Stiffness-induced cancer-associated fibroblasts are responsible for immunosuppression in a platelet-derived growth factor ligand-dependent manner

Pancreatic ductal adenocarcinoma (PDAC) is associated with a vast stromal reaction that arises mainly from cancer-associated fibroblasts (CAFs) and promotes both immune escape and tumor growth. Here, we used a mouse model with deletion of the activin A receptor ALK4 in the context of the KrasG12D mutation, which strongly drives collagen deposition that leads to tissue stiffness. By ligand-receptor analysis of single-cell RNA-sequencing data, we identified that, in stiff conditions, neoplastic ductal cells instructed CAFs through sustained platelet-derived growth factor (PDGF) signaling. Tumor-associated tissue rigidity resulted in the emergence of stiffness-induced CAFs (siCAFs) in vitro and in vivo. Similar results were confirmed in human data. siCAFs were able to strongly inhibit CD8+ T-cell responses in vitro and in vivo, promoting local immunosuppression. More importantly, targeting PDGF signaling led to diminished siCAF and reduced tumor growth. Our data show for the first time that early paracrine signaling leads to profound changes in tissue mechanics, impacting immune responses and tumor progression. Our study highlights that PDGF ligand neutralization can normalize the tissue architecture independent of the genetic background, indicating that finely tuned stromal therapy may open new therapeutic avenues in pancreatic cancer.

Proteomics of Plasma and Plasma-Treated Podocytes: Application to Focal and Segmental Glomerulosclerosis

Focal and segmental glomerulosclerosis (FSGS) is a severe form of idiopathic nephrotic syndrome (INS), a glomerulopathy of presumably immune origin that is attributed to extrarenal pathogenic circulating factors. The recurrence of FSGS (rFSGS) after transplant occurs in 30% to 50% of cases. The direct analysis of patient plasma proteome has scarcely been addressed to date, mainly due to the methodological difficulties associated with plasma complexity and dynamic range. In this study, first, we compared different methods of plasma preparation, second, we compared the plasma proteomes of rFSGS and controls using two preparation methods, and third, we analyzed the early proximal signaling events in podocytes subjected to patient plasma, through a combination of phosphoproteomics and lipid-raft proteomics (raftomics). By combining immunodepletion and high pH fractionation, we performed a differential proteomic analysis of soluble plasma proteins and of extracellular vesicles (EV) obtained from healthy controls, non-INS patient controls, and rFSGS patients (n = 4). In both the soluble- and the EV-protein sets from the rFSGS patients, we found a statistically significant increase in a cluster of proteins involved in neutrophil degranulation. A group of lipid-binding proteins, generally associated with lipoproteins, was found to be decreased in the soluble set from the rFSGS patients. In addition, three amino acid transporters involved in mTORC1 activation were found to be significantly increased in the EV from the rFSGS. Next, we incubated human podocytes for 30 min with 10% plasma from both groups of patients. The phosphoproteomics and raftomics of the podocytes revealed profound differences in the proteins involved in the mTOR pathway, in autophagy, and in cytoskeleton organization. We analyzed the correlation between the abundance of plasma and plasma-regulated podocyte proteins. The observed changes highlight some of the mechanisms involved in FSGS recurrence and could be used as specific early markers of circulating-factor activity in podocytes.

FC065: Combined Proteomic Analyses of Recurrent Idiopathic Nephrotic Syndrome Plasma and Plasma-Treated Human Podocytes

BACKGROUND AND AIMS

Idiopathic nephrotic syndrome (INS) comprises a group of rare glomerulopathies attributed to direct or indirect interaction of putative circulating factors with podocytes. One of the pathological manifestations of INS is the rapid recurrence of focal and segmental glomerulosclerosis (rFSGS) after renal transplant, which occurs in 30–50% of cases. To date, the nature and identity of circulating factors have not been confirmed, while the pathogenic mechanisms in the podocyte are partially understood. Direct analysis of patient plasma proteome has been scarcely addressed, mainly due to methodological difficulties associated with plasma complexity and dynamic range. To better understand the mechanisms involved in FSGS recurrence, the present study had two main objectives: (i) to perform a differential proteomic analysis of soluble plasma proteins and of extracellular vesicles (EV) from rFSGS patients and from controls; and (ii) to study the early proximal signaling events in podocytes in response to plasma from post-transplant rFSGS patients as compared to plasma from controls, by a combination of phosphoproteomics and lipid raft proteomics (raftomics).

METHOD

We obtained first post-transplant plasma exchange fluid from either rFSGS or non-INS patients (n = 4), the latter used as controls, as well as blood plasma from healthy individuals (n = 4). In a first study, by a combination of immunodepletion and high pH fractionation, we performed in parallel a differential proteomic analysis of soluble plasma proteins and of extracellular vesicles (EV) from the three groups. In a second study, we incubated differentiated human podocytes for 30 min with 10% of plasma exchange fluid from either rFSGS or non-INS patients. Then, we isolated lipid rafts from podocytes by a detergent-free method and performed differential proteomics. In addition, we performed differential phosphoproteomics after phosphopeptide enrichment in a TiO2 column. Proteomics by LC-MS/MS analysis was performed in a TimsTOF Pro mass spectrometer on plasma samples, and in a nanoRSLC-Q Exactive PLUS instrument on podocyte samples.

RESULTS

The approximate number of proteins identified was 500 in immunodepleted plasma, 1400 in EV, 2500 in podocyte rafts and 4900 podocyte phosphosites. In both soluble and EV protein sets from rFSGS patients, we found a statistically significant increase in a cluster of proteins involved in neutrophil degranulation. A group of lipid binding proteins, generally associated with lipoproteins, was found decreased in the soluble set from rFSGS patients. In addition, several aminoacid transporters involved in mTORC1 activation were found significantly increased in EV from rFSGS individuals. As regards podocyte proteome analyses, the differences found in protein expression and phosphorylation associated with rFSGS plasma incubation suggested alterations in the mTOR pathway, in autophagy, in mitochondrial metabolism and in cytoskeleton organization. In particular, validation experiments indicated an altered phosphorylation pattern of Hsp27.

