Phase II Multi-Institutional Study of a Low-Dose (4 Gy) Palliative Response-Adapted Radiotherapy Regimen for Symptomatic Bone Metastases from Multiple Myeloma: Planned Interim Analysis of First 40 Patients

PURPOSE/OBJECTIVE(S)

Painful bone lesions are common in patients with multiple myeloma (MM). Radiotherapy (RT) is effective in providing pain relief from MM bone lesions in over 80% of patients. There is no consensus as to the most effective dose or fractionation for palliation. Shorter courses of therapy are not only more convenient for patients, but they also have less impact on timing of systemic therapies. There is precedent for using 4 Gy in the palliation of lymphomas, which have similar radiosensitivity to myeloma. The primary objective of this trial is to determine whether treatment with a total dose of 4 Gy to a painful myeloma bone lesion achieves patient-reported pain reduction comparable to historical controls at 4 weeks.

MATERIALS/METHODS

Patients with a known diagnosis of MM and a painful bone lesion that was not at the base of skull, in need of stabilization, or causing cord compression were treated with 4 Gy (2 Gy x 2 or 4 Gy x 1). Patients' pain was measured using the brief pain index (BPI) prior to treatment and at 2, 4, 8 weeks and 6 months following treatment. Pain response was determined by the international consensus on palliative radiotherapy and considered change in BPI and oral morphine equivalent dose (OMED). A planned interim analysis for futility was completed after 40 patients. Reirradiation with clinician choice regimens could be considered at ≥4 weeks following initial treatment for indeterminate pain response or pain progression.

RESULTS

Forty patients were treated at 6 institutions between 2019 and 2022. Median age was 65 years with 40% women and 88% with an ECOG of 0-1. A complete response (CR) was defined as a BPI score of 0 with no concomitant increase in OMED. A partial response (PR) was defined as BPI reduction in 2 or more without analgesic increase, or an OMED reduction of 25% or more without an increase in pain. An indeterminate response (IR) was any response that is not captured by a CR, PR or pain progression. A CR was achieved in 48%, a PR in 38% of patients, an IR in 13% with 1 patient who refused participation. Pain response was achieved in 86% of patients. Seven patients (18%) requested reirradiation at ≥4 weeks. Median BPI at baseline and 4 weeks after RT for patients with CR, PR, and IR were 3.75 and 0, 4.00 and 1, and 5.25 and 4.75, respectively. Median change of BPI between baseline and 4 weeks after RT for all responders (CR and PR) was -3.25. The median PTV volume (cc) for patients with CR, PR and IR were 81, 140 and 226, respectively. Based on these results, the futility threshold was not met, and the recommendation by the DSMC is to continue the trial.

CONCLUSION

In the first 40 patients who received 4 Gy palliation for painful bone lesions from multiple myeloma, there were 86% that had a pain response (48% CR, 38% PR). This low dose, response-adapted treatment, led to reirradiation in less than 20% of patients.

Sub-100 mA/cm2 CO2-to-CO Reduction Current Densities in Hierarchical Porous Gold Electrocatalysts Made by Direct Ink Writing and Dealloying

While most research efforts on CO₂-to-CO reduction electrocatalysts focus on boosting their selectivity, the reduction rate, directly proportional to the reduction current density, is another critical parameter to be considered in practical applications. This is because mass transport associated with the diffusion of reactant/product species becomes a major concern at a high reduction rate. Nanostructured Au is a promising CO₂-to-CO reduction electrocatalyst for its very high selectivity. However, the CO₂-to-CO reduction current density commonly achieved in conventional nanostructured Au electrocatalysts is relatively low (in the range of 1-10 mA/cm²) for practical applications. In this work, we combine direct ink writing-based additive manufacturing and dealloying to design a robust hierarchical porous Au electrocatalyst to improve the mass transport and achieve high CO₂-to-CO reduction current densities on the order of 64.9 mA/cm² with CO partial current density of 33.8 mA/cm² at 0.55 V overpotential using an H-cell configuration. Although the current density achieved in our robust hierarchical porous Au electrocatalyst is one order of magnitude higher than the one achieved in conventional nanostructured electrocatalysts, we found that the selectivity of our system is relatively low, namely 52%, which suggests that mass transport remains a critical issue despite the hierarchical porous architecture. We further show that the bulk dimension of our electrocatalyst is a critical parameter governing the interplay between selectivity and reduction rate. The insights gained in this work shed new light on the design of electrocatalysts toward scale-up CO₂ reduction and beyond.

Cardiovascular diseases among diffuse large B-cell lymphoma long-term survivors in Asia: a multistate model study

BACKGROUND

We modeled the clinical course of a cohort of diffuse large B-cell lymphoma (DLBCL) patients with no prior cardiovascular diseases (CVDs) using a multistate modeling framework.

PATIENTS AND METHODS

Data on 2600 patients with DLBCL diagnosed between 2000 and 2018 and had received chemotherapy with or without radiotherapy were obtained from a population-wide electronic health database of Hong Kong. We used the Markov illness-death model to quantify the impact of doxorubicin and various risk factors (therapeutic exposure, demographic, comorbidities, cardiovascular risk factors, and lifestyle factors which included smoking) on the clinical course of DLBCL (transitions into incident CVD, lymphoma death, and other causes of death).

RESULTS

A total of 613 (23.6%) and 230 (8.8%) of 2600 subjects died of lymphoma and developed incident CVD, respectively. Median follow-up was 7.0 years (interquartile range 3.8-10.8 years). Older ages [hazard ratio (HR) for >75 versus ≤60 years 1.88; 95% confidence interval (CI) 1.25-2.82 and HR for 61-75 versus ≤60 years 1.60; 95% CI 1.12-2.30], hypertension (HR 4.92; 95% CI 2.61-9.26), diabetes (HR 1.43; 95% CI 1.09-1.87), and baseline use of aspirin (HR 5.30; 95% CI 3.93-7.16) were associated with an increased risk of incident CVD. In a subgroup of anticipated higher-risk patients (aged 61-75 years, smoked, had diabetes, and received doxorubicin), we found that they remained on average 7.9 (95% CI 7.2-8.8) years in the DLBCL state and 0.1 (95% CI 0.0-0.4) years in the CVD state, if they could be followed up for 10 years. The brief time in the CVD state is consistent with the high chance of death in patients who developed CVD. Other causes of death have overtaken DLBCL-related death after about 5 years.

CONCLUSIONS

In this Asian population-based cohort, we found that incident CVDs can occur soon after DLBCL treatment and continued to occur throughout survivorship. Clinicians are advised to balance the risks and benefits of treatment choices to minimize the risk of CVD.

An electrochemical biosensor exploiting binding-induced changes in electron transfer of electrode-attached DNA origami to detect hundred nanometer-scale targets

The specific detection in clinical samples of analytes with dimensions in the tens to hundreds of nanometers, such as viruses and large proteins, would improve disease diagnosis. Detection of these "mesoscale" analytes (as opposed to their nanoscale components), however, is challenging as it requires the simultaneous binding of multiple recognition sites often spaced over tens of nanometers. In response, we have adapted DNA origami, with its unparalleled customizability to precisely display multiple target-binding sites over the relevant length scale, to an electrochemical biosensor platform. Our proof-of-concept employs triangular origami covalently attached to a gold electrode and functionalized with redox reporters. Electrochemical interrogation of this platform successfully monitors mesoscale, target-binding-induced changes in electron transfer in a manner consistent with coarse-grained molecular dynamics simulations. Our approach enables the specific detection of analytes displaying recognition sites that are separated by ∼40 nm, a spacing significantly greater than that achieved in similar sensor architectures employing either antibodies or aptamers.

Extending Screening in "Elderly" Patients: Should We Consider a Selective Approach?

BACKGROUND

Breast cancer screening has been shown to reduce breast cancer-associated mortality. However, screening is limited to the targeted age group of 45 to 69 years in New Zealand despite the recognized increased risk with age. This study aims to compare the outcomes of women aged over 70 years with screen-detected and clinically detected cancers.

