Late-onset and long-lasting neutropenias in the young: A new entity anticipating immune-dysregulation disorders

This study identifies a new chronic form of immune neutropenia in the young with or without detectable indirect anti-neutrophil antibodies, characterized by mild/moderate neutropenia low risk of severe infection (14%), tendency to develop autoimmune phenomena over the course of the disease (cumulative incidence of 58.6% after 20 years of disease duration), leukopenia, progressive reduction of absolute lymphocyte count and a T- and B-cell profile similar to autoimmune disorders like Sjogren syndrome, rheumatoid arthritis, and systemic lupus erythematosus (increased HLADR+ and CD3 + TCRγδ cells, reduced T regulatory cells, increased double-negative B and a tendency to reduced B memory cells). In a minority of patients, P/LP variants related to primary immuno-regulatory disorders were found. This new form may fit the group of "Likely acquired neutropenia," a provisional category included in the recent International Guidelines on Diagnosis and Management of Neutropenia of EHA and EUNET INNOCHRON ACTION 18233. The early recognition of this form of neutropenia would help clinicians to delineate better specific monitoring plans, genetic counseling, and potentially targeted therapies.

Analysis of the impact of sub-acute care activities on consumption of hospital resources in Milan

Background

In 2011, a new health service called 'sub-acute care activities' (SA) has been provided by Lombardy. It is a protected hospitalization of patients, especially elderlies, suffering for clinical issues following an acute disease or for non-complex clinical failures due to a chronic pathology. This is a hospitalization area between the hospital and home, created to reduce the number of post-acute hospitalized patients who can't be discharged. The goal of this study is the analysis of the hospitalizations in the SA setting within medical structures located in the Metropolitan area of Milan.

Methods

The data extracted from the hospital discharge card database, is focused on hospitalizations in SA that occurred from 2016 to 2019. The analysis describes yearly production, the characteristics of hospitalizations and patients, finally some trends.

Results

16,395 hospitalizations in SA were analyzed (0.7% of the total). Some data are constant in time: hospitalizations (1%), age (average 79), days of hospitalization (average 26). Patients coming from public hospitals (from 28% to 22%) are decreasing while those coming from other in-patient admission typologies within the same organization (from 44% to 54%) are increasing. The major diagnostic categories are related to cardiovascular and respiratory diseases. Over the 85% of hospitalizations are paid with the highest daily rate among those allowed by law. Talking about discharge typologies, 57% of patients return home, 20% are re-transferred to the acute ward, 16% are sent to rehabilitation/long-term care while 7% have died.

Conclusions

The use of the highest daily tariff and the high number of patients who need to be re-transferred to the acute ward place, gives many doubts on how appropriate is allocation of resources and about the accuracy of admissions in the SA unit during the patient care path. We're planning to return to these issues with further targeted studies.

Key messages

The analysis showed constant characteristics of SA activities during the four years. Data showed that there may be management issues in the appropriate use of resources in SA assistence.

Assessment of the attractiveness of robotic-assisted radical prostatectomy in the hospitals in Milan

Background

Robotic-Assisted Radical Prostatectomy (RARP) performed in the hospitals of the Health Protection Agency (ATS) of Milan increased from 302 in 2011 to 1275 in 2019. On the contrary, Traditional Radical Prostatectomy (TRP) remained essentially unchanged (919 hospitalization in 2011, 937 in 2019). The increase in RARP occurred both for Lombardy (L) (223,7%) and particularly for out-of-Lombardy residents (EL) (565,5%). In 2011 66.5% of all EL treated with Radical Prostatectomy (RP) (RARP + TRP) in the ATS area were enrolled in hospitals equipped with robots, while in 2019 this percentage rose to 97.5%. In view of this important increase and considering the high density of hospitals with robots in Milan, it was analyzed if the reason for the EL displacement could be due to the possibility of performing a RARP.

Methods

The Hospital Discharge Cards (SDO) database was used for the analysis. Admissions to be considered were identified through the main diagnosis of localized malignant prostatic cancer and the surgical intervention of RP. The other urological interventions were identified through the discharge ward. The “residency” field allowed to separate L from EL.

Results

Considering the four hospitals where robot technology was already available in 2011, the percentage changes in hospitalizations were compared for: only RP interventions, all urological interventions excluding RP, total hospital production distinguishing between L and EL. RP increased by about 5 percentage points in EL (from 43.5% in 2011 to 48.7% in 2019). For other urological surgeries excluding RP, the increase was about 11 pp (from 16.1% in 2011 to 27.3% in 2019), as well as for general procedures (15.5% in 2011, 26, 2% in 2019).