CONCLUSION

The technological approaches used in the plasma study show the feasibility of direct proteomic analysis of this material, as well as the potential of some of the identified differential proteins as FSGS biomarkers. The observed changes in podocyte proteome associated with rFSGS plasma incubation highlight some of the potential mechanisms involved in FSGS recurrence and could be used as specific early markers of circulating factor activity on podocytes. Further research will be necessary to confirm and validate these findings.

The feasibility of T2 mapping in the assessment of hepatic steatosis, inflammation, and fibrosis in patients with non-alcoholic fatty liver disease: a preliminary study

AIM

To determine the feasibility of magnetic resonance imaging T2 mapping in the quantification of liver steatosis in patients with biopsy-proven non-alcoholic fatty liver disease (NAFLD), and to assess the effect of inflammation and fibrosis on T2 values of the liver.

MATERIAL AND METHODS

Twenty-three consecutive patients with biopsy-proven NAFLD who underwent T2 mapping between December 2013 and September 2014 were included in this study. All patients underwent fast spin echo multi-echo sequence with eight echoes for T2 measurements.

RESULTS

The mean liver T2 value and percentage of histological steatosis was 64.9 ± 7.4 ms and 46.5 ± 27.6%, respectively. There was a good correlation between the liver T2 value and histology-determined steatosis (r = 0.780, p<0.001) and grade of steatosis (r_s = 0.779, p<0.001). The mean T2 value in patients with definitive non-alcoholic steatohepatitis (NASH) was significantly higher in comparison with patients without NASH (69 ± 7.37 versus 61.73 ± 5.99 ms, p=0.016). The correlation between T2 value and NAFLD activity score (NAS) was significant (r_s = 0.443, p=0.034); however, the correlation disappeared after adjustment for hepatic steatosis and fibrosis (r=0.131, p=0.572). There was a close inverse correlation between T2 value and fibrosis stage after adjusting for hepatic steatosis (r=-0.536, p=0.012).

CONCLUSION

T2 mapping can be used for quantification of hepatic steatosis, as there is a close correlation between T2 relaxation values and histology-determined steatosis. Patients with definite NASH have increased T2 values and there is an inverse correlation between the T2 value and fibrosis stage of the liver. T2 mapping in NAFLD may be a useful clinical tool for disease assessment and prognostication.

Gangliosides in Podocyte Biology and Disease

Gangliosides constitute a subgroup of glycosphingolipids characterized by the presence of sialic acid residues in their structure. As constituents of cellular membranes, in particular of raft microdomains, they exert multiple functions, some of them capital in cell homeostasis. Their presence in cells is tightly regulated by a balanced expression and function of the enzymes responsible for their biosynthesis, ganglioside synthases, and their degradation, glycosidases. The dysregulation of their abundance results in rare and common diseases. In this review, we make a point on the relevance of gangliosides and some of their metabolic precursors, such as ceramides, in the function of podocytes, the main cellular component of the glomerular filtration barrier, as well as their implications in podocytopathies. The results presented in this review suggest the pertinence of clinical lipidomic studies targeting these metabolites.

Differential diagnosis of traditional serrated adenomas and tubulovillous adenomas: a compartmental morphologic and immunohistochemical analysis

AIM

Traditional serrated adenomas are the rarest member of the serrated polyps, that have endoscopic and morphologic similarities with conventional adenomas, tubulovillous adenomas, in particular. We aimed to compare the histopathologic and immunohistochemical features of TSAs showing overt dysplasia with conventional TVAs in a compartmental manner using digitalized images.

PATIENTS AND METHODS

For 25 TSAs and 25 TVAs, extent of the morphologic features including cytoplasmic eosinophilia, mid-zonal nuclei, ECFs, slit-like serration, brush border, gastric foveolar-like epithelium and goblet cells were evaluated. Immunohistochemistry was perfomed using primary antibodies including CK7, CK20, MUC2, MUC5AC, MUC6, B-catenin, Ki67, p53, p16, MLH1, MSH2, MSH6 and PMS2.

RESULTS

Eosinophilic cells, mid-zonal nuclei, slit-like serration and ECF were significantly more extensive in TSAs compared to TVAs (p<0,001) while gastric epithelium was also more extensive in TSA cohort with a lower significance (p<0,01). Cut-offs for these features yielding the highest sensitivity and specificity in discriminating TSAs from TVAs were determined ; mid-zonal nucleus resulted as the best discriminating histopathologic feature (100%, 92%) followed by eosinophilia (88%, 92%),and slit-like serration (84%, 92%) with highest sensitivity and specificities, respectively. Compartmental immunohistochemical evaluation revealed that CK20 and CK7 were mainly expressed in ECF while MUC5AC together with CK7 were found in epithelial compartment more frequently in TSAs compared to TVAs. P16 was more common in TSAs in all compartments whereas Ki67 and p53 were restricted to dysplastic compartments in both polyp groups.

CONCLUSIONS

The present study demonstrated that mid-zonal nuclei, eosinophilic cells and slit-like serration followed by ECF proved to be the most discriminatory features for TSAs.The correct diagnosis of TSAs will allow to develop appropriate treatment and follow up modalities which seem to be crucial as their progression rate may be different from TVAs.

CMIP is a negative regulator of T cell signaling

Upon their interaction with cognate antigen, T cells integrate different extracellular and intracellular signals involving basal and induced protein–protein interactions, as well as the binding of proteins to lipids, which can lead to either cell activation or inhibition. Here, we show that the selective T cell expression of CMIP, a new adapter protein, by targeted transgenesis drives T cells toward a naïve phenotype. We found that CMIP inhibits activation of the Src kinases Fyn and Lck after CD3/CD28 costimulation and the subsequent localization of Fyn and Lck to LRs. Video microscopy analysis showed that CMIP blocks the recruitment of LAT and the lipid raft marker cholera toxin B at the site of TCR engagement. Proteomic analysis identified several protein clusters differentially modulated by CMIP and, notably, Cofilin-1, which is inactivated in CMIP-expressing T cells. Moreover, transgenic T cells exhibited the downregulation of GM3 synthase, a key enzyme involved in the biosynthesis of gangliosides. These results suggest that CMIP negatively impacts proximal signaling and cytoskeletal rearrangement and defines a new mechanism for the negative regulation of T cells that could be a therapeutic target.