PATIENTS AND METHODS

A retrospective review was performed of prospectively collected data from June 2000 to May 2013 by the Auckland Breast Cancer Register. Demographic and tumor characteristics of women with invasive cancer and ductal carcinoma in situ diagnosis aged 70 years and over were compared between those screened and clinically detected. Five-year disease-free and overall survival outcomes were reviewed.

RESULTS

A total of 2128 women aged 70 years and over were diagnosed with breast cancer (median, 77 years; interquartile range [IQR], 74-84 years). Of these, 416 (19.5%) were diagnosed through mammography screening, with a median age of 74 years (IQR, 71-77 years) compared with 79 years (IQR, 74-85 years) for those with clinical detected cancer diagnosis. Screen-detected cancers accounted for a significantly higher proportion of diagnoses in those aged 70 to 74 years compared with older patients (P < .001). Screen-detected cancers were of lower T and N stages. Disease-specific survival was significantly longer in screen-detected cancers versus other cancers (5-year survival, 93.7% vs. 81.9%; P < .001), as was overall survival (5-year survival, 84.7% vs. 57.4%; P < .001).

CONCLUSION

Screening in those aged 70 years and over continues to identify breast cancer at early stages and with improved survival. Although aware of the potential for lead-time bias and the healthy volunteer effect, there should still be consideration to extend breast cancer screening to patients aged to up 74 years after appropriate assessment of comorbidities and functional status.

Early-stage mantle cell lymphoma: a retrospective analysis from the International Lymphoma Radiation Oncology Group (ILROG)

Background

Mantle cell lymphoma (MCL) rarely presents as early-stage disease, but clinical observations suggest that patients who present with early-stage disease may have better outcomes than those with advanced-stage disease.

Patients and methods

In this 13-institution study, we examined outcomes among 179 patients with early-stage (stage I or II) MCL in an attempt to identify prognostic factors that influence treatment selection and outcome. Variables examined included clinical characteristics, treatment modality, response to therapy, sites of failure, and survival.

Results

Patients were predominantly male (78%) with head and neck being the most common presenting sites (75%). Most failures occurred outside the original disease site (79%). Although the administration of radiation therapy, either alone or with chemotherapy, reduced the risk of local failure, it did not translate into an improved freedom from progression or overall survival (OS). The treatment outcomes were independent of treatment modality. The 10-year OS for patients treated with chemotherapy alone, chemo-radiation therapy and radiation therapy alone were 69%, 62%, and 74% (P = 0.79), and the 10-year freedom from progression were 46%, 43%, and 31% (P = 0.64), respectively.

Conclusion

Given the excellent OS rates regardless of initial therapy in patients with early-stage MCL, de-intensified therapy to limit treatment-related toxicity is a reasonable approach.

Salvage radiotherapy in patients with recurrent or refractory primary or secondary central nervous system lymphoma after methotrexate-based chemotherapy

BACKGROUND

To assess the efficacy of salvage radiation therapy (RT) in patients with recurrent/refractory primary or secondary central nervous system lymphoma (CNSL) after initial methotrexate (MTX)-based chemotherapy and to identify factors associated with treatment outcome.

PATIENTS AND METHODS

We reviewed 36 patients with primary or secondary CNSL who relapsed after MTX therapy and received salvage RT. Primary end points were radiographic response and overall survival (OS).

RESULTS

After salvage RT, 18 patients (50%) achieved a complete radiographic response and 6 (17%) achieved a partial response, for an overall response rate of 67% [95% confidence interval (CI) 49% to 81%]. The median OS from start of salvage RT was 11.7 months (range: 0.6-94.7). Patients treated with less than five cycles of MTX before failure had a significantly shorter OS than patients who received five or more cycles (9.2 months versus not reached, P = 0.04). Patients with CNSL limited to brain only had a significantly longer OS than patients with disease in the brain and other central nervous system locations (16.5 versus 4.5 months, P=0.01).

CONCLUSION

Salvage RT is effective for patients with recurrent/refractory primary or secondary CNSL after initial MTX therapy. Having received five or more cycles of MTX before failure and CNSL limited to the brain at relapse are associated with longer OS.

Response to low-dose involved-field radiotherapy in patients with non-Hodgkin's lymphoma

BACKGROUND

The purpose of this study was to analyze response to palliative low-dose involved-field radiotherapy (LD-IF-RT) (two 2-Gy fractions), explore factors predicting for response, and determine the time course to subsequent treatment.

PATIENTS AND METHODS

Thirty-three patients with advanced or recurrent indolent non-Hodgkin's lymphoma (NHL) received LD-IF-RT to 43 sites. Response was assessed by physical examination and radiographic studies. Median follow-up for individual sites was 14 months. Fisher's exact test was used to evaluate prognostic factors for response and in-field progression.

RESULTS

Overall response was 95%. Thirty-six sites (84%) had a complete response (CR), five sites (12%) had a partial response, and two sites (5%) had progressive disease. The CR rate of head and neck sites was significantly higher than that of pelvic and/or inguinofemoral sites (95% versus 64%, P = 0.04). The CR rate was significantly higher for sites < or =40 mm than for sites >40 mm (90% versus 56%, P = 0.04). Ten sites (23%) had in-field progression diagnosed at a median of 9 months. Sixteen patients (48%) received systemic treatment at a median of 8 months. Fourteen patients (42%) did not require additional treatment.

CONCLUSIONS

LD-IF-RT for selected NHL subtypes has excellent local CR and in-field control rates and may postpone the need for systemic therapy.

Role of radiation therapy in the treatment of stage I/II mucosa-associated lymphoid tissue lymphoma

BACKGROUND

Few large studies exist on the outcome of patients treated for stage I/II mucosa-associated lymphoid tissue (MALT) lymphoma.

PATIENTS AND METHODS

We retrospectively reviewed the records of 77 patients consecutively treated for stage I (n = 66) or II (n = 11) MALT lymphoma at our institution. Progression-free survival (PFS), freedom from treatment failure (FFTF), and overall survival (OS) were calculated using the Kaplan-Meier method.

RESULTS

The median follow-up time was 61 months (range 2-177 months). Fifty-two patients (68%) received local radiation therapy (RT) alone, 17 (22%) had surgery followed by adjuvant RT, five (6%) had surgery alone, two (3%) had surgery and chemotherapy, and one patient had chemotherapy alone. The median RT dose was 30 Gy (range 18-40 Gy). The 5-year PFS, FFTF, and OS rates were 76%, 78%, and 91%, respectively. The 5-year PFS (79% versus 50%; P = 0.002) and FFTF (81% versus 50%; P = 0.0004) rates were higher for patients who received RT as compared with patients who did not.

CONCLUSIONS

The prognosis following treatment of stage I/II MALT lymphoma is excellent. RT improves PFS and FFTF and has an important role in the curative treatment of patients with localized disease.

Long-term results of a prospective trial of mantle irradiation alone for early-stage Hodgkin's disease

BACKGROUND

To determine the long-term treatment outcome and late effects of mantle irradiation alone in selected patients with early-stage Hodgkin's disease.

METHODS

Between 1988 and 2000, 87 patients with pathologic stage (Ann Arbor) I-IIA or clinical stage IA Hodgkin's disease were entered on to a prospective trial of mantle irradiation alone. Patients with B symptoms, large mediastinal adenopathy, or subcarinal or hilar involvement were excluded. The median doses to the mantle field and mediastinum were 36 Gy (range 30.3-40) and 38.6 Gy (range 30.6-44), respectively. The actuarial freedom from treatment failure (FFTF) and overall survival (OS) rates were calculated using the Kaplan-Meier technique.

RESULTS

The median follow-up was 107 months (range 23-192). Thirteen of 87 patients (15%) relapsed at a median of 30 months (range 5-62). The 5- and 10-year actuarial FFTF rates were 86% and 84.7%, respectively. All 13 patients who relapsed are alive without evidence of disease at a median of 84 months (range 30-156) post-salvage therapy. Five patients developed a second malignancy at a median of 93 months (range 27-131). The 10-year actuarial risk of a second malignancy was 4.5%. There have been two deaths to date, both due to second malignancies. The 10-year OS rate was 98.2%.

