CB307: A Dual Targeting Costimulatory Humabody VH Therapeutic for Treating PSMA-Positive Tumors

PURPOSE

CD137 is a T- and NK-cell costimulatory receptor involved in consolidating immunologic responses. The potent CD137 agonist urelumab has shown clinical promise as a cancer immunotherapeutic but development has been hampered by on-target off-tumor toxicities. A CD137 agonist targeted to the prostate-specific membrane antigen (PSMA), frequently and highly expressed on castration-resistant metastatic prostate cancer (mCRPC) tumor cells, could bring effective immunotherapy to this immunologically challenging to address disease.

EXPERIMENTAL DESIGN

We designed and manufactured CB307, a novel half-life extended bispecific costimulatory Humabody VH therapeutic to elicit CD137 agonism exclusively in a PSMA-high tumor microenvironment (TME). The functional activity of CB307 was assessed in cell-based assays and in syngeneic mouse antitumor pharmacology studies. Nonclinical toxicology and toxicokinetic properties of CB307 were assessed in a good laboratory practice (GLP) compliant study in cynomolgus macaques.

RESULTS

CB307 provides effective CD137 agonism in a PSMA-dependent manner, with antitumor activity both in vitro and in vivo, and additional activity when combined with checkpoint inhibitors. A validated novel PSMA/CD137 IHC assay demonstrated a higher prevalence of CD137-positive cells in the PSMA-expressing human mCRPC TME with respect to primary lesions. CB307 did not show substantial toxicity in nonhuman primates and exhibited a plasma half-life supporting weekly clinical administration.

CONCLUSIONS

CB307 is a first-in-class immunotherapeutic that triggers potent PSMA-dependent T-cell activation, thereby alleviating toxicologic concerns against unrestricted CD137 agonism.

The murine IgH locus contains a distinct DNA sequence motif for the chromatin regulatory factor CTCF

Antigen receptor assembly in lymphocytes involves stringently-regulated coordination of specific DNA rearrangement events across several large chromosomal domains. Previous studies indicate that transcription factors such as paired box 5 (PAX5), Yin Yang 1 (YY1), and CCCTC-binding factor (CTCF) play a role in regulating the accessibility of the antigen receptor loci to the V(D)J recombinase, which is required for these rearrangements. To gain clues about the role of CTCF binding at the murine immunoglobulin heavy chain (IgH) locus, we utilized a computational approach that identified 144 putative CTCF-binding sites within this locus. We found that these CTCF sites share a consensus motif distinct from other CTCF sites in the mouse genome. Additionally, we could divide these CTCF sites into three categories: intergenic sites remote from any coding element, upstream sites present within 8 kb of the V_H-leader exon, and recombination signal sequence (RSS)-associated sites characteristically located at a fixed distance (∼18 bp) downstream of the RSS. We noted that the intergenic and upstream sites are located in the distal portion of the V_H locus, whereas the RSS-associated sites are located in the D_H-proximal region. Computational analysis indicated that the prevalence of CTCF-binding sites at the IgH locus is evolutionarily conserved. In all species analyzed, these sites exhibit a striking strand-orientation bias, with >98% of the murine sites being present in one orientation with respect to V_H gene transcription. Electrophoretic mobility shift and enhancer-blocking assays and ChIP–chip analysis confirmed CTCF binding to these sites both in vitro and in vivo.

A new look at the heart-novel imaging techniques

The development and successful implementation of cutting-edge imaging technologies to visualise cardiac anatomy and function is a key component of effective diagnostic efforts in cardiology. Here, we describe a number of recent exciting advances in the field of cardiology spanning from macro- to micro- to nano-scales of observation, including magnetic resonance imaging, computed tomography, optical mapping, photoacoustic imaging, and electron tomography. The methodologies discussed are currently making the transition from scientific research to routine clinical use, albeit at different paces. We discuss the most likely trajectory of this transition into clinical research and standard diagnostics, and highlight the key challenges and opportunities associated with each of the methodologies.

An initial evaluation of analyser-based phase-contrast X-ray imaging of carotid plaque microstructure

Carotid artery plaque instability can result in rupture and lead to ischaemic stroke. Stability of plaques appears to be a function of composition. Current non-invasive imaging techniques are limited in their ability to classify distinct histological regions within plaques. Phase-contrast (PC) X-ray imaging methods are an emerging class of techniques that have shown promise for identifying soft-tissue features without use of exogenous contrast agents. This is the first study to apply analyser-based X-ray PC imaging in CT mode to provide three-dimensional (3D) images of excised atherosclerotic plaques. The results provide proof of principle for this technique as a promising method for analysis of carotid plaque microstructure. Multiple image radiography CT (MIR-CT), a tomographic implementation of X-ray PC imaging that employs crystal optics, was employed to image excised carotid plaques. MIR-CT imaging yields three complementary images of the plaque's 3D X-ray absorption, refraction and scatter properties. These images were compared with histological sections of the tissue. X-ray PC images were able to identify the interface between the plaque and the medial wall. In addition, lipid-rich and highly vascularized regions were visible in the images as well as features depicting inflammation. This preliminary research shows MIR-CT imaging can reveal details about plaque structure not provided by traditional absorption-based X-ray imaging and appears to identify specific histological regions within plaques. This is the first study to apply analyser-based X-ray PC imaging to human carotid artery plaques to identify distinct soft-tissue regions.