Can positron emission tomography-computed tomography predict response in locally advanced rectal cancer patients treated with induction folinic acid and 5-florouracil?

OBJECTIVE

The aim of this study was to determine the pathological complete response rates in a group of locally advanced rectal cancer patients who underwent chemoradiotherapy (CRT) after treatment with induction folinic acid and 5-florouracil (FOLFOX) chemotherapy and the relationship between the complete response and positron emission tomography-computed tomography (PET-CT).

MATERIALS AND METHODS

The files of 239 patients who were diagnosed with rectal cancer between January 2008 and January 2012 were evaluated retrospectively. Of these, there were 24 locally advanced rectal cancer patients who met the following criteria: They were administered CRT after receiving four courses induction oxaliplatin, FOLFOX and they underwent PET-CT for staging and for the evaluation of their response to FOLFOX treatment. Of these 24 patients, 20 operable patients were included in the study.

RESULTS

The pathological complete response was obtained in seven patients (35%) who were operated on and then given induction four courses FOLFOX chemotherapy and CRT. We determined that age, gender, clinical stage at diagnosis and PET-CT before and after induction chemotherapy were not predictive of the pathological complete response to tumor fluorodeoxyglucose uptake activity.

CONCLUSION

The rates of pathological complete response were increased in locally advanced rectal cancer patients who underwent short-term induction chemotherapy. Although the PET-CT has retained its importance in predicting pathological complete response, there is still a need for studies with a larger number of patients and long-term follow-ups.

The importance of COX-2 expression as prognostic factor in early breast cancer

PURPOSE

A number of studies have been carried out, showing that the risk for breast carcinoma is decreased in those using non-steroidal anti-inflammatory drugs (NSAIDs). Increased cyclooxygenase-2 (COX-2) level is considered as a factor indicating poor prognosis and responsible for angiogenesis, increased cellular proliferation, apoptotic defect and aromatase enzyme induction. For this reason the level of COX-2 might have a prognostic and predictive value in breast cancer as well. This question has become the basis of the present study.

METHODS

Eighty-eight female patients with early stage breast cancer being under adjuvant anthracycline based chemotherapy were prospectively recruited. The patient age, body weight, menopausal status, tumor size and grade as well as axillary lymph node involvement were recorded. Routine pathological examination was performed, and COX-2, CerbB2 (HER2), estrogen (ER) and progesterone receptors (PR) levels in breast cancer tissue were determined immunohistochemically.

RESULTS

Multivariate analysis confirmed the independent predictive value of both menopausal status and ER expression for overall survival (OS) (p=0.009, HR=1.92, and p=0.014, HR=0.20, respectively). A negative correlation was observed between COX-2 levels and the levels of ER and PR (p=0.006, R= -0.303, and p=0.004, R=-0.312, respectively) whereas no significant correlation was observed concerning CerbB2. No statistically significant correlation was determined between COX-2 levels and the disease-free (DFS) and OS rates.

CONCLUSION

Further studies investigating the role of COX- 2 levels in breast cancer progression are needed.

The role of VEGF and other parameters in tracking the clinical course in metronomic chemotherapy

PURPOSE

The purpose of this study was to investigate the effect of metronomic chemotherapy on serum vascular endothelial growth factor (VEGF) levels in cancer patients.

METHODS

The study included 11 metastatic cancer patients who received daily 50 mg cyclophosphamide and biweekly 5 mg methotrexate per os as metronomic chemotherapy. Bevacizumab together with FOLFIRI chemotherapy was administered as anti-angiogenic treatment in another group of 16 metastatic colorectal carcinoma patients. Furthermore, VEGF levels of 10 healthy individuals and 5 cord blood samples served for comparisons. VEGF levels of patients before therapy and 3 months after treatment were analyzed and compared.

RESULTS

Serum VEGF levels prior to metronomic chemotherapy were higher compared with the healthy controls (p=0.0001). Similarly, serum VEGF levels prior to the bevacizumab-based chemoimmunotherapy were significantly higher compared with the healthy controls (p=0.005). In patients on metronomic chemotherapy VEGF levels showed non significant decrease (p=0.075). On the contary, VEGF levels decreased significantly (p=0.002) with bevacizumab treatment.

CONCLUSION

Serum VEGF levels may be used for assessing of the efficacy of anti-angiogenic therapies.

Malign peritoneal mesothelioma with nephrotic syndrome

Nephrotic syndrome may occur in malignancies like Hodgkin Disease and other solid tumors due to glomerulonephritis, amyloidosis or other causes. However, it is rare in peritoneal mesothelioma. We report a 42-year old female patient with peritoneal mesothelioma and nephrotic syndrome together with a review of literature (Tab. 1, Fig. 3, Ref. 7).

The predictors of information needs and different views of patients and relatives on disclosure and treatment participation: A multicentric survey study