CONCLUSION

In selected patients with early-stage Hodgkin's disease, mantle irradiation alone has an excellent long-term survival rate, comparing favorably with the previous standard treatment of extended-field radiation therapy and the current standard of combined modality therapy.

Computed tomography screening for lung cancer in Hodgkin's lymphoma survivors: decision analysis and cost-effectiveness analysis

BACKGROUND

Hodgkin's lymphoma patients have an elevated risk of developing lung cancer and may be targeted for lung cancer screening. We used a decision-analytic model to estimate the potential clinical benefits and cost-effectiveness of computed tomography (CT) screening for lung cancer in Hodgkin's lymphoma survivors.

MATERIALS AND METHODS

We developed a Markov decision-analytic model to compare annual low-dose CT screening versus no screening in a hypothetical cohort of patients diagnosed with stage IA-IIB Hodgkin's lymphoma at age 25, with screening starting 5 years after initial diagnosis. We derived model parameters from published studies and the Surveillance, Epidemiology and End Results (SEER) Program, and assumed that stage-shift produces a survival benefit.

RESULTS

Annual CT screening increased survival by 0.64 years for smokers and 0.16 years for non-smokers. The corresponding benefits in quality-adjusted survival were 0.58 quality-adjusted life-years (QALYs) for smokers and 0.14 QALYs for non-smokers. The incremental cost-effectiveness ratios for annual CT screening compared with no screening were $34 100/QALY for smokers and $125 400/QALY for non-smokers.

CONCLUSIONS

Our analysis suggests that if early promising results for lung cancer screening hold, CT screening for lung cancer may increase survival and quality-adjusted survival among Hodgkin's lymphoma survivors, with a benefit and incremental cost-effectiveness ratio for smokers comparable to that of other recommended cancer screening strategies.

A comparison between long-term survivors of Hodgkin's disease and their siblings on fatigue level and factors predicting for increased fatigue

PURPOSE

To compare the level of fatigue in survivors of Hodgkin's disease and their siblings, and to explore factors associated with increased fatigue.

METHODS

Survivors of Hodgkin's disease 5 years or more from diagnosis and their siblings completed a questionnaire study. Fatigue level was measured using the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) instrument, with lower scores reflecting increased fatigue. Multiple regression models were used to identify factors associated with fatigue level in the two populations.

RESULTS

Five hundred and eleven survivors (median age 44 years; range 16-82) and 224 siblings (median age 44 years; range 16-79) returned the completed questionnaire. The response rates were 61% and 58%, respectively. Compared with siblings, survivors were significantly more likely to report the presence of cardiac disease (26% versus 16%; P = 0.001) and hypothyroidism (65% versus 3%; P <0.001), and had a significantly lower mean FACIT-F score (40.7 and 42.2; P = 0.05). On multivariable analysis, factors significantly associated with increased fatigue in survivors were reports of cardiac disease (P <0.001), psychiatric condition (P <0.001), history of tobacco use (P = 0.004) and low exercise frequency (P = 0.03). For siblings, the only independent factor associated with increased fatigue was low exercise frequency (P = 0.03).

CONCLUSIONS

Survivors of Hodgkin's disease were more fatigued than their siblings. The difference was modest but statistically significant. The significant association between fatigue and cardiac disease suggests the importance of screening for underlying cardiac dysfunction in survivors with symptoms of fatigue. The association between fatigue and smoking history may be due to exacerbation of late medical complications of Hodgkin's disease by tobacco use.

Clinical course of thoracic cancers in Hodgkin's disease survivors

BACKGROUND

Hodgkin's disease survivors have a high risk of subsequently developing thoracic cancers. Our goal was to evaluate the prognosis and treatment outcomes of thoracic cancers after Hodgkin's disease.

PATIENTS AND METHODS

Thirty-three patients treated for Hodgkin's disease at Harvard-affiliated hospitals subsequently developed small-cell lung carcinoma, non-small-cell lung carcinoma (NSCLC) or mesothelioma. Information was obtained from medical records about the initial treatment for Hodgkin's disease, any salvage therapy, smoking history, and the stage, histology, treatment and survival for thoracic cancers.

RESULTS

Of the 33 patients, 29 (88%) had a history of radiotherapy to the thorax, 17 (52%) had received alkylating chemotherapy, and 24 (73%) had a known history of smoking. The median time between diagnosis of Hodgkin's disease and diagnosis of thoracic cancer was 17.3 years (range 1.2-27.9 years). Among patients with NSCLC and a known stage, 85% presented with stage III or stage IV disease. Among patients whose treatment details were available, 40% underwent surgery, 40% received radiotherapy and 65% received chemotherapy. The median survival was 9 months (range 1-47 months).

CONCLUSIONS

Most patients with thoracic cancers after Hodgkin's disease have a history of exposure to risk factors and present at an advanced stage. Patients with thoracic cancers after Hodgkin's disease have a poor survival.

Factors influencing treatment recommendations in early-stage Hodgkin’s disease: a survey of physicians

BACKGROUND

The aim of this study was to explore variation in practice patterns and identify factors associated with physicians' treatment decisions for early-stage Hodgkin's disease.

METHODS

We conducted a one-time mail survey of oncologists randomly selected from directories of national oncology societies (n = 207) and Hodgkin's disease experts (n = 147). The survey included questions on (i) physician factors, (ii) preferred treatment choices for six case scenarios of early-stage Hodgkin's disease that varied by patient factors, and (iii) thresholds for changing treatment recommendations.

RESULTS

The response rate was 50%. For non-bulky Hodgkin's disease, 69% of respondents chose combined modality therapy (CMT). On multivariate analysis, physician factors that independently predicted for choice of CMT included a high Hodgkin's disease case load (P = 0.02) and a high percentage of patients enrolled in clinical trials (P = 0.05). Radiation oncologists had a lower threshold for adding radiation therapy (P = 0.02). More experience with second malignancy cases and longer time in practice were associated with a higher threshold for adding radiation therapy (P = 0.04 and P = 0.008, respectively). In stratified analyses, treatment decisions of non-experts were significantly influenced by physician factors, but not by patient factors. Conversely, choices of Hodgkin's disease experts were insensitive to all physician factors, but experts were significantly more likely to select chemotherapy alone in young women and CMT in older patients.

CONCLUSIONS

Our results indicate that physician factors including practice type and experience may in part explain variation in practice pattern for Hodgkin's disease therapy. Hodgkin's disease experts are more likely to tailor therapy according to individual patient factors.

Comparison of MOPP versus ABVD as salvage therapy in patients who relapse after radiation therapy alone for Hodgkin’s disease

BACKGROUND

The aim of this study was to determine salvage outcome in patients with Hodgkin's disease who relapse after radiation therapy, and to compare the efficacy of mechlorethamine, Oncovin, procarbazine and prednisone (MOPP) versus Adriamycin, bleomycin, vinblastine and dacarbazine (ABVD) as salvage treatment.

PATIENTS AND METHODS

One hundred patients with Hodgkin's disease (97 with stage I-II disease at presentation) who relapsed after radiation therapy alone were salvaged with either MOPP or ABVD. Freedom from second relapse (FFSR) and overall survival (OS) were determined, and prognostic factors for salvage outcome were evaluated.

RESULTS

The median follow-up time since salvage therapy was 12 years. The 10-year FFSR and OS rates were 70% and 89%, respectively. Forty-one patients were salvaged with MOPP and 59 received ABVD. The type of salvage chemotherapy did not significantly influence FFSR or OS. Age >50 years at initial diagnosis was the only significant predictor for an inferior FFSR and OS on both univariate and multivariate analyses.

CONCLUSIONS

The two salvage regimens of MOPP and ABVD had similar efficacy in this group of patients with predominantly early-stage disease at initial radiation therapy. The inferior salvage outcome in patients aged >50 years is a contributing factor to the overall poor prognosis of patients presenting with Hodgkin's disease at an older age.

Digital hand-held sonography utilised for the focused assessment with sonography for trauma: a pilot study

OBJECTIVE

To evaluate the accuracy of the focused assessment with sonography for trauma (FAST) exam performed with a digital hand-held ultrasound machine in the emergency evaluation and resuscitation of trauma victims.

