Baseline mutational profiles of patients with carcinoma of unknown primary origin enrolled in the CUPISCO study

BACKGROUND

Patients with unfavorable carcinoma of unknown primary origin (CUP) have an extremely poor prognosis of ∼1 year or less, stressing the need for more tailored treatments, which are currently being tested in clinical trials. CUPISCO (NCT03498521) was a phase II randomized study of targeted therapy/cancer immunotherapy versus platinum-based chemotherapy in patients with previously untreated, unfavorable CUP, defined as per the European Society for Medical Oncology guidelines. We present a preliminary, descriptive molecular analysis of 464 patients with stringently diagnosed, unfavorable CUP enrolled in the CUPISCO study.

MATERIALS AND METHODS

Genomic profiling was carried out on formalin-fixed, paraffin-embedded tissue to detect genomic alterations and assess tumor mutational burden and microsatellite instability.

RESULTS

Overall, ∼32% of patients carried a potentially targetable genomic alteration, including PIK3CA, FGFR2, ERBB2, BRAFV600E, EGFR, MET, NTRK1, ROS1, and ALK. Using hierarchical clustering of co-mutational profiles, 10 clusters were identified with specific genomic alteration co-occurrences, with some mirroring defined tumor entities.

CONCLUSIONS

Results reveal the molecular heterogeneity of patients with unfavorable CUP and suggest that genomic profiling may be used as part of informed decision-making to identify the potential primary tumor and targeted treatment options. Whether stringently diagnosed patients with unfavorable CUP benefit from targeted therapies in a similar manner to those with matched known primaries will be a key learning from CUPISCO.

Targeted therapies and checkpoint inhibitors in sarcoma

Sarcomas are defined as a group of mesenchymal malignancies with over 100 heterogeneous subtypes. As a rare and difficult to diagnose entity, micrometastasis is already present at the time of diagnosis in many cases. Current treatment practice of sarcomas consists mainly of surgery, (neo)adjuvant chemo- and/or radiotherapy. Although the past decade has shown that particular genetic abnormalities can promote the development of sarcomas, such as translocations, gain-of-function mutations, amplifications or tumor suppressor gene losses, these insights have not led to established alternative treatment strategies so far. Novel therapeutic concepts with immunotherapy at its forefront have experienced some remarkable success in different solid tumors while their impact in sarcoma remains limited. In this review, the most common immunotherapy strategies in sarcomas, such as immune checkpoint inhibitors, targeted therapy and cytokine therapy are concisely discussed. The programmed cell death (PD)-1/PD-1L axis and apoptosis-inducing cytokines, such as TNF-related apoptosis-inducing ligand (TRAIL), have not yielded the same success like in other solid tumors. However, in certain sarcoma subtypes, e.g. liposarcoma or undifferentiated pleomorphic sarcoma, encouraging results in some cases when employing immune checkpoint inhibitors in combination with other treatment options were found. Moreover, newer strategies such as the targeted therapy against the ancient cytokine macrophage migration inhibitory factor (MIF) may represent an interesting approach worth investigation in the future.

OP0102 THE SYNOVIUM IN CHRONIC INFLAMMATORY JOINT DISEASES: COMPARISON OF CLINICAL, HISTOLOGICAL AND scRNA-SEQ Data BETWEEN RA, PsA, SpA AND UA

Background

The synovium is the primary location of inflammation in various rheumatic diseases. However, specific differences of joint inflammation have not been explored on a single-cell level so far.

Objectives

To characterize the synovium of rheumatoid arthritis (RA), psoriatic arthritis (PsA), spondyloarthritis (SpA) and undifferentiated arthritis (UA) based on clinical and histological characteristics and single-cell RNA sequencing (scRNA-seq).

Methods

We performed ultrasound (US) guided synovial biopsy in patients fulfilling classification criteria: 10 RA, 4 PsA, 4 SpA and 3 UA. 3 osteoarthritis (OA) samples were obtained from surgery. Clinical data were collected at time of biopsy. Histological analysis of the synovium included Krenn score [1], synovial pathotype [2], vascularization [3] and presence of lymphoid follicles. OA histology was not available. We prepared scRNA-seq libraries with 10X Genomics and sequenced on NovaSeq 6000. ScRNA-seq data was analysed with Cell Ranger, Seurat and Harmony R packages. We selected overexpressed genes using log2 ratio (>0.25) and FDR adjusted p value < 0.05.

Results

Patients showed typical disease characteristics. In RA, 6/10 were seropositive, 8/10 were female and median age was 59 years (IQR 12). Patients with PsA, SpA and UA were seronegative. 2/4 SpA and 1/4 PsA patients were HLA-B27 positive. Median age was 53 years in PsA (IQR 14.2), 52.5 in SpA (IQR 14.8) and 53 in UA (IQR 3.5). In PsA 3/4, SpA 2/4 and UA 1/3 patients were male.

RA joints had significantly higher B-Mode US scores compared to PsA and SpA joints (mean B-Mode Score: RA 2.7; PsA 2; SpA 2). Correspondingly, RA patients reported a significantly higher amount of swelling in the biopsied joint compared to PsA and SpA (mean “Swelling-Score”: RA 6.85; PsA 4.25; SpA 4).

Histology showed no clear differences in the cell composition; most joints showed a lympho-myeloid pathotype. Mean Krenn Score was highest in RA (4.78) and lowest in SpA (3.33). PD-Mode US score showed a significant positive association with histological vascularization. Lymphoid follicles were significantly more seen in RA compared to all other diseases.

