Reduced-Dose Apixaban in the Treatment of Left Ventricular Thrombus: A Report of 2 Cases

According to the American College of Cardiology and the American Heart Association, warfarin has historically been the standard of care anticoagulant for the treatment of left ventricular thrombus. The use of direct oral anticoagulants (DOACs) has become more prevalent, as they require less frequent laboratory monitoring, offer fixed-dose regimens, are associated with fewer drug-drug and drug-food interactions, and provide more favorable safety profiles when compared to warfarin. However, DOACs are not currently FDA-indicated in the treatment of left ventricular (LV) thrombus. Numerous recent studies have reported and evaluated the use of DOACs for treatment of LV thrombus. Recently, a prospective, open-label, multicenter study evaluated warfarin compared to DOACs for LV thrombus treatment. The AHA recently published a scientific statement regarding the management of patients at risk for and with left ventricular thrombus, which included DOACs as a reasonable alternative to warfarin. This report describes two patients treated with DOACs following LV thrombus diagnosis. The first case is a 71-year-old male admitted for cerebrovascular accident and non-ST-elevation myocardial infarction complicated by a LV thrombus. The second case is an 83-year-old female admitted for acute myocardial infarction complicated with an LV thrombus. Both patients were prescribed apixaban 2.5 mg twice daily. Neither patient has experienced LV thrombus or DOAC treatment related complications. This case series serves as evidence for reduced-dose DOACs as an alternative to warfarin in the treatment of LV thrombus.

Pharmacotherapy Considerations in Heart Failure with Mildly-Reduced Ejection Fraction

Heart failure with mildly reduced ejection fraction (HFmrEF) has been classified using various definitions since its first mention in the literature in 2014. This group was most recently defined in the Universal Definition and Classification of Heart Failure (HF) as HF with a left ventricular ejection fraction of 41% to 49%. An increasing emphasis has been placed on HFmrEF over the past several years, with many recent publications suggesting that common therapies used in HF with reduced ejection fraction provide benefit in this population as well. Patients with HFmrEF comprise approximately one-quarter of all patients with HF. The lack of authoritative guidance concerning pharmacotherapeutic approaches in these patients leaves a significant portion of HF patients without an evidence-based approach. Although it remains unclear if HFmrEF is simply a transitional state from preserved to reduced ejection fraction, or a distinct phenotype requiring medical optimization, there are clear cardiovascular benefits to managing this subset appropriately. This publication was created to help serve as a resource for clinicians on this evolving subset of HF and aid in preventing the progression of this disease state through improved therapy optimization. The objective of this article is to briefly discuss the epidemiology and pathophysiology of HFmrEF and review the pharmacology and clinical application of therapies for the management of HFmrEF.

Metformin-Induced Fixed-Drug Eruption Confirmed by Multiple Exposures

Patient: Female, 56

Final Diagnosis: Fixed-drug eruption

Symptoms: —

Medication: Metformin

Clinical Procedure: Discontinued metformin

Specialty: Family Medicine

Next-generation IgVH sequencing CLL-like monoclonal B-cell lymphocytosis reveals frequent oligoclonality and ongoing hypermutation

Chronic lymphocytic leukemia (CLL) develops from CLL-like monoclonal B-cell lymphocytosis (MBL) which represents a low-level asymptomatic expansion of cells that phenotypically resemble CLL. Although antigen selection plays a key role during CLL development, it is not known whether this occurs in early MBL or only during progression to CLL. Recent studies suggested that MBL sometimes displays oligoclonality, but these used techniques with limited sensitivity and specificity and were not conclusive. In this study, we combine cell sorting and next-generation sequencing of rearranged immunoglobulin heavy chain variable (IgVH) genes to thoroughly assess the VH repertoire and oligoclonality of purified MBL cells. Clonal functional rearrangements or clonotypes were identified in 29 of 30 sequenced cases, with 7 or 24% having two clonotypes with unrelated CDR3 sequences. In four of the seven cases with unrelated clonotypes, VH segments from the same family were used. In addition, 6 of 29 cases showed clear evidence of ongoing VH gene hypermutation with three of these being among the seven with unrelated clonotypes. This study conclusively shows that MBL cases often contain multiple B-cell clones, the first to report ongoing VH gene mutation in MBL, and that antigen selection appears to occur in early MBL.

Influence of skin colour on diagnostic accuracy of the jaundice meter JM 103 in newborns

AIM

To assess the diagnostic accuracy of the JM 103 as a screening tool for neonatal jaundice and explore differential effects based on skin colour.

METHODS

We prospectively compared the transcutaneous bilirubin (TcB) and serum bilirubin (TSB) measurements of newborns over a 3 month-period. Skin colour was assigned via reference colour swatches. Diagnostic measures of the TcB/TSB comparison were made and clinically relevant TcB cut-off values were determined for each skin colour group.

RESULTS

451 infants (51 light, 326 medium and 74 dark skin colour) were recruited. The association between TcB and TSB was high for all skin colours (rs>0.9). The Bland-Altman analysis showed an absolute mean difference between the two measures of 13.3±26.4 µmol/L with broad limits of agreement (-39.4-66.0 µmol/L), with TcB underestimating TSB in light and medium skin colours and overestimating in dark skin colour. Diagnostic measures were also consistently high across skin colours, with no clinically significant differences observed.

CONCLUSIONS

The JM 103 is a useful screening tool to identify infants in need of serum bilirubin, regardless of skin colour. The effect of skin colour on the accuracy of this device at high levels of serum bilirubin could not be assessed fully due to small numbers in the light and dark groups.

Evaluation of the impact of fetal fibronectin test implementation on hospital admissions for preterm labour in Ontario: a multiple baseline time-series design

OBJECTIVE

To determine the impact of a health system-wide fetal fibronectin (fFN) testing programme on the rates of hospital admission for preterm labour (PTL).

DESIGN

Multiple baseline time-series design.

SETTING

Canadian province of Ontario.

POPULATION

A retrospective population-based cohort of antepartum and delivered obstetrical admissions in all Ontario hospitals between 1 April 2002 and 31 March 2010.

METHODS

International Classification of Diseases codes in a health system-wide hospital administrative database were used to identify the study population and define the outcome measure. An aggregate time series of monthly rates of hospital admissions for PTL was analysed using segmented regression models after aligning the fFN test implementation date for each institution.

MAIN OUTCOME MEASURE

Rate of obstetrical hospital admission for PTL.

RESULTS

Estimated rates of hospital admission for PTL following fFN implementation were lower than predicted had pre-implementation trends prevailed. The reduction in the rate was modest, but statistically significant, when estimated at 12 months following fFN implementation (-0.96 hospital admissions for PTL per 100 preterm births; 95% confidence interval [CI], -1.02 to -0.90, P = 0.04). The statistically significant reduction was sustained at 24 and 36 months following implementation.

CONCLUSIONS

Using a robust quasi-experimental study design to overcome confounding as a result of underlying secular trends or concurrent interventions, we found evidence of a small but statistically significant reduction in the health system-level rate of hospital admissions for PTL following implementation of fFN testing in a large Canadian province.

Ziv-aflibercept (Zaltrap) for the treatment of metastatic colorectal cancer

OBJECTIVE

Review pharmacology, pharmacokinetics, efficacy, and safety of ziv-aflibercept in combination with FOLFIRI for treatment of metastatic colorectal cancer (mCRC) resistant to or progressed following oxaliplatin-containing regimens.

DATA SOURCES

Articles indexed in PubMed (1948-August 2013), TOXLINE (2001-August 2013), and Google Scholar as well as meeting abstracts were identified using the search terms ziv-aflibercept and colorectal cancer.

STUDY SELECTION AND DATA EXTRACTION

Available English-language articles

DATA SYNTHESIS

Ziv-aflibercept, a selective vascular endothelial growth factor antagonist, was evaluated as monotherapy for treatment of mCRC in a phase 2 study and added to FOLFIRI in a phase 3 trial. Patient response to ziv-aflibercept as monotherapy did not reach statistical significance. Results suggest that response to ziv-aflibercept treatment is not influenced by prior bevacizumab therapy. A phase 3 trial compared the safety and efficacy of ziv-aflibercept plus FOLFIRI with placebo plus FOLFIRI in patients with mCRC who experienced disease progression on an oxaliplatin-containing regimen. Patients in the ziv-aflibercept arm had a median overall survival of 13.5 months, versus 12.06 months for those receiving placebo (hazard ratio [HR] = 0.817, 95% CI = 0.713 to 0.937). Progression-free survival for patients receiving ziv-aflibercept was higher compared with placebo (HR = 0.758; 95% CI = 0.661 to 0.869). The most common adverse effects observed were anemia, diarrhea, and neutropenia.

