Abstract PD8-04: Neoadjuvant chemotherapy for breast cancer: Nodal downstaging is highly correlated with pathological complete response

Background: Neoadjuvant chemotherapy (NAC) is employed in patients with larger tumors to attempt to downstage locally advanced cancers to allow breast conservation and to assess in vivo tumor response. The Multi-Institutional Neoadjuvant Therapy MammaPrint Project I (MINT) study asked a secondary question of whether complete nodal downstaging could also be achieved with NAC.

Methods: This analysis included 147 eligible invasive breast cancer patients with high tumor burdens, classified as cT2-4N0-3M0 (T2 greater than 3.5cm if N0). Patients who had a positive core biopsy and/or fine needle aspiration (FNA) on an axillary node prior to starting NAC were included in this analysis. Those who had a surgical sentinel lymph node biopsy were not included. Nodal involvement was established following neoadjuvant treatment by axillary lymph node dissection (ALND).

Results: This population was 54% postmenopausal, average age 53 yrs (range 25 to 80 yrs). Tumor characteristics were 91% invasive ductal carcinoma; 65% T2, 29% T3, 6% T4; 87% LN1, 13% LN2-3; 3% low grade, 38% intermediate grade, 59% high grade; 65% ER-positive, 49% PR-positive, and 28% HER2-positive by immunohistochemistry; 84% High Risk (HR) and 16% Low Risk (LR) by MammaPrint (MP). After NAC, 45% (66/147) of these LN-positive patients were down-staged to ypN0 and also achieved a complete pathological response in the primary tumor. The potential for down-staging was inversely-related to tumor burden, where 47% (60/128) of N1, 35% (6/17) of N2, and 0% (0/2) of N3 patients were down-staged to ypN0. There were 3 patients who were down-staged (2 N2 to N1, and 1 N3 to N2), but not to ypN0. At surgery, 34% (44/128) of patients had no change, and 19% (24/129) progressed in LN staging.

Pre vs Post NAC Nodal StagePre NAC Nodal StageypN0ypN1ypN2ypN3TotalcN16044222128cN2626317cN3  112Total6646296147

Conclusions: We confirmed that upon achieving a complete response of the primary tumor that there was also a pathologic complete response in the LN. About 53% of patients had no change or progression of LN involvement following NAC.

Citation Format: Blumencranz P, Habibi M, Treece T, Blumencranz L, Yoder E, Audeh W, Carter E, McNaughton L, Roussos J, Shivers S, Acs G, Cox C, MINT Investigators Group. Neoadjuvant chemotherapy for breast cancer: Nodal downstaging is highly correlated with pathological complete response [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD8-04.

Abstract P6-09-45: Long-term follow-up of early stage breast cancer patients with results of MammaPrint®, Oncotype DX® and MammoStrat® risk classification assays

Introduction: The use of genomic tests for the prediction of breast cancer recurrence is becoming more common. MammaPrint® (MP, Agendia Inc.) is a 70-gene microarray assay designed to assess the 10-year risk of recurrence in an untreated population that was not selected for ER/HER2 results. The Oncotype DX® Recurrence Score® (RS, Genomic Health, Inc.) is a 21-gene RT-PCR assay that is clinically validated to predict the 10-year risk of distant recurrence in ER+ patients treated with Tamoxifen. MammoStrat® (MS, Clarient, Inc.) is an IHC assay that uses 5 antibodies and has been validated in a similar population as RS. Several recent reports show that these assays classify patients differently with significant discordances for all risk groups (Shivers, et al., SABCS 2013; Denduluri, et al., ASCO Breast 2011; Poulet, et al., SABCS 2012; Schneider, et al., ASCO 2013). The present study is an analysis of long-term follow-up in a cohort of patients who have results for all three of these risk-stratifying assays side by side in the same samples.

Methods: Patients with ER+ N0-N1 early-stage breast cancer with an MP result obtained as part of their routine clinical care were identified at the University of South Florida (USF, N=65) and Morton Plant Hospital (N=83). After local IRB approval, slides and/or blocks were cut and de-identified at USF and sent to Genomic Health and Clarient for blinded testing. Clinicopathological features were also reviewed by 3 breast pathologists.

Results: 148 patients with an MP result had tissue available to send for RS and MS assays. These patients had a median age of 62 years; median tumor size 1.8 cm; 9% low grade, 59% intermediate grade and 32% high grade. In our previous analysis of this study, of 148 patients with MP results, 53% were low risk and 47% were high risk. Of 135 samples that yielded enough RNA to produce an RS result, 53% were low risk, 26% were intermediate risk and 21% were high risk. Of 129 samples that yielded an MS result, 44% were low risk, 28% were moderate risk and 28% were high risk. Of 121 patients with results for all 3 assays, only 22% were concordant for low risk and 9% were concordant for high risk across all 3 assays. Overall, 30% of cases showed a major discordance such as low risk for one assay and high risk for another. After median follow-up of 54 months, 9 patients have had a distant metastasis and/or 8 patients have died (11 patients total). One patient who had bone metastasis and died had been classified as low risk by all 3 assays. Three patients with distant metastases had a major discordance between assays, with two high risk and one low risk result. Seven patients were classified as high or intermediate/moderate risk by all 3 assays.