e20526

Background: We wanted to explain if the views of patients and their relatives differed on disclosure and treatment participation or not, and if so, to evaluate the predictors of this difference. Methods: The survey aimed to unveil the attitude of patients and their relatives in 3 domains; disclosure of diagnosis, prognosis and participation to treatment. Multinomial logistic regression models with forward selection procedure were constructed for the multivariate analysis to explain the origins of discordance in these domains. Results: A total of 1,052 consecutive cases (526 patients and their 526 relatives) were interviewed. The relatives, when they were asked to imagine themselves with a new diagnosis of cancer, opted for disclosure of diagnosis, prognosis, and participation to treatment in 92.4%, 84.6%, and 86.3% of cases. When patients were asked for their information needs in disclosure of diagnosis, prognosis, and participation to treatment, 83.8%, 70.2%, and 70% wanted disclosure, whereas, their relatives wanted disclosure for their patients in these 3 domains in 32.9%, 40.5%, and 60.3% of cases, respectively. The multivariate predictors of discordance for disclosure of diagnosis between patients and relatives were patient age, social insurance, and oncology centers (P=0.003, 0.007, and <0.001, respectively). The associates of discordance for disclosure of prognosis were again oncology centers and relatives’ relationship with the patients (P<0.001 and 0.012). Likewise, the correlates of discordance for treatment participation were again oncology centers and patient age (P<0.001 and 0.016). Conclusions: Information needs of patients and their relatives, when they imagine themselves as cancer patients, are quite similar. However, relatives are not in favor of disclosure to their patients of diagnosis and prognosis, moreover, in spite of this, they want their patients to actively participate in treatment decisions. We believe this paradox represents a desire of the relatives to escape from responsibility and emotional burden of the care of the cancer patients. This paradox, in addition, is a threat to a healthy patient and physician communication.

No significant financial relationships to disclose.

COX-2 expression and clinical outcome in early-stage breast cancer patients treated with adjuvant chemotherapy: A prospective study

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Background: To evaluate the association of cox-2 expression with the outcome after adjuvant chemotherapy in patients with early breast cancer. Methods: This was planned as a prospective study recruiting consecutive patients receiving adjuvant anthracycline based chemotherapy and with available tissue blocks permitting all immunohistochemical analyses. Cox-2 expression, in addition to other classical biological factors, was evaluated with immunohistochemistry. Disease and patient related, and biological predictors of both overall survival (OAS) and relapse free survival (RFS) were analyzed by Cox regression analysis. Median and mean survival times were calculated according to the Kaplan Meier method. Results: A total of 88 patients were recruited over a period of 24 months. Median age was 45 (29 to 70), and 60% of subjects were premenapausal. Median tumour diameter and number of axillary lymph nodes involved were 2 cm (1 to 6 cm), and 2 (0 to 15), respectively. Median follow up is 74.2 months. Univariate analysis revealed menopausal status and estrogen receptor expression as predictors of OAS, and menopausal status as the correlate of RFS. Multivariate analysis confirmed the independent predictive value of both menopausal status and estrogen receptor expression for OAS (P=0.009, HR=4.18, and P=0.014, HR=0.20, respectively). No multivariate analysis could be performed for RFS. Cox-2 expression was not associated with OAS or RFS (P=0.208, HR=1.92, and P=0.132, HR=1.89, respectively). Interestingly, Cox-2 expression was correlated with Estrogen receptor (ER) and Progesteron receptor (PR) expression (P=0.006, R=-0.303, and P=0.004, R=-0.312, respectively). Conclusions: Cox-2 expression fails to predict clinical outcome of early breast cancer patients treated with adjuvant chemotherapy. However, Cox-2 expression seems to negatively correlate with ER and PR expression. It should be tested in this patient population whether Cox-2 may play a part in hormonal resistance.

No significant financial relationships to disclose.

Impressive survival data with semimetronomic oral chemotherapy with old agents in heavily treated metastatic breast cancer patients

1082

Background: To assess the efficacy of semi-metronomic regimen metronomic cyclophosphomide with oral etoposide in heavily treated patients with metastatic breast cancer. Methods: Consecutive metastatic breast cancer (MBC) patients predominantly refractory to antracyclines, taxanes, and antimetabolites receiving semi-metronomic regimen of metronomic cyclophosphomide with oral etoposide were evaluated for clinical efficacy and toxicity. This novel regimen comprised of continuous oral cyclophosphomide 50 mg/day, and oral etoposide given as 2 x 50 mg/day for 5 days. Results: A total of 42 MBC patients received this treatment in 2.5 years (May 2005-October 2008). The median age was 51.5 (29–81), ER and/or PR receptor status was positive in 67%, and c-erb-B2 overexpression existed in 50%. The biologically favorable group, hormone responsive and c-erb-B2 negative comprised of 36% of cases. The portions of patients with visceral metastases, cranial metastases, and 2 or more organ involvement were 82%, 24%, and 65%, respectively. Subjects had received this treatment in the fourth or more advanced setting in 50% of cases (after a median of 2.5 cycles). The median overall and progression free survival figures were 25 and 10.5 months, respectively. No toxic mortality occurred, and the treatment was well tolerated. Toxicity and response data are being updated currently. Conclusions: Semi-metronomic treatment with metronomic cyclophosphomide and oral etoposide is a novel and effective strategy in heavily pretreated MBC patients. Survival data and low cost may make this regimen a highly preferable option in this difficult patient group.

No significant financial relationships to disclose.

High-dose chemotherapy and stem cell support in the management of metastatic germ cell cancer: A quantitative review

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Background: To analyze the independent associates of outcome in metastatic germ cell cancer (MGCC) patients treated with high dose chemotherapy (HDC) and stem cell rescue. Methods: Thirty-two published patient cohorts with MGCC (encompassing 2176 patients; 510 patients treated upfront and 1666 at relapse) were identified from PUBMED and Cochrane Registry of Clinical Trials. Weighed Regression Analyses of these trials were conducted to define prognosticators. Results: Correlate of overall survival (OAS) and survival with no evidence of disease (NED) in upfront HDC trials was number of chemotherapeutics in HDC (OAS with 2 agents: 60% vs. 3 or more agents: 72%, p = 0.047, survival with NED with 2 agents: 47% vs. 3 or more agents: 64%, p = 0.009). In trials of HDC at relapse, independent associates of OAS with multivariate analysis were line of chemotherapy index, an indicator of line of chemotherapy utilization (p = 0.004), and median age (≤30: 42%, >30: 49%, p = 0.023), whereas independent correlates of better survival with NED were again number of chemotherapeutics in HDC (2 agents: 54% vs. 3 or more agents: 33%, p = 0.001), and seminoma fraction (seminoma fraction ≤9%: 28% vs. seminoma fraction >9%: 49%, p < 0.001 ). Toxic mortality of HDC regimens employed in these trials ranged between 0% and 17%. Conclusions: HDC can cure patients with MGCC both as initial or salvage therapies. However, this study shows that type and setting of HDC, as well as patient age, and seminoma fraction all appear to be linked with benefit from HDC in MGCC. Future trials should continue to address the usage of tandem HDC cycles with multiagent protocols in high risk patients with MGCC.