Complete Sequence Assembly and Characterization of the C57BL/6 Mouse Ig Heavy Chain V Region

The mechanisms that regulate variable (V) gene selection during the development of the mouse IgH repertoire are not fully understood, due in part to the absence of the complete locus sequence. To better understand these processes, we have assembled the entire 2.5-Mb mouse IgH (Igh) V region sequence of the C57BL/6 strain from public sequences and present the first complete annotated map of the region, including V genes, pseudogenes, repeats, and nonrepetitive intergenic sequences. In so doing, we have discovered a new V gene family, VH16. We have identified clusters of conserved region-specific intergenic sequences and have verified our assembly by genic and intergenic Southern blotting. We have observed that V pseudogenes are not evenly spread throughout the V region, but rather cluster together. The largest J558 family, which spans more than half of the locus, has two strikingly different domains, which suggest points of evolutionary divergence or duplication. The 5' end contains widely spaced J558 genes interspersed with 3609 genes and is pseudogene poor. The 3' end contains closely spaced J558 genes, no 3609 genes, and is pseudogene rich. Each occupies a different branch of the phylogenetic tree. Detailed analysis of 500-bp upstream of all functional genes has revealed several conserved binding sites, general and B cell-specific, as well as key differences between families. This complete and definitive assembly of the mouse Igh V region will facilitate detailed study of promoter function and large-scale mechanisms associated with V(D)J recombination including locus contraction and antisense intergenic transcription.

Antisense intergenic transcription in V(D)J recombination

Antigen receptor genes undergo variable, diversity and joining (V(D)J) recombination, which requires ordered large-scale chromatin remodeling. Here we show that antisense transcription, both genic and intergenic, occurs extensively in the V region of the immunoglobulin heavy chain locus. RNA fluorescence in situ hybridization demonstrates antisense transcription is strictly developmentally regulated and is initiated during the transition from DJ(H) to VDJ(H) recombination and terminates concomitantly with VDJ(H) recombination. Our data show antisense transcription is specific to the V region and suggest transcripts extend across several genes. We propose that antisense transcription remodels the V region to facilitate V(H)-to-DJ(H) recombination. These findings have wider implications for V(D)J recombination of other antigen receptor loci and developmental regulation of multigene loci.

Skewing X chromosome choice by modulating sense transcription across the Xist locus

The X-inactive-specific transcript (Xist) locus is a cis-acting switch that regulates X chromosome inactivation in mammals. Over recent years an important goal has been to understand how Xist is regulated at the initiation of X inactivation. Here we report the analysis of a series of targeted mutations at the 5' end of the Xist locus. A number of these mutations were found to cause preferential inactivation, to varying degrees, of the X chromosome bearing the targeted allele in XX heterozygotes. This phenotype is similar to that seen with mutations that ablate Tsix, an antisense RNA initiated 3' of Xist. Interestingly, each of the 5' mutations causing nonrandom X inactivation was found to exhibit ectopic sense transcription in embryonic stem (ES) cells. The level of ectopic transcription was seen to correlate with the degree of X inactivation skewing. Conversely, targeted mutations which did not affect randomness of X inactivation also did not exhibit ectopic sense transcription. These results indicate that X chromosome choice is determined by the balance of Xist sense and antisense transcription prior to the onset of random X inactivation.

Enox, a novel gene that maps 10 kb upstream of Xist and partially escapes X inactivation

Dosage compensation in mammals is accomplished by the transcriptional silencing of a single X chromosome in female cells, a process termed X inactivation. A cytogenetically defined region of the X chromosome, the X-inactivation center (Xic), is necessary in cis for this process. Although the precise nature of the Xic remains unknown, a key component, the Xist gene, has been shown to be essential for X inactivation. In XX somatic cells, Xist RNA is specifically transcribed from the inactive X chromosome, which is otherwise essentially heterochromatic. Previous studies aimed at defining the proximal limit of the Xic have indicated that it lies within 30 kb upstream of the Xist promoter. Here we describe a novel gene, Enox (expressed neighbor of Xist), that maps to an unmethylated CpG island 10 kb upstream of Xist. Enox transcripts are antisense relative to Xist, highly heterogeneous, and apparently noncoding. In female somatic tissue Enox partially escapes from X inactivation. We discuss the implications of these findings in relation to our understanding of the Xic.

Endoscopic spray cryotherapy: a new technique for mucosal ablation in the esophagus

BACKGROUND

A simple and safe method for controlled ablation of esophageal mucosa is not currently available. Therefore, an endoscopic cryotherapy device was developed and its efficacy and safety were assessed in a swine model.