CONCLUSIONS

Ziv-aflibercept is a safe and effective option in combination with FOLFIRI for the treatment of mCRC in patients who progress on oxaliplatin-containing therapy. Superiority over other antiangiogenic treatment has not been established.

The de-ubiquitinase UCH-L1 is an oncogene that drives the development of lymphoma in vivo by deregulating PHLPP1 and Akt signaling

De-ubiquitinating enzymes (DUBs) can reverse the modifications catalyzed by ubiquitin ligases and as such are believed to be important regulators of a variety of cellular processes. Several members of this protein family have been associated with human cancers; however, there is little evidence for a direct link between deregulated de-ubiquitination and neoplastic transformation. Ubiquitin C-terminal hydrolase (UCH)-L1 is a DUB of unknown function that is overexpressed in several human cancers, but whether it has oncogenic properties has not been established. To address this issue, we generated mice that overexpress UCH-L1 under the control of a ubiquitous promoter. Here, we show that UCH-L1 transgenic mice are prone to malignancy, primarily lymphomas and lung tumors. Furthermore, UCH-L1 overexpression strongly accelerated lymphomagenesis in Emu-myc transgenic mice. Aberrantly expressed UCH-L1 boosts signaling through the Akt pathway by downregulating the antagonistic phosphatase PHLPP1, an event that requires its de-ubiquitinase activity. These data provide the first in vivo evidence for DUB-driven oncogenesis and suggest that UCH-L1 hyperactivity deregulates normal Akt signaling.

Transpupillary thermotherapy of occult choroidal neovascularization in age-related macular degeneration

PURPOSE

To evaluate the efficacy of transpupillary thermotherapy (TTT) in management of occult subfoveal choroidal neovascularization (CNV) in exudative age-related macular degeneration (AMD).

METHODS

Retrospective chart review of eyes that were treated with TTT and had at least 12 weeks of follow-up. Base-line and final ETDRS visual acuity and fluorescein angiography (FA) were compared.

RESULTS

For the 48 eyes which met inclusion criteria, mean pre-operative visual acuity was 20/128 (range: 20/50-20/500). Average follow-up was 27 weeks (range: 12 weeks-55 weeks). At 3 months after treatment, 12 eyes (25%) improved 2 lines or more, 18 eyes (37.5%) had no change or 1 line of visual improvement, and 18 eyes (37.5%) worsened 1 or more lines. No significant adverse event was noted during treatment. Three eyes developed large submacular hemorrhage within 2 months of treatment. Based on clinical examination and FA, 61% of the eyes appeared to have reduction of subretinal fluid compared to pre-operative evaluations.

CONCLUSION

Visual acuity was stable or improved in 62.5% of eyes in our series and the treatment was well tolerated. Longer follow up and larger number of patients would be required to evaluate the ultimate benefit of TTT in management of occult CNV due to AMD.

Heritable T-cell malignancy models established in a zebrafish phenotypic screen

T cell neoplasias are common in pediatric oncology, and include acute lymphoblastic leukemia (T-ALL) and lymphoblastic lymphoma (T-LBL). These cancers have worse prognoses than their B cell counterparts, and their treatments carry significant morbidity. While many pediatric malignancies have characteristic translocations, most T lymphocyte-derived diseases lack cytogenetic hallmarks. Lacking these informative lesions, insight into their molecular pathogenesis is less complete. Although dysregulation of the NOTCH1 pathway occurs in a substantial fraction of cases, many other genetic lesions of T cell malignancy have not yet been determined. To address this deficiency, we pioneered a phenotype-driven forward-genetic screen in zebrafish (Danio rerio). Using transgenic fish with T lymphocyte-specific expression of enhanced green fluorescent protein (EGFP), we performed chemical mutagenesis, screened animals for GFP⁺ tumors, and identified multiple lines with a heritable predisposition to T cell malignancy. In each line, patterns of infiltration and morphologic appearance resembled human T-ALL and T-LBL. T cell receptor analyses confirmed their clonality. Malignancies were transplantable and contained leukemia-initiating cells (LIC), like their human correlates. In summary, we have identified multiple zebrafish mutants that recapitulate human T cell neoplasia and show heritable transmission. These vertebrate models provide new genetic platforms for the study of these important human cancers.

The effect of tobacco exposure on the fetal hypothalamic-pituitary-adrenal axis

OBJECTIVE

Our objective was to determine if maternal smoking is associated with programming of the fetal hypothalamic-pituitary-adrenal (HPA) axis. Cigarette smoking, which induces a state of hypoxia in the fetus, may promote in utero'programming' of the HPA axis. In utero, adaptations to the HPA axis, which become maladaptive later in life, have been hypothesised to contribute to the development of adult cardiovascular disease and metabolic disorders.

DESIGN

This was a prospective cohort study of term infants.

POPULATION AND SETTING

The study involved 104 infants born by elective caesarean section, 21 of whom were exposed to in utero tobacco and 83 were nonexposed.

METHODS

Healthy women with healthy pregnancies were recruited if they were undergoing elective caesarean section. Maternal blood was drawn for cortisol and cotinine in the morning, and the umbilical blood was drawn immediately after delivery of the baby.

MAIN OUTCOME MEASURES

Umbilical arterial cortisol and adrenocorticotropin hormone (ACTH) levels.

RESULTS

ACTH levels were significantly elevated in smoke-exposed infants [17 (4-22) pmol/l versus 4 (2-11) pmol/l, respectively, P= 0.005], while cortisol levels were similar [182 (130-240) nmol/l versus 192 (127-265) nmol/l, respectively, P= 0.541].

CONCLUSIONS

For the first time, it was shown that infants exposed to in utero tobacco smoke have significantly elevated ACTH levels compared with nonexposed infants. The results of this study warrant further exploration of the effect of smoking on the neonatal HPA axis as a potential set up for 'programming'.

Feasibility of upfront dose-intensive chemotherapy in children with advanced-stage Hodgkin's lymphoma: preliminary results from the Children's Cancer Group Study CCG-59704

BACKGROUND

Treatment strategies involving dose intensification have recently demonstrated improvements in cure compared with older trials. However, dose-intensive therapy is associated with increased acute and long-term toxicities, particularly in pediatric patients. The Children's Cancer Group initiated this pilot study to assess the feasibility and toxicity of a moderate dose-intensive regimen, BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine and prednisone), in children and adolescents with advanced-stage Hodgkin's lymphoma (HL).

PATIENTS AND METHODS

Children with stage IIB or IIIB with bulk disease, or stage IV were eligible. Induction consisted of four cycles of escalated dose BEACOPP. The rapidity of response, defined as >70% reduction in disease burden, was assessed after two and four cycles. Rapid responders then received consolidation therapy as per gender-specific guidelines to reduce the risk of gender-specific long-term toxicities of therapy, i.e. females received four cycles of COPP/ABV (cyclophosphamide, vincristine, procarbazine, prednisone, doxorubicin, bleomycin and vinblastine) without radiation therapy and males received two cycles of ABVD (doxurubicin, bleomycin, vinblastine and dacarbazine) with involved field radiation therapy (IFRT). Slow responders received four cycles of BEACOPP and IFRT.

RESULTS

Ninety-nine patients were enrolled. Myelosuppression was frequent. Non-hematological grade 4 toxicities included allergic reaction (two patients), hypotension (one), mucositis (four), infection (three), seizure (one) and elevated transaminases (one). Typhlitis developed in four patients; three recovered and completed dose-modified chemotherapy, while one died of sepsis associated with grade 4 neutropenia. A rapid response was achieved by 45 and 72% of patients after two and four cycles, respectively. There are no disease progressions or secondary malignancies to date. There is only one reported relapse to date. Median follow-up for the cohort is 6 months.

CONCLUSIONS

BEACOPP chemotherapy is feasible and generally well tolerated in children with advanced-stage HL. The absence of reported progressive disease and only one relapse to date is encouraging.

Diversity of the apoptotic response to chemotherapy in childhood leukemia

Apoptosis is the primary mechanism through which most chemotherapeutic agents induce tumor cell death. The purpose of this study was to determine the extent to which blasts from children with leukemia undergo a uniform apoptotic death pathway in vivo. The expression of pro- and anti-apoptotic proteins p53, p21, MDM-2, BCL-2, BCL-X(L), BCL-X(S), and BAX, and caspase-3 activity was determined in circulating blasts collected from the peripheral blood of children with leukemia prior to, and at serial time points following chemotherapy. Culturing blasts ex vivo for 12 h assessed spontaneous apoptosis and the increment induced by chemotherapy. Baseline apoptosis varied between 3% and 29%. Twenty-four hours following chemotherapy the increase in the percentage of cells undergoing apoptosis ranged from <1% to 38%. Eleven of 20 patients who received initial treatment with a p53-dependent drug showed an increase in p53 expression. In these patients, the levels of p53 target genes were also increased. A uniform pattern of BCL-2 family protein expression was not observed and only a minority of samples showed a change that would favor apoptosis. We conclude that that the initial apoptotic response to chemotherapy in children with leukemia is variable involving both p53-dependent and p53-independent pathways.