No significant financial relationships to disclose.

The prevalance of chronic autoimmune urtiker and angioedema among lung and breast carcinoma cases

e20707

Background: Although the risk of allergy and atopy in cancer patients has been studied in various prospective studies previously, no significant association was found between leukemia, breast, colorectal, lung cancers and allergic disorders or atopy. Our purpose in this study was to investigate the prevalance of chronic urticeria and angioedema in breast and lung carcinoma of adults in Mediterrianean Coast of Turkey, Antalya. Methods: 86 breast and 62 lung carcinoma patients that had diagnosed and underwent chemotherapy in Akdeniz University Oncology Clinic were studied. Blood eosinophil, total IgE, ANA, C3, C4, hepatitis markers and autologous skin test were examined in the cases with probable chronic autoimmune urticeria, angioedema. The data were statistically assessed with SPSS version 13.00. Results: Overall 148 patients were included. Median age was 62.4±14.6 years, 60.1% of the patients were women (47.2% of which is not working). 55.6% of the patients are living in apartments. In general, 5.4% (8 case) of the investigated population were diagnosed as autoimmun urticeria; Seven of the 8 of these were breast carcinoma cases (7 out of 86 breast Ca). In contrast, only one of them was lung carcinoma (1 out of 62 lung Ca). Total IgE level was 122 ± 21.4. None of the cases with positive autologous skin test has ANA positivity. Similarly, these cases were also HBV and HCV seronegative. Accompanying angioedema was present 3 cases (with no drug or food history). One case has a hashimato tiroiditis who underwent LT4 replacement. Another patient with autoimmun urticeria has allergical asthma together with 5 cases of allergical rhinitis and conjunctivitis. Conclusions: In this study the frequency of autoimmune urticeria is much higher in breast carcinoma cases compared to patients with lung carcinoma. Further researchs are needed to verify these results and to determine why such association exist.

No significant financial relationships to disclose.

Quantitative endoscopic and histologic activity assessment of ulcerative colitis

BACKGROUND

Correct assessment of the severity and activity of ulcerative colitis (UC) is necessary for determining effective treatment and predicting prognosis. The correlation between histologic activity and endoscopic activity, however, has not yet been determined by using a quantitative scoring system.

STUDY AIMS

To compare the endoscopic activity index (EAI), detected during colonoscopy, with the histologic activity index (HAI) detected in biopsy samples taken from the same colon segments of UC patients in order to determine the degree of agreement between both assessments.

PATIENTS AND METHODS

Ninety-six UC patients participated in this prospective study. EAIs and HAIs were obtained by summing the scores given for each mucosal/histological change to produce a total score between 1 and 12. The correlation between EAI and HAI was calculated.

RESULTS

There was a positive correlation between HAI and EAI (r = 0.78; p < 0.001). There was no statistical inconsistency between the EAI and HAI results (p = 0.625, using the McNemar test). The whole group kappa coefficient was 0.607 (p < 0.001).

CONCLUSION

Endoscopic and histologic activity of mucosal disease in patients with UC are generally consistent. Measuring both histologic and endoscopic activity with a quantitative scoring system during patient follow-up would be a more accurate method for monitoring UC patients.

The usefulness of chromoendoscopy with methylene blue in Barrett's metaplasia and early esophageal carcinoma

BACKGROUND

Barrett's esophagus is a condition that is premalignant for adenocarcinoma of the esophagus and the esophagogastric junction. Early detection of Barrett's metaplasia and dysplasia is very important to decrease the mortality and morbidity from esophageal adenocarcinoma cancer. This study aimed to evaluate the effectiveness of methylene blue-targeted biopsies in the differential diagnosis of intestinal metaplasia, dysplasia, and superficial esophageal carcinoma.

METHODS

A total of 109 patients (43 women and 66 men; average age, 62.32 +/- 10.61 years; range, 33-82 years) were enrolled for the study. Four groups were designed before endoscopic examinations. The patients for these groups were selected at the conventional endoscopy, and then chromoendoscopy was performed. The esophagus was stained with methylene blue, after which six biopsies were taken from stained and unstained areas.

RESULTS

Conventional and chromoendoscopic assessments were compared with histopathologic examination. The sensitivity of chromoendoscopy for Barrett's epithelium was superior to that of conventional endoscopy (p < 0.05). However, there was no statistical difference between the two methods in the diagnosis of esophagitis or esophageal carcinoma (p > 0.05). Stained biopsies were superior to unstained biopsies in terms of sensitivity for Barrett's epithelium and esophageal carcinoma (p < 0.001).

CONCLUSION

Chromoendoscopy is useful for delineating Barrett's epithelium and for indicating the correct location for securing biopsies where dysplasia or early esophageal cancer is suspected.

The development of papillary serous carcinoma of the peritoneum subsequent to endometrial carcinoma: a case report and review of the literature

Metachronous papillary serous carcinoma of the peritoneum (PSCP) after endometrial carcinoma (EC) is an extremely rare condition. Only three patients have been reported in the English literature. We present the fourth patient who had a more aggressive and fatal clinical course. A 79-year-old multiparous woman complained of progressive abdominal pain and distension after 5 years, subsequent to total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometrioid type EC. Serum CA-125 level being followed routinely rose above 500 IU/mL. Abdominal and pelvic computed tomography demonstrated ascites, omental thickening, and nodularity. Paracentesis showed malignant cells resembling papillary adenocarcinoma. Omentectomy and bilateral pelvic lymphadenectomy were performed as cytoreductive surgery. The histologic slides of the totally sampled ovaries obtained from the first operation were reexamined and the corresponding paraffin blocks were re-sectioned but no tumor was detected. The microscopic appearance of the tumor in the omentum differed from that of the previous EC. Immunohistochemically, while the tumor showed reactivity for low and high molecular weight cytokeratin (CK) cocktail, epithelial membrane antigen, CK7, CA-125, and Ber-EP4, the immunostains for calretinin, monoclonal carcinoembryonic antigen, and CK20 were negative. On the basis of these results and the criteria proposed by the Gynecologic Oncology Group, the tumor was diagnosed as metachronous PSCP developed after EC, which corresponded to stage IIIC according to FIGO criteria for ovarian carcinoma. The patient received two cycles of carboplatin and paclitaxel and died 2 months after the cytoreductive surgery.