Conclusions: This direct comparison demonstrates that although the assays classify a large proportion of patients differently, the patients who ended up with a distant metastasis and/or died of breast cancer had been classified as high risk by at least two of the three assays. This study has important clinical implications since these assays are used to help make treatment decisions regarding which patients might benefit from chemotherapy.

Citation Format: Shivers SC, Russell S, Blumencrancz L, Mehindru A, Acs G, Ellis D, Vrcelj V, Zanchi A, Blumencrancz PW, Carter E, King J, Cox CE. Long-term follow-up of early stage breast cancer patients with results of MammaPrint®, Oncotype DX® and MammoStrat® risk classification assays [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-09-45.

P4-09-28: Comparison of Oncotype DX (ODX) and Mammostrat (MS) Risk Estimations and Correlations with Histologic Tumor Features in Low Grade, ER-Positive Invasive Breast Carcinoma (BC)

Several molecular tests have been developed to estimate risk of distant recurrence (RDR) and help clinical decision-making regarding adjuvant chemotherapy in early stage BC. The ODX assay is a 21-gene expression profile mainly based on expression levels of genes related to hormone receptor / HER2 signaling and cell proliferation. MS is an immunohistochemistry-based assay measuring the expression of five markers thought to play a significant role in BC biology. Although both validated tests were shown to stratify patients into groups with low, intermediate and high RDR, the tests have not been compared head-to-head in the same cohort of patients and little data is available regarding their correlation with clinicopathologic tumor features. We have previously shown that a proliferative, cellular stroma and inflammatory cells associated with tumor cells may account for unexpected intermediate/high risk estimations based on ODX in low grade BC. In this study we compared the clinicopathologic tumor features with risk estimations by ODX and MS in 106 low grade ER-positive BC. The histologic features of tumors were prospectively determined without knowledge of test results. The tumor stroma was evaluated for increased cellularity and presence of inflammatory cells. Double immunostain for pancytokeratin and Ki67 was performed to assess cell proliferation in cancer vs stromal/inflammatory cells. Based on ODX and MS, among the 106 cases 68, 38 and 0, and 91, 14 and 1 tumors showed low, intermediate and high RDR, respectively. Assessment of the concurrence between the tests to predict low vs intermediate/high RDR showed a kappa value of 0.0541. There was no statistically significant correlation between ODX Recurrence Score (RS) and MS risk index values. We found no correlation between low vs intermediate/high risk estimation by either test and patient age, tumor size, nuclear atypia, mitotic rate, ER and HER2 expression levels. BC with intermediate/high RDR by ODX, but not by MS, showed significantly lower PR expression, increased stromal cellularity and presence of inflammatory cells. Double immunostains showed increased proliferation in stromal/inflammatory cells compared to cancer cells in cases showing intermediate/high RDR by ODX; no such association was seen with regards to MS risk estimations. The ratio of Ki67-positive stromal/inflammatory vs tumor cells >1 had an area under the curve of 0.8929 (p<0.0001) and 0.5026 (p=0.9823) to predict intermediate/high RDR based on ODX and MS, respectively. Cases showing intermediate/high RDR by ODX but low risk by MS were associated with increased stromal cellularity, presence of inflammatory cells and increased numbers of Ki-67 positive stromal/inflammatory cells, compared to cases showing low risk by both assays. Our results suggest that low grade ER-positive BC with increased stromal/inflammatory cell proliferation may show an apparent increased RDR as assessed by ODX, which uses RNA extracted from a mixture of tumor and stromal/inflammatory cells in the assay. MS, which examines cancer cells only (thus, not influenced by stromal and inflammatory cells), may provide a better estimation of likely tumor behavior in low grade BC.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-09-28.

P5-11-14: Flat Epithelial Atypia of the Breast: A Single Institution Experience

Background: Flat epithelial atypia of the breast is a relatively new entity of unknown significance. Our objective is to evaluate our surgical experience with this diagnosis.

Methods: A single institution database of breast patients from 2005–2010 was used to identify women who were diagnosed with flat epithelial atypia on core biopsy and subsequently underwent surgical excision. Patient data regarding history, type and reason for biopsy, and associated pathology was collected. Individuals diagnosed with flat epithelia atypia and cancer on core biopsies in the same breast were excluded.

Results: There were 52 patients who underwent surgical excision for the primary diagnosis of flat epithelial atypia. There were 3 (6%) patients with a personal history of breast cancer, 14 (27%) patients with a family history of breast cancer, and 11 (21%) patients with a concurrent new diagnosis of breast cancer in the contralateral breast. Core biopsy was recommended in most (81%) cases because of suspicious calcifications on mammography. Twenty-eight (54%) patients were found to have flat epithelial atypia associated with other atypical breast hyperplasia and 24 (46%) had flat epithelial atypia as the most significant lesion on core biopsy. In 8 (15%) patients, there was a sonographic correlate that was biopsied; 5 had only flat epithelial atypia and 3 had flat epithelial atypia associated with other atypical hyperplasia. Of the 52 patients there were 4 (8%) patients who upstaged to ductal carcinoma in-situ on surgical excision. There were no cases of invasive carcinoma. All ductal carcinoma in-situ cases were associated with other atypical breast hyperplasia, not flat epithelial atypia alone.