Phylogeography of Caribbean lizard malaria: tracing the history of vector-borne parasites

The Anolis lizards of the eastern Caribbean islands are parasitized by several species of malaria parasites (Plasmodium). Here I focus on two species of Plasmodium, using molecular data (mitochondrial cytochrome b sequences) to recover the phylogeography of the parasites throughout the Lesser Antilles and Puerto Rico. The two parasites were originally described as a single species, P. azurophilum, which infects both red and white blood cells. Here the two species are termed P. azurophilum Red and P. azurophilum White based on their host cell type. Six haplotypes were found in 100 infections sequenced of P. azurophilum Red and six in 45 infections of P. azurophilum White. Nested clade analysis revealed a significant association of geographical location and clades as well as a pattern of past fragmentation of parasite populations. This is consistent with the hypothesis that vector-borne parasites such as malaria may be subject to frequent local extinctions and recolonizations. Comparison of the phylogeography of the lizard and parasites shows only weak concordance; that is, the parasites colonized the lizards in the islands, but dispersal events between islands via vectors or failed lizard colonizations were present. The two parasites had different histories, P. azurophilum Red colonized the islands from both the north and south, and P. azurophilum White originated in the central Lesser Antilles, probably from P. azurophilum Red, then moved to both north and south. This is the first study to examine the biogeography of a pair of sibling species of vector-borne parasites within an island archipelago system.

Are myogenin and myoD1 expression specific for rhabdomyosarcoma? A study of 150 cases, with emphasis on spindle cell mimics

Rhabdomyosarcoma (RMS), the most common soft tissue sarcoma of childhood, displays a variety of histologic patterns. Immunohistochemistry is used extensively to distinguish RMS from its mimics. Myogenin and MyoD1, myogenic transcriptional regulatory proteins expressed early in skeletal muscle differentiation, are considered sensitive and specific markers for RMS and are more specific than desmin and muscle-specific actin and more sensitive than myoglobin. Previous studies have focused on expression of myogenin and MyoD1 in small round cell tumors. This study assesses myogenin and MyoD1 in rhabdomyosarcoma subtypes and spindle cell tumors considered in the differential diagnosis of RMS. Formalin-fixed, paraffin-embedded archival tissue from 32 RMS, 107 non-RMS, and 11 benign skeletal muscle samples was stained for myogenin and MyoD1 with standard immunohistochemical techniques. Nuclear positivity was scored on a three-tiered scale. All RMSs expressed myogenin. Alveolar RMS (ARMS) showed strong nuclear staining, especially in tumor cells lining fibrous septae and perivascular regions. In cases with a subtle alveolar architecture on routinely stained sections, myogenin highlighted and enhanced visualization of the alveolar morphologic pattern. Embryonal RMSs (ERMSs) were more variable in myogenin staining pattern and intensity. No cases of nodular fasciitis, malignant fibrous histiocytoma, malignant peripheral nerve sheath tumor, inflammatory myofibroblastic tumor, myofibrosarcoma, leiomyoma, leiomyosarcoma, or alveolar soft part sarcoma stained for myogenin. Focal nuclear reactivity was seen in desmoid (2 of 10), infantile myofibromatosis (2 of 10), synovial sarcoma (1 of 10), and infantile fibrosarcoma (2 of 10). Non-neoplastic skeletal muscle fiber nuclei stained positively for myogenin in both tumor-associated samples (25 of 40) and benign skeletal muscle samples (5 of 11). Although all RMSs were immunoreactive for MyoD1, cytoplasmic and nonspecific background staining and reactivity of nonmyoid tissues hindered its practical utility in paraffin-embedded samples in this study. Although myogenin is a highly sensitive and specific marker for RMS, it is rarely seen in other spindle cell soft tissue tumors. As previously reported, ARMS stained more strongly than ERMS. In contrast to previous studies, rare non-RMS (7 of 107) displayed focal nuclear reactivity, and entrapped atrophic or regenerative skeletal muscle fibers also stained positively. Although these are potential pitfalls in the interpretation of myogenin, careful attention to morphology and other features, to the relative paucity of myogenin-positive nuclei in non-RMS. and to the presence of entrapped muscle fibers should prevent incorrect interpretation. Because the extent of myogenin expression in RMS is much greater than in non-RMS, it is a very useful marker when interpreted in the context of other clinicopathologic data.

Phylogeny of nuclear small subunit rRNA genes of hemogregarines amplified with specific primers

Hemogregarines, apicomplexan intracellular blood parasites, are cosmopolitan in distribution and infect a broad range of vertebrate and invertebrate hosts. Molecular phylogenetic studies have been hampered by lack of hemogregarine-specific polymerase chain reaction primers that would allow amplification of parasite, but not host, DNA. A novel method for separating parasite and host 18S rRNA genes has been developed, and new primers that are specific for hemogregarine rRNA genes have been designed. These primers were used to obtain sequences from 4 isolates of hemogregarines of lizards from California, the Caribbean island of Grenada, eastern Australia, and Israel. Combining these results with already published sequences, a preliminary phylogeny of hemogregarines and several other apicomplexan taxa has been created. The hemogregarines form a monophyletic group and appear to be more closely related to coccidia than to Plasmodium species. The difficulty of using 18S genes that have multiple copies in some apicomplexan parasites was explored for systematic studies.

Phylogeny of nuclear small subunit rRNA genes of hemogregarines amplified with specific primers

Hemogregarines, apicomplexan intracellular blood parasites, are cosmopolitan in distribution and infect a broad range of vertebrate and invertebrate hosts. Molecular phylogenetic studies have been hampered by lack of hemogregarine-specific polymerase chain reaction primers that would allow amplification of parasite, but not host, DNA. A novel method for separating parasite and host 18S rRNA genes has been developed, and new primers that are specific for hemogregarine rRNA genes have been designed. These primers were used to obtain sequences from 4 isolates of hemogregarines of lizards from California, the Caribbean island of Grenada, eastern Australia, and Israel. Combining these results with already published sequences, a preliminary phylogeny of hemogregarines and several other apicomplexan taxa has been created. The hemogregarines form a monophyletic group and appear to be more closely related to coccidia than to Plasmodium species. The difficulty of using 18S genes that have multiple copies in some apicomplexan parasites was explored for systematic studies.

CD30 expression in follicular lymphoma

CONTEXT

CD30(+) anaplastic large cell lymphomas were originally described as being of T-cell, null cell, and B-cell origin. CD30, however, is not a specific marker of anaplastic large cell lymphoma and has been found to be expressed in reactive as well as neoplastic populations as a probable activation marker. In addition, CD30(+) cells have also been described in both diffuse large B-cell and follicular lymphomas (FLs), resembling the pattern seen in reactive tonsils and lymph nodes.

OBJECTIVE

We report an index case of FL with CD30 expression, which on initial touch preparations and flow cytometric immunophenotyping revealed a prominent population of CD30(+) cells with marked cellular pleomorphism (anaplasia) in a background of typical FL. Immunohistochemistry of the paraffin section for CD30 in our index case confirmed unequivocal CD30(+) pleomorphic cells in the malignant nodules in occasional clusters. This case prompted a study of additional cases of FL for pattern of immunoreactivity with CD30 on paraffin sections.

DESIGN

Twenty-two additional cases of FL (grades 1-3) were retrieved for CD30 immunoperoxidase staining as in the index case.

RESULTS

This study demonstrated 32% of the additional cases of FL had definitive CD30(+), large, pleomorphic malignant cells by paraffin immunohistochemistry. In 2 cases (9%), the pattern of immunoreactivity with CD30 showed clustering and variable staining of large cells, as our index case.

CONCLUSION

This study underscores the morphologic and immunophenotypic spectrum of FL that includes CD30 staining and cellular pleomorphism.

Mantle cell leukemia, prolymphocytoid type: a rarely described form

Leukemic manifestations of mantle cell lymphoma are seen in a minority of cases, usually associated with extensive tumor. Usually the neoplastic cells in the peripheral blood resemble mantle cells with a mature chromatin pattern and irregular nuclear contours, or less frequently with a more "blastic" chromatin pattern. A prolymphocytic leukemia with t(11;14)(q13;q32) has previously been reported; however, a complete flow cytometric immunophenotypic profile was lacking. Mantle cell leukemia, prolymphocytoid type with complete flow cytometric data has not previously been described and is the purpose of this report. We report such a case in a 90 year-old female who presented with an elevated white blood cell count. The diagnosis was based on flow cytometric immunophenotyping and the cytomorphology of the peripheral blood combined with cyclin D1 immunohistochemical staining of the bone marrow. We describe our findings and her clinical course in order to heighten awareness of this previously rarely described entity.