Effects of vitamin E treatment on peroxisome proliferator-activated receptor-? expression and insulin resistance in patients with non-alcoholic steatohepatitis: results of a pilot study

BACKGROUND

Insulin resistance (IR) is commonly associated with non-alcoholic steatohepatitis (NASH). Peroxisome proliferator-activated receptor-alpha (PPAR-alpha) may also play a role in the pathogenesis of NASH. A pivotal role in NASH pathogenesis depends on the hypothesis of increased oxidative stress. The aim of our study was to evaluate the effects of supplemental oral vitamin E, a potent antioxidant, on liver functions, PPAR-alpha expression and IR in patients with NASH.

METHODS

Nine patients with biopsy-proven NASH were given oral vitamin E 800 mg daily for 24 weeks. Liver functions, lipid parameters, IR index with homeostatic metabolic assessment and liver histology and PPAR-alpha staining index in biopsy specimens were detected before and after the treatment.

RESULTS

Seven patients (78%) had IR initially. After 6 months of therapy in nine patients, fasting insulin improved (P = 0.01), but serum cholesterol, triglyceride, fasting blood glucose levels and body mass index remained unchanged. Aspartate aminotransferase and alanine aminotransferase levels decreased (P = 0.01 and P = 0.01, respectively). IR index with homeostatic metabolic assessment resistance improved (P = 0.01), but PPAR-alpha staining index did not change (P = 0.37). Although the histological grade of steatosis decreased (P = 0.01), necroinflammation and fibrosis remained unchanged. In seven patients with IR, however, necroinflammation and PPAR-alpha staining index were improved (P = 0.04 and P = 0.02).

CONCLUSION

Vitamin E treatment, in addition to its previously shown beneficial effect by suppressing oxidative stress, may also achieve improvement by reducing IR and PPAR-alpha expression in NASH.

Does serum VEGF predict prognosis in metastatic colorectal carcinoma patients treated with XELIRI?

13548

Background: Serum vascular endothelial growth factor (sVEGF) levels have been shown to possess prognostic value in different solid tumors. However, there is no solid information on the prognostic use of sVEGF in metastatic colorectal carcinoma (MCRC) patients treated with a standard regimen. Methods: 37 consecutive MCRC patients were given XELIRI chemotherapy as the 1st line treatment (irinotecan 250 mg/m2 on day one, and Capecitabine 2000 mg/m2/day, for 14 days starting on day1, repeated in every 3 weeks). Serum VEGF levels prior to the 1st cycle of chemotherapy was measured by ELISA. Kaplan-Meier survival curves and Cox regression analyses to adjust for basic clinical features were used for the survival analysis. Binary logistic regression analysis was employed to determine correlates of objective response (CR+PR). Results: Best objective response was CR+PR in 20/33(61%) cases (3 CR; 9% + 17 PR; 52%). In 4 patients, response assessment was not possible. Median sVEGF was 650(107–1865) pg/ml. Median OAS and PFS was 16.2 and 5.9 months, respectively. Increased age turned out to be the only predictor of better OAS with borderline significance (P=0.09). After adjustment for performance status (0, 1 versus 2) and disease extent (single vs. multiple metastatic sites), age was statistically significant (P=0.042, HR=0.95(0.90–0.99)). For PFS, again age (P=0.038) was the only correlate. After controlling for performance status and disease extent, age (P=0.014, HR=0.95(0.92–0.99)) and performance status (P=0.036, HR=3.27(1.08–9.88)) were significant. No factor was associated with the likelihood of objective response. Conclusion: In this study, we failed to determine any prognostic value for sVEGF in MCRC. However, older age and good performance status appear to have a borderline positive prognostic value for MCRC patients treated with XELIRI.

No significant financial relationships to disclose.

The value of pharmacogenomic analysis of microsatellite instability (MSI) and XPD, XRCC1 genotype polymorphisms to predict clinical outcome in metastatic colorectal carcinoma

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Background: Previous work suggests that DNA repair enzyme polymorphism and microsatellite instability (MSI) may bear prognostic value in metastatic colorectal carcinoma (MCRC), but this is either retrospective or do not involve irinotecan-based regimens. Methods: We prospectively treated 43 MCRC patients with irinotecan-based regimens (XELIRI or IFL). MSI was measured by PCR at 5 different chromosomal loci: BAT-25, BAT-26, D5S346, D2S123, and D17S250. XPD (Lys751Gln) and XRCC1 (Arg399Gln) polymorphisms were also analysed by PCR-RFLP method. Clinical outcome variables; overall survival (OAS), progression free survival (PFS) and the occurrence of grade 3 or 4 hematological and gastrointestinal (GIS) toxicities were evaluated. Results: MSI subtypes MSS, MSI-L and MSI-H were seen in 23.3%, 43.3% and 33.3% of cases. In the univariate analysis for OAS (n=43) only XPD and XRCC1 polymorphisms were significant (P=0.05 and P=0.04, respectively). After adjustment for performance status (ECOG=0, 1 vs. 2) and disease extent (single vs. multiple metastatic site), XRCC1 genotype and performance status retained significance (P=0.04, HR=2.85, and P=0.02, HR=3.19, respectively). Arg/Gln versus Arg/Arg and Gln/Gln versus Arg/Gln genotypes indicated approximately 3 times increased risk of death for each comparison. Type of presentation (metastatic versus local disease at first presentation) was the only significant predictor of PFS in the univariate analysis (n=40, P=0.003). After adjustment for performance status and disease extent, type of presentation retained its significance (P=0.003, HR=4.35). MSI was not associated with survival. Although absence of “liver only” disease was associated with the occurrence of grade 3–4 GIS toxicity, it lost significance in the multivariate analysis. None of the factors tested correlated with the likelihood of grade 3–4 hematological toxicity. Conclusions: XRCC1 genotype independently predicted overall survival in metastatic colorectal carcinoma patients treated with irinotecan-based chemotherapy. However, MSI status did not emerge as a prognostic factor in our cohort.