INTRODUCTION

The FAST exam is a valuable screening tool in the evaluation of abdominal trauma. New digital ultrasound units have recently become available which can be hand-carried by clinicians responding to the earliest phases of trauma care.

MATERIALS AND METHODS

Forty-seven victims of blunt trauma and 3 victims of penetrating trauma underwent FAST examinations performed by an attending trauma surgeon. Scans were performed with a Sonosite 180, 2.4-kg machine utilising a 5-2 MHz curved array transducer. The results of the hand-held FAST were compared with formal sonographic examinations performed by radiology department personnel, computed tomographic (CT) studies, operative findings and ultimate hospital course.

RESULTS

In victims of blunt trauma, 7 of 8 true fluid collections were detected, and 38 out of 39 cases without the presence of fluid were correctly excluded. There was 1 false positive and 1 false negative determination, resulting in a sensitivity of 86%, specificity of 97%, positive predictive value of 88%, and a negative predictive value of 97%. The overall accuracy was 96% for victims of blunt trauma. The technique expediently detected intra-peritoneal bleeding in 2 victims of lateral penetrating abdominal trauma. Utilised as the initial component of a diagnostic protocol, no inappropriate management strategies were suggested.

CONCLUSIONS

Digital hand-held sonography by clinicians can accurately allow the early performance of FAST exams. This exam may accurately and safely extend the physical senses of the examining physician.

Costs and effectiveness of staging and treatment options in early-stage Hodgkin's disease

PURPOSE

Using a cost-effectiveness analysis, to weigh the costs and benefits of the different staging and treatment options in early-stage Hodgkin's disease.

METHODS

We constructed a decision-analytic model for a hypothetical cohort of 25-year-old patients with early-stage Hodgkin's disease. Markov models were used to simulate the lifetime costs and prognosis of each staging and treatment strategy. Baseline probabilities and cost estimates were derived from published studies and bills of relevant patient cohorts.

RESULTS

Among the six management strategies considered, the incremental cost-effectiveness ratio of laparotomy and tailored treatment compared with mantle and para-aortic-splenic radiation therapy in all clinical stage I-II patients was $24,100/quality-adjusted life year, while that of the strategy of combined modality therapy in all clinical stage I-II patients compared with laparotomy was $61,700/quality-adjusted life year. All the remaining strategies were dominated by one of these three strategies. Sensitivity analysis showed that the cost-effectiveness ratios were driven predominantly by the effectiveness rather than the cost of each strategy. In particular, the analysis was heavily influenced by the utility of the post-laparotomy health state.

CONCLUSIONS

In considering the various alternative management strategies in early-stage Hodgkin's disease, even very small gains in effectiveness were enough to justify the additional costs of more expensive treatment options.

Significance of epitrochlear lymph node involvement in Hodgkin disease

BACKGROUND

Epitrochlear involvement in Hodgkin disease (HD) is a rare event, with only limited data available describing this unique presentation, its treatment, and long term outcome.

METHODS

Between 1968 and 1997, 1180 patients with clinical stage (CS) IA-IIB HD were treated at the Harvard Longwood Area Hospitals, among whom 11 were identified to have presented with epitrochlear lymphadenopathy (1%). Together with 6 CS III-IV patients also with clinically involved epitrochlear lymph nodes at diagnosis, these 17 patients form the basis of the current study. The clinical characteristics, histopathologic distribution, and treatment details are described. Two radiation therapy techniques were used: the "single field" and "separate-field" techniques. The median dose to the epitrochlear region was 3600 centigrays. Survival outcome was calculated by the Kaplan-Meier method. The median follow-up was 17 years.

RESULTS

The actuarial 15-year freedom from recurrence, cause specific survival, and overall survival (OS) rates for the 17 patients were 70%, 88%, and 70%, respectively. Among the CS IA-IIB patients, the 15-year OS rates of the 1169 patients and 11 patients without and with epitrochlear involvement were 80% and 90%, respectively. Two of the 11 CS IA-IIB and 3 of the 6 CS III-IV patients experienced recurrence. None of the recurrences involved the epitrochlear or ipsilateral brachial region regardless of the treatment technique, and no complications from the local radiation therapy were observed.

CONCLUSIONS

Feasible and effective radiation therapy techniques are available for patients with HD with epitrochlear involvement. If appropriately treated, the prognosis of patients with this unique presentation appears to be similar to that of other HD patients.

Results of a prospective trial of mantle irradiation alone for selected patients with early-stage Hodgkin's disease

PURPOSE

To determine the efficacy of mantle radiation therapy alone in selected patients with early-stage Hodgkin's disease.

PATIENTS AND METHODS

Between October 1988 and June 2000, 87 selected patients with pathologic stage (PS) IA to IIA or clinical stage (CS) IA Hodgkin's disease were entered onto a single-arm prospective trial of treatment with mantle irradiation alone. Eighty-three of 87 patients had > or = 1 year of follow-up after completion of mantle irradiation and were included for analysis in this study. Thirty-seven patients had PS IA, 40 had PS IIA, and six had CS IA disease. Histologic distribution was as follows: nodular sclerosis (n = 64), lymphocyte predominant (n = 15), mixed cellularity (n = 3), and unclassified (n = 1). Median follow-up time was 61 months.

RESULTS

The 5-year actuarial rates of freedom from treatment failure (FFTF) and overall survival were 86% and 100%, respectively. Eleven of 83 patients relapsed at a median time of 27 months. Nine of the 11 relapses contained at least a component below the diaphragm. All 11 patients who developed recurrent disease were alive without evidence of Hodgkin's disease at the time of last follow-up. The 5-year FFTF in the 43 stage I patients was 92% compared with 78% in the 40 stage II patients (P =.04). Significant differences in FFTF were not seen by histology (P =.26) or by European Organization for Research and Treatment of Cancer H-5F eligibility (P =.25).

CONCLUSION

Mantle irradiation alone in selected patients with early-stage Hodgkin's disease is associated with disease control rates comparable to those seen with extended field irradiation. The FFTF is especially favorable among stage I patients.

Analysis of local recurrence and optimizing excision margins for cutaneous melanoma

BACKGROUND

Current guidelines for the treatment of melanoma favour conservatism; however there is still uncertainty regarding best practice for lesions of intermediate thickness. Local recurrence, a measure of treatment adequacy, can be used to determine optimum excision margins and give prognostic information for survival.

METHODS

An analysis of the Auckland Melanoma Unit database was performed. Patients with local recurrence were identified and stratified by lesion thickness. Optimum excision margins were derived by regression analysis and evaluated against the database population. Survival and prognostic factors were studied.

RESULTS

Eighty-four of 1155 patients (7 per cent) developed local recurrence. Median follow-up was 51 months. Margins predicted to give a local recurrence of zero were: 1 cm for lesions < or = 1 mm thick; 1.5 cm for lesions 1-2 mm thick; and 2 cm for lesions > 2 mm thick. Applied to 1155 patients, there were significant differences in both local recurrence and mortality rates between optimally and suboptimally excised lesions, except for those > 4 mm thick. Thirty-three patients (39 per cent) with local recurrence died. Thickness, local recurrence and ulceration were of prognostic significance.

CONCLUSION

Development of local recurrence in melanomas < or = 4 mm thick is due to inadequate treatment. It signifies progressive disease and a poor prognosis. Care must be taken to ensure that all such lesions are optimally excised.

Multimodal chronic pain rehabilitation program: its effect on immune function, depression, and health behaviors

This pilot study examined the effects of a multimodal pain rehabilitation program on the immune function, self-reported pain, depression levels, and health behaviors of patients with chronic back pain. It also estimated the relationships between self-reported pain levels, immune function, depression, and health behaviors. Data were collected at week 1 (baseline) and at week 4 (last week of treatment program) on a convenience sample of 23 patients. In general, the patients' mean T lymphocyte proliferation levels showed a decline from baseline to week 4, while natural killer cell activity showed a slight increase in cell lysis. None of the findings were statistically significant. Failure to detect significant differences may be attributed to a small effect size due to the relatively small sample size. The depression levels dropped significantly during the treatment program (p = .001). Reported levels of pain and health behaviors did not significantly change. More research is needed to determine treatment effects on immune function as well as relationships between pain levels, immune function, depression, and health behaviors in this patient population.