Pharmacokinetics of the ganciclovir implant in the silicone-filled eye

PURPOSE

Ganciclovir (GCV) implants are highly effective in delaying the progression of cytomegalovirus (CMV) retinitis. Rhegmatogenous retinal detachments can occur in untreated eyes with CMV retinitis or in eyes treated with anti-CMV therapy, which may include placement of a GCV implant. The clinical management of CMV retinitis and associated retinal detachment often involves the concurrent use of silicone oil and GCV implants. The authors investigated the effect of silicone oil tamponade on intravitreal drug levels achieved with the GCV implant.

METHODS

The authors performed gas compression vitrectomy in the right eyes of 29 New Zealand white rabbits. They then inserted a 5-mg GCV implant into the vitreous cavity through an inferotemporal sclerotomy. Saline (1 cc), silicone oil 0.5 cc, or silicone oil 1.0 cc was then injected into the midvitreous cavity of 9, 8, and 12 rabbits, respectively. On postoperative days 21, 42, and 70, the rabbits were killed and the right eyes were immediately collected and stored at -70 degrees C until all samples were obtained. Vitreous was then isolated and drug levels were determined by high-pressure liquid chromatography.

RESULTS

Vitreous GCV levels at days 21 and 42 were similar in both the saline-filled and silicone oil-filled eyes. At day 70, GCV levels in both the saline- and silicone-filled eyes were statistically significantly lower than at day 21 (P < 0.05 for all groups). In addition, at day 70, GCV levels in the saline-filled eyes were significantly lower than in silicone-filled eyes (saline versus 0.5 cc oil, P = 0.01; saline versus 1 cc oil, P = 0.09).

CONCLUSIONS

Effective GCV levels are maintained in the aqueous phase of the vitreous cavity of eyes with silicone oil tamponade. Ganciclovir levels may be maintained longer in eyes with silicone oil tamponade than in those without. These results support the use of combined GCV implants and silicone oil tamponade in patients with CMV retinitis and associated retinal detachment.

Large cell variants of CD5+, CD23- B-cell lymphoma/leukemia

CONTEXT

Mantle cell lymphoma (MCL), and its leukemic phase, constitute a well-studied hematologic malignancy with known overall survival, prognostic indicators, morphologic findings at diagnosis and in bone marrow, and known incidence of the bcl-1 immunoglobulin gene rearrangement. Large cell variants of B-cell lymphoma/leukemia with a mantle cell immunophenotype (CD5+, CD23-), including but not limited to blastic MCL, prolymphocytoid MCL, blastic mantle cell leukemia, and prolymphocytic mantle cell leukemia, are not as well characterized. Although blastic MCL is known to be associated with a shorter overall survival than conventional MCL, the large cell variants of B-cell lymphoma/leukemia with a mantle cell immunophenotype have not been described as fully as conventional MCL.

OBJECTIVE

The purpose of the present study was to describe the large cell variants of B-cell lymphoma/leukemia with a mantle cell immunophenotype.

DESIGN

Nineteen cases of large cell variants of CD5+, CD23- B-cell lymphoma/leukemia are reviewed and described in regard to morphology, bone marrow morphological findings, Cyclin D1 immunostaining, and bcl-1 analysis. Clinical data were not available owing to the varied clinical sources of the specimens.

SETTING

Tertiary-care academic institution.

RESULTS

Lymph node involvement in blastic CD5+, CD23- B-cell lymphoma was diffuse (100%) with a nodular component (33%) or focal mantle zone pattern (10%). Bone marrow involvement in blastic CD5+, CD23- B-cell lymphoma was seen in only 27% of cases and was composed predominantly of small, slightly irregular lymphocytes. Cyclin D1 was demonstrated in 60% of the 15 cases analyzed and more sensitive in B5-fixed tissue. Bcl-1 (performed in 5 cases) was not detected in the 4 cases of blastic CD5+, CD23- B-cell lymphoma analyzed and was detected in the case of the prolymphocytoid MCL. Cyclin D1 was demonstrated in all 4 bcl-1 negative cases and was negative in the bcl-1 positive prolymphocytoid MCL.

CONCLUSION

Careful analysis of clinical data, morphology, immunophenotype, Cyclin D1 expression, and molecular analysis are required to differentiate the unusual large cell variants of MCL from other processes.

Pharmacokinetics of the fluocinolone/5-fluorouracil codrug in the gas-filled eye

PURPOSE

To determine the effect of intraocular gas tamponade on drug levels achieved with the intravitreal sustained-release fluocinolone (FL)/5-fluorouracil (5-FU) codrug pellet.

METHODS

After insertion of a 10-mg codrug pellet into the right eyes of 43 New Zealand white rabbits, perfluoropropane (0.4 mL of 100% C3F8) or a control sham was then injected into the midvitreous cavity. On postoperative days 2, 4, 7, 21, and 42, aqueous samples were collected, the rabbits were killed, and the right eyes were enucleated. The vitreous and remaining codrug pellet were then isolated. Pellet and intravitreal drug levels were determined by high-pressure liquid chromatography.

RESULTS

No measurable drug levels were detected in any of the aqueous samples. Maximal gas expansion occurred by day 4 and partial resorption was observed by days 14 to 21. Vitreous FL and 5-FU levels during C3F8 expansion (day 2) were statistically significantly higher in the gas-filled eyes. On postoperative days 4, 7, 21, and 42, there were no statistically significant differences between FL and 5-FU drug levels in eyes containing C3F8 as compared with control eyes. Pellet codrug, FL, and 5-FU levels over time were similar in gas-filled and control eyes.

CONCLUSIONS

Intraocular gas tamponade does not significantly affect the sustained intravitreal drug levels achieved with the FL/5-FU codrug. If clinically efficacious, the FL/5-FU codrug formulation does not need to be altered to treat proliferative vitreoretinopathy in the presence of intraocular gas.

Species concepts and malaria parasites: detecting a cryptic species of Plasmodium

Species of malaria parasite (phylum Apicomplexa: genus Plasmodium) have traditionally been described using the similarity species concept (based primarily on differences in morphological or life-history characteristics). The biological species concept (reproductive isolation) and phylogenetic species concept (based on monophyly) have not been used before in defining species of Plasmodium. Plasmodium azurophilum, described from Anolis lizards in the eastern Caribbean, is actually a two-species cryptic complex. The parasites were studied from eight islands, from Puerto Rico in the north to Grenada in the south. Morphology of the two species is very similar (differences are indistinguishable to the eye), but one infects only erythrocytes and the other only white blood cells. Molecular data for the cytochrome b gene reveal that the two forms are reproductively isolated; distinct haplotypes are present on each island and are never shared between the erythrocyte-infecting and leucocyte-infecting species. Each forms a monophyletic lineage indicating that they diverged before becoming established in the anoles of the eastern Caribbean. This comparison of the similarity, biological and phylogenetic species concepts for malaria parasites reveals the limited value of using only similarity measures in defining protozoan species.

Large-cell lymphoma arising in the mediastinum in children and adolescents is associated with an excellent outcome: a Children's Cancer Group report

PURPOSE

Large-cell lymphoma (LCL) arising in the mediastinum (LCL-M) is a heterogeneous group of non-Hodgkin's lymphoma (NHL) that includes B-cell lymphomas as well as T-cell lymphomas, including anaplastic LCL. LCL-M is well recognized in young adults but is less well characterized and infrequent in children and adolescents.

METHODS

A retrospective review of Children's Cancer Group therapeutic studies for nonlymphoblastic lymphomas (CCG-551, CCG-503, CCG-552, and CCG-5911) identified 20 patients with LCL-M, representing 7.2% of all LCLs classified by central pathology review.

RESULTS

The patients ranged in age from 4 to 19 years (median, 12.5 years; mean, 12 years); 55% of the patients were male. Although a variety of chemotherapy regimens were used, response was excellent, with all 20 patients (100%) achieving a complete response. Four patients (20%) experienced relapse locally or in distant sites including brain and kidney. One patient died of sepsis during therapy. For the 20 patients with LCL-M, the product-limit estimated 5-year event-free survival (EFS) and 5-year overall survival (OS) rates are 75% +/- 10% and 85% +/- 8%, respectively. For disseminated LCLs (192 cases), the EFS and OS rates were 50% +/- 4% and 63% +/- 4%, respectively, which differ significantly from the those of the LCL-M cases (EFS, P =.025; OS, P =.034). The 5-year EFS and OS rates for patients with localized LCL (67 cases) were 92 +/- 3% and 97 +/- 2%, respectively.

CONCLUSION

LCL-M is a heterogeneous group of NHLs that makes up approximately 7.2% of LCL in children and adolescents. Response to therapy and OS in this young age group seems excellent and superior to that of disseminated LCLs but inferior to that of other localized LCL. Future studies of LCL-M will evaluate short intense chemotherapy administered without radiation therapy.