METHODS

The device consists of a cryogenic system that delivers cold nitrogen gas via a catheter introduced into the esophagus through the accessory channel of an upper GI endoscope. Esophagoscopy was performed in 20 swine under conscious sedation, and cold nitrogen gas was sprayed on the distal 2 to 3 cm of the esophagus under direct visualization.

RESULTS

Freezing of the esophageal mucosa was evidenced by the appearance of a white "cryoburn" with sharply demarcated margins. Hemicircumferential to circumferential freezing of the distal esophagus was achieved in 20 swine by varying the duration of cryoburn from 10 to 60 seconds. Mucosal ablation was noted 2 to 7 days after treatment in 95% of the swine. Complications included 3 esophageal strictures and 1 aspiration pneumonia.

CONCLUSIONS

Cryotherapy performed by spraying liquid nitrogen at upper GI endoscopy is a simple technique capable of inducing controlled superficial mucosal necrosis with complete healing in the esophagus. This method warrants further evaluation as a treatment for esophageal lesions including Barrett's esophagus.

Comparison of mutations of Ki-RAS and p53 immunoreactivity in borderline and malignant epithelial ovarian tumors

Ovarian tumors of low malignant potential ("borderline tumors") have been proposed variably to represent a distinctive type of malignancy, precursors of frank ovarian malignancy, or a nonmalignant process. We analyzed 81 malignant and 39 borderline ovarian tumors for p53 immunoreactivity and alterations in codon 12 of Ki-RAS in order to correlate these alterations with tumor and cell type. Diffuse p53 immunoreactivity was significantly more prevalent among malignant (36 of 81, 44%) than among borderline (3 of 39, 8%) tumors and was particularly prevalent among serous invasive carcinomas (16 of 26, 62%). Conversely, mutations in codon 12 of Ki-RAS were significantly more prevalent in borderline (16 of 39, 41%) than in malignant (9 of 81, 11%) ovarian tumors and were most prevalent among mucinous tumors. This preliminary molecular analysis suggests that serous borderline tumors have some molecular features usually associated with malignancy but are unlikely to represent a precursor of invasive serous carcinoma. In contrast, mucinous borderline tumors may represent a precursor or variant of mucinous carcinoma of the ovary.

Bromodeoxyuridine alternating with radiation for advanced uterine cervix cancer: a phase I and drug incorporation study

PURPOSE

Preclinical studies show a significant increase in the ratio of the radiosensitizer bromodeoxyuridine (BUdR) in tumors versus the intestinal mucosa during the drug elimination period, compared with the ratio during drug infusion. We constructed a phase I study in patients with locally advanced cervix cancer, using alternating cycles of BUdR and radiation therapy (RT).

PATIENTS AND METHODS

Eighteen patients with stage IIB to IVA cervix cancer participated. A treatment cycle consisted of a 4-day BUdR infusion followed by a week of pelvic RT, 15 Gy twice daily in 1.5-Gy fractions. After three cycles, additional BUdR was infused, followed by brachytherapy. The fraction of thymidine replaced by BUdR and the fraction of cells incorporating BUdR were determined in rectal mucosa and tumor biopsies at the end of the first BUdR infusion (day 5), at the middle of the first RT week (day 10), and at the time of brachytherapy.

RESULTS

Dose-limiting toxicity was observed in one of 16 patients receiving 1,000 mg/m2/d x 4 days and in both patients receiving 1,333 mg/m2/d x 4 days each cycle. After a median follow-up of 39 months, 12 patients (66%) were free of pelvic disease and nine (50%) were alive and disease free. The ratio of tumor to rectum BUdR incorporation averaged 1.5 to 1.8 and did not differ significantly between day 5 and day 10. A trend toward reduced ratio was observed at brachytherapy. Drug-containing cells in rectal biopsies migrated from the crypts to the mucosal surface.

CONCLUSION

In this schedule, 1,000 mg/m2/d is the maximum-tolerated dose of BUdR. BUdR incorporation levels in tumors were consistent with clinically significant radiosensitization. The migration of BUdR-containing rectal mucosa cells from the crypts to the surface at the time of RT suggests that this regimen may offer a relative sparing of the mucosa from radiosensitization.

Developmentally regulated Xist promoter switch mediates initiation of X inactivation

Developmental regulation of the mouse Xist gene at the onset of X chromosome inactivation is mediated by RNA stabilization. Here, we show that alternate promoter usage gives rise to distinct stable and unstable RNA isoforms. Unstable Xist transcript initiates at a novel upstream promoter, whereas stable Xist RNA is transcribed from the previously identified promoter and from a novel downstream promoter. Analysis of cells undergoing X inactivation indicates that a developmentally regulated promoter switch mediates stabilization and accumulation of Xist RNA on the inactive X chromosome.