Integration of scRNA-seq data revealed 16 cell clusters with respective marker gene: PRG4 synovial fibroblasts (SF), THY1 SF, ACTA2 smooth muscle cells, VWF endothelial cells, TPSB2 mastcells, IGHG plasma cells, CD79 B-cells, CD69 T-Cells, CCL5 natural killer cells, DMTN Treg-cells, CXC2 neutrophil granulocytes, TREM2 macrophages, CD48 macrophages, CLEC10A macrophages, CD4 dendritic cells, MKI67 proliferating cells. OA had the lowest and RA the highest number of inflammatory cells within the synovium. SpA synovium had the highest number of neutrophils. Re-Clustering of only SF revealed 4 subtypes: PRG4 SF (3578 cells), CXCL12 SF (4539 cells), POSTN SF (2387 cells) and MFAP5 SF (1734 cells). Top 5 marker genes are shown in the Table 1. Most differentially expressed genes in OA were found in PRG4 SF; the previously described OA specific gene CSN1S1 [3] was not only underexpressed in RA but also in other inflammatory joint diseases (Figure 1). PGF, a gene associated with pathological angiogenesis, was one of the top discriminator genes, highly expressed in PsA SF (mostly PRG4 SF). RA SF (mostly CXCL12 SF) showed a high expression of CHI3L1, which is a RA specific autoantigen. High expression of hemoglobin genes was found in SpA PRG4 SF; an unexplored but previously described finding [5, 6].

Table 1.

Top 5 synovial fibroblast (SF) marker genes.

ClusterGenePRG4 SFPRG4CSN1S1MMP3CRTAC1HTRA1CXCL12 SFAPOECXCL12CCL2PTGDSCD74POSTN SFCOMPCOL1A1POSTNCILPPTNMFAP5 SFMFAP5SFRP2APODCXCL14CFD

Conclusion

We were able to compare the synovium of the most common chronic inflammatory joint diseases on various levels for the first time. The findings set the path for future diagnostic, prognostic, and therapeutic approaches in inflammatory joint diseases.

References

[1]Krenn et al, Histopath. 2006

[2]Humby et al, ARD 2019

[3]Kennedy et al, AR 2010

[4]Galligan et al, GI 2007

[5]Yeremenko et al, A&R 2012

[6]Park et al, JRD 2016

Disclosure of Interests

None declared

OP0092 DECIPHERING THE SYNOVIAL TISSUE AND FIBROBLAST SUBSETS IN SYSTEMIC SCLEROSIS

Background

Articular involvement is underestimated in systemic sclerosis (SSc), but represents a major cause of disability and is a marker of disease severity. There is no approved effective therapy for arthritis in SSc and immunosuppressive treatments are given to SSc patients by analogy with rheumatoid arthritis (RA), but with limited effect. The last few years have revolutionized the understanding of the pathogenesis of RA by deciphering the heterogeneity of synovium at both the cellular and molecular levels. Nevertheless, the pathogenesis of joint involvement in SSc remains largely unknown.

Objectives

To characterize the synovium in SSc at tissue and cellular levels and to compare it with RA synovium.

Methods

Nine consecutive patients fulfilling SSc classification criteria and having joint synovitis were included. Patients with overlap with other autoimmune rheumatic diseases were excluded. Synovial tissues (8 wrists, 1 knee) were obtained by ultrasound-guided biopsy and were compared to those obtained from five RF and CCP positive RA patients (3 wrists, 3 knees). Tolerance of the procedure was assessed after 3-5 days. Histological analysis of the synovium determined the Krenn synovitis score (0-9) and stratified the synovial tissue according to previously published histological features1. One biopsy, without synovial tissue, was not processed further. ScRNA-seq libraries were prepared with 10X Genomics technology and sequenced on NovaSeq 6000. Integrated bioinformatics analysis used Cell Ranger and Seurat software. Overexpressed genes were selected using log2 ratio (>0.25) and false discovery rate adjusted p value (< 0.05). For pathway enrichment analysis, Enrichr software was used.

Results

Of the nine SSc-patients, 6 were women, median age was 65 [IQR: 58-67] years, median disease duration was 2 [0.5-5] years and 2 had diffuse cutaneous subtype. The antibody status was as follows: anti-Scl70 (2), anti-centromere (2), anti-RNA polymerase III (3), anti-Ku (1) and isolated ANA (1). In the RA cohort, 4/5 were women, median age was 56 [54-59] years and median disease duration 6.5 [5-7.5] years. Synovial biopsy was well-tolerated by all the patients. Krenn synovitis score was lower in SSc as compared to RA across the three components of the synovitis score (lining layer, stroma and inflammatory infiltrate). In SSc, 7/8 (87.5%) biopsies were characterized by a pauci-immune pathotype, whereas in RA 3/6 (50%) were pauci-immune. Due to the low inflammatory pauci-immune pathotype in all but one SSc patients, we focused the scRNA sequencing analysis on synovial fibroblasts (SF) (number of SF studied: 4876 in SSc and 5885 in RA). We identified four clusters of SF with respective marker genes: SF1 (CXCL12, APOE, RARRES2, CCL2), SF2 (PRG4, MMP1, MMP3, CD55), SF3 (POSTN, ASPN, COMP, COL1A1) and SF4 (FN1, TIMP1, SERPIN2, PRELP). Comparison between SSc and RA SF subtypes showed differences in the proportion of the clusters between both diseases with higher enrichment of SF2 corresponding to the lining SF in SSc. 741 genes were differentially expressed between SSc and RA SF with 414 genes overexpressed in SSc SF. Pathway enrichment analysis of these 414 genes identified TGF-β (p.adj: 3.708e-18) and interferon (p.adj: 1.071e-8) signaling pathways. TGF-β signaling was enriched across all the clusters of SF, whereas interferon signaling mostly in sublining SF. The most overexpressed genes in SSc included PLCG2 (encoding the signaling enzyme PLCγ2, which plays a regulatory role in various immune pathways), PCOLCE2 (encoding a procollagen C-endopeptidase enhancer) and the transcription factor AHR (negative regulator of TGF-β).