Conclusions

The increase in EL for RP is lower than the increase observed for other urological surgeries and on all hospital production. It can be concluded that it is not the RARP technique itself that is attractive to EL, but rather the reputation of the hospital.

Key messages

In 2019 the number of robotic-assisted radical prostatectomy increased 4,2 times compared to 2011. R-assisted radical prostatectomy is not a determining factor for health mobility towards Lombardy.

Endocrine Effects of Tamoxifen in Postmenopausal Breast Cancer Patients

The effects of tamoxifen on plasma concentration of gonadotropins, prolactin (PRL), estrone (E1), estradiol-17β (E2), and sex hormone-binding globulin (SHBG) were studied in 40 postmenopausal breast cancer patients. In addition, the changes induced by the drug on endometrium and vaginal epithelium were investigated. After 6–8 weeks of tamoxifen treatment, a significant decrease in FSH, LH and PRL basal levels was observed, whereas the concentrations of E1 and E2 were not significantly affected. A significant increase in SHBG levels was induced by prolonged treatment with the drug. In addition, tamoxifen caused a partial estrogenization of vaginal smears, and a weak stimulatory effect on endometrium was also apparent. These findings indicate that tamoxifen produced agonistic effects on some targets and antagonistic effects on the others.

Preliminary Study on Serum Levels of Mucinous like Cancer Antigen (MCA) in Patients with Breast Disease: Comparison with CEA

MCA (mucinous-like cancer antigen) can be measured in the biological fluids of patients by means of a solid phase enzyme immunoassay. This study describes the results of MCA determination in sera of 230 patients with benign (99) and malignant (131) breast diseases. MCA levels were significantly higher in breast cancer patients than in non cancer patients and in healthy subjects (p < 0.001). MCA concentrations tended to increase as the stage of the disease advanced. The 95th percentile of MCA value distribution in normal subjects showed a diagnostic sensitivity in breast cancer patients of 16.3% at stage I,26.2% at stages II-III and 52% at stage IV. In a group of 118 cancer patients, MCA and CEA were tested simultaneously. The diagnostic sensitivity and specificity of MCA and CEA assays was very similar; nevertheless the association of the two tests showed 11 cases with high levels of MCA and low levels of CEA and 9 patients with high levels of CEA and low levels of MCA. Seventy-four out of 118 patients were negative for both markers and in 22 out of 118 patients markers were positive. The new marker MCA appeared to correlate with breast cancer and gave different information complementary to CEA.

Abstract P2-05-01: A Comparative Study of 18F-Fluoride PET/CT and Whole-Body High Resolution CT (HRCT) for the Detection of Bone Metastases in Patients with Advanced Breast Cancer

Background: Bone scintigraphy (BS) have been shown to be of value in detecting bone metastases several months before conventional radiography, whereas computed tomography (HRCT) and magnetic resonance imaging (MRI) can reveal more metastases in the spine than conventional BS. 18F-Fluoride PET has been shown to be more accurate than BS for the detection bone lesions in different malignancies and has been suggested as an alternative to BS. Recent studies have shown that integrated 18F-Fluoride-PET/CT is both sensitive and specific for detection of lytic and sclerotic lesions and is superior to 18F-Fluoride PET. The aim of our study is to evaluate the diagnostic accuracy of 18F-Fluoride-PET/CT in comparison to HRCT for the detection of bone metastases in breast cancer patients.

Material and methods: The study involved 39 patients with breast cancer with known bone metastases or at high risk for its presence. All patients presented indications for skeletal surveys. Imaging was performed on an integrated PET/CT system. All PET scans were acquired in 2D mode and were reconstructed using an iterative reconstruction algorithm; diagnostic HRCT data of PET/CT were acquired for detecting bone lesions and were used for attenuation correction. PET acquisition started 60 min after intravenous injection of 370-550 MBq 18F-labelled NaF and included 10-12 bed positions.