Familial Wilms' tumor with neural elements: characterization by histology, immunohistochemistry, and genetic analysis

Wilms' tumor (WT) is the most common renal malignancy of children. While most occur sporadically, a small percentage are familial or occur as part of a developmental syndrome. Classic WTs exhibit a triphasic histologic pattern composed of blastema, epithelium, and stroma. Occasionally, heterologous elements may also be observed. In this study we investigated a series of four WTs that occurred within a single familial aggregate and contained focal areas of neural differentiation. The tumors were evaluated histologically for the presence of neural elements and immunohistochemically for expression of neural-related markers. Genetic linkage analysis was performed on 3 of the 4 WTs. In addition to the classic triphasic histology, the WTs contained tumor rosettes (4/4), ganglion cells (2/4), foci of ganglioneuromatous differentiation (2/4), and anaplasia (1/4). Staining for chromogranin, S-100, synaptophysin, vimentin, and neuron-specific enolase was positive in all 4 tumors within the areas of neural differentiation whereas staining for CD99 (013) and glial fibrillary acidic protein was negative. Linkage analysis studies suggest that the familial predisposition gene segregating in this family is at 19q13.4. To our knowledge, this is the first reported series of WTs with neural differentiation that occurred within a single family aggregate. Genetic linkage analysis of this family is consistent with linkage to the FWT2 WT predisposition gene at 19q13.4. We propose that these tumors may represent a unique manifestation of tumor susceptibility in this family.

Anaplastic large cell lymphoma arising in bone: report of a case of the monomorphic variant with the t(2;5)(p23;q35) translocation

Anaplastic large cell lymphoma (ALCL) represents approximately 2% of all non-Hodgkin lymphomas according to the recent Non-Hodgkin Lymphoma Classification Project. As defined in the revised European-American classification of lymphoid neoplasms (REAL), ALCL is a neoplasm of T-cell or null-cell lineage; 20% to 60% of cases are associated with the t(2;5)(p23;q35) translocation. ALCL commonly involves nodal as well as a wide variety of extranodal sites, although primary or secondary involvement of bone is rare. We describe the case of a 71-year-old man with stage IE T-cell ALCL, monomorphic variant, arising in the left anterior fifth rib and involving adjacent soft tissue without other sites of disease. The monomorphic histologic features hindered the initial recognition of this neoplasm as ALCL. However, strong uniform CD30 antigen expression and subsequent demonstration of the t(2;5)(p23;q35) translocation and anaplastic lymphoma kinase (ALK) immunoreactivity led to the correct diagnosis. We identified only 5 reported cases of T-cell and null-cell ALCL arising in bone and only 2 of these cases involved a single bone site. All 5 previously reported cases were ALCL of the classic type. We report a case of ALCL that is unique to our knowledge. This case of monomorphic ALCL was localized to bone and tumor cells contained the t(2;5)(p23;q35) translocation.

Simultaneous presence of t(2;8)(p12;q24) and t(14;18)(q32;q21) in a B-cell lymphoproliferative disorder with features suggestive of an aggressive variant of splenic marginal-zone lymphoma

We report a case of an aggressive variant of splenic marginal-zone lymphona (SMZL) with circulating villous lymphocytes. The karyotype of all examined cells had multiple structural and numerical abnormalities, including two lymphoma characteristic translocations, t(2;8)(p12;q24) and t(14;18)(q32;q21). Based on a literature review of cytogenetic aberrations of splenic lymphoma with villous lymphocytes (SLVL) and SMZL, this is apparently the first documentation of these two translocations in a case of SMZL, and could reflect the heterogeneity of the disorder.

Work-up and diagnosis of pediatric non-Hodgkin's lymphomas

Non-Hodgkin's lymphomas (NHL) in children and adolescents represent about 10% of childhood cancers. Although the types of NHL commonly seen in this population are relatively limited to lymphoblastic lymphomas, Burkitt's and Burkitt-like lymphomas, and large cell lymphomas, correct diagnosis and classification are essential for optimal therapy. Careful handling of pathologic specimens, along with collection of proper materials for ancillary studies such as immunophenotyping, cytogenetics, or molecular studies, will aid the pathologist in reaching a correct diagnosis. Specific morphologic, immunophenotypic, and genetic features of the commonly seen types of pediatric NHL are described.

T-cell-rich large B-cell lymphoma in children and adolescents: a clinicopathologic report of six cases from the Children's Cancer Group Study CCG-5961

BACKGROUND

T-cell-rich large B-cell lymphoma (TCRLBCL) is a morphologic subset of diffuse large B-cell lymphoma that has been confused with Hodgkin disease and reactive lymphadenopathies. To the authors' knowledge the majority of reports of TCRLBCL are from adults, and it is not widely recognized as occurring in the pediatric population. The current study reports a cohort of six cases of TCRLBCL from the Children's Cancer Group CCG-5961 study.

METHODS

Biopsies from patients entered on CCG-5961 were submitted for central pathology review and immunophenotyping. Six cases of TCRLBCL were identified and correlated with clinical characteristics.

RESULTS

Of 86 cases centrally reviewed to date on CCG-5961, 20 (23%) were diagnosed as diffuse large B-cell lymphomas. Of these, 6 cases (7% of total cases and 30% of large B-cell cases) were TCRLBCL, based on a diffuse growth pattern with a minor population of neoplastic large B cells and an associated extensive reactive T-cell infiltrate. All patients with TCRLBCL were males ages 12-16 years. Three patients with TCRLBCL had advanced stage disease. No bone marrow or central nervous system involvement was detected in any case.

CONCLUSIONS

TCRLBCL is a morphologic subtype of diffuse large B-cell lymphoma that may be difficult to recognize due to the extensive infiltrate of reactive T cells. This entity is not well recognized in pediatric patients, but in the current study represented 7% of all cases and 30% of large B-cell lymphomas received for central review from the ongoing CCG-5961 protocol. Because TCRLBCL may be confused with Hodgkin disease and reactive lymphadenopathies, it is essential that this entity be recognized in the pediatric age group.

Complications of pneumatic retinopexy

Pneumatic retinopexy is a retinal reattachment procedure involving transconjunctival injection of gas into the vitreous cavity, combined with cryotherapy or laser retinopexy and followed by postoperative positioning. Although generally a safe procedure, it may be associated with certain adverse outcomes. These most commonly include misplaced gas injection, subretinal gas, vitreous hemorrhage, new retinal breaks, failure to reattach the retina, proliferative vitreoretinopathy, and delayed reabsorption of subretinal fluid. Less common problems include endophthalmitis, macular folds, angle-closure glaucoma, and macular hole. In most cases, complications are successfully managed, and a favorable outcome is achieved.

Prevalence of malaria parasites (Plasmodium floridense and Plasmodium azurophilum) infecting a Puerto Rican lizard (Anolis gundlachi): a nine-year study

The prevalence of malaria parasites was studied in the lizard Anolis gundlachi over a 9-yr period at a site in the wet evergreen forest of eastern Puerto Rico. Three forms of the parasite infected the lizards; these were Plasmodium floridense, Plasmodium azurophilum in erythrocytes, and P. azurophilum in white blood cells. Overall prevalence of infection for 8 samples during the study period was significantly higher for males than females (32% of 3,296 males and 22% of 1,439 females). During the study, the site experienced substantial climatic and physical disturbance including rising temperature, droughts, and hurricanes that severely damaged the forest. Parasite prevalence in the first sample, 8 mo after the massive hurricane Hugo, was slightly, though significantly, lower than for subsequent samples. However, overall prevalence was stable during the 9-yr period. The results show malaria prevalence is more constant at the site than found for 2 studies in temperate forests, and that the Puerto Rico system may be an example of the stable, endemic malaria described by standard models for human malaria epidemiology.

Diagnosis and classification of lymphoma based on cytospin preparations: a comparison of hematopathologists and cytopathologists

The diagnosis of malignant lymphoma based on cytologic preparations is a source of much debate. The purpose of this study was to assess the ability of a number of pathologists to diagnose and classify lymphoma using cytospin preparations, and to compare the rate of agreement between cytopathologists and hematopathologists. One hundred twenty-five cytospins prepared from histologically confirmed hematologic lesions were examined retrospectively and independently by four hematopathologists/fellows and two cytopathologists without knowledge of the final diagnosis; the results were compared with the final diagnoses derived from histology and immunophenotyping. Eighty-one cases were histologically diagnosed as lymphoma (including 67 cases of B-cell non-Hodgkin's lymphoma), and 44 cases represented a reactive process histologically. The distinction of a malignant from a benign process was made in 75% of the cases by cytospin examination, with cytopathologists correctly diagnosing 75% and hematopathologists 76% of the cases. The accuracy rate for subclassification of the lymphoma cases was 49% (46% for cytopathologists, 52% for hematopathologists). The cytopathologists correctly recognized large-cell lymphoma at an increased frequency compared with the hematopathologists (70% vs. 56%, P = 0.11), while the hematopathologists showed a greater ability to recognize and classify nonfollicle center low-grade B-cell lymphomas (57% vs. 28%, P = 0.01). We conclude that cytopathologists and hematopathologists generally achieve similar accuracy rates in the morphologic evaluation of cytologic preparations of lymphoid lesions, though some differences in their performance do exist.