Longitudinal study of inflammatory factors in serum, cerebrospinal fluid, and brain tissue in Alzheimer disease: interleukin-1beta, interleukin-6, interleukin-1 receptor antagonist, tumor necrosis factor-alpha, the soluble tumor necrosis factor receptors I and II, and alpha1-antichymotrypsin

There is evidence consistent with the hypothesis that inflammatory and immune mechanisms are involved in the pathogenesis of Alzheimer disease (AD). We have investigated whether the levels of inflammatory associated proteins in serum or lumbar cerebrospinal fluid (CSF) reflect the progressive cognitive decline and brain atrophy of AD-patients. Levels of interleukin-1beta(IL-1beta), IL-1 receptor antagonist (IL-1ra), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), the soluble TNF receptors type I and II (sTNFR I and II), and the acute phase protein alpha1-antichymotrypsin (x1-ACT) were determined in paired serum and CSF samples taken yearly over a period of 2-5 years from pathologically confirmed AD patients (n = 8) and normal controls or non-AD subjects with other CNS pathology (n = 9). No significant differences were found between AD subjects and controls in the mean levels of the above mediators. There was also no correlation in either subject group between the levels of these inflammatory mediators in serum or CSF, and the change in cognitive status or the progression of the atrophy of the medial temporal lobe measured by X-ray computed tomography (CT). The concentrations of IL-1beta, IL-6, and TNF-alpha were determined in brain tissue specimens of five to nine different brain regions in six of the AD patients and four of the non-AD subjects. The levels of IL-1beta and IL-6 in the various brain regions were not significantly different in the AD and the non-AD group. However, in AD patients the level of TNF-alpha was significantly lower in the frontal cortex (32%, p = 0.024), the superior temporal gyrus (57%, p = 0.021), and the entorhinal cortex (49%, p = 0.009) compared with non-AD subjects. Low levels of TNF-alpha in the brain areas that showed neuropathology in AD may indicate a dysregulation of the inflammatory process in AD. Despite this finding, this study does not support the use of measurements of any of the inflammatory mediators investigated here as a diagnostic parameter for AD, due the large overlap in the levels of these factors between AD patients and other subjects, and the poor relation to clinical signs of AD.

Customized gynecologic interstitial implants: CT-based planning, dose evaluation, and optimization aided by laparotomy

PURPOSE

Interstitial perineal implants may be utilized to deliver a high local radiation dose in the treatment of advanced gynecologic malignancies. Lack of knowledge of the precise anatomic relationships between the implant and the target and critical organs may limit efficacy and increase complication risks. Computed tomography (CT)-based planning, dose evaluation, and optimization of customized interstitial implants, aided by laparotomy, have been developed to overcome these limitations.

METHODS AND MATERIALS

Twenty patients with locally advanced gynecologic malignancies treated between May 1990 to October 1996 with external irradiation and one or two implants. Interstitial implants were performed when intracavitary brachytherapy was judged to be inadequate or when the response to external radiation and an intracavitary implant was not satisfactory. Customized interstitial implants were planned using preimplantation CT to determine catheter angles and paths that best implanted the target while avoiding pelvic bones and organs. Laparotomy aimed at lysing bowel adhesions, placement of omental carpet, and refining needle placement. Postimplantation CT was used for loading optimization and dose evaluation.

RESULTS

Catheter angles 15-25 degrees were found to adequately implant anteriorly laying targets while avoiding pubic bones and bladder. Adhesiolysis of bowel loops from the vaginal apex was required in patients with prior hysterectomy. Small modifications in catheter placements were made during laparotomy in all implants. Postimplantation CTs showed deviations of the catheter positions compared with the planning CTs and were essential in determining target and organ doses and loading optimization. At a median follow-up of 42 months (range: 9-80 months), local control rate is 55% and disease-free survival 40%. Late complications occurred in 2 of 11 of patients without local recurrence.

CONCLUSIONS

CT-based planning, loading optimization, and dose evaluation of customized implants improve radiation dose delivery. Laparotomy enhances implant accuracy and safety. Local tumor control rate is still unsatisfactory. It reflects the shortcomings of technical advances alone in poor prognosis tumors like those selected for this series.

Molecular analysis in endometrial cancer

The molecular events that occur during the development of endometrial carcinoma are largely uncharacterized. Carcinomas of the endometrium are associated as extracolonic malignant tumors in patients with hereditary nonpolyposis colorectal cancer syndrome. Endometrium and ovary may develop histologically homologue cancers especially endometrioid and papillary serous carcinomas. Colon and ovarian carcinoma might serve as model systems for the molecular analysis in endometrial carcinoma. We sought to analyze in endometrial carcinoma frequent molecular mechanisms of colon and ovarian carcinoma, including Ki-ras codon 12 mutations, microsatellite instability, p53 and c-erb B-2 immunohistochemical expression and allelic loss on chromosome 17q. Our results indicate that molecular mechanisms in endometrial carcinoma are different than those responsible for colorectal carcinomas and that uterine papillary serous carcinomas shares with its ovarian counterpart several molecular alterations in contrast to the histologically homologue uterine and ovarian endometrioid carcinoma. Furthermore there is a molecular basis to distinguish uterine endometrioid and papillary serous carcinoma.