The interpretation of PET/CT and High resolution CT studies was made as a consensus reading of two nuclear medicine physicians and a radiologist who had access to clinical, as well as previous radiological imaging information. 12 months follow-up based on previous and/or following imaging studies was considered the gold standard. Results: Overall 671 bone lesions were detected in our analysis including both PET/CT and CT results. Of these lesions 530 malignant, 32 equivocal and 109 benign were classified by consensus reading. 18F-Fluoride PET/CT detected 491 bone metastases, 114 (23%) of which without any clear morphological changes on CT. HRCT detected 416 bone metastases, 39 (9.3%) of which without any 18F-fluoride uptake. The overall sensitivity and specificity was 90% and 91% for 18F-Fluoride-PET/CT and 79 and 93% for HRCT, respectively. In a patients based analysis both 18F-Fluoride-PET/CT and HRCT identified the same number of patients with bone metastases (27 of 39).

Conclusions: Our data show a high agreement (71% of lesions and 100% of the patients) between 18F-Fluoride-PET/CT and HRCT for bone metastases detection. However integrated analysis of 18F-Fluoride-PET/HRCT has the best diagnostic option to evaluate bone involvement in breast cancer, and 18F-Fluoride-PET/CT seems to have the highest sensitivity. Follow-up is ongoing to assess the prognostic/predictive value of 18F-Fluoride-PET/CT.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-05-01.

Phase I-II trial of weekly bicalutamide in men with high PSA and negative biopsy

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Background: Men with persistent PSA elevation after non-cancer findings are at high risk of prostate cancer (PC). Bicalutamide (Bic) is an androgen receptor antagonist, which, unlike finasteride, is not associated with testosterone (T) escape. Given its long half-life (6–8 days), allowing for a weekly administration with potentially reduced side effects, Bic may be a suitable chemopreventive agent. We assessed the activity and safety of a weekly low-dose Bic in a phase I-II study in subjects with PSA >4 ng/ml and no PC at initial biopsies (10- 12 cores). Methods: Eligible subjects were sequentially assigned to either Bic 50 mg/week (group A), or 100 mg/week (group B), or no treatment (group C) for 6 mos. The outcome measures were the 6 mos changes in tissue Ki67 (primary endpoint), topoisomerase-IIa, Bcl- 2, and COX-2 by IHC, morphology and circulating PSA, prostatic acid phosphatase (PAP) and hormones. Results: From May, 2004 to June, 2006, 107 subjects were screened and 80 were enrolled: 26 in group A, 28 in group B, and 26 in group C. High-grade (HG) PIN decreased from 32% to 23% in the treated group and increased from 24% to 34% in controls; proliferative inflammatory atrophia (PIA) decreased from 41% to 32% in the treated group and increased from 14% to 19% in the controls. Complete remission of HG-PIN was found in 10/14 treated subjects versus 1/5 controls. Cancer or HG-PIN were found in 11 control subjects (52%) versus 16 subjects (36%) in the treated arms at 6 mos. Ki67 expression was significantly higher in HG-PIN lesions than in normal tissue (12% vs. 3%, p<0.01), but it was not modulated by Bic. Bcl-2 expression in normal tissue was 0/1+ in most subjects, and increased in 36% of treated subjects versus 20% of controls. Total and free PSA, as well as PAP, decreased by >30% on Bic. T, LH, estradiol and SHBG increased on Bic by 50–60%. There was no dose-related modulation in any biomarker. Treatment was well tolerated, mild (G1) breast pain and gynecomastia being recorded in 40% of treated subjects. Conclusions: Weekly Bic is active and safe in subjects with high PSA and negative biopsy. It seems to be associated with HG- PIN remission, Bcl-2 overexpression and a favorable modulation of PSA. The dose of 50 mg/week should be selected for future chemoprevention trials.

No significant financial relationships to disclose.

The risk of premalignant and malignant pathology in endometrial polyps: should every polyp be resected?

AIM

There is no wide consensus in the literature on the clinical significance and management of symptomatic and asymptomatic polyps. Aims of the study are to evaluate frequency of premalignant and malignant histo-pathologic features in endometrial polyps resected hysteroscopically and identify clinical parameters able to predict final histopathologic diagnosis.

METHODS

Clinical data and pathologic report of 90 consecutive operative hysteroscopies performed on women with endometrial polyps were collected. Frequency of premalignant and malignant histopathologic features on the polyps were calculated and relation to clinical risk factors analyzed.

RESULTS

The frequency of premalignant and malignant histopathologic features in polyps was 6.7% and 2.2% respectively. Owing to the small sample size no statistical analysis to detect clinical risk factor for premalignant or malignant histopathologic features could be performed.

CONCLUSION

Frequency of premalignant and malignant histopathologic features in symptomatic and asymptomatic patients is not negligible. Reported clinical risk factors for malignant degeneration of endometrial polypoid lesions are the same as those reported for endometrial cancer and are very common in patients with endometrial polyps. Every endometrial polyp should be resected.