Expression of DNA toposiomerase I and DNA topoisomerase II-alpha in testicular seminomas

DNA topoisomerase I (topo I) is the molecular target of the camptothecin group of anticancer drugs. These drugs are S-phase specific and require elevated topo I for tumor cell killing. To determine whether increased topo I expression occurs in testicular seminomas, 20 cases of testicular seminoma were retrieved from the surgical pathology files at the University of Utah Health Sciences Center and stained with an antibody that recognizes topo I in paraffin embedded human tissue sections. Topo I elevation was observed in 30% (6/20) of the seminomas. Because the response to topo I targeted drugs requires cell proliferation, the proliferative index of the seminomas was determined by immunohistochemical staining for DNA topoisomerase II-alpha (topo II-alpha) a new marker of cell proliferation. AU seminomas had easily detectable topo II-alpha. The average topo II-alpha index of the 20 cases was 52.1 +/- 15.3. Seminomas with elevated topo I had an average topo II-alpha proliferative index of 60.8 +/- 17.5 and seminomas with normal topo I expression had a topo II-alpha proliferative index of 48.4 +/- 13.2. This is significantly different at the 0.05% confidence level. Focal expression of CD30 was seen in 60% (12/20) of the neoplasms. None of the cases showed positive staining for CD15 and c-erbB-2. Our results suggest that chemotherapeutic protocols involving topoisomerase targeting drugs might be useful against testicular seminomas.

T-cell-rich large B-cell lymphoma in children and adolescents: a clinicopathologic report of six cases from the Children's Cancer Group Study CCG-5961

BACKGROUND

T-cell-rich large B-cell lymphoma (TCRLBCL) is a morphologic subset of diffuse large B-cell lymphoma that has been confused with Hodgkin disease and reactive lymphadenopathies. To the authors' knowledge the majority of reports of TCRLBCL are from adults, and it is not widely recognized as occurring in the pediatric population. The current study reports a cohort of six cases of TCRLBCL from the Children's Cancer Group CCG-5961 study.

METHODS

Biopsies from patients entered on CCG-5961 were submitted for central pathology review and immunophenotyping. Six cases of TCRLBCL were identified and correlated with clinical characteristics.

RESULTS

Of 86 cases centrally reviewed to date on CCG-5961, 20 (23%) were diagnosed as diffuse large B-cell lymphomas. Of these, 6 cases (7% of total cases and 30% of large B-cell cases) were TCRLBCL, based on a diffuse growth pattern with a minor population of neoplastic large B cells and an associated extensive reactive T-cell infiltrate. All patients with TCRLBCL were males ages 12-16 years. Three patients with TCRLBCL had advanced stage disease. No bone marrow or central nervous system involvement was detected in any case.

CONCLUSIONS

TCRLBCL is a morphologic subtype of diffuse large B-cell lymphoma that may be difficult to recognize due to the extensive infiltrate of reactive T cells. This entity is not well recognized in pediatric patients, but in the current study represented 7% of all cases and 30% of large B-cell lymphomas received for central review from the ongoing CCG-5961 protocol. Because TCRLBCL may be confused with Hodgkin disease and reactive lymphadenopathies, it is essential that this entity be recognized in the pediatric age group.

Expression of c-Myc and p53 correlates with clinical outcome in diffuse large B-cell lymphomas

We performed a retrospective immunohistochemical study of the relationships between clinical manifestations and outcomes of diffuse large B-cell lymphoma (DLBCL) and expression of oncogenic proteins in 21 cases of DLBCL at various clinical stages. Cases of nodal origin expressed p53 more often and presented with high clinical stage more frequently than those of extranodal origin. Expression of c-Myc or p53, but not Bcl-6, Bcl-2, or Bcl-1, showed a statistically significant positive correlation with high clinical stage at presentation and with high or high-intermediate risk. Coexpression of c-Myc and p53 occurred in 7 of 12 patients with high clinical stage but was absent in patients with low clinical stage; coexpression was more frequent in patients with high or high-intermediate risk than in patients with low or low-intermediate risk. Four patients with this coexpression pattern demonstrated an unusually aggressive clinical course (median survival, 7 months). Coexpression of c-Myc and p53 seems to be a better indicator than the MIB1 proliferative index for identification of a cohort of aggressive disease in patients with DLBCL.

Maternal smoking and fetal erythropoietin levels

OBJECTIVE

To determine the influence of maternal smoking on fetal erythropoietin concentrations in health term pregnancies and test the correlation between cotinine, a biomarker of maternal smoking, and erythropoietin levels in fetuses.

METHODS

We invited women with healthy term pregnancies to participate in the study, excluding those with conditions previously known to be associated with elevated fetal erythropoietin levels. We recorded demographic data, smoking status, and labor outcome prospectively for each patient. Umbilical venous samples were collected, and serum was stored at -70C to be analyzed later for erythropoietin and cotinine. Umbilical arterial samples were tested for pH and base excess determination. We compared fetal erythropoietin and cotinine between smokers and nonsmokers and examined correlations between erythropoietin and cotinine. Kruskal-Wallis test, t test, median test, and Spearman rank correlation test were used when appropriate. Statistical significance was P <.05.

RESULTS

We recruited 35 nonsmokers and 26 smokers and analyzed their samples. The two groups were comparable in demographics and birth outcomes, except for birth weights, which were lower in smokers. Fetal erythropoietin concentrations increased significantly with increasing maternal cigarette consumption, ranging from none to more than 15 cigarettes per day (P =.03). There was positive correlation between fetal erythropoietin and cotinine concentrations (r =.41; P =.04), suggesting a dose-response relationship.

CONCLUSION

Fetuses of smokers had increased erythropoietin concentrations that correlate positively with fetal cotinine levels; which suggests an increased risk of subacute hypoxia related to degree of maternal cigarette consumption.

Review of cellular mechanisms of tumor osteolysis

The cellular and biochemical mechanisms that direct the destruction of bone at sites of tumor osteolysis are unknown. To better understand the mechanisms through which tumors direct bone resorption, research has focused on developing in vivo and in vitro experimental models that are useful for studying this process. In vivo experimental systems have been developed that permit study of tumor osteolysis from human and murine tumors, and that permit the study of tumors that arise from (sarcoma) or can metastasize (breast cancer) to bone. Recent research has focused on three questions: (1) Are osteoclasts or tumor cells responsible for bone resorption during tumor osteolysis? (2) What are the cellular mechanisms that are responsible for bone resorption during tumor osteolysis, and (3) what are the tumor cell products that regulate the cellular mechanisms that are responsible for tumor osteolysis? It has been determined that osteoclasts are responsible for bone resorption at sites of tumor osteolysis by enhancing the binding of osteoclast to bone, by inducing osteoclastic bone resorption, and by stimulating osteoclast formation. Attempts to identify tumor cell products that regulate these cellular mechanisms are in progress, and findings suggest that production of macrophage colony stimulating factor may be required for tumor osteolysis to occur with some tumors.

Comparison of serum progesterone as an indicator of pregnancy nonviability in spontaneously pregnant emergency room and infertility clinic patient populations

OBJECTIVE

To compare the predictive value of serum progesterone in identifying nonviable pregnancy in symptomatic spontaneously pregnant emergency department patients and asymptomatic patients attending an infertility clinic.

DESIGN

Retrospective study.

SETTING

Tertiary-care academic health center.

PATIENT(S)

One hundred thirty-seven pregnant patients who presented to the emergency department for whom clinical outcomes were available, and 123 consecutive patients who became pregnant during treatment at the infertility clinic.

INTERVENTION(S)

Serum progesterone measurement.

MAIN OUTCOME MEASURE(S)

The sensitivity, specificity, and predictive value of serum progesterone <45 nmol/L in identifying nonviable pregnancies were determined for each of the groups.

RESULT(S)

Sensitivity and specificity of serum progesterone <45 nmol/L in predicting nonviable pregnancies were 88.6% and 87.5%, respectively, in spontaneously pregnant patients who presented to the emergency department with pain or bleeding and 58.8% and 100% in infertility patients who had undergone controlled ovarian hyperstimulation for in vitro fertilization or intrauterine insemination. Sensitivity and specificity for all other infertility clinic patients were variable.

CONCLUSION(S)

The predictive value of low serum progesterone in identifying nonviable pregnancies varies with patient populations.