No significant financial relationships to disclose.

A simple and accurate prediction model to estimate the intrahospital mortality risk of hospitalised cancer patients

We aimed to form a risk prediction model to assess the probability of intrahospital death in cancer patients at the time of hospitalisation. The medical records and the relevant clinical parameters of cancer patients who died in or who were discharged from a teaching hospital between 1997 and 2000 (n = 334) were reviewed to explore the determinants of intrahospital death, which later were verified prospectively (n = 131). Eastern Cooperative Oncology Group (ECOG) performance status of four, short duration of disease (on a logarithmic scale), emergency admission, low haemoglobin (Hb) value (on a linear scale) and lactate dehydrogenase (LDH) value greater than 378 micro/ml were significantly and independently associated with the risk of intrahospital death. This model had a receiver operating characteristic area of 0.88 in the derivation cohort and 0.82 in the validation cohort. Using readily available clinical parameters, it is possible to devise an accurate and applicable risk prediction model for the hospitalised cancer patients.

N-acetylcysteine enhances multidrug resistance-associated protein 1 mediated doxorubicin resistance

BACKGROUND

Resistance of cancer cells against anticancer agents is caused partly by multidrug resistance-associated protein 1 (MRP1). The exact mechanism of MRP1-involved multidrug resistance has not yet been clarified, although glutathione (GSH) is likely to have a role for the resistance to occur. N-acetylcysteine (NAC) is a pro-glutathione drug. DL-buthionine (S,R)-sulfoximine (BSO) inhibits GSH synthesis. The aim of our study was to investigate the effect of NAC and BSO on MRP1-mediated doxorubicin resistance in human embryonic kidney (HEK293) and its MRP1-transfected 293MRP cells.

MATERIALS AND METHODS

Human embryonic kidney cells were transfected with a plasmid encoding the whole MRP1 gene. Both cells were incubated with doxorubicin in the presence or absence of NAC and/or BSO. The viability of both cells was determined under different incubation conditions. Glutathione, glutathione S-transferase (GST) and glutathione peroxidase (GPx) levels were measured in the cell extracts obtained from both cells incubated with different drugs.

RESULTS

N-acetylcysteine increased the resistance of both cells against doxorubicin. DL-buthionine (S,R)-sulfoximine decreased NAC-enhanced MRP1-mediated doxorubicin resistance, indicating that induction of MRP1-mediated doxorubicin resistance depends on GSH synthesis. Doxorubicin decreased the cellular GSH concentration and increased GPx activity. Glutathione S-transferase activity was decreased by NAC.

CONCLUSION

Our results demonstrate that NAC enhances MRP1-mediated doxorubicin resistance and this effect depends on GSH synthesis. DL-buthionine (S,R)-sulfoximine seems a promising chemotherapy improving agent in MRP1 overexpressing tumour cells.

Factors associated with utilization of nonproven cancer therapies in Turkey. A study of 135 patients from a single center

In their search for a cure, a significant number of cancer patients use nonproven treatment (NPT) methods. However, little is known about patient and disease characteristics associated with the use of these methods. In this trial, we evaluated the prevalence of and the factors associated with the usage of nonproven cancer remedies in a teaching hospital in Turkey. A self-administered questionnaire was given to 135 cancer patients attending the outpatient clinics of a medical oncology department. Patients' demographic data, their usage of nonproven methods, and possible contributing factors were explored. Our cohort mainly comprised poor patients with only primary school education. Overall, 50% of our patients had used or were using NPT methods. Medicinal herbs (mainly stinging nettle) were the most frequently used remedy. In contrast, such "complementary therapies" as exercise, relaxation, and meditation were not employed. In multivariate analysis, only duration of disease was found to be significantly associated with NPT utilization [P=0.05, relative risk (RR)=1.94]. In addition, patient education level was marginally significant (P=0.07, RR=0.36). Apart from long duration of disease and being better educated, no other clinical, social, economic and cultural factors evaluated were associated with the use of NPT in our group of Turkish patients. Since these treatments are sometimes costly and have questionable efficacy and toxicity, proper scientific trials are needed to clarify whether such methods have a real role in cancer management.

Multidrug resistant malignant melanoma with intracranial metastasis responding to immunotherapy

Metastatic malignant melanoma (MM) is well known for its poor response to chemotherapy, radiotherapy, and its remarkable susceptibility to interleukin-2 (IL-2) based immunotherapies. MM with brain metastatis in particular, has 4-5 months life expectancy from metastasis to death. Drug efflux pumps such as P-glycoprotein (P-gp), or drug detoxifying mechanisms e.g. glutathion epsilon S-transferase-pi (GST) are some of the possible multidrug resistance (MDR) mechanisms in MM. Here we report the first P-gp+ MDR MM with brain metastasis in the literature, demonstrating a remarkable response to IL-2, interferon-alpha (IFN), 5-fluorouracil (5FU) regimen. A 41-year old man was admitted with multiple inoperable brain lesions. Biopsies from intracranial and dermal lesions revealed MM. Cisplatin, carmustine, dacarbazine, tamoxifen (CCDT) together with external cranial radiotherapy were administered, and partial response in lesions and symptoms was achieved. However, after the third course of CCDT treatment, he was admitted to the emergency ward with dramatically increased intracranial lesions, and recurring dermal lesions. A biopsy from the recurred lesions revealed that MM cells were P-gp+, but GST. Administration of a IL-2, IFN and 5FU regimen achieved a remarkable decline in the brain lesions with almost total disappearance of symptoms. He was well and capable of doing work for 18 months. Dermal lesions had not recurred since the beginning of immunotherapy. In contrast, another 34-year old man who developed brain metastases after CCDT for MM, was negative for P-gp and GST. Cranial radiotherapy was started and the above mentioned IL-2 based regimen was administered. However, no response was observed. These two cases together with previous studies demonstrating the susceptibility of P-gp+ MDR cancer cell lines to IL-2 activated killer (LAK) cells in this report suggest that P-gp+ MDR MM is probably a good candidate for IL-2 based treatments.