Protection against ischemic injury in primary cultured mouse astrocytes by bis(7)-tacrine, a novel acetylcholinesterase inhibitor [corrected]

The effects of bis(7)-tacrine, a novel acetylcholinesterase inhibitor, on ischemia-induced cell death and apoptosis were investigated in primary cerebral cortical astrocytes of mice. Following a 6 h in vitro ischemic incubation of the cultures, a marked decrease in the percentage of viable cells was observed by lactate dehydrogenase (LDH) release assay. Furthermore, using bisbenzimide staining, we determined that approximately 65% of the cells underwent apoptosis. Treatment with bis(7)-tacrine (1-10 nM) during ischemic incubation effectively inhibited the ischemia-induced apoptosis, as demonstrated by morphological and biochemical tests. Our results demonstrated that bis(7)-tacrine could protect astrocytes against ischemia-induced cell injury, indicating that the drug might be beneficial for the treatment of vascular dementia, in addition to Alzheimer's disease.

Ultrastructural localization of monoclonal antiphospholipid antibody binding to rat brain

Antiphospholipid antibodies (aPL), in the presence or absence of systemic lupus erythematosus, are associated with a number of neurologic complications. However, the role aPL play in pathology is unclear. A thrombotic etiology seems likely for many associated disorders, but not for others. Here we describe aPL-reactive sites in the central nervous system (CNS). Previously, using light microscopy, we showed direct binding of two monoclonal phosphatidylserine-reactive antibodies (aPS) to ependyma and myelin of fixed cat brain. In this study we determined the ultrastructural localization of their binding sites in rat CNS using immunogold electron microscopy techniques. Both monoclonal antibodies reacted strongly with myelin, preferentially with the major dense line formed by the cytoplasmic apposition of the oligodendrocyte plasma membrane. Both monoclonal antibodies also reacted with an antigen that appears associated with the axoneme in cilia of ependymal and choroid plexus epithelium. One monoclonal aPS also showed some reactivity with brain vascular endothelium and reacted slightly with mitochondria, while the other aPS did not react with these structures. While the etiology of aPL-associated neurologic disorders remains unclear, our data suggest possible target sites within the CNS with which aPL can react.

Decision analysis on alternative treatment strategies for favorable-prognosis, early-stage Hodgkin's disease

PURPOSE

To compare the therapeutic outcomes of various treatment strategies in early-stage, favorable-prognosis Hodgkin's disease (HD) using methods of decision analysis.

METHODS

We constructed a decision-analytic model to determine the life expectancy and quality-adjusted life expectancy for a hypothetical cohort of clinically or pathologically staged 25-year-old patients with early-stage, favorable-prognosis HD treated with varying degrees of initial therapy. Markov models were used to simulate the lifetime clinical course of patients, and baseline probability estimates were derived from published study results.

RESULTS

Among patients with pathologic stage (PS) I to II, mantle and para-aortic (MPA) radiotherapy was favored over combined-modality therapy (CMT), mantle radiotherapy, and chemotherapy by 1.18, 1.33, and 1.55 years, respectively. For patients with clinical stage (CS) I to II, the treatment options of MPA-splenic radiotherapy, CMT, and chemotherapy yielded similar survival outcomes. Sensitivity analysis showed that the decision between CMT and MPA-splenic radiotherapy was highly influenced by the precise values of the estimates of treatment efficacy and long-term morbidity, the quality-of-life value assigned to the postsplenic irradiation state, and the time discount value used in the model. Probabilistic sensitivity analysis demonstrated that even if future studies doubled the precision of the estimates of the treatment-related variables, it would be impossible to demonstrate the superiority of one treatment over the other.

CONCLUSION

Our model predicted that on average, MPA radiotherapy was clearly the preferred treatment for PS I to II patients. For CS I to II patients the treatment decision is a toss-up between MPA-splenic radiotherapy and CMT, emphasizing the importance of patient preference exploration and shared decision making between patient and physician when choosing between treatments.

Incidence of malignant melanoma in Auckland, New Zealand: highest rates in the world

The calculation of incidence rates of melanoma in New Zealand has been hampered in the past by incomplete registration of cases. The aim of this study was to document the incidence of melanoma in the Auckland Caucasian population and to define the pathologic characteristics of these lesions. Data were collected for the Auckland region from the New Zealand Cancer Registry and the Auckland Melanoma Unit database for 1995 and combined with census statistics to give the crude and age-standardized rates for invasive melanoma. The results were analyzed by gender, morphology, body site, and thickness. The crude annual incidence for invasive cutaneous malignant melanoma was 77.7/100,000. The age-standardized annual rate was 56.2/100,000 with no statistically significant differences in the rates for males and females. The cumulative risk of developing melanoma over a lifetime, from age 0 to 74, was 5.7% overall. The age-specific rates steadily increase with advancing age. The lesions were generally thin; 64% were less than 0.76 mm, and only 7% were thicker than 3.00 mm. In conclusion, the Caucasian population in the Auckland region has the highest incidence of melanoma in the world.

Radiation therapy in Hodgkin's lymphoma

Radiation therapy continues to play a primary role for the definitive treatment of early-stage Hodgkin's disease. Its value as an adjunct for chemotherapy in patients with unfavorable features such as bulky disease is also obvious. The indications for radiation therapy in addition to chemotherapy for patients with advanced-stage disease are less clear. Nevertheless, there is adequate evidence that consolidative irradiation is of benefit in at least a subset of such patients. Future directions in radiation therapy for Hodgkin's disease include efforts to reduce treatment extent (both field size and dose) without compromising disease control; further technological advances in improving planning and treatment equipment, to allow better tumor targeting while minimizing dose to surrounding normal tissue; close follow-up evaluation of patients treated for Hodgkin's disease, which may allow better selection of patients for the different treatment schemes and tailoring therapy according to risks for relapse as well as treatment complications; optimizing a follow-up plan; and implementing preventive measures for long-term complications of treatment. The goal is not only to maximize survival but also to optimize patient quality of life.

Laparotomy versus no laparotomy in the management of early-stage, favorable-prognosis Hodgkin's disease: a decision analysis

PURPOSE

To perform a decision analysis that compared the life expectancy and quality-adjusted life expectancy of early-stage, favorable-prognosis Hodgkin's disease (HD) managed with and without staging laparotomy, incorporating data on treatment outcomes of HD in the modern era.

METHODS

We constructed a decision-analytic model to compare laparotomy versus no laparotomy staging for a hypothetical cohort of 25-year-old patients with clinical stages I and II, favorable-prognosis HD. Markov models were used to simulate the lifetime clinical course of patients, whose prognosis depended on the true pathologic stage and initial treatment. The baseline probability estimates used in the model were derived from results of published studies. Quality-of-life adjustments for procedures and treatments, as well as the various long-term health states, were incorporated.

RESULTS

The life expectancy was 36.67 years for the laparotomy strategy and 35.92 years for no laparotomy, yielding a net expected benefit of 0.75 years for laparotomy staging. The corresponding quality-adjusted life expectancies for the two strategies were 35.97 and 35.38 quality-adjusted life years (QALYs), respectively, resulting in a net expected benefit of laparotomy staging of 0.59 QALYs. Sensitivity analysis showed that the decision of laparotomy versus no laparotomy was most heavily influenced by the quality-of-life weight assigned to the postlaparotomy state.

CONCLUSION

Our model predicted that on average, for a 25-year-old patient, proceeding with staging laparotomy resulted in a gain in life expectancy of 9 months, or 7 quality-adjusted months. These results suggest that a role remains for surgical staging in the management of early-stage HD.

The role of placental trophoblast in the pathophysiology of the antiphospholipid antibody syndrome

PROBLEM

The antiphospholipid (aPL) antibody syndrome is characterized by severe pregnancy complications, the cause of which remains unknown. We hypothesized that the placental trophoblast is a target for aPLs.