Conclusion

Synovitis in SSc differs from RA synovitis both at histological and molecular levels. By highlighting the low inflammatory nature of the synovium and the enrichment in TGF-β and interferon signaling pathways in SSc SF, our study questions the use of the same immunosuppressive therapies in RA and SSc. These results are the basis for the development of specific targeted therapies for arthritis in SSc.

References

[1]Humby F, et al. Ann Rheum Dis 2019;78:761–72.

Disclosure of Interests

Miranda Houtman: None declared, Raphael Micheroli: None declared, Kristina Bürki: None declared, Chantal Pauli: None declared, Sam G. Edalat: None declared, Mojca Frank Bertoncelj: None declared, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur.

Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Caroline Ospelt: None declared, Muriel Elhai Speakers bureau: BMS.

THU0013 INTEGRATED ANALYSIS OF SYNOVIAL SINGLE CELL RNA SEQUENCING DATA DEEPENS THE CURRENT KNOWLEDGE OF SYNOVIAL PATHOLOGY IN ARTHRITIS

Background:

The heterogeneity of synovial tissues from patients with arthritis could contribute to the interpatient variability in disease course, prognosis and treatment response. Single-cell RNA sequencing (scRNA-seq) permits in-depth analysis of tissue heterogeneity, which could facilitate drug discovery and patient stratification for precision medicine.

Objectives:

To construct a comprehensive landscape of synovial cell types and molecular pathways in arthritis by integrating our and published scRNA-seq data, generated across different scRNA-seq technologies [Smart-seq2, Drop-seq], cell preparation protocols [dissociated unsorted, sorted cells] and types of arthritis [undifferentiated (UA), rheumatoid arthritis, osteoarthritis].

Methods:

Synovial tissues were obtained by ultrasound-guided biopsy from patients with UA [not fulfilling the classification criteria for a specific arthritis, n=3]. Biopsies were disintegrated [enzymatic and mechanical disruption] and cell viability assessed with trypan blue. ScRNA-seq libraries [2 per patient] were prepared with 10X Genomics Drop-Seq and sequenced on NovaSeq6000. Bioinformatics analysis of our and published [n=35] datasets1-3was performed using Seurat protocol4with correction for batch effects and filtering low-quality cells. Functional enrichment analysis of marker genes in clusters was done with STRING Protein-Protein networks. Synovitis was assessed with ultrasound and histology.

Results:

Our tissue disintegration protocol resulted in good cell yield and viability (92%, 72%, 100%). The synovial cellular heterogeneity detected by scRNA-seq reflected the histological findings [Krenn score, pathotype]. These were supported with the ultrasound and clinically assessed disease activity. The integrated analysis of 41 datasets from 38 donors yielded 41845 scRNA-seq cell profiles, 50% contributed by our dataset. An independent analysis of our data and their integration with published data showed that different scRNA-seq methods and protocols can identify all the major synovial cell types and their activation states (Figure 1) with large heterogeneity between donors. We identified a previously undescribed synovial cell population, which was located near the fibroblast cluster, was negative for canonical cell markers, but highly enriched in cell division genes (80% of marker genes). These cells comprised a mixed population of CD34-, podoplanin (PDPN)highor PDPNlowcells that were mostly negative for the sub-lining fibroblast marker THY. Furthermore, they appeared to be highly secretory (extracellular matrix components) and their gene expression profile was inclined towards cell migration, vascular development and insulin growth factor-dependent processes.

Figure 1.

Heatmap with top 20 cluster gene markers, gene enrichment analysis and UMAP plot of synovial cell clusters.

Conclusion:

By integrating synovial scRNA-seq data from 41845 cells, we identified a previously undescribed, highly proliferative and secretory synovial cell population in arthritis. We increased the number of known scRNA-seq synovial cell profiles in arthritis by two-fold and demonstrated the robustness of synovial scRNA-seq data outputs across different technologies and protocols. This broadens the current knowledge of synovial tissue heterogeneity and pathology in arthritis.

References:

[1]Stephenson W. et al. Nat Commun 2017.

[2]Mizoguchi F. et al. Nat Commun 2017.

[3]Zhang F. et al. Nat Immunol 2018.

[4]Stuart T et al. Cell 2019

Acknowledgments:

This work is supported by Vontobel Foundation and medAlumni University of Zurich

Disclosure of Interests:

Sam G. Edalat: None declared, Raphael Micheroli: None declared, Tadeja Kuret: None declared, Kristina Buerki: None declared, Chantal Pauli: None declared, Snežna Sodin-Šemrl: None declared, Adrian Ciurea Consultant of: Consulting and/or speaking fees from AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Merck Sharp & Dohme, Novartis and Pfizer., Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche, Caroline Ospelt Consultant of: Consultancy fees from Gilead Sciences., Gregor Rot: None declared, Mojca Frank-Bertoncelj: None declared

Challenges in diagnosis and management of neutropenia upon exposure to immune-checkpoint inhibitors: meta-analysis of a rare immune-related adverse side effect

BACKGROUND

Cancer immunotherapy via immune-checkpoint inhibition (ICI) by antibodies against cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and cell death protein 1 (PD-1) have significantly improved the outcome of metastasized melanoma and of a rapidly increasing number of other cancer types. The anti-tumor effect is often accompanied by immune-related adverse events (irAE). Hematological irAE, specifically neutropenia, are rarely observed. However, neutropenia is associated with high morbidity and mortality due to infection complications. Thus, early detection and treatment is crucial.

METHODS

We present the clinical course of two patients with severe neutropenia after ICI therapy and demonstrate the difficulty of the diagnosis when a comedication of metamizole, a well-known analgesic drug used to treat cancer pain, is present. Further, we provide a comprehensive descriptive and statistical analysis of published data on diagnostics, treatment and infection complication in patients with at least grade 4 neutropenia by a systematic database search.