Clinical trials with retinoids for breast cancer chemoprevention

Retinoids have been studied as chemopreventive agents in clinical trials due to their established role in regulating cell growth, differentiation and apoptosis in preclinical models. Experimental evidence suggests that retinoids affect gene expression both directly, by activating and/or repressing specific genes, and indirectly, by interfering with different signal transduction pathways. Induction of apoptosis is a unique feature of fenretinide, the most widely studied retinoid in clinical trials on breast cancer chemoprevention due to its selective accumulation in breast tissue and to its favourable toxicological profile. In a phase III breast cancer prevention trial, fenretinide showed a durable trend to a reduction of second breast malignancies in premenopausal women. This pattern was associated with a favourable modulation of circulating IGF-I and its main binding protein (IGF-binding protein-3, IGFBP-3), which have been associated with breast cancer risk in premenopausal women in different prospective studies. In a subsequent biomarker study on premenopausal women who had participated in the phase III trial, high IGF-I and low IGFBP-3 baseline levels were found to predict second breast cancer risk, although the magnitude of their changes during treatment did not fulfil the requirements for suitable surrogate end-point biomarkers. In postmenopausal women, fenretinide did not reduce second breast cancer incidence, nor did it induce significant modulation of the IGF system. Similarly, fenretinide was not found to affect risk biomarkers significantly in early postmenopausal women on hormone replacement therapy, who are at increased risk of developing breast cancer. Biomarker studies of fenretinide alone or in combination with different nuclear receptor ligands are being conducted. In particular, clinical trials of fenretinide and tamoxifen have proved to be feasible, and this combination appears to be safe and well tolerated in high-risk women, especially when low-dose tamoxifen is employed. Novel retinoid X receptor-selective retinoids, or rexinoids, have been shown to suppress the development of breast cancer in several animal models with minimal toxicity, and are being intensively studied either alone or in combination with selective oestrogen receptor modulators, both in vitro and in vivo. The rexinoid, bexarotene, has recently been approved for the treatment of patients with cutaneous T-cell lymphoma, and a biomarker trial with bexarotene in women with high breast cancer risk is currently underway.

CD1d expression on B-precursor acute lymphoblastic leukemia subsets with poor prognosis

Acute lymphoblastic leukemia (ALL) is the most frequent malignancy of childhood. Although therapeutical advances have been achieved, some ALL subgroups still fare poorly. CD1d is a monomorphic molecule that provides a suitable target for immunotherapy in view of the characterization of a glycolipid, alpha-galactosylceramide (alpha-GalCer), capable of being presented to CD1d-restricted T cells with cytotoxic potential. We investigated CD1d expression in 80 pediatric B-cell precursor (BCP) ALL cases defined according to immunophenotype, cytogenetic features and age at onset. CD1d was detected on ALL cells in 15% of the patients. CD1d+ ALLs were significantly associated with infant leukemia, pro-B phenotype and mixed-lineage leukemia (MLL)/AF4 gene rearrangement. Accordingly, overall survival of patients with CD1d+ ALL was significantly shorter. CD1d+ leukemic blasts were able to present alpha-GalCer via CD1d to cytotoxic CD1d-restricted T cells, which induced apoptosis of ALL cells that was inhibited by mAb to CD1d. CD1d+ blasts loaded with alpha-GalCer elicited cytokine secretion by CD1d-restricted T cells. Analysis of bone marrow (BM) cells derived from normal donors revealed that CD19+/CD1d+ cells were mostly mature B lymphocytes. However, a minority of BCPs expressed CD1d. Thus, expression of CD1d in ALL cases heralds an adverse prognosis but may provide a therapeutic tool.

Analysis of the distribution and genetic variability of viral isolates in a cohort of HCV-positive hepatopathic patients

The genotyping of the hepatitis C virus (HCV) by viral nucleic acids sequencing allows accurate epidemiological evaluation of a cohort of patients suffering from HCV-related chronic hepatopathy. The identification of viral isolates, which can be generally associated with hepatic damage or, vice versa, which are more responsive to pharmacological treatment, might enhance clinical interest on the nature of the infecting genotypes. We, therefore, draw attention to those viral genotypes that are characterised by significantly high or altered viremic and enzymatic levels.