Mature B-cell lymphoma/leukemia in children and adolescents: intergroup pathologist consensus with the revised European-American Lymphoma Classification

BACKGROUND

The Revised European-American Lymphoma (R.E.A.L.) Classification criteria were evaluated in the international protocol FAB LMB 96 Treatment of Mature B-cell Lymphoma/Leukemia: A SFOP LMB 96/CCG-5961/UKCCSG NHL 9600 Cooperative Study. This includes B-lineage lymphomas: Burkitt's lymphoma (including ALL-L3); high-grade B-cell lymphoma, Burkitt-like; diffuse large B-cell lymphoma (excluding anaplastic large cell Ki-1 lymphoma).

PATIENTS AND METHODS

Cases were independently reviewed by eight hematopathologists from the three cooperative national groups (two SFOP, two CCG, four UKCCSG), without prior discussion of classification criteria or guidelines for case rejection. Consensus diagnosis was determined by each national cooperative group, and final consensus diagnosis established when at least two national consensus diagnoses were in agreement, or following group agreement at a multiheaded microscope.

RESULTS

Two hundred eight cases were reviewed, with final consensus diagnosis established in two hundred three. The percent agreement of each group's national consensus diagnosis with final consensus diagnosis was 86%, 86% and 71%. The percent agreement of the group's national consensus diagnosis with final consensus diagnosis for Burkitt's and diffuse large B-cell lymphoma were 88% and 80%, respectively, but only 42% for Burkitt-like lymphoma.

CONCLUSIONS

International panel review of mature B-cell lymphoma/leukemia in children and adolescents highlighted difficulties in subclassification, particularly with Burkitt-like, which is a 'provisional entity' in the R.E.A.L. Classification. The absence of previous discussion of classification and guidelines for case rejection may in part explain the discrepancy between pathologists. These results underline that morphology may need to be complemented by other studies, such as molecular genetic and cytogenetics, to discriminate between the mature B-cell lymphomas.

Conserved polymerase chain reaction primers fail in diagnosis of parasitic infections

We demonstrate that a set of previously described polymerase chain reaction primers used for detection of hemogregarines in reptiles will also amplify the same region of the 18S rRNA gene of reptiles, amphibians, mammals, and insects and thus should not be used for molecular diagnosis. These same primers have also been used to differentiate 2 species of Plasmodium that infect lizards. We provide evidence that the observed variance may have been dependent on parasitemia and not representative of actual molecular differences between the 2 parasite species.

Comparison of DNA ploidy, histologic, and immunohistochemical findings with clinical outcome in inflammatory myofibroblastic tumors

Inflammatory myofibroblastic tumors (IMTs) are uncommon spindle cell proliferations that occur in the viscera and soft tissue of children and young adults. Their biologic potential is indeterminate: 25% of IMTs recur, and rare examples undergo malignant transformation (MT). This study investigates histologic features, DNA ploidy, and expression of apoptotic regulatory and oncogenic proteins in IMTs in an attempt to identify those deviances that might correlate with aggressive behavior or MT. Twenty-four formalin-fixed, paraffin-embedded IMTs for which clinical outcome was known were evaluated for cellularity, cytologic atypia, mitoses, ganglion-like cells, inflammatory infiltrate, DNA ploidy by flow cytometric examination, and bax, bcl-2, p53, and c-myc expression by immunohistochemical analysis. Sixteen (67%) of the IMTs did not recur, 6 (25%) recurred, and 2 (8%) underwent MT. Cellular atypia was observed in 69% of the cases without recurrence, 100% with recurrence, and 100% with MT. Ganglion-like cells were present in 56, 100, and 100% of the IMTs without recurrence, with recurrence, and with MT, respectively. There was no difference in the degree of cellularity, mitoses, or inflammatory infiltrate among the outcome groups. All of the tumors expressed bax, and none expressed c-myc. Two (8%) were immunoreactive for p53, one of which recurred and one of which underwent MT. bcl-2 expression was observed in 9 (37%) of the IMTs, with no difference among the three groups. Two IMTs were aneuploid, one of which underwent MT. Neither morphologic evaluation for cellularity, mitosis, or inflammatory infiltrate nor expression of bax or c-myc were useful for prediction of clinical outcome. The combination of atypia, ganglion-like cells, p53 expression and DNA ploidy analysis, however, might be useful to identify IMTs that might undergo MT or pursue a more aggressive clinical course with recurrences.

Divergent regulation of 1,25-dihydroxyvitamin D3 on human bone marrow osteoclastogenesis and myelopoiesis

The physiologically active form of vitamin D3, 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) has influence over osteoclastogenesis and myelopoiesis, but the regulational mechanism is not well-defined. In this report, formation of osteoclast-like (OCL) cells from primitive myeloid colony-forming cells (PM-CFC) as mediated by 1,25(OH)2D3 was examined. Our results present in this report clearly show that 1,25(OH)2D3 dose-dependently stimulated OCL cell formation when added to suspension cultures of individually replated PM-CFC colonies. Marrow cells were plated with either granulocyte-macrophage colony-stimulating factor (GM-CSF) or the human bladder carcinoma cell line 5637 conditioned medium (5637 CM) as the source of colony-stimulating activity. The 1,25(OH)2D3 effect of osteoclast differentiation was associated with a concomitant decrease in clonogenic growth of myelopoietic progenitors in response to colony-stimulating activity. Secondly, the effect of adding the known stimulator of hematopoiesis, interleukin-1beta (IL-1beta) and/or 1,25(OH)2D3 on human myeloid colony growth was assessed. IL-1beta enhanced the formation of primitive myeloid colonies in response to GM-CSF by 160%. On the other hand, 1,25(OH)2D3 dose-dependently inhibited both GM-CSF- and 5637 CM-driven myeloid colony formation by as much as 90% at 100 nM. Addition of IL-1beta to GM-CSF-stimulated cultures dampened the inhibitory effect of 1,25(OH)2D3. The inhibition of myeloid clonogenic growth by 1,25(OH)2D3 was almost abolished (89%) by simultaneously adding anti-tumor necrosis factor-alpha monoclonal antibody (anti-TNF-alpha MoAb) to the culture medium. These results collectively suggest divergent roles for 1,25(OH)2D3 in osteoclastogenesis and myelopoiesis, promoting the differentiation of OCL cells from primitive myeloid cells but inhibiting the proliferation of later myeloid progenitor cells. This inhibition of myeloid progenitors may be mediated by TNF-alpha.

Changes in homocysteine levels during normal pregnancy

OBJECTIVE

The objective of this study was to determine the changes in total plasma homocysteine concentration that occur during normal pregnancy.

STUDY DESIGN

In this cross-sectional study homocysteine was measured in 155 normal women in the first, second, and third trimesters and in nonpregnant controls. In addition, albumin, serum B12, serum folate, and red blood cell folate concentrations were measured and correlated to homocysteine values.

RESULTS

The mean homocysteine concentration (in micromoles per liter) was 5.6 (95% confidence interval 3.9-7.3) at 8-16 weeks' gestation, 4.3 (95% confidence interval 3.5-5.3) at 20-28 weeks' gestation, 5.5 (95% confidence interval 3.3-7.5) at 36-42 weeks' gestation, and 7.9 (95% confidence interval 6.2-9.6) in the nonpregnant control group. Homocysteine was significantly lower in all 3 trimesters of pregnancy compared with nonpregnant controls (P <.001). Homocysteine levels were directly correlated with albumin levels, which decreased during pregnancy. Homocysteine concentrations were decreased in subjects taking folic acid supplementation.

CONCLUSION

Serum concentrations of homocysteine decrease during pregnancy. This occurs in association with the physiologic fall in albumin during pregnancy, as well as with folic acid supplementation.

Coexpression of genes involved in apoptosis in central nervous system neoplasms

PURPOSE

Apoptosis plays a crucial role in normal development and mediates tumor response to chemotherapy. This study investigated the pattern of apoptotic gene expression in brain tumor tissue specimens and cell lines.

MATERIALS AND METHODS

BCL2, BCLXL, BCLXS, and BAX transcripts were amplified using reverse transcriptase polymerase chain reaction in 7 high-grade gliomas (HGGs), 7 ependymomas, and 6 cell lines (2 glioblastomas, 3 medulloblastomas, and 1 supratentorial-primitive neuroectodermal tumor [PNET]). Immunohistochemical staining for BCL2, BCLX, BAX, and p53 was performed in 7 pediatric low-grade gliomas (LGGs) and 7 pediatric HGGs.

RESULTS

Six of seven gliomas, all ependymomas, and all glioblastoma and medulloblastoma cell lines expressed BCLXL and BAX. BCL2 expression was only detected in the supratentorial PNET line PFSK. BCLXS was absent in all tumors. By immunohistochemistry, no glial tumors stained positively for BCL2. Similar BAX and BCLX protein expression was observed in LGG and HGG. Three of five glioblastomas showed significant p53 expression.

