the identification and the interaction cell-cell, a degeneration of the tumoral cell was observed. These observations allowed us to suppose that the interaction between the two types of cells may be mediated by a receptoral membrane system without the action of lytic enzymes.

Therapeutic embolization of bronchial artery: a successful treatment in 209 cases of relapse hemoptysis

Still today bronchial artery embolization (BAE) is an important procedure in the management of hemoptysis, as an alternative to, or in association with, surgical or medical therapy. From 1974 to 1990, BAE was performed in 209 patients who suffered from hemoptysis with different etiopathogeneses and severity. Bronchiectasis were the most frequent indication (46%) followed by tuberculosis (31%), cystic fibrosis (16%), lung cancer (4%), and aspergillosis (3%). BAEs were performed by means of polyvinyl alcohol particles and absorbable gelatin sponge. In a few cases complete occlusion of the main truncus of particularly large bronchial arteries was obtained by use of Gianturco steel coin (5 mm o) technique. In the last seven years, together with the traditional angiographic techniques, selective digital angiography (SDA) was performed, above all in preliminary control phases, to evaluate occlusion during embolization. SDA reduced catheterization time and the mean quantity of contrast administered, decreasing side effects; 98% of hemoptysis was controlled in the first twenty-four hours, the other 2% in the following forty eight hours; 16% relapses occurred within the first year; 27 patients needed reembolization (15 patients twice, 11 patients three times, 1 patient five times). No complications were seen. If diagnosis, therapeutic indications, operative technique, and equipment selection are adequate, BAE has a high reliability in patients affected by relapsing hemoptysis, which is difficult to resolve.

Pneumocystis carinii pneumonia in heart transplant recipients

Seven cases of Pneumocystis carinii pneumonia (PCP) (two in 1988, three in 1989, one in 1990 and one in 1991) have been observed in a group of 241 heart transplant recipients transplanted in Pavia, Italy, from November 1985 through December 1991. Median time to onset of symptoms was 100 days after transplantation (range 59-333 days). Diagnosis was achieved in all patients by cytological examination of bronchoalveolar lavage (BAL) fluid and/or transbronchial biopsy. Clinical and roentgenographic features were remarkably similar in all PCP-affected heart transplant recipients. A dry, persistent hacking cough associated with dyspnoea was consistently observed. Fever ranged from 37.6 to 39.4 degrees C, median leukocyte count and median arterial oxygen saturation (SaO2) values were 7,300/mm3 (range 3,000-16,000/mm3) and 61% (range 49.3-93%), respectively. Median CD4+ count at the onset of symptoms was 211/mm3 (range 28-739/mm3). The only patient experiencing a recurrence of PCP had a CD4+ cell count of 28/mm3 at the end of treatment with trimethoprim-sulfamethoxazole (TMP-SMX). In all patients human cytomegalovirus was isolated from BAL fluids; however, treatment with TMP-SMX alone (20 mg/kg/day of TMP) was consistently followed by a complete recovery.

Report of one case of familial sarcoidosis

Familial sarcoidosis is a quite unusual occurrence. We describe two affected sisters, in which the clinical features of the disease were fairly similar. Interestingly, the two patients and two unaffected siblings share an HLA haplotype [A10 (26); CW7; B16 (38); DRW6; DQW1] rare in Caucasians.

Detection of malignant pleural effusions by tumor marker evaluation

Cytologic examination and determination of tumor markers (PHI, LDH, alpha-1-glycoprotein, alpha-2-HS-glycoprotein, beta 2-microglobulin, ferritin [corrected], sialic acid, IgE, fetoprotein, CEA, beta HCG and beta 1-SP-glycoprotein) were carried out in pleural fluid samples obtained from 70 patients with suspected neoplasia. Tumor markers were also determined in sera. The protein content of all pleural effusions was greater than or equal to 3 g/dl. Patients were grouped according to diagnosis as follows: (a) 42 with neoplastic diseases (7 mesotheliomas and 19 lung, 4 ovarian, 3 breast and 8 miscellaneous cancers), (b) 22 with benign inflammations and (c) 6 with congestive effusions. Of the parameters examined, only CEA and beta-HCG [corrected] gave information that the effusion was probably malignant. Using 6 ng/ml as cut-off for CEA and 10 mIU/ml for beta HCG, the sensitivity was 57.1% and 45.2%, respectively, specificity was 92.8% for both parameters and test efficiency 0.75 and 0.69, respectively. When CEA and beta HCG were considered together sensitivity increased to 73.8% and efficiency to 0.78. CEA and/or beta HCG were positive in the pleural effusions of 19 of the 20 malignant pleural effusions, all with a negative cytologic examination, which subsequently became positive in 8. Because of their high specificity, these two parameters are a useful tool and can be routinely measured to evaluate pleural effusions of dubious origin, even if CEA and beta HCG cannot, on [corrected] their own, define the primary malignancy.

[Serum and bronchial concentrations of amoxicillin administered with a bronchial fluidizer]

The authors compared the serum and bronchial concentration of amoxycillin administered alone and in association with carboxymethylcysteine. The determinations were carried out in 10 patients affected with exacerbated acute and chronic bronchopneumopathies, treated first with amoxycillin alone (15 g/day in 3 administrations) and then with amoxycillin at the same dosage and carboxymethylcysteine (450 mg/day in 3 administrations). The bronchial secretions were collected during bronchoscopy performed 2 hours after the last administration of antibiotic. The bronchial secretion values of amoxycillin administered alone varied from 0.92 mcg/ml to 1.88 mcg/ml with a mean value of 1.44 mcg/ml. The percentage ratio between levels in bronchial secretion and levels in the serum varied from 12.7 to 36.1 with a mean value of 23.2. The administration of the amoxycillin-fluidizing agent association determined a statistically significant increase of the antibiotic levels in the bronchial secretions, varying from 1.26 mcg/ml to 6.39 mcg/ml, with a percentage ratio from 19.6 to 103.0.

[Immunological monitoring of patients operated on for epidermoid bronchogenic carcinoma]

Sequential monitoring of non specific immunity has been carried out in 16 patients with squamous cell bronchogenic carcinoma undergoing radical surgery. At the time of diagnosis total lymphocyte counts, T-lymphocyte counts and the blastogenic response of lymphocytes to PHA were only slightly depressed; on the contrary C3c and C4 serum levels were significantly increased (P less than 0.01). Sequential determinations of the immunologic profile at monthly intervals up to the 12th postoperative month showed a transient increase of total lymphocyte and T-lymphocyte levels; the lymphocyte blastogenic response to PHA and also C3c and C4 serum levels progressively decreased. Delayed hypersensitivity response to cutaneous antigens, neutrophil chemotaxis, serum levels of IgG, IgA, IgM and B-lymphocyte counts were constantly found within normal range.