Asthma and rhinitis in schoolchildren: the impact of allergic sensitization to aeroallergens

This study aimed to evaluate the prevalence of asthma and rhinitis in schoolchildren living in the Genoa area by using a validated questionnaire and to investigate the prevalence of sensitizations using skin prick tests. An ATS modified questionnaire was given to 781 schoolchildren (all of them aged between 11 and 14 years) resident in the Genoa area. The main outcome of the present survey demonstrates a high prevalence of sensitized children (40.7%). Asthma and rhinitis prevalences are very high, mainly concerning the lifetime diagnosis. Actual asthma prevalence is about 6%, confirming ISAAC results, but rhinitis prevalence is notably higher and there is no difference between seasonal and perennial forms. Mites are the most important cause of sensitization and pollens are more frequently the cause of polysensitization. A distinct percentage of the asthmatic children and a higher percentage of rhinitic children are nonallergic. On the other hand, about one third of the sensitized children are without symptoms: They may be considered as subjects at risk of developing clinical respiratory diseases later. In conclusion, this study shows the importance of evaluating the existence of atopy, since there are many subjects with asthma and rhinitis who are nonallergic, and subjects at risk of developing respiratory allergies may be detected.

Role of viral isolate in the etiopathogenetic determinism of HCV infection: diagnostic and epidemiological evaluation

HCV genotyping by nucleic acid sequencing emphasizes the difficulties involved in carrying out a more precise determination of the infectant viral population, probably due in part to the finding of still unknown isolates. Signs of heterogeneity in the genotype composition of the viral quasi-species and its evolutionary dynamism over time, together with the role played by some, more potentially aggressive, isolates in causing hepatic damage, encourage a more in-depth study of such topics.

Frequency of pregnancy-related venous thromboembolism in anticoagulant factor-deficient women: implications for prophylaxis

BACKGROUND

It has been reported that women with an inherited deficiency of antithrombin, protein C, or protein S have an increased risk for developing venous thromboembolic disease during pregnancy and the postpartum period. However, because the available data on risk are flawed, it is difficult to define a rational, efficacious, and safe policy about prophylaxis for venous thromboembolism in these women.

OBJECTIVE

To determine the frequency of venous thromboembolism during pregnancy and the postpartum period in women with heritable deficiencies of anticoagulant factors.

DESIGN

Retrospective cohort study.

SETTING

University outpatient clinics in the Netherlands and Italy.

PARTICIPANTS

129 otherwise asymptomatic female family members of patients with a history of venous thromboembolism and an established deficiency of antithrombin, protein C, or protein S.

MEASUREMENTS

Medical history, with specific attention to episodes of venous thromboembolism and obstetric history, was taken. The anticoagulant factor status of the study participants was determined. If a patient had an episode of venous thromboembolism, subsequent pregnancies in that patient were not analyzed.

RESULTS

Of the 129 women who participated in the study, 60 had anticoagulant factor deficiency and 69 did not. In the nondeficient group, 198 pregnancies occurred; 1 of these (0.5%) was complicated by an episode of venous thromboembolism during the postpartum period. In the deficient group, 169 pregnancies occurred; 7 of these (4.1%) were complicated by an episode of venous thromboembolism during the third trimester of pregnancy (2 pregnancies [1.2%]) and the postpartum period (5 pregnancies [3.0%]). The risk for venous thromboembolism was increased eightfold in deficient women compared with nondeficient women (hazard ratio, 8.0 [95% CI 1.2 to 184]).

CONCLUSIONS

Anticoagulant factor-deficient women have an increased risk for venous thromboembolism during pregnancy and the postpartum period. Although data from an appropriate randomized clinical trial are lacking, the frequency of venous thromboembolism seen in deficient women might justify the use of anticoagulative prophylaxis during the third trimester of pregnancy and the postpartum period.

Thromboembolic disease developing during oral contraceptive therapy in young females with antiphospholipid antibodies

The role of oral contraceptives as a triggering factor for thrombosis in patients with lupus anticoagulant (LA) and/or anticardiolipin antibodies (ACA) has not yet been established. We describe the cases of three women aged 19, 29 and 48 years who developed venous thrombosis after 16 +/- 3.4 (mean +/- SD) cycles of oral contraceptives. They were all asymptomatic before taking the pill. Two patients subsequently developed venous and/or arterial recurrence of thrombosis. Laboratory studies performed after the diagnosis of thrombosis, showed the presence of LA and elevated levels of ACA (IgG and IgM) in all three patients. None of these patients had autoimmune diseases and therefore appeared to have a primary antiphospholipid antibody syndrome. The three patients belonged to a group of 45 young females who experienced their first thrombotic event while taking the pill. This group had a similar prevalence (8%) for antithrombin deficiency and antiphospholipid antibodies. We surmise that some of the women who developed venous thrombosis while taking the pill might have an undetected primary antiphospholipid syndrome.