CONCLUSIONS

Coexpression of proapoptotic and antiapoptotic genes in human brain tumors supports the hypothesis that the relative expression of competing genes determines apoptotic threshold.

Cytokeratin-positive cells in PBSC collections from normal donors and patients with non-epithelial cell-derived tumors

BACKGROUND

It is possible that post-transplant relapse in patients with breast cancer may result, in part, from residual tumor in the autologous PBSC product. It is unclear from the literature what effect residual breast tumor cells have on clinical outcome and whether purging tumor cells would be beneficial. We hypothesized that lack of standardization of assays for detection of residual breast tumor may be responsible for the inconclusive clinical data.

METHODS

We compared two assays routinely for detection of cytokeratin (CK)-positive cells in stem-cell grafts, immunohistochemistry (IHC) and flow cytometry (FCM). The patient population consisted of individuals with breast cancer, non-epithelial cell-derived tumors and normal donors. A rigorous statistical model was developed for evaluation of the data.

RESULTS

We found that the IHC assay out-performed the FCM assay. Importantly, both assays detected CK-positive cells in PBSC collections of patients with non-epithelial cell-derived tumors and in normal donors. No distinguishing morphological characteristics could be identified to differentiate potentially malignant from non-malignant CK-positive cells. Due to the inability to distinguish true positive from false positive results, we developed a statistical model to establish a quantitative threshold to discriminate positive from negative samples. Among the patients tested, no clinical outcome differences were detected, regardless of where the threshold of CK-positive cells was set.

DISCUSSION

We conclude the more stringent criteria and more specific markers, rather than the presence or absence of CK-positive cells, need to be established to determine the clinical significance of minimal residual disease in autologous breast-cancer

Extramedullary plasmacytoma. A form of marginal zone cell lymphoma?

Extramedullary plasmacytoma (EMP), solitary plasmacytoma of bone, and multiple myeloma are related neoplasms, but EMP is clearly a distinct entity. Moreover, there are histologic and clinical similarities between EMP and marginal zone B-cell lymphomas (MZLs) displaying extensive plasma cell differentiation, suggesting a possible histogenetic relationship. The histologic and clinical features of 5 EMPs with extensive plasma cell differentiation were histologically reviewed for features of MZL. The previously diagnosed MZLs, mucosa-associated lymphoid tissue (MALT) type, of 2 patients also were reviewed. All patients were women aged 48 to 79 years. The EMPs originated in the parotid gland, lymph nodes, dura, or small bowel. The initial tumors diagnosed as MALT-type MZL were located in the lung and small bowel. All patients were treated with resection, with or without irradiation therapy. One patient also received systemic chemotherapy. All patients are alive with no evidence of disease. All tumors contained large numbers of plasma cells, constituting between 55% and 90% of the lymphoid cells. Centrocyte-like cells and monocytoid B cells each represented 0% to 25% of the infiltrate. Lymphoepithelial lesions were observed in all of the tumors in sites where epithelium was present. Reactive follicles were found in all of the tumors. EMPs may represent MZLs that have undergone an extensive degree of plasmacytic differentiation.

Proliferation and cellular phenotype in lymphomatoid granulomatosis: implications of a higher proliferation index in B cells

Pulmonary involvement by lymphomatoid granulomatosis (LYG) is characterized by nodules of a polymorphous lymphoreticular infiltrate with necrosis, angioinvasion, and variable numbers of large, atypical cells. Using combined immunohistochemistry, the authors compared the expression of a marker of proliferation (DNA topoisomerase IIalpha) between B cells, T cells, and histiocytes. Sixteen cases of LYG were stained by combined immunohistochemistry for DNA topoisomerase IIalpha and CD-20, CD-3, CD-68, and CD-57. A proliferation index was determined for B cells, T cells, histiocytes, and natural killer cells by dividing the number of cells with coexpression of DNA topoisomerase IIalpha and CD-20, CD-3, CD-68, or CD-57 by the total number of CD-20+, CD-3+, CD-68+, or CD-57+ cells, respectively. A significantly higher proliferation index was present in B cells compared to T cells, histiocytes, or natural killer cells (p < 0.002). The average proliferation index for B cells was 0.25+/-0.24 (range, 0.00-0.76), for T cells was 0.02+/-0.01 (range, 0.00-0.04), for histiocytes was 0.00+/-0.01 (range, 0-0.02), and for natural killer cells was 0.00+/-0.00 (range, 0.0-0.02). The average proliferation index of CD-20+ cells was greater in grade III LYG (0.36) than in grade II LYG (0.17) or the single case of grade I LYG (0.00). The authors conclude that (1) there is a spectrum of B-cell proliferation in LYG that roughly correlates with histologic grade, (2) T cells, histiocytes, and natural killer cells do not proliferate but are recruited, and (3) the average B-cell proliferation index in grade III LYG is similar to that observed in large cell non-Hodgkin's B-cell lymphomas. These observations provide a possible rationale for the use of chemotherapy for grade III LYG and observation or immunologic adjuvants for LYG with grade I or grade II histology.

Laboratory and clinical evaluation of two glucose meters for the neonatal intensive care unit

OBJECTIVE

To evaluate the analytical and clinical performance of the One Touch II and Advantage glucose meters for use in neonatal specimens.

DESIGN AND METHODS

For the laboratory evaluation, a total of 96 umbilical cord whole blood specimens were analyzed on the One Touch II and/or Advantage meters. Samples were centrifuged after analysis on the meters and plasma glucose was determined on the Hitachi 917. For the clinical evaluation, a total of 64 infants had specimens analyzed on each of the meters as well as on the laboratory analyzer.

RESULTS

In the laboratory and clinical evaluations, both meters correlated well (r > 0.9, p < 0.001) with the plasma values for the Hitachi 917. However, the mean difference between the Advantage and Hitachi 917 was lower than that of the One Touch II in both the laboratory (-0.23 vs -0.64 mmol/L) and the clinical evaluations (-0.08 vs -0.60 mmol/L). 53.1% of One Touch and 26.6% of Advantage results from the clinical study had a discrepancy of > 0.5 mmol/L from the laboratory value.

CONCLUSIONS

For neonatal specimens, glucose meters must have good low end precision, sensitivity and accuracy, In this study, the Advantage meter had fewer discordant results and better correlation with the Hitachi 917. Overall, nursing and laboratory staff preferred the performance and characteristics of the Advantage meter.

Immunohistochemical staining for DNA topoisomerase IIa in Hodgkin's disease

The topoisomerase II alpha (topo II alpha) enzyme is the target for several chemotherapeutic agents, including etoposide, teniposide, mitoxantrone, and doxorubicin (topo II poisons). The enzyme also is a marker of cell proliferation. Most cases of Hodgkin's disease (HD) are responsive to combination chemotherapy regimes that include topo II poisons such as doxorubicin. Immunoperoxidase methods for detection of the topo II alpha isoenzyme are now available for use in formalin-fixed, paraffin-embedded tissues, which may provide information about the proliferative capacity and possible sensitivity of tumors to drugs that target topo II. We used a specific antibody to analyze subsets of HD for topo II alpha staining patterns. Formalin-fixed blocks from 49 cases of HD, including 20 nodular sclerosis (NS), 14 mixed-cellularity (MC), and 15 lymphocyte-predominant (LP) subtypes, were analyzed by dual staining for topo II in combination with monoclonal antibodies against Reed-Sternberg (RS) cells consisting of CD15 for the NS and MC subtypes and CD20 for LP lymphocytic and histiocytic (L & H) cells. The number of morphologically appropriate cells coexpressing the RS or L & H marker and topo II alpha was quantitated. Positive nuclear staining for topo II alpha in RS or L & H cells was seen in 100% of cases, irrespective of subtype. Coexpression of CD15 and topo II alpha was seen in 58.4% of the RS cells or mononuclear variants in NSHD cases and 68.4% in MCHD cases. No significant difference in the percentage of neoplastic cells expressing topo II alpha was found between NS and MC subtypes. Cases of LPHD showed coexpression of CD20 and topo II alpha in 84.4% of the L & H cells, a significant increase over the level of tumor cell coexpression seen in NSHD and MCHD (P < .001). Only one case was found to have a low (< 25% of tumor cell coexpression) level of topo II alpha expression. Immunohistochemical detection of a high level of topo II alpha expression in HD, irrespective of subtype, suggests a molecular explanation for the excellent response of most HD to standard combination chemotherapy, which can include topo II poisons. The LP subtype has a higher expression of topo II alpha in the neoplastic cell population than do NS or MC subtypes, perhaps indicating increased sensitivity of these tumors to topo II poisons. It may be possible to identify subsets of HD that are more or less sensitive to conventional chemotherapeutic regimes, which would help in the selection of appropriate treatment.