RESULTS

Finally, 34 patients were analyzed, including the two case reports from our cohort. The median onset of neutropenia was 10.5 weeks after first ICI administration (interquartile range: 6 weeks). In 76% (N = 26), a normalization of the neutrophil count was achieved after a median duration of neutropenia of 13 days. In a subsample of 22 patients with detailed data, the infection rate was 13%, proven by positive blood culture in 3 cases, but 68% (N = 15) presented with fever > 38 °C. Treatment regime differed relevantly, but mainly included G-CSF and intravenous corticosteroids. Death was reported in 14 patients (41%), 3 of whom (9%) were associated with hematological irAE but only two directly associated with neutropenia.

CONCLUSION

With an increasing number of cancer patients eligible to ICI therapy, the incidence of severe hematological toxicities may rise substantially over the next years. Clinicians working in the field of cancer immune therapies should be aware of neutropenia as irAE to provide immediate treatment.

[Establishment of a living biobank : Improved guidance of precision cancer care with in vitro and in vivo cancer models]

BACKGROUND

Precision oncology is a clinical approach aimed towards tailoring treatment strategies for patients based on the genetic profile of each patient's cancer. The integration of a living biobank, consisting of patient-derived tumor organoids and PDXs, with next generation sequencing approaches and high-throughput drug screening help to guide clinical decision-making and clinical trial development.

METHODS

Tumor organoids derived from fresh tumor samples were used for in vitro and in vivo high-throughput drug testing.

RESULTS

Over a period of two years we established 56 in vitro tumor organoids and 19 in vivo xenografts from 18 different solid tumor types. Tumor morphology and molecular profiles show good concordance between the in vitro and in vivo models compared to their native tumor. High-throughput drug screening (up to 160 drugs) has been tested on eight tumor organoid lines. Seven of them underwent an additional combination drug screen. We nominated several targeted small molecules and novel combinations that have been validated in corresponding xenograft models.

CONCLUSION

This precision medicine approach outlines the integration of genomic data with drug screening from personalized preclinical cancer models to guide precision cancer care. It also fuels next generation research and has been implemented for clinical trial development.

Comparison of cartilage histopathology assessment systems on human knee joints at all stages of osteoarthritis development

OBJECTIVE

To compare the MANKIN and OARSI cartilage histopathology assessment systems using human articular cartilage from a large number of donors across the adult age spectrum representing all levels of cartilage degradation.

DESIGN

Human knees (n=125 from 65 donors; age range 23-92) were obtained from tissue banks. All cartilage surfaces were macroscopically graded. Osteochondral slabs representing the entire central regions of both femoral condyles, tibial plateaus, and the patella were processed for histology and Safranin O - Fast Green staining. Slides representing normal, aged, and osteoarthritis (OA) tissue were scanned and electronic images were scored online by five observers. Statistical analysis was performed for inter- and intra-observer variability, reproducibility and reliability.

RESULTS

The inter-observer variability among five observers for the MANKIN system showed a similar good Intra-class correlation coefficient (ICC>0.81) as for the OARSI system (ICC>0.78). Repeat scoring by three of the five readers showed very good agreement (ICC>0.94). Both systems showed a high reproducibility among four of the five readers as indicated by the Spearman's rho value. For the MANKIN system, the surface represented by lesion depth was the parameter where all readers showed an excellent agreement. Other parameters such as cellularity, Safranin O staining intensity and tidemark had greater inter-reader disagreement.

CONCLUSION

Both scoring systems were reliable but appeared too complex and time consuming for assessment of lesion severity, the major parameter determined in standardized scoring systems. To rapidly and reproducibly assess severity of cartilage degradation, we propose to develop a simplified system for lesion volume.

Macroscopic and histopathologic analysis of human knee menisci in aging and osteoarthritis

OBJECTIVE

Meniscus lesions following trauma or associated with osteoarthritis (OA) have been described, yet meniscus aging has not been systematically analyzed. The objectives of this study were to (1) establish standardized protocols for representative macroscopic and microscopic analysis, (2) improve existing scoring systems, and (3) apply these techniques to a large number of human menisci.

DESIGN

Medial and lateral menisci from 107 human knees were obtained and cut in two different planes (triangle/cross section and transverse/horizontal section as well) in three separate locations (middle portion, anterior and posterior horns). All sections included vascular and avascular regions and were graded for (1) surface integrity, (2) cellularity, (3) matrix/fiber organization and collagen alignment, and (4) Safranin-O staining intensity. The cartilage in all knee compartments was also scored.

RESULTS

The new macroscopic and microscopic grading systems showed high inter-reader and intra-reader intraclass correlation coefficients. The major age-related changes in menisci in joints with no or minimal OA included increased Safranin-O staining intensity, decreased cell density, the appearance of acellular zones, and evidence of mucoid degeneration with some loss of collagen fiber organization. The earliest meniscus changes occurred predominantly along the inner rim. Menisci from OA joints showed severe fibrocartilaginous separation of the matrix, extensive fraying, tears and calcification. Abnormal cell arrangements included decreased cellularity, diffuse hypercellularity along with cellular hypertrophy and abnormal cell clusters. In general, the anterior horns of both medial and lateral menisci were less affected by age and OA.

CONCLUSIONS

New standardized protocols and new validated grading systems allowed us to conduct a more systematic evaluation of changes in aging and OA menisci at a macroscopic and microscopic level. Several meniscus abnormalities appear to be specific to aging in the absence of significant OA. With aging the meniscal surface can be intact but abnormal matrix organization and cellularity were observed within the meniscal substance. The increased Safranin-O staining appears to represent a shift from fibroblastic to chondrocytic phenotype during aging and early degeneration.