Molecular evolution of the ZFY and ZNF6 gene families

Members of the ZFY and ZNF6 gene families have been cloned from species representing different taxa and different modes of sex determination. Comparisons of these genes show the ZFY-like and ZNF6 sequences to be strongly conserved across marsupials, birds, and lepidosaurians. Sequence analyzed by neighbor-joining indicated that both gene families are monophyletic with a high bootstrap value. Pairing of sequences from males and females of nonmammalian species showed there to be no significant difference between male and female sequences from a single species, consistent with autosomal locations. The molecular distances between murine Zfy-1, Zfy-2, and other ZFY-like sequences suggested that Zfy genes have undergone a period of rapid evolutionary change not seen in human ZFY.

Stabilization of Xist RNA mediates initiation of X chromosome inactivation

The onset of X inactivation is preceded by a marked increase in the level of Xist RNA. Here we demonstrate that increased stability of Xist RNA is the primary determinant of developmental up-regulation. Unstable transcript is produced by both alleles in XX ES cells and in XX embryos prior to the onset of random X inactivation. Following differentiation, transcription of unstable RNA from the active X chromosome allele continues for a period following stabilization and accumulation of transcript on the inactive X allele. We discuss the implications of these findings in terms of models for the initiation of random and imprinted X inactivation.

The practice of surgical staging and its impact on adjuvant treatment recommendations in patients with stage I endometrial carcinoma

A survey of American gynecologic oncologists was undertaken to assess their compliance with current surgical staging criteria in patients with early endometrial carcinoma. One hundred forty-four members of the Society of Gynecologic Oncologists responded to the survey. Respondents treated an average of 22 new cases annually. Tumor grade and intraoperative determination of depth of myometrial invasion were demonstrated to influence the frequency of lymphatic dissection. In grade 1, 2, and 3 lesions, 76, 60, and 34% of responders, respectively, indicated that depth of invasion influenced their decision to perform lymphadenectomy. In addition, depth of invasion was important in determining type and extent of lymphatic resection. Further, the impact of pathologic lymph node status on postoperative adjuvant radiation therapy recommendations was evaluated for various stratifications of endometrial adenocarcinoma confined to the corpus. The greatest differences in treatment recommendations were noted in the 50-66% invasion category. For grade 1 and 2 cancers, adjuvant therapy recommendations were reduced by 23 and 16% respectively when comparing pelvic and combined therapy versus none and vaginal therapy. The effect of surgical staging data on clinical decisions is clearly evident. The knowledge of pathologically negative lymph node status reduces the recommendation for postoperative adjuvant radiotherapy in patients with adenocarcinoma otherwise confined to the uterine corpus.

Clinical and pathological significance of microsatellite instability in sporadic endometrial carcinoma

Defective DNA mismatch repair in neoplasia is manifested by extra, aberrant bands within multiple microsatellite markers. The replication error (RER) phenotype is present in most colorectal and endometrial carcinomas in patients with the hereditary nonpolyposis colorectal carcinoma syndrome. In addition, a minority of sporadic colorectal and endometrial carcinomas are RER positive. RER in sporadic colorectal carcinomas has been associated with improved prognosis, but its clinical significance in sporadic endometrial cancer has not been characterized. We analyzed DNA extracted from 109 formalin-fixed sporadic endometrial carcinomas for microsatellite instability. The RER-positive phenotype was demonstrated by microsatellite instability in more than one of the eight dinucleotide markers tested. RER was correlated with pathological and clinical parameters as well as with immunohistochemical staining for the p53 gene product and alterations in codon 12 of Ki-ras. Nine percent of the endometrial carcinomas were RER positive, and RER was significantly associated with high grade and adverse outcome. We found no significant correlation of RER with histological subtype, stage, depth of invasion, mutations in the 12th codon of Ki-ras, or p53 immunoreactivity. We conclude that the RER phenotype is present in a minority of sporadic endometrial carcinomas and is associated with high grade and poor prognosis.

LY290181, an inhibitor of diabetes-induced vascular dysfunction, blocks protein kinase C-stimulated transcriptional activation through inhibition of transcription factor binding to a phorbol response element