The risk of abortion and stillbirth in antithrombin-, protein C-, and protein S-deficient women

Hereditary deficiencies of the naturally occurring anticoagulants are well recognized conditions predisposing to recurrent venous thromboembolism. Since thrombotic phenomena have been implied as a cause of abortion and stillbirth, we hypothesized that these deficiencies increase the risk of fetal demise. A group of 129 female subjects who had been pregnant at least once and who had a family member with documented venous thrombosis associated with a deficiency of AT, PC or PS were studied. We first assessed the obstetric history and subsequently determined the deficiency status. In the 60 deficient subjects 42 (22.3%) of the 188 pregnancies resulted in miscarriage or stillbirth as compared to 23 (11.4%) of the 202 pregnancies in the 69 non-deficient subjects. The relative risk of abortion and stillbirth per pregnancy for deficient women as compared to non-deficient women was 2.0 (95% C.I. 1.2-3.3).

Epidermal growth factor content of breast cyst fluids from women with breast cancer or proliferative disease of the breast

The intracystic electrolyte content is generally used to identify different breast cyst subpopulations: cysts containing high K+ levels have been associated with an increased risk of subsequent breast cancer. In order to define whether other biochemical features of breast cyst fluid (BCF) might further explain such an increased risk, we determined the content of epidermal growth factor (EGF), a known mitogenic factor for normal and transformed breast epithelium, in cysts of women with breast cancer or proliferative lesions of the breast (atypical ductal or lobular hyperplasia and proliferative disease without atypia). Median intracystic EGF levels were significantly higher in patients with breast cancer or atypical hyperplasia than in cysts of women without any clinical or instrumental evidence of proliferative disease chosen as controls (p < 0.05 and p < 0.01, respectively). In patients affected by proliferative disease without atypia, intracystic EGF levels were not different either from controls or from the other study groups. No significant difference among groups was observed in the prevalence of Na+/K+ < 3 cysts, this being the most frequently observed type of cysts in all groups except in that with proliferative disease without atypia. No significant difference in EGF levels between cysts ipsilateral or contralateral to the biopsy was observed within each histological group. Our results indicate that EGF levels are higher in cysts aspirated from breasts with an associated proliferative pathology, either benign or neoplastic. The determination of intracystic EGF, combined with that of electrolyte content, might help to identify a subset of patients with gross cystic disease of the breast at potentially higher risk of developing breast cancer.

Presence of immunoassayable transforming growth factor-beta 1 (TGF-beta 1) in breast cyst fluid (BCF): relationship with the intracystic electrolyte and epidermal-growth-factor (EGF) content

We evaluated the presence and distribution of transforming growth factor-beta 1 (TGF-beta 1) in breast cyst fluid (BCF), and its relationship with intracystic epidermal growth factor (EGF). EGF and TGF-beta 1 were determined by radioimmunoassay on 47 BCFs (27 of the Na+/K+ < 3 type and 20 of the Na+/K+ > 3 type). As expected, EGF levels were inversely correlated with the Na+/K+ ratio, and were consequently higher in Na+/K+ < 3 cysts as compared with Na+/K+ > 3 cysts, (p < 0.005). By contrast, TGF-beta 1 levels were directly correlated with the Na+/K+ ratio (p < 0.01), being higher in Na+/K+ > 3 cysts, though not significantly (p = 0.057). A significant negative relationship was found between EGF and TGF-beta 1 concentration. When the analysis was performed separately in the 2 cyst sub-populations, EGF and TGF-beta 1 were found to be negatively and significantly correlated in Na+/K+ < 3 cysts only (p < 0.01). Our results demonstrate that Na+/K+ < 3 cysts contain high levels of EGF, a growth-stimulating factor, and very low levels of TGF-beta 1, a growth-inhibiting factor. This may provide an explanation for the higher risk of breast cancer observed in women with Na+/K+ < 3 cysts. Our results also suggest that EGF accumulation in this type of cysts might be regulated by TGF-beta 1.