[Polyposis nasi--improvement in quality of life by the influence of leukotrien receptor antagonists]

BACKGROUND

Sulfido-Leukotrienes are important inflammatory mediators of bronchial asthma, intolerance of acetylsalicylic acid (ASA), polyposis nasi and allergic rhinitis. Receptorantagonists like Montelukast constitute a well-established asthma- and ASA intolerance-therapy. The aim of our study was to evaluate changes in patients Health-Related-Quality-of-Life (HRQL) during Montelukast-monotherapy of nasal polyposis.

METHODS

The study was performed in a prospective, double blind and placebo-controlled matter. The study included 30 patients of our ENT outpatient's dept. (77 % male, mean age 49 yrs), suffering from nasal polyposis grade II to IV. Polyps were endoscopically graded, nasal Eosinophilic Cationic Protein (ECP) was measured, and HRQL-score was taken prior to and four weeks after Montelukast-(0 - 0 - 10 mg) compared to placebo. An established HRQL-questionnaire - including 25 items, summarized in 6 symptom-groups - was used. Given was a symptom-score of 1 (not troubled) to 4 (extremely troubled).

RESULTS

Patients treated with Montelukast improved their nasal symptoms (Delta HRQL-score 0.58 +/- 0.94, P < 0.01), practical problems (Delta HRQL-score 0.42 +/- 0.71, P < 0.05), headaches (Delta HRQL-score 0.38 +/- 0.56, P < 0.05), non-nasal symptoms (Delta HRQL-score 0.35 +/- 0.92, P < 0.05), sleep (Delta HRQL-score 0.26 +/- 0.71) and emotional problems (Delta HRQL-score 0.18 +/- 0.75). Intranasal ECP (Delta 210.67 ng/ml +/- 332.68) and polyp grading (Delta 0.72 +/- 1.77) tended to improve as well, but did not reach statistical significance. Patients treated with placebo revealed no significant changes neither in HRQL-score, ECP, nor polyp grading.

CONCLUSIONS

Montelukast-therapy of nasal polyposis significantly improved patient's HRQL in 4 out of 6 symptom-groups. Measuring HRQL proofed to constitute a more sensitive tool than looking at eosinophilic parameters of inflammation or polyp size.

Clinical relevance of circulating tumour cells in the bone marrow of patients with SCCHN

BACKGROUND

Clinical outcome of patients with head and neck squamous cell carcinoma (SCCHN) depends on several risk factors like the presence of locoregional lymph node or distant metastases, stage, localisation and histologic differentiation of the tumour. Circulating tumour cells in the bone marrow indicate a poor prognosis for patients with various kinds of malignoma. The present study examines the clinical relevance of occult tumour cells in patients suffering from SCCHN.

PATIENTS AND METHODS

Bone marrow aspirates of 176 patients suffering from SCCHN were obtained prior to surgery and stained for the presence of disseminated tumour cells. Antibodies for cytokeratin 19 were used for immunohistochemical detection with APAAP on cytospin slides. Within a clinical follow-up protocol over a period of 60 months, the prognostic relevance of several clinicopathological parameters and occult tumour cells was evaluated.

RESULTS

Single CK19-expressing tumour cells could be detected in the bone marrow of 30.7% of the patients. There is a significant correlation between occult tumour cells in the bone marrow and relapse. Uni- and multivariate analysis of all clinical data showed the metastases in the locoregional lymph system and detection of disseminated tumour cells in the bone marrow to be statistically highly significant for clinical prognosis.

CONCLUSION

The detection of minimal residual disease underlines the understanding of SCCHN as a systemic disease. Further examination of such cells will lead to a better understanding of the tumour biology, as well as to improvement of diagnostic and therapeutic strategies.

[Acute otitis media in childhood]

Because of its distinct anatomy, pathogens can quickly reach the middle ear of a child and cause acute otitis media. Depending on the age of the child, the clinical symptoms can vary from intense earaches, fever, pressure sensation and hearing loss to vomiting, diarrhea and refusal of food by infants. The progression of otitis media through four phases can be observed in an otoscopic examination. To improve Eustachian tube ventilation in uncomplicated cases, nose drops to reduce swelling along with pain therapy are employed first. Antibiotics can be administered to reduce the rate of complications from, for example, mastoiditis, paresis of the facial nerve, and labyrinthitis. In recurrent middle ear infections, an operative therapy should also be considered.

MHC-class I antigen expression on micrometastases in bone marrow of patients with head and neck squamous cell cancer

Although squamous cell carcinoma of the head and neck region very rarely metastasize to the skeleton, epithelial cells have been found in bone marrow aspirates of these patients. This observation reflects the general spread of the disease, indicating a poor clinical prognosis with a much higher risk of developing local or distant recurrences. In a first attempt to characterize the phenotypic properties, the expression of the major histo-compatibility complex (MHC) class I antigens on bone marrow micrometastases was assessed. It has been shown that the down-regulation of these molecules is a potential mechanism to escape from HLA class I restricted lysis by cytotoxic T-cells. The significance of reduced MHC class I expression might be relevant for the survival of residual metastatic cells in the bone marrow of patients with squamous cell carcinoma of the head and neck region. Bone marrow aspirates were screened for individual disseminated epithelial cells using the immunoalkaline phosphatase technique with monoclonal antibodies to the epithelial differentiation marker cytokeratin 19 (CK19), as described previously. Specimens containing CK19-positive cells were colabelled with the monoclonal antibody W6/32. The loss of MHC expression is not related to the tumor stage but clearly to the degree of differentiation: 6 out of 7 patients with low-grade SCCHN, but only 3 out of 13 patients with medium-grade SCCHN showed a complete loss of MHC class I molecules. This finding could indicate the reduced prognosis of undifferentiated SCCHN. The lack of MHC class I expression could encourage the survival of residual tumor cells in the bone marrow of patients with SCCHN that evade immunosurveillance.