METHOD OF STUDY

The effects of monoclonal aPLs on trophoblast function, including the invasion of JAR into matrigel-coated filters and the effects of annexin V expression on BeWo, were investigated using choriocarcinoma models.

RESULTS

aPLs against phosphatidylserine (PS) significantly (P < 0.001) decreased the migration of JAR across the membrane. In the annexin V studies, undifferentiated BeWo did not express surface annexin V. After differentiation, BeWo expressed surface annexin V, which was removed in the presence of aPLs, resulting in increased binding of prothrombin.

CONCLUSIONS

PS is expressed on the trophoblast surface during differentiation and invasion of extracellular matrix. Our data suggest that aPLs against PS can directly affect trophoblast function by limiting the depth of decidual invasion and by concurrently creating a procoagulant surface on trophoblast exposed to the maternal circulation.

Antiphosphatidylserine antibody removes annexin-V and facilitates the binding of prothrombin at the surface of a choriocarcinoma model of trophoblast differentiation

OBJECTIVE

Trophoblast differentiation is associated with externalization of phosphatidylserine from the inner to the outer surface of the plasma membrane. In this study we tested the hypothesis that concurrent externalization and binding of annexin-V blocks the phosphatidylserine-rich surface from acting as a site for activation of coagulation and that antiphospholipid antibodies lead to a procoagulant state by preventing annexin-V binding.

STUDY DESIGN

A choriocarcinoma model of trophoblast differentiation, forskolin-activated BeWo cells and immunoperoxidase techniques were used to determine surface and cytoplasmic localization of annexin-V related to differentiation. Monoclonal immunoglobulin M antibodies against phosphatidylserine- and cardiolipin-dependent antigens were used to determine the effects of antiphospholipid antibodies on annexin-V localization and on the binding of prothrombin to the BeWo surface.

RESULTS

During differentiation BeWo cells externalized phosphatidylserine and increased the expression of surface annexin-V. Monoclonal antibody against phosphatidylserine removed annexin-V from the BeWo surface and increased binding of prothrombin.

CONCLUSION

Antiphosphatidylserine antibody induces sites for prothrombin binding on the surface of a BeWo model of trophoblast, most likely by removing annexin-V. This mechanism could explain the frequent observation of increased thrombosis at the maternal-fetal interface in miscarriages associated with antiphospholipid antibodies.

Monoclonal antiphosphatidylserine antibodies react directly with feline and murine central nervous system

OBJECTIVE

Antiphospholipid antibodies (aPL), especially against phosphatidylserine and cardiolipin, are associated with a variety of neurological disorders. While it is believed aPL react with endothelial cells to cause cerebral thrombosis, it is not known to what degree aPL react with neural tissue nor which particular aPL specificities may be more relevant. We investigated direct aPL reactivity with the central nervous system (CNS) using 3 monoclonal IgM aPL that differentiate between cardiolipin and phosphatidylserine dependent antigens.

METHODS

Brain and spinal cord from normal cat Felis domesticus and brain from CD-1 mice were reacted with aPL using indirect immunoperoxidase techniques. Monoclonal aPL were reacted with whole brain myelin by dot immunoblots.

RESULTS

Monoclonal D11A4, reactive with cardiolipin and not phosphatidylserine (CL+/PS-), did not react with any portion of the tissue. Both monoclonal 3SB9b (CL-/PS+) and BA3B5C4 (CL+/PS+) reacted in feline and murine CNS. Both labeled myelinated fibers in grey and white matter of brain and spinal cord in an identical pattern with positive control antibody against myelin basic protein and reacted with whole human brain myelin by dot immunoblot. 3SB9b (CL-+PS+) additionally reacted with ependyma and epithelium of the choroid plexus.

CONCLUSION

aPL, especially those reactive with phosphatidylserine dependent antigens, react directly with epitopes associated with myelin, brain ependyma, or choroid epithelium. Direct reactivity of aPL with nervous tissue may be relevant to neurological disorders.

Sphincter preservation therapy for distal rectal carcinoma: a review

BACKGROUND

There has been increasing interest in the use of sphincter-preserving therapy for patients with distal rectal carcinomas. The outcomes of conservative treatments for early stage rectal carcinoma appear to be comparable to that achieved with abdominoperineal resection.

METHODS

Retrospective and prospective clinical series of patients with distal rectal carcinoma treated by local excision alone, local excision with postoperative adjuvant therapy, preoperative radiation followed by local excision, or radical circumferential sphincter-sparing surgeries were reviewed. The local control rates, salvage rates, and treatment complications in patients treated by these various methods were examined.

RESULTS

Patients with T1 distal rectal carcinoma with favorable clinical and histopathologic characteristics treated with local excision alone had a local control rate of greater than 90% in most series. Postoperative chemoradiation improved local control for those with T1 disease with unfavorable characteristics, or those with T2 disease. Most T3 patients had failure rates of greater than 30% despite adjuvant local and systemic therapy. With high dose preoperative radiation, approximately 80% of patients with locally advanced or unresectable tumors were able to undergo sphincter-preservation treatment.

CONCLUSIONS

Patients with favorable T1 rectal carcinoma are likely to be adequately treated with local excision alone. Patients with T1 disease with unfavorable characteristics as well as T2 patients will benefit from postoperative chemoradiation. The use of local therapy in T3 patients needs to be carefully considered because these patients are at relatively high risk for local recurrence despite adjuvant therapy. Preoperative radiation followed by either local excision or radical circumferential sphincter-sparing resections appears promising in allowing sphincter preservation in patients with locally advanced tumors.

A model for the antiphospholipid antibody syndrome: monoclonal antiphosphatidylserine antibody induces intrauterine growth restriction in mice

OBJECTIVE

Antiphospholipid antibodies are associated with clinical intrauterine growth restriction. In this study we investigated whether immunoglobulin M monoclonal antibodies against phosphatidylserine or cardiolipin or cross-reactive with both phospholipids would induce intrauterine growth restriction in an experimental model of the antiphospholipid antibody syndrome.

STUDY DESIGN

Balb/c or CD-1 mice were injected intraperitoneally on day 8 of pregnancy with three immunoglobulin M monoclonal antibodies that differentiated between cardiolipin- and phosphatidylserine-dependent antigens or with control immunoglobulin M monoclonal antibodies against irrelevant antigens. The animals were killed on day 15 of pregnancy and placental and fetal weights were measured.

RESULTS

Monoclonal antibody 3SB9b, which reacted in enzyme-linked immunosorbent assays with phosphatidylserine but not cardiolipin, induced a significant reduction in both fetal and placental weights. Monoclonal antibodies BA3B5C4, which was cross-reactive with cardiolipin and phosphatidylserine, and D11A4, which reacted with cardiolipin, did not alter fetoplacental weights.

CONCLUSION

An antiphospholipid antibody that reacts with phosphatidylserine induces significant fetal and placental intrauterine growth restriction in a mouse model for the antiphospholipid antibody syndrome, but those that react with cardiolipin do not.

Monoclonal antiphosphatidylserine antibody inhibits intercellular fusion of the choriocarcinoma line, JAR

Naturally occurring antiphospholipid antibodies are strongly associated with placental dysfunction and severe obstetrical complications. We have produced three monoclonal antiphospholipid antibodies that differentiate between phosphatidylserine (PS)- and cardiolipin (CL)-dependent antigens, 3SB9b (CL-/PS+), BA3B5C4 (CL+/PS+), and D11A4 (CL+/PS-). We tested these monoclonal antiphospholipid antibodies in an assay for intertrophoblastic fusion. A JAR choriocarcinoma cell line was induced to undergo intercellular fusion by forskolin in the presence or absence of monoclonal antiphospholipid antibodies. The amount of syncytium formation was quantified by using fluorescein isothiocyanate (FITC)-conjugated anti-desmosome antibody to visualize intercellular membranes and propidium iodide to stain nuclei and by counting those cells with multiple nuclei. Without the presence of antiphospholipid antibodies, and in cultures containing BA3B5C4 (CL+/PS+) or D11A4 (CL+/PS-), approximately 70% of JAR formed syncytial cells after 24 h of forskolin treatment. Less than 13% of the cells formed synctia in 2-day cultures that were not exposed to forskolin or that contained forskolin in the presence of 3SB9b (CL-/PS+). These data suggest that phosphatidylserine is externalized during intertrophoblastic fusion and that antiphospholipid antibody with reactivity against PS, but not CL, can affect placental development by interfering with the normal formation of syncytiotrophoblast.