Combined inherited protein S and heparin co-factor II deficiency in a patient with upper limb thrombosis: a family study

A 42-year-old Italian woman presenting with spontaneous deep vein thrombosis of the right arm, was found to have inherited a deficiency of both protein S (PS) and heparin co-factor II (HC II). The two defects seemed to segregate independently, since her son exhibited only a HC II deficiency while one of her sisters manifested only the PS defect. All affected patients appeared heterozygous for one or other or both deficiency states. The proposita and her sister exhibited a congenital PS deficiency consisting of normal or near normal levels of total PS antigen and C4b-binding protein (C4b-BP) but a moderate reduction both of free PS antigen and of PS functional activity. In addition, the proposita and her son had half normal levels of HC II antigen and activity. Except for the proposita, all were asymptomatic. Inherited deficiencies either of PS or of HC II have been associated with thrombotic manifestations. Since the proposita had an inherited combined defect of the two proteins, severe thrombotic events might be expected. However, this was not found to be the case. The role of HC II deficiency in the pathogenesis of thrombosis whether alone or combined remains to be fully investigated.

The role of drugs, particularly oral contraceptives, in triggering thrombosis in congenital defects of coagulation inhibitors: a study of six patients

It is well established that pregnancy and puerperium, surgery and trauma may often trigger thrombotic events even in the normal population. On the other hand, patients with congenital deficiency of clotting inhibitors may develop spontaneous thrombotic episodes, although they become often symptomatic when one of the above-mentioned triggering factors is present. We found this to be true in 40 out of 81 symptomatic patients with congenital defects of coagulation inhibitors. In six (15%) of these cases medications (mainly oral contraceptives) triggered the thrombotic event. The incidence of pharmacological factors as a cause of thrombosis is commonly maintained to be low. This study indicates that this is not so and underlines the potential importance of drugs, particularly oral contraceptives, in the pathogenesis of thrombotic events in patients with congenital defects of clotting inhibitors.

EGF in breast cyst fluid: relationships with intracystic androgens, estradiol and progesterone

The relationship between intracystic levels of epidermal growth factor (EGF) and those of dehydroepiandrosterone sulphate (DHEA-S), delta-4-androstenedione (delta-4-A), 17-beta-estradiol (17-beta-E) and progesterone (PROG) have been studied in 77 breast cyst fluid (BCF) samples. EGF and all tested hormones appeared to be inversely correlated with the intracystic Na+/K+ ratio (p less than 0.001). Consequently, when the BCFs were subdivided according to the Na+/K+ ratio, significantly higher levels of EGF, DHEA-S, delta-4-A, 17-beta-E and PROG were found in Na+/K+ less than 3 BCFs compared with Na+/K+ greater than 3 BCFs (p less than 0.001 in all cases). Strong direct relationships were found among all steroid hormones when they were correlated to one another (p less than 0.001). Intracystic EGF concentration was directly and significantly correlated with each tested hormone (p less than 0.001). However, the relationship between EGF and steroid hormones appeared to be different in the 2 BCF types (Na+/K+ less than 3 or greater than 3).

Epidermal growth factor in breast cyst fluid: relationship with intracystic cation and androgen conjugate content

In recent years, several studies focused on the biochemical analysis of breast cyst fluid composition. It has been shown that breast cysts lined by apocrine epithelium contain higher levels of potassium and dehydroepiandrosterone-sulphate as compared to cysts lined by flattened cells, and that women with apocrine cysts are more likely to develop breast cancer. In the present study, we measured the intracystic levels of sodium (Na+), potassium (K+), dehydroepiandrosterone-sulphate (DHEA-S), and epidermal growth factor (EGF), a factor which could play a role in the autocrine or paracrine control of breast cancer cell growth as recently proposed by some investigators. Breast cyst fluids obtained by fine-needle aspiration from 86 women with gross cystic breast disease were assayed. On the basis of the relative intracystic concentrations of Na+ and K+ two main classes of cysts were defined. An arbitrary cut-off value of 3 for the Na+/K+ ratio seemed adequate to separate these two types of cysts. An inverse relationship was found between the Na+/K+ ratio and DHEA-S concentration, median levels of the androgen conjugate being 3615 micrograms/dl in Na+/K+ less than 3 cysts and 480 micrograms/dl in Na+/K+ greater than 3 cysts (P less than 0.001). EGF levels were found to be significantly higher in Na+/K+ less than 3 cysts as compared to Na+/K+ greater than 3 cysts: 103.26 ng/ml versus 57.22 ng/ml, respectively (P less than 0.001). EGF appeared inversely correlated with total protein concentration in the Na+/K+ greater than 3 cysts, while in the Na+/K+ less than 3 cysts high EGF levels were observed independently of total protein content. In addition, a direct correlation was found between EGF and DHEA-S concentrations. On the basis of these results, the hypothesis can be made that EGF, which is measurable in all breast fluids tested and is nearly undetectable in plasma, is actually produced by the epithelium lining the cyst wall, particularly as far as the Na+/K+ less than 3 cysts are concerned. In view of our results this type of cyst, which has been shown to be lined by apocrine epithelium, appears to be characterized by high DHEA-S and EGF levels. It is suggested that the latter finding could provide a clue for understanding the increased risk of subsequent breast cancer in women bearing apocrine cysts.