U7 snRNAs induce correction of mutated dystrophin pre-mRNA by exon skipping

Most cases of Duchenne muscular dystrophy are caused by dystrophin gene mutations that disrupt the mRNA reading frame. Artificial exclusion (skipping) of a single exon would often restore the reading frame, giving rise to a shorter, but still functional dystrophin protein. Here, we analyzed the ability of antisense U7 small nuclear (sn)RNA derivatives to alter dystrophin pre-mRNA splicing. As a proof of principle, we first targeted the splice sites flanking exon 23 of dystrophin pre-mRNA in the wild-type muscle cell line C2C12 and showed precise exon 23 skipping. The same strategy was then successfully adapted to dystrophic immortalized mdx muscle cells where exon-23-skipped dystrophin mRNA rescued dystrophin protein synthesis. Moreover, we observed a stimulation of antisense U7 snRNA expression by the murine muscle creatine kinase enhancer. These results demonstrate that alteration of dystrophin pre-mRNA splicing could correct dystrophin gene mutations by expression of specific U7 snRNA constructs.

The significance of Tenascin-C serum level as tumor marker in squamous cell carcinoma of the head and neck

BACKGROUND

Tenascin, an extracellular matrix glycoprotein, is transiently present in embryonic tissue, in benign granulation tissue, but also in several highly anaplastic tumors like fibrosarcoma, melanoma and squamous cell carcinoma of the skin. This study was performed to validate elevated Tenascin serum levels as a possible marker for head and neck squamous cell carcinomas (HNSCC).

PATIENTS AND METHODS

Tenascin serum levels were evaluated in patients with primary (n = 92) and with recurrent (n = 28) HNSCC. Patients with benign, non inflammatory ear, nose and throat diseases (n = 16) served as the control. The Tenascin serum levels were measured by ELISA (Aventis).

RESULTS

Serum Tenascin concentrations of patients with benign ENT diseases ranged between 0.37 and 2.19 micrograms/ml (n = 16, mean +/- SD: 1.23 +/- 0.59 micrograms/ml), of patients with HNSCC (primary diagnosis) between 0.05 and 8.75 micrograms/ml (n = 92, mean +/- SD: 1.81 (1.36 micrograms/ml) and of patients with recurrent HNSCC between 0.53 and 10.0 micrograms/ml (n = 28, mean +/- SD: 2.78 +/- 2.2 micrograms/ml).

CONCLUSION

We found a significant elevation of Tenascin serum levels only in patients with higher tumor stages (T4/UICC4) (p < 0.01/p < 0.1) or recurrent disease compared to Tenascin serum levels in healthy controls. Thereby Tenascin serum levels cannot be used clinically as a routine serum marker for the control of head and neck cancer. Further investigations are necessary to evaluate whether the measurement of Tenascin levels as tumor markers could offer additional information to the clinical outcome of patients with HNSCC.

Cardiac output determination in children: equivalence of the transpulmonary thermodilution method to the direct Fick principle

OBJECTIVE

To show the equivalence of the transpulmonary thermodilution method to the direct Fick principle in children.

DESIGN

Prospective single-centre study.

SETTING

A 16-bed paediatric cardiac ICU and a cardiac catheterisation laboratory at an university affiliated centre for paediatric cardiology and congenital heart disease.

PATIENTS

We consecutively investigated 18 patients (mean age 12.1 +/- 6.4 years) during cardiac catheterisation and after corrective cardiac operation.

METHODS AND RESULTS

We prospectively defined limits of equivalence for cardiac index (CI) for both methods of +/- 0.25 l/min x m(2). We measured oxygen consumption for determination of CI by Fick as the clinical "gold standard" and performed a set of three transpulmonary thermodilution measurements. The mean CI(Fick) was 2.88 +/- 1.07 l/min x m(2) (range 1.10-4.62 l/min x m(2)) and CI(TPID)was 2.85 +/- 1.03 l/min x m(2)(range 1.02-4.49 l/min x m(2)). The mean difference between CI(Fick) and CI(TPID)was 0.030 +/- 0.168 l/min x m(2), and limits of agreement -0.306 to 0.366 l/min x m(2)(90% confidence interval -0.040 to 0.099 l/min x m(2)). The regression equation was : CI(Fick)=1.0244 x CI(TPID)-0.040, r(2) = 0.976, P < 0.0001. The intraclass coefficient of reliability for three repeated measurements of CI(TPID) was 0.97, the corresponding lower limit of the 95% confidence interval was 0.94.

CONCLUSION

We demonstrated the equivalence of CI measurement by transpulmonary thermodilution and the Fick principle in children. This new method may improve hemodynamic monitoring and management in seriously ill children.

[Dyspnea caused by leiomyomatous tumor of the oropharynx]

BACKGROUND

Leiomyoma and Leiomyosarkoma are not often found in ENT-diseases.

PATIENTS

We report on a 62-year old female patient presenting with a 3 x 4 cm tumor in the oropharynx that had developed within a period of about three weeks. The patient complained of increasing dysphagia and dyspnea especially when lying on the left side. To secure breathing the patient had to be primarily ventilated by placing a needle percutaneously through the conical ligament and was then intubated. For this procedure the patient was positioned on the right side. The tumor measuring 3 cm, was removed surgically.

RESULTS

The tumor turned out to be a leiomyomatous neoplasia of undetermined malignant potential. Since an unfavourable behaviour of such neoplasms cannot be excluded, patients with tumors of this type should be followed closely.

CONCLUSIONS

In this case the tumor leads to an acute dyspnoea and a special procedure of anesthesia was necessary. Therapeutic considerations and differential diagnosis of this very rare tumor of the oropharynx are discussed by reviewing the literature.