Previous studies have shown that high glucose levels and diabetes induce an elevation in protein kinase C (PKC) activity in vascular cells and tissues susceptible to diabetic complications. In addition, PKC activation has been shown to modulate vascular cell growth, permeability, and gene expression, processes thought to be involved in the development of vascular complications. Using two in vivo model systems, we have identified a novel inhibitor of diabetic vascular dysfunction, LY290181. LY290181 prevented glucose-induced increases in blood flow and permeability in rat granulation tissue and corresponding vascular changes in the retina, sciatic nerve, and aorta of diabetic rats. Tested for its ability to inhibit PKC-regulated processes, LY290181 inhibited phorbol ester-stimulated plasminogen activator activity in a dose-dependent manner in bovine retinal endothelial cells and in human dermal fibroblasts. In addition, LY290181 inhibited phorbol ester-stimulated activation of the porcine urokinase plasminogen activator (uPA) promoter (-4600/+398) linked to the chloramphenicol acetyltransferase (CAT) reporter gene (p4660CAT). More detailed analysis of the uPA promoter revealed that LY290181 inhibited phorbol ester-stimulated activation of the uPA phorbol response element (-2458/-2349) located upstream of the thymidine kinase promoter (puPATKCAT). LY290181 appears to inhibit uPA promoter activation by blocking phorbol ester-stimulated binding of nuclear proteins to the uPA PEA3/12-0-tetradecanoylphorbol 13-acetate responsive element (TRE). These results suggest that LY290181 may inhibit diabetes-induced vascular dysfunction by inhibiting transcription factor binding to specific PKC-regulated genes involved in vascular function.

The molecular biology of temperature-dependent sex determination

Many reptiles do not have heteromorphic sex chromosomes and for these species sex is determined during embryogenesis by the temperature of egg incubation rather than at conception. The phenomenon of temperature-dependent sex determination (TSD) was discovered almost thirty years ago, but few advances have been made towards the elucidation of its mechanism. In the past few years substantial progress has been made in the understanding of the molecular basis of XY chromosomal (genetic) sex determination (GSD) through the discovery of SRY. It is now possible to start comparing TSD with GSD. TSD is found in some evolutionarily ancient vertebrates and has been postulated to be the ancestral process from which GSD has evolved. If this is true then the two mechanisms may share a common molecular basis. This paper details the current knowledge of TSD, our progress on the investigation of the involvement of SRY-type proteins, and finally presents some of the problems that need to be resolved to gain an understanding of the molecular basis of TSD.

Absence of cumulative bone marrow suppression in heavily pretreated ovarian cancer patients undergoing salvage chemotherapy with paclitaxel

This retrospective study was undertaken to investigate whether paclitaxel was associated with cumulative bone marrow toxicity in patients undergoing salvage chemotherapy for refractory ovarian cancer. Seventy-seven patients were treated with paclitaxel 135 mg/m2 every 21 days, with granulocyte-colony-stimulating factor (G-CSF) support as necessary according to standard criteria. The mean white blood cell nadir was significantly higher and the incidence of severe leukopenia (Gynecologic Oncology Group grade 3-4) significantly lower after ten cycles than after the first cycle for the entire study population (3.4 vs. 1.6 x 10(3)/mm3 and 29 vs. 77%, respectively) and the patients who received G-CSF (3.5 vs. 1.4 x 10(3)/mm3 and 33 vs. 89%, respectively), but did not differ significantly for the patients who did not require G-CSF (2.9 vs. 2.5 x 10(3)/mm3 and 40 vs. 59%, respectively). The mean hematocrit and platelet nadirs, as well as the incidence of severe anemia and thrombocytopenia, did not differ significantly after ten cycles from those after the first cycle for the entire study population and both subgroups. Thirty-two (42%) patients received G-CSF, each initiated within four cycles. The indications for initiating G-CSF support were febrile leukopenia (53%) and treatment delay (47%). The average duration of G-CSF support was 4.6 days, and did not increase significantly as the number of paclitaxel cycles increased. We conclude that paclitaxel was not associated with cumulative bone marrow toxicity in patients undergoing salvage chemotherapy for refractory ovarian cancer.

Mutations of the Ki-ras oncogene in carcinoma of the endometrium

Mutations of the Ki-ras oncogene in endometrial carcinoma have been reported in Japan, but the prevalence and clinical significance of such mutations in the United States remains unclear. DNA extracted from paraffin sections of 112 carcinomas of the endometrium was amplified by the polymerase chain reaction with mismatched primers that generated a BstNI recognition site with the wild-type codon 12. Loss of this recognition site indicating Ki-ras codon 12 mutations was observed in 13 tumors (11.6%), including 11 endometrioid carcinomas, one undifferentiated carcinoma, and one carcinosarcoma. None of 17 papillary serous-clear cell carcinomas contained Ki-ras codon 12 mutations. These mutations were confirmed and characterized by direct sequencing. We found no evidence of correlation of the presence of Ki-ras mutations with stage, grade, depth of invasion, or clinical outcome. Our results indicate that Ki-ras oncogene mutations in carcinoma of the endometrium may be less prevalent in the United States than in Japan.