Expression of phosphatidylserine-dependent antigens on the surface of differentiating BeWo human choriocarcinoma cells

PROBLEM

Antiphospholipid antibodies (aPLs) are associated with pregnancy loss, pregnancy-induced hypertension, and intrauterine growth retardation. We have previously reported that phosphatidylserine (PS)-dependent antigens are expressed in formalin-fixed cells concurrent with differentiation in a choriocarcinoma model (BeWo) of cytotrophoblast. That study, however, could not differentiate between cytoplasmic or surface antigen expression.

METHOD

Three monoclonal aPLs that differentiate between PS- and cardiolipin (CL)-dependent antigens were reacted with BeWo, with or without forskolin activation, before fixation, and antibody binding was evaluated by immunoperoxidase techniques.

RESULTS

Activation with forskolin induced a PS-dependent antigenic determinant on the surface on BeWo cells. CL-reactive monoclonal antibodies did not react with the cell surface, whether forskolin treated or not.

CONCLUSION

These observations demonstrate that a PS-dependent antigen is expressed on the surface of a model of differentiating cytotrophoblastic cells and should be accessible in vivo to circulating aPLs.

Monoclonal IgM antiphosphatidylserine antibody reacts against cytoskeleton-like structures in cultured human umbilical cord endothelial cells

PROBLEM

It has been proposed that antibodies against phospholipid-dependent antigens (aPLs), induce recurrent pregnancy loss and thrombosis through modulation of endothelial cell function, yet aPLs have not been conclusively shown to bind with endothelial cells.

METHOD

Using indirect immunofluorescence we investigated the anti-endothelial cell reactivity of three monoclonal antibodies that differentiate between the phospholipids cardiolipin (CL) and phosphatidylserine (PS): BA3B5C4 (CL+/PS+); 3SB9b (CL-/PS+); and D11A4 (CL+/PS-). Cultured umbilical cord endothelial cells were prepared without fixation or with cold acetone fixation.

RESULTS

None of the aPLs reacted with endothelial cells prepared without fixation. 3SB9B reacted strongly with cytoskeletal-like components in acetone-fixed cells, whereas BA3B5C4 and D11A4 were unreactive. The cytoskeletal-like binding of 3SB9b was completely blocked by a monoclonal antibody against vimentin, whereas antibodies against tubulin or actin were not inhibitory. Lipid extraction of the cells destroyed the 3SB9b reactive antigen without affecting the reactivity of anti-vimentin.

CONCLUSION

These results suggest that phospholipid-dependent antigenic determinants are not expressed on the surface of resting endothelial cells but that a PS-dependent antigenic determinant is associated with endothelial cell intermediate filaments.

Modulation of phosphatidylserine epitope expression by BeWo cells during forskolin treatment

The adenylcyclase activator forskolin induces the human choriocarcinoma line, BeWo, to undergo differentiation and fusion within 48 to 72 h. Using three monoclonal antibodies that differentiate between the anionic phospholipids cardiolipin (CL) and phosphatidylserine (PS) and immunoperoxidase techniques we investigated the expression of PS by BeWo during 48 h of forskolin treatment. We observed that BeWo cells not exposed to forskolin express an epitope of pS that reacts strongly with monoclonal antibody BA3B5C4 (CL+/PS+), whereas following treatment with forskolin there is a decrease in reactivity with BA3B5C4 and a concurrent increased activity with a second PS-reactive monoclonal antibody, 3SB9b (CL-/PS+). A third monoclonal antibody, D11A4 (CL+/PS-), that reacted with all anionic phospholipids except PS did not bind to BeWo cells, whether forskolin treated or not. These observations support previous interpretations using human placenta that during cytotrophoblast differentiation two antigenic forms of PS are expressed. Based on the described relationship of PS with cellular fusion events in other systems and the association of naturally occurring antibodies against PS with pregnancy loss and intrauterine growth retardation in humans, we propose that altered expression of PS during normal placental development and in BeWo after exposure to forskolin may be critical in the cytotrophoblast differentiation process.

Immunologic detection of phosphatidylserine externalization during thrombin-induced platelet activation

The antiphospholipid antibody syndrome is characterized by circulating antiphospholipid antibodies against cardiolipin (CL) and phosphatidylserine (PS) and clinically associated with a high risk of spontaneous thrombosis. Three monoclonal antibodies that differentiate between CL or PS were tested against resting and thrombin-activated platelets by flow cytometry. Each antibody reacted differently with CL and PS; 3SB9b reacted with PS, D11A4 reacted with CL, and BA3B5C4 reacted with both CL and PS. Activated platelets bound BA3B5C4 and 3SB9b, but not D11A4. The BA3B5C4-reactive epitope appeared earlier during activation than the epitope reactive with 3SB9b. These data suggest that antibodies against PS are reactive with activated platelets and that two immunoreactive forms of PS are sequentially expressed on platelets during activation.

Monoclonal antiphospholipid antibody reactivity against human placental trophoblast

Naturally occurring antibodies against the negatively charged phospholipids cardiolipin (CL) and phosphatidylserine (PS) have been associated with recurrent pregnancy loss. One prevalent hypothesis proposes that antiphospholipid antibody (aPL) mediated pathophysiology is through increased placental thrombosis. In this study we investigated the reactivity of three mouse monoclonal aPLs with term and 26 week human placental preparations. Each monoclonal antibody reacted differently with CL and PS; 3SB9b reacted with PS (CL-/PS+), D11A4 reacted with CL (CL+/PS-) and BA3B5C4 reacted with both CL and PS (CL+/PS+). 3SB9b reacted strongly with the syncytiotrophoblastic layer of both formalin fixed and frozen placental tissue. Sporadic reactivity was observed against the cytotrophoblastic layer. BA3B5C4 reacted strongly and specifically with cytotrophoblastic cells. D11A4 had only weak reactivity in the subtrophoblastic stromal region of the placenta in frozen sections. aPL staining was also observed against extravillous cytotrophoblast. BA3B5C4 stained cytoplasmic structures, whereas 3SB9b stained the plasma membrane region with little cytoplasmic staining. These data suggest that the trophoblastic layer is reactive with aPLs and may potentially be directly damaged through mechanisms unrelated to thrombosis. In addition, the trophoblastic layer directly in contact with the maternal circulation is most reactive with aPLs that are PS+ rather than CL+. The differential reactivity of 3SB9b and BA3B5C4 suggests that the antigenic conformation involving PS on the cytotrophoblast is altered concurrent with fusion into the syncytium.

An analysis of donor blood wastage due to outdating in a large teaching hospital

We analyzed the pattern and rate of donor blood outdating in our hospital from 1986 to 1990. We found that there was a sharp drop in blood outdating since the implementation of the Type and Screen crossmatch protocol. The outdating rate was reduced from 11.5% to 1.3% for whole blood and from 4.9% to 0.4% for red cells. In absolute numbers, wastage of blood due to outdating was cut from 2,570 units in 1986-87 (a 2 yr period before Type and Screen) to only 227 units in 1988-89 (a 2 yr period after Type and Screen). We also found that the outdating rate varied among different blood groups (group 0 less than A = B less than AB), and the outdating of whole blood was consistently more than red cells throughout the study period. The results of our utilization review were conveyed to local hospitals and the blood supplier in an effort to preserved donor blood.