[IL-2 gene therapy in ENT carcinomas]

Suppressed cellular immunity is common in patients with squamous cell carcinoma of the head and neck (HNSCC). It was demonstrated in previous studies that administration of interleukin 2 (IL-2) results in enhanced antitumoral immunity in vitro as well as in vivo. Since the serum half-life of IL-2 is relatively short, repeated applications are necessary to achieve therapeutically effective serum concentrations, but this strategy might cause severe side effects. Therefore, methods that provide high local cytokine levels over a prolonged period of time without the need for repeated injections are desirable. Gene therapy as an innovative treatment approach using tumor cells stably transduced to produce IL-2 might meet these criteria. In vitro manipulated tumor cells, if readministered in the vicinity of non-manipulated tumor cells, may enhance a specific anti-tumor response in vivo without systemic side effects. The present manuscript reviews the current literature dealing with IL-2-protein and -gene therapy with special emphasis on head and neck cancer. Our own in vitro results with IL-2 gene therapy in conjunction with published data from other authors argue in favour of an in vivo approach for this therapeutic strategy that is currently in progress in our department.

Abeta-induced inflammatory processes in microglia cells of APP23 transgenic mice

A microglial response is part of the inflammatory processes in Alzheimer's disease (AD). We have used APP23 transgenic mice overexpressing human amyloid precursor protein with the Swedish mutation to characterize this microglia response to amyloid deposits in aged mice. Analyses with MAC-1 and F4/80 antibodies as well as in vivo labeling with bromodeoxyuridine demonstrate that microglia in the plaque vicinity are in an activated state and that proliferation contributes to their accumulation at the plaque periphery. The amyloid-induced microglia activation may be mediated by scavenger receptor A, which is generally elevated, whereas the increased immunostaining of the receptor for advanced glycation end products is more restricted. Although components of the phagocytic machinery such as macrosialin and Fc receptors are increased in activated microglia, efficient clearance of amyloid is missing seemingly because of the lack of amyloid-bound autoantibodies. Similarly, although up-regulation of major histocompatibility complex class II (IA) points toward an intact antigen-presenting function of microglia, lack of T and B lymphocytes does not indicate a cell-mediated immune response in the brains of APP23 mice. The similar characteristics of microglia in the APP23 mice and in AD render the mouse model suitable to study the role of inflammatory processes during AD pathogenesis.

Gene therapy--phase I trial for primary untreated head and neck squamous cell cancer (HNSCC) UICC stage II-IV with a single intratumoral injection of hIL-2 plasmids formulated in DOTMA/Chol

Recombinant IL-2 protein has shown many immunostimulatory effects in a variety of human tumors. However, the clinical use of rIL-2 is limited by common and serious side effects after systemic administration. IL-2 expression plasmids may circumvent these drawbacks, producing high local IL-2 concentrations that cause limited or no systemic side effects. Due to the superficial growth of squamous cell carcinoma of the head and neck (HNSCC) are readily accessible for direct intratumoral injection and therefore an optimal target for such a gene therapy approach. There has been evidence for local and systemic activation of immune cells by peritumoral injections of IL-2 in patients with advanced HNSCC (Whiteside et al. 1993; Cortesina et al. 1994; De Stefani et al. 1996). We now perform a placebo-controlled, dose-rising study of the safety and tolerability of a single intratumoral injection of hIL-2 plasmid at four dose levels formulated in DOTMA/Chol in patients with primary untreated head and neck squamous cell cancer (HNSCC) TNM stage II-IV. The patients will be monitored for the occurrence of any adverse reactions to the given medication. In addition, we will determine whether the intratumoral administration of the plasmid induces and or enhances tumor-specific host responses at the immunological and or clinical level.

Immunochemical detection of CoA-modified mitochondrial matrix proteins

An in vitro assay mixture consisting of mitochondrial matrix proteins from rat liver and CoA resulted in the formation of CoA-modified proteins. CoA-modified proteins were demonstrated by detection of CoA. CoA was released from the proteins by dithioerythritol treatment under denaturing conditions and was identified by (a) its retention time on HPLC, (b) its absorption spectrum and (c) its activity in a CoA-specific assay. This CoA represents protein-bound CoA and, in addition, protein-bound palmitoyl-CoA when MgATP was also present in the in vitro assay. The detection of immunoreactive proteins using mono-specific anti-CoA antibodies exclusively identifies CoA-modified proteins. The specificity of these antibodies can be used to identify both endogenously occurring CoA-modified proteins and proteins that have been modified in the in vitro assay. An intact thiol group of CoA is an essential precondition for the modification to occur.

Action and binding of the endothelin antagonist bosentan on astrocytes of cultured rat central nervous system. Electrophysiological and autoradiographic studies

Our autoradiographic studies demonstrate that astrocytes in explant cultures of rat central nervous system possess binding sites for the first orally active, mixed, nonpeptide endothelin receptor antagonist [3H] bosentan. Binding of [3H]bosentan was inhibited by unlabelled bosentan and endothelin-1 at high concentrations, suggesting specific binding of the antagonist. Electrophysiological studies have revealed that bosentan reversibly blocked the depolarizations by endothelin but not by angiotensin II, indicating that the antagonist specifically antagonizes the action of endothelin on the glial membrane. This is consistent with biochemical studies from other laboratories demonstrating that bosentan did not interfere with binding of angiotensin II. The availability of bosentan, a potent and selective endothelin receptor antagonist should help to elucidate the role of endothelin on astrocyte function.

Immunoblot detection of antibodies to Toscana virus

Sera from patients with sandfly fever caused by Toscana virus (TOSV) infection were tested by immunoblot for specific antibody response to TOSV derived from infected Vero-E6 cells. The 28 kDa TOSV nucleoprotein (N) was identified as the major immunodominant protein recognized by immunoblot. In sera of patients with acute TOSV infection, specific antibodies of the IgM, IgA, and IgG class were detected. Using sandfly fever virus, serotypes Sicilian (SFSV) and Naples (SFNV), as antigens for immunoblot, TOSV antibody-positive sera cross-reacted with the corresponding N proteins. These sera reacted for IgM and IgG by SFSV immunoblot, and for IgM by SFNV immunoblot. The diagnosis of sandfly fever may be confirmed by TOSV immunoblot.