Surrogate endpoint biomarkers for cervical cancer chemopreventive trials

Cervical intraepithelial neoplasia (CIN) represents a spectrum of epithelial changes that provide an excellent model for developing chemopreventive interventions for cervical cancer. Possible drug effect surrogate endpoint biomarkers are dependent on the agent under investigation. Published and preliminary clinical reports suggest retinoids and carotenoids are effective chemopreventive agents for CIN. Determination of plasma and tissue pharmacology of these agents and their metabolites could serve as drug effect intermediate endpoints. In addition, retinoic acid receptors could serve a both drug and biological effect intermediate endpoints. Possible biological effect surrogate endpoint biomarkers include cytomorphological parameters, proliferation markers, genomic markers, regulatory markers, and differentiation. Given the demonstrated causality of human papillomavirus (HPV) for cervical cancer, establishing the relationship to HPV will be an essential component of any biological intermediate endpoint biomarker. The pathologic effect surrogate endpoint biomarker for cervical cancer is CIN, used clinically for years. The desired effect for chemopreventive trials is complete regression or prevention progression. In planning chemoprevention trials, investigators need to consider spontaneous regression rates, the subjective nature of detecting CIN, and the impact of biopsy on regression. If intermediate endpoint biomarkers that met the above criteria were available for cervical cancer, then new chemopreventive agents could be rapidly explored. The efficacy of these new agents could be determined with a moderate number of subjects exposed to minimal risk over an acceptable amount of time. The impacts on health care for women would be significant.

Exponential regression of CA 125 during salvage treatment of ovarian cancer with taxol

The role of serum CA 125 in monitoring the response of epithelial ovarian cancer to treatment has been extensively investigated. The exponential regression curve [1n(CA 125) = i+s (days after initiation of treatment)] has been reported to describe the rate of change of serum CA 125 during treatment. In this model, the y-axis intercept (i) represents the initial CA 125-secreting tumor burden, while the slope (s) is determined by the response to treatment. The exponential regression curve was calculated for 66 patients undergoing salvage chemotherapy with taxol. At a mean follow-up of 121 days, 50 (75%) patients had progressed and 35 (53%) had died. Stratification of the patients by stage, grade, or histology did not reveal any significant differences in the regression rate. When the patients were stratified by response, the mean regression rate was 0.0157 +/- 0.011 for patients with progressive disease (N = 19) vs -0.0250 +/- 0.031 for those with stable disease (N = 25) and -0.0250 +/- 0.015 for those with a partial response (N = 22) (P < 0.0001). The regression rate did not correlate with progression-free interval or survival (P > 0.05). We conclude that changes in serum CA 125 levels follow an exponential regression curve in patients undergoing salvage chemotherapy with taxol for progressive or recurrent ovarian cancer. A positive regression rate may predict which patients will progress prior to the time progression becomes clinically evident. However, a negative rate fails to provide discriminatory utility in predicting progression-free interval or survival.

Synchronous dual primary ovarian and endometrial carcinomas

OBJECTIVES

The synchronous occurrence of carcinoma confined to the ovary and endometrium presents a diagnostic and therapeutic dilemma. These tumors have been variously staged as FIGO Stage IIA ovarian carcinoma, Stage III endometrial carcinoma, or synchronous dual primary carcinomas. Accumulating evidence suggests such patients have a favorable outcome. This retrospective study was undertaken to review our experience with these fascinating tumors.

METHODS

The clinical records and the pathologic findings of 16 patients with synchronous dual primary ovarian and endometrial carcinomas were reviewed.

RESULTS

The median age was 51 years. Abnormal uterine bleeding was the most common presenting symptom (70%). All patients had Stage I ovarian and endometrial carcinomas. Fourteen patients (88%) had endometrioid carcinoma in both sites, while two patients (12%) had dissimilar histology. For 15 patients (94%), the grade of both tumors was identical. Only three (19%) patients had myometrial invasion, with less than 50% involvement in each case. All patients underwent surgical staging, 11 (70%) of whom received adjuvant radiation or chemotherapy. The five patients treated with surgery alone had Grade 1 endometrioid tumors. The only relapse occurred in a patient with a clear cell component in both sites. No patient has died of disease.

CONCLUSIONS

Patients with synchronous dual primary carcinomas appear to have a more favorable prognosis than that expected with Stage IIA ovarian or Stage III endometrial carcinoma (100% vs. 63% or 42% survival at 3 years, respectively). The excellent survival for patients with Grade 1 dual endometrioid tumors treated with surgery alone suggests that adjuvant therapy may not be necessary for this sub-group.

A comparison of staging systems for squamous cell carcinoma of the vulva

A review of 172 patients with squamous cell cancer of the vulva treated at the University of Michigan Medical Center from 1975-1989 was performed to compare the 1988 FIGO Staging System to the 1970 FIGO Staging System. The stage distribution according to the 1970 FIGO Staging System was stage I, 65; stage II, 44; stage III, 50; and stage IV, 13. The cumulative 5-year survival under the old system was stage I, 94%; stage II, 91%; stage III, 36%; and stage IV, 26%. The distribution changed under the 1988 FIGO system to stage I, 58; stage II, 36; stage III, 49; stage IVA, 16; and stage IVB, 13. The cumulative survival also changed to stage I, 94%; stage II, 89%; stage III, 71%; stage IVA, 19%; and stage IVB, 8%. The new FIGO stage distribution shifted for the worse due to the influence of positive lymph nodes found at the time of surgery. The survival was then analyzed for death from all causes. This was markedly decreased when compared to the cumulative corrected survival. This relates to the high number of other primary malignancies and the age of the patients. Among these 172 patients, other primary malignancies included squamous cell cancer of the cervix (11), squamous cell cancer of the vagina (2), endometrial cancer (3), squamous cell cancer of the lung (2), colon cancer (3), and others (6). An additional 5 patients died from myocardial infarction within 2 years of diagnosis. The new 1988 FIGO Staging System provides for better discrimination of survival between stages than the 1970 FIGO Staging System.