Lymphokine-activated killer cell susceptibility and multidrug resistance in small cell lung carcinoma

Intrinsic or acquired resistance to anticancer drugs necessitated the search for different treatment modalities. The sensitivity of tumor cells to lysis by natural killer (NK) and lymphokine-activated killer (LAK) cells was studied in multidrug resistant (MDR) small cell lung carcinoma (SCLC) by 51Chromium (51Cr) release and conjugate formation assays. The following observations were made: P-glycoprotein positive (P-gp+) MDR SCLC cell line variants were lysed by human LAK cells to a greater extent than were their drug sensitive counterparts. In contrast, P-gp, multidrug resistance protein positive (MRP+) variants of the same line did not exhibit an increased susceptibility to LAK cells. Differential LAK susceptibility is not due to a generalized increase in target fragility to cellular immunity, because NK sensitivity was not increased. Moreover, the P-gp+ MDR SCLC cells showed a higher frequency of binding to LAK cells than did the drug-sensitive parental line. These observations may lead to new insights on combining chemotherapy with immunotherapy.

The effect of recombinant human granulocyte/macrophage-colony-stimulating factor (rHu GM-CSF) and rHu G-CSF administration on neutrophil chemiluminescence assay in patients following cyclic chemotherapy

Secondary infections related to neutropenia and functional defects of phagocytes are common consequences in patients treated for cancer. The hematopoietic colony-stimulating factors (CSF) have been introduced into clinical practice as additional supportive measures that can reduce the incidence of infectious complications in patients with cancer and neutropenia. The aim of this study was to determine the role of granuolcyte/macrophage(GM)-CSF and granulocyte(G)-CSF in enhancing in vivo human neutrophil function. A luminol-dependent chemiluminescence assay was developed to evaluate whether the repair in neutropenia accompanies the ability of neutrophils to function. A dose of 5 microg G-CSF kg(-1) day(-1) [recombinant human (rHu) G-CSF; filgrastim] or 250 microg GM-CSF m(-2) day(-1) (rHu GM-CSF; molgramostim) was administered subcutaneously once daily to 12 metastatic cancer patients being treated with different cytotoxic regimens. All injections of CSF were given after the initiation of neutropenia and continued until the occurrence of an absolute neutrophil recovery. rHu GM-CSF and rHu G-CSF, administered once daily at the 250 microg m(-2) day(-1) and 5 microg kg(-1) day(-1) level, were effective in increasing the absolute neutrophil count and neutrophil function, as measured by an automated chemiluminescence system.

P-glycoprotein-mediated multidrug resistance and lymphokine-activated killer cell susceptibility in ovarian carcinoma

The sensitivity of tumor cells to lysis by natural killer (NK) and interleukin-2 (IL-2)-activated killer (LAK) cells was studied in three ovarian carcinoma cell lines (2780.9S, SKOV-3, and CHOAUXB1), four multidrug-resistant (MDR) variants, and a melphalan-resistant line. The antitumor activity of LAK cells was evaluated both by 51Cr release and by conjugate formation assays. Four of four P-glycoprotein-positive (P-gp+) MDR ovarian carcinoma cell line variants were lysed by human LAK cells to a greater extent than were their drug-sensitive counterparts. In contrast, a melphalan-resistant ovarian carcinoma cell line that does not overexpress P-gp (P-gp-) did not exhibit an increased susceptibility to LAK cells relative to its parental cell line. Two of the four P-gp+ MDR ovarian carcinoma cell line variants were tested for human NK cell susceptibility and this was found to be unchanged or decreased. The P-gp+ MDR ovarian carcinoma cell line 2780.AD645 showed a higher frequency of tumor cell binding to LAK cells than did the drug-sensitive parental line. A monoclonal antibody (mAb) against a cell surface epitope of P-gp, MRK16, used at 1 microgram/ml, enhanced the LAK susceptibility of P-gp+ MDR ovarian carcinoma cell lines. However, when incubation with 10 micrograms/ml MRK-16 antibody (Ab) was followed by 12.5 micrograms/ml F(ab')2 goat anti-mouse (GAM) immunoglobulin (Ig), the increased LAK susceptibility of P-gp+ MDR cell lines was inhibited. These data strongly suggest that P-glycoprotein-positive MDR ovarian carcinoma cells not only are targets for LAK cells, but are more sensitive than their drug-sensitive parental lines. This is in contrast to their susceptibility to NK cells, which is low to start with and remains unchanged or even decreased in MDR cells. It is postulated here that P-gp or associated changes result in a greater frequency of effector-target cell binding, leading to increased LAK cell cytotoxicity.

P-glycoprotein-mediated multidrug resistance and cytotoxic effector cells

Multidrug resistance (MDR) is one of the major obstacles to successful cancer chemotherapy. MDR is a complex and multifactorial phenomenon. One important and common mechanism used by cancer cells as a defense against cytotoxic drugs is a 170-kD plasma membrane glycoprotein, P-glycoprotein (P-gp). P-gp confers resistance by actively pumping cytotoxic drugs out of cancer cells. Paradoxically, P-gp overexpression on tumor cells is frequently associated with enhanced susceptibility to lymphokine-activated killer cell activity. This enhanced susceptibility is not observed with P-gp- MDR cells, nor is susceptibility to natural killer cells increased. The physiologic, evolutionary and immunologic concepts with regard to the P-gp and the possible intervention of the function of the P-gp in cancer therapy are reviewed.