Travel-related vector-borne virus infections in Germany

Laboratory diagnosis of imported, vector-borne virus diseases during a 22-month-period in Munich, Germany, is summarized. IN 13/317 Germans returning from the Mediterranean with suspected sandfly fever, acute sandfly fever, serotype Toscana, was confirmed serologically: 84.6% of the infections were acquired in Italy. Of 249 German tourists with febrile disease returning from the tropics, acute infection with dengue virus was diagnosed serologically in 26 (10.4%): most infections were acquired in Thailand (57.7%). In a seroepidemiological study of 670 German aid workers who had spent two years in the tropics, 49 (7.3%) were positive for antibodies to dengue, 9 (1.3%) to chikungunya, and 1 (0.1%) to Sindbis virus. Of 17 Middle Eastern patients with suspected viral haemorrhagic fever, genomic Crimean-Congo haemorrhagic fever virus RNA was amplified in 4 (23.5%) by semi-nested reverse transcriptase polymerase chain reaction, and confirmed by molecular characterization of nucleic acid. With the increase in travel to and from endemic areas, imported vector-borne virus infections are increasingly important in Germany.

[Neurological symptoms after an infection by the sandfly fever virus]

CASE 1: A few days after returning from a holiday in Italy a 50-year-old man developed acute gastrointestinal symptoms, followed by headache, fever and joint pains. After transitory remission he had a relapse with fever, headache and meningitis 2 weeks later. Cerebrospinal fluid contained gram-negative diplococci, but no bacteria grew on culture. Under the suspected diagnosis of meningitis he was treated with penicillin. Ten days later he suddenly developed deafness in his right ear. The various signs and symptoms gradually disappeared and the patient was discharged after 24 days in hospital. Retrospectively serological tests indicated sandfly fever (SF) virus infection with serotype Toscana. This is thought to be the first reported case of deafness associated with this disease. CASE 2: One week after returning from a holiday in Tunisia a 34-year-old man fell ill with fever, headache, rigor, nausea, joint pains and a maculopapular rash for which he was treated as an outpatient. The symptoms improved after 7 days, except for the headache which persisted another 5 days. Serology demonstrated an acute infection by SF virus, serotype Sicilian.

CONCLUSION

Sandfly fever should be included in the differential diagnosis of headache, fever and signs of meningitis in persons who have recently been to mediterranean countries.

[Meningitis after travel in the Mediterranean region, caused by the sandfly fever virus]

Sandfly fever virus is the causative agent of sandfly fever (pappataci fever). The virus is endemic in the Mediterranean region and is transmitted by bites of Phlebotomus species. The three sandfly fever virus serotypes, Sicilian (SFS), Naples (SFN) and Toscana (TOS), are of travel-related significance. In addition to a flu-like illness, the sandfly fever virus may result in a serious neurological disease with meningitis and encephalitis. Due to the high number of travelers may occur in nonimmune persons. Since many clinicians are not aware of this disease, sandfly fever is still rarely diagnosed.

Serosurvey and laboratory diagnosis of imported sandfly fever virus, serotype Toscana, infection in Germany

Of eight acute infections in German tourists caused by sandfly fever virus, serotype Toscana (TOS), and diagnosed clinically and serologically, seven were acquired during visits to Tuscany, Italy, and one to Coimbra, Portugal. An indirect immunofluorescence assay (IFA) using infected cells, and a newly developed enzyme-immunoassay (EIA) using crude virus antigen prepared from infected Vero-E6 cells was used to detect anti-TOS IgM and IgG. In a seroepidemiological survey of 859 health care workers and medical students, anti-TOS IgG was detected in 1.0% by IFA, and in 0.7% by EIA. In 2034 German patients hospitalized for various diseases, 1.6% were positive for anti-TOS IgG by IFA, and 0.8% by EIA. Anti-TOS IgG was detected in 43 samples of commercial immunoglobulins at titres of 10-1000 by EIA. Although the seroprevalence of antibodies to TOS is low in Germany, TOS infection should be considered in patients returning from endemic areas who complain of fever, and headaches, and have symptoms of meningitis.

[Amniocentesis: psychological stress and coping by the pregnant female]

Anxiety as induced by aminocentesis and consequential strategies for coping there with, are the focus of this study. A group of 32 women were selected for AC due to age, and a second group of 30 women as a result of risk factors in the case history. Anxiety related to AC was self-assessed by the patients and coping strategies were rated according to the "Bernese Coping Modes" prospectively and retrospectively. Results indicate, that AC is anxiety-inducing, but does not vary with parity, indication or the degree of information, but solely with the fact of preexisting experience or absence of such with AC. 50% of the patients would have been willing to interrupt the pregnancy, had the result indicated a high risk of malformation. The coping with the waiting time until the result of AC was known was such, that the "age" group showed a great deal of optimism, whereas the risk group used several coping modes, which are more complex and also potentially problematic. This does not make the somatic risk group a psychological hazard group, but nevertheless suggests, that professionals should stand by to intervene on a psychological plane.

Treatment of acute nonlymphoblastic leukemia in adults with daunorubicin-DNA complex: a preliminary report

Forty-four adult patients under 60 years of age with acute nonlymphoblastic leukemia were randomized for induction treatment with one of the following three regimens: R 1 = courses of daunorubicin on day 1 + ARA-C on days 1--5; R 2 = courses of daunorubicin on days 1 and 2 + ARA-C on days 4--8; R 3 = courses of daunorubicin-DNA complex on days 1--2 + ARA-C on days 4--8. Out of 14 patients, 9 went into remission on R 1, 6 out of 14 on R 2, and 8 out of 16 on R 3. The preliminary results suggest that daunorubicin-DNA complex has the same efficacy for inducing remission as daunorubicin alone, if the same time intervals and dosages are used.