Production of monoclonal antibodies specific for platelet activation antigens and their use in evaluating platelet function

Monoclonal antibodies (MAb) were used to identify platelet membrane molecules that are expressed after platelet activation. Balb/C mice were immunized with fixed thrombin-activated human platelets and their spleen cells were fused with the murine myeloma cell line NS1-Ag4/1. The resulting hybridomas were screened for antibody production against fixed thrombin-activated platelets and fixed resting platelets by flow cytometry. Two MAbs 2C8 (an IgM) and 1E3 (an IgG2a) demonstrated significant binding to fixed thrombin-activated platelets while reacting minimally with fixed resting platelets. The reactivity of 2C8 and 1E3 were compared to MAb's S12 and AC1.2, both of which have known specificity for an alpha-granule membrane protein (GMP-140) expressed on the surface of activated platelets. In radioimmunoprecipitation studies, both 2C8 and 1E3 immunoprecipitated a protein of approximately 140 kDa similar to that precipitated by S12 and AC1.2. Immunodepletion studies, with S12, AC1.2, 1E3, and 2C8 confirm that they all react with the same antigen. 2C8 may recognize the same epitope as S12, whereas 1E3 appears to recognize a different epitope of the same molecule. The use of these MAbs to measure platelet activation in whole blood correlates well with the results of conventional platelet aggregometry.

The mechanism of the induction of immunologic unresponsiveness to rat cardiac allografts by recipient pretreatment with donor lymphocyte subsets

In continuation of our studies using UV-B-irradiated DST and donor leukocyte (DL) recipient pretreatment to induce specific unresponsiveness to organ allografts, we have examined the relative contributions of splenic lymphocyte populations and T lymphocyte subsets in the induction of immunologic unresponsiveness. Our data show that enriched populations of MHC class II-positive B lymphocytes and the W3/25+ T cell subset obtained from splenic leukocytes using immunoadsorbent columns in conjunction with mAbs led to indefinite graft survival (greater than 100 days) in the Lewis-to-ACI rat cardiac allograft model. In contrast, pretreatment with T lymphocytes or the Ox8+ T subset was relatively ineffective in prolonging cardiac allograft survival. In addition, third-party (W/F) W3/25+ T cell recipient pretreatment did not influence the survival of Lewis cardiac allografts in ACI recipients, thus confirming the specificity of pretreatment with the T cell subset in graft prolongation. Furthermore, we have examined the underlying mechanisms of donor-specific unresponsiveness induced by donor spleen cells, B lymphocytes, and W3/25+ T cells using adoptive transfer assays. Serial adoptive transfer studies demonstrated the presence of 0x8+ suppressor T cells in the spleens of unresponsive recipients bearing well-functioning cardiac allografts and of serum "suppressor factors" that have the capacity for specifically prolonging donor-type test graft survival in naive syngeneic rats. Our findings suggest that the induction of specific unresponsiveness in this model is dependent on a sequential collaboration between the appearance of donor-specific serum factor(s) (humoral phase) and donor-specific suppressor T cells (cellular phase). These results may be potentially useful in planning future strategies for the induction of unresponsiveness to clinical organ allografts by immunologic manipulation of the host with MHC class II-positive B cell and CD4+ T cell clones.

Co-existing hyperparathyroidism and sarcoidosis presenting with hypercalcaemia--a diagnostic challenge

We recently encountered two patients with coexistent hyperparathyrodism and sarcoidosis presenting with hypercalcaemia. The association between hypercalcaemic primary hyperparathyroidism and sarcoidosis is reviewed.

Expression of class I and class II major histocompatibility antigens on human hepatocellular carcinoma

Previous reports indicate that human hepatocytes do not express class I and class II MHC antigens. Our analyses on 10 human hepatocellular carcinoma (HCC) cell lines by immunofluorescence tests and RIA, demonstrate that all the human HCC cell lines tested express class I MHC antigens and among them, three poorly differentiated human HCC cell lines also express class II MHC antigens. Results of immunoprecipitation and/or Western blotting experiments indicate similarity in the chemical nature of both the class I and class II MHC antigens expressed by the human HCC cell lines and by a human B lymphoblastoid cell line Raji. Furthermore, a new variant form of class I antigen was detected in some of these HCC cell lines. Immunohistochemical studies of HCC tissues using the peroxidase-antiperoxidase staining method indicated that class I and class II antigens were detectable in 7 out of 11 and 3 out of 11 HCC tissues from patients, respectively. The availability of MHC class I antigen-positive cultured HCC cell lines, including the poorly differentiated lines that also express MHC class II antigen, has provided us with interesting models to study the relationship between expression of MHC antigen and transformation and differentiation of human hepatocytes. These studies will also allow us some insight into the role of MHC class I and class II antigen in the immunosensitivity and immunogenicity of HCC cells to the host-immune response.

Hemodialysis-related induction of beta-2-microglobulin and interleukin-1 synthesis and release by mononuclear phagocytes

We have investigated beta 2-microglobulin (beta 2M) synthesis and release by blood leukocytes and isolated mononuclear phagocytes. Recent interest in beta 2M has developed since the discovery that this protein forms amyloid fibrils in patients undergoing long-term, chronic hemodialysis and that these patients have greatly elevated levels of monomeric beta 2M in their circulation. Since hemodialysis-related factors that increase beta 2M production are unknown, we evaluated beta 2M production by freshly prepared leukocytes and monocyte-derived macrophages under a variety of conditions. We utilized a novel enzyme-linked immunoabsorbant assay to quantitate beta 2M concentrations, and monitored interleukin-1 and beta 2M synthesis by immunoprecipitation. Incubation of leukocytes with Cuprophan or Hemophan does not increase beta 2M release. Adherence of macrophages onto polystyrene or Cuprophan membranes induces neither interleukin-1 nor beta 2M synthesis or release. In contrast, interaction of macrophages with lipopolysaccharide, gamma-interferon, tumor necrosis factor, or interleukin-1 induces synthesis and release of beta 2 M, indicating that beta 2 M synthesis is increased during macrophage activation. Exposing leukocytes or macrophages to changes in osmotic or oncotic pressure induces a rapid release of beta 2M and interleukin-1 into the cellular medium. These results suggest that during hemodialysis, beta 2M production is more likely to result from endotoxin contamination, or osmotic and oncotic changes, rather than direct interaction of mononuclear phagocytes with Cuprophan membranes.

Beta-2-microglobulin synthesis is increased during activation of human monocytes

We have investigated the regulation of beta 2-microglobulin (beta 2-M) synthesis by monocytes. Recent interest in beta 2-M has developed since the discovery that this protein forms amyloid fibrils in patients undergoing long-term, chronic hemodialysis. The beta 2-M amyloidosis is linked to the greatly elevated levels of monomeric beta 2-M in their circulation. Since factors that govern beta 2-M release from plasma membranes are not known, we endeavored to evaluate beta 2-M release during monocyte activation. Utilizing a human monocyte-like cell line, U937, we studied the effect of bacterial toxin stimulation on levels of membrane, cell surface, and supernatant beta 2-M. We now present a novel method to purify beta 2-M, a solid-phase radioimmunoassay to measure soluble beta 2-M, and an ELISA to measure membrane beta 2-M. Using these methods we found that the levels of beta 2-M in the cell membrane or on the cell surface did not change during monocyte activation. However, activation did induce a significant increase in the concentration of beta 2-M in monocyte supernatants, indicating that beta 2-M synthesis by monocytes is increased during monocyte activation. These results suggest that monocyte activation by hemodialysis membranes may be a contributing factor to the observed increase in circulating beta 2-M levels.

Application of avidin-biotin-peroxidase complex method with a monoclonal antibody to human Ia-like antigen in immunoelectron microscopy

Monoclonal antibody (MAb) to human Ia-like (HLA-DR) antigen was applied with the avidin-biotin-peroxidase complex (ABC) immunostaining method to localize the Ia-like antigen at the electron microscopic level. Our results indicated that in human tonsils and adenoids fixed with 4-6% phosphate-buffered paraformaldehyde for 4-6 hr, sharply delineated electron-dense products of the antigen and antibody complex were detectable on the outer cell membranes of lymphoblasts, lymphocytes, reticular cells, and macrophages. In our study, the vibratome sections of the paraformaldehyde-fixed, pre-embedding immunostained tissues consistently showed more satisfactory morphology than frozen sections. The combined use of the anti-human Ia monoclonal antibody and the ABC procedure with paraformaldehyde fixation provides a simple and sensitive method to study at the ultrastructural level the Ia-like antigen-bearing cells, which are vital in the immune response.