Priming action on progesterone receptor synthesis by estradiol and tamoxifen in the 7,12-dimethylbenz(a)anthracene-induced rat mammary carcinoma

The priming action of estradiol and the antiestrogen tamoxifen (TMX) on progesterone receptor (PgR) synthesis has been investigated in the 7,12-dimethylbenz(a)anthracene-induced rat mammary tumor model testing different priming times. Rats received either TMX or estradiol benzoate (E2B) for 3 or 7 days. Tumors were assayed before and after treatment to investigate the changes produced by each treatment on estrogen receptor (ER) and PgR concentration. As expected, ER concentration decreased in each treatment group. PgR concentration increased after 3 days of either E2B or TMX administration, but decreased when treatment was prolonged to 7 days. These findings point out the time dependency of PgR induction in this tumor model, similarly to what was observed in other experimental and clinical conditions.

Fibronectin concentration in the plasma of patients with malignant and benign breast disease

Fibronectin concentration was determined in plasma from 97 patients with benign or malignant breast disease and from 62 controls. Median plasma fibronectin concentration (microgram FN/ml plasma) appeared to be significantly higher in patients with non-metastatic or metastatic breast cancer as compared to age-matched controls (P less than 0.01 and P less than 0.03, respectively); however, statistical significance disappeared when results were expressed as a function of total plasma protein content (microgram FN/mg total plasma protein). In patients with benign breast disease plasma fibronectin values were not significantly different from control levels. Our data indicate that the clinical usefulness of measuring FN in breast cancer patients appears to be very limited.

Effects of tamoxifen, estradiol benzoate and medroxyprogesterone acetate on the growth of DMBA-induced rat mammary carcinoma

The potential synergism of sequential combinations of tamoxifen (TMX) or estradiol benzoate (E2B) with medroxyprogesterone acetate (MPA) in inhibiting the growth of 7.12-dimethylbenz(a)anthracene(DMBA) - induced rat mammary tumors has been investigated. In addition, the effect of TMX and E2B on estrogen and progesterone receptors' (ERs and PgRs) synthesis has been evaluated in the attempt to elucidate possible mechanisms involved. Previous treatment both with TMX and E2B has been shown to strongly enhance the antitumor activity of MPA. A priming on PgR synthesis has been observed only after E2B administration, TMX producing a sharp decrease in PgR levels. It is concluded that, while the priming action exerted by E2B on PgRs might explain the potentiating effect shown by E2B on MPA activity, the synergism observed between TMX and MPA should be explained on an extrareceptorial basis, an induction on PgR synthesis by TMX not being evident at the dosage and priming time employed in this study.

[Natural history and staging of brain metastases]

Intracranial metastases represent 7-17% of all brain tumours, their incidence at autopsy varying between 5.8 and 22% in different series. The neoplasms most commonly metastasizing to the brain are those of lung, breast, renal and skin (melanoma) origin. In two-thirds of cases, intracranial metastases are located within the brain parenchyma, while the remaining third involves the pachymeningeal envelopes. Leptomeningeal metastases are rare and develop mainly from leukemia, lymphomas and breast carcinoma. The route of spread to the central nervous system is usually hematogenous but occasionally direct involvement from adjacent bone or pachymeningeal metastases can occur. Median survival from clinical presentation usually doesn't exceed a few months. However brain metastases are the cause of death only in about 15% of patients. This is probably due because they occur late in the course of the natural history of the disease, when metastatic deposits in other viable organs have already developed. Due to this reason, systematic assessment of metastases to the brain is not advisable in all patients but it should be restricted to symptomatic patients and to asymptomatic patients affected by small cell carcinoma and adenocarcinoma of the lung, who could benefit from prophylactic brain irradiation. In symptomatic patients, plain skull X-ray, electroencephalography and computed tomography represent appropriate diagnostic tools to provide accurate informations about number, size, site and morphological characteristics of brain metastases.