Managers' perceptions of customers' satisfactions with their hospital cafeteria services

It is important that hospital cafeterias deliver products that create customer satisfaction so that financial objectives are met. An exploratory descriptive survey of 12 selected hospital cafeterias used a self-administered questionnaire to determine how satisfied customers were with services provided. It also asked cafeteria managers to give their perceptions of their customers' relative satisfaction/dissatisfaction with the service. Principal components analysis, followed by varimax rotation, identified four underlying constructs of the 15 pre-selected foodservice characteristics used to measure relative satisfaction. A multiple regression model, controlling for country, hospital size and customer demographics, in which the dependent variable was overall rating, found that the independent variables, the underlying rating constructs--food and service--made a much greater impact on overall rating than environment and accessibility. Most cafeteria managers' predictions about their customers' satisfaction were within two standard deviations of their customers' mean scores of satisfaction. While the managers' close association with their service may have accounted for this, it does not necessarily follow that they have the power to implement policy and product improvements.

Recurrent cervical squamous cell carcinoma in an ovary following ovarian conservation and radical hysterectomy

This is the second reported case of an ovarian recurrence of Stage I squamous cell carcinoma of the cervix. It occurs following radical hysterectomy, chemotherapy, and radiotherapy. The issue of ovarian conservation is addressed.

The influence of electrical variables on analgesia produced by low current transcranial electrostimulation of rats

Pulsed low current transcranial electrostimulation (TE) has been shown to induce analgesia in rats as measured by the wet tail flick test. This study investigates the effect of varying stimulus frequency, pulse width, charge balance and polarity, as well as the influence of electrode placement and time of day at which stimulus occurred. A biphasic, charge balanced waveform with a first phase duration of 2 msec, current 10 microA and repetition rate 10 Hz was found to induce maximum tail flick latency changes. The effects of morning or nighttime stimulation were statistically indistinguishable, as were the differences between monophasic and biphasic stimulation. Analgesia was maximized when a positive first phase was delivered into the right ears of the rats, but monolateral stimulation with both electrodes on either the left or the right ear produced no measurable effect. Examination of TE responses in sham and stimulated populations reveals normal response distributions with the stimulated group skewed toward a positive effect.

Impact of administrative technology on acute care bed need

This article reports an evaluation of the impact of three administrative technologies--Admission Scheduling (AS) Systems, Outpatient Surgery (OPS) Programs, and Preadmission Testing (PAT) Programs--on the number of acute care beds required by a hospital. The evaluation mechanism reported here is called the ADTECH Computerized Planning Model. ADTECH uses parameters of each technology, identified from previous literature and discussions with health care professionals, to predict the changes in bed requirements resulting from implementation of these programs. Data from eight hospitals of various characteristics and sizes were run to test the ADTECH model. The results from these test runs indicate that the proper implementation of AS, OPS, and PAT can significantly influence a hospital's required bed complement.

Xenopsylla cheopis: cellular expression of hypersensitivity in guinea pigs

Guinea pigs multiply exposed to Xenopsylla cheopis adult fleas exhibited marked blood basophil responses to challenge infestation with only minor changes in blood eosinophil levels. Dermal responses to flea feeding were marked by dominant neutrophil (52% of the infiltrate) and eosinophil (32%) accumulations 24 hr after primary feeding, with a weak basophil response (11%). However, after challenge feeding 14 days later, eosinophils dominated, representing 59% of the infiltrate with basophils comprising 30% of the cellular response; neutrophils were rare (7%). Mast cells did not exhibit any increases in density during either the primary or secondary infestation, representing 4-7% of the infiltrate. These results demonstrate that flea feeding induces systemic and local basophil responses as demonstrated for all hematophagous arthropods examined so far. Flea feeding success was not adversely affected by feeding on homologously hypersensitized guinea pigs or guinea pigs sensitized by Ornithodoros parkeri feeding. However, basophil responses at flea feeding sites in heterologous (tick) sensitized animals were more basophilic (26 +/- 4 cells/0.03-mm2 area) than feeding sites in homologous (flea) sensitized hosts (9 +/- 6 cells). Furthermore, primary tick feeding sites become erythematous and indurated after flea feeding on the opposite flank, and were marked histologically by strong basophil abscess (276 +/- 56 cells/0.03-mm2 area); primary flea feeding sites were not activated by tick challenge feeding. These cross-generic challenge feeding experiments suggest antigen cross-reactivity, resulting in activation of feeding sites of a heterologous arthropod.(ABSTRACT TRUNCATED AT 250 WORDS)