Conclusion: Though flat epithelial atypia may be associated with an increased risk of breast cancer, surgical excision of pure flat epithelial atypia may not be necessary. Larger studies are needed to corroborate these findings.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-11-14.

Results of Oncotype DX in early-stage invasive lobular carcinoma

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Background: The Oncotype DX (ODX) genomic assay has been used since 2004 to estimate prognosis and guide adjuvant treatment in patients with estrogen receptor-positive, node-negative invasive breast tumors. However, the impact of ODX assay testing in patients with invasive lobular carcinoma (ILC) has not been specifically reported. We describe our experience in patients with ILC who underwent ODX assay testing and how this affected adjuvant treatment.

Methods: An IRB approved retrospective review was performed on all patients undergoing treatment for early stage, node-negative ILC from 2006-2011. All cases were reviewed by a single pathologist (GA) for verification of histology and subtype. The impact of ODX assay testing on treatment management was evaluated.

Results: Thirty-nine patients underwent ODX genomic assay testing of early stage, node-negative ILC with a median age of 62 years. ILC tumor classification included classic (67%), pleomorphic (23%) and mixed (10%) subtypes with a median tumor size of 2.0 cm (0.6-6.0). Ninety-seven percent of tumors were estrogen receptor-positive, 74% progesterone receptor-positive. Median ODX recurrence score was 15 (0-34) with an ODX 10-yr risk of 10% (3-23). ODX risk classification was: Low (N=26), Intermediate (N=12), and High (N=1). There was no difference in ODX recurrence score or risk classification between ILC subtypes (p=0.52 and p=0.35, respectively). Adjuvant chemotherapy was used in 26% (TC N=8, AC N=1, FEC 100 N=1). Tumor size or ILC tumor subtype were not significant for adjuvant chemotherapy use while tumor grade (p=0.046), ODX recurrence score (22.8 vs 13.6, p<0.0001), ODX risk classification (p=0.009) and ODX 10 year risk (15.9 vs 9.0, p<0.0001) were significant. With a median follow up of 16.5 months, there were no recurrences or tumor-related deaths.

Conclusions: ODX testing on early stage node-negative ILC may serve as a useful adjunct when counseling patients on the decision for adjuvant therapy. The long-term impact on recurrence or survival in patients with ILC who receive adjuvant chemotherapy based on ODX recurrence score remains undetermined and warrants further testing.

Abstract P6-01-03: Invasive Micropapillary Carcinoma (IMPC) of the Breast: An Uncommon but Aggressive Special Type of Breast Cancer

IMPC is an uncommon type of invasive breast cancer. However, in comparison to invasive ductal carcinoma of no special type (IDC), it is reported to have a more aggressive behavior. Our objective was to compare and contrast IMPC with IDC in terms of clinicopathologic features and outcome. One hundred-thirty-one IMPC cases were compared to 1295 IDC and 189 invasive lobular carcinoma (ILC). Medical records and pathology slides were reviewed for traditional factors (tumor grade, lymphatic invasion [LVI], lymph node [LN] status, stage, receptor status, treatment) and specific tumor features (extent of retraction artifact [RA]). Clinicopathologic features between groups were compared and clinical outcome of IMPC was recorded. All patients were women with a median age of 57.6 yrs (range 22-93) for IMPC, 56.3 yrs (range 22-96) for IDC and 60.7 (range35-85) for ILC, respectively (P&lt;0.0001). There were no differences noted for family history, race, or presentation (symptomatic vs. screening). Surgical treatment was partial mastectomy in 770 (47.7%) and mastectomy in 845 (52.3%). All patients had axillary lymph node biopsy. The median tumor size was 2.2 (range 0.3-15.2) cm for IMPC, 2.0 (range 0.05-11.0) cm for ILC and 1.7 (range 0.05-19.0) cm for IDC, respectively (P&lt;0.). The extent of micropapillary features in IMPC ranged from 3% to 100% with a median value of 20%. LVI was more likely to be present in IMPC (67.9%) compared to IDC (28.3%) and ILC (6.9%) (P&lt;0.0001). Axillary LN metastases were seen in 71.8% of IMPC compared to 44.1 % of IDC and 54.5% of ILC (P&lt;0.0001). IMPC and ILC was significantly more frequently ER and PR positive (P&lt;0.0001 each) compared to IDC, while ILC was significantly less frequently HER2 positive (2.8%) compared to IDC (17.9%) and IMPC (8.2%). The mean percent of tumors showing retraction artifact (RA) was 60.2% in IMPC compared to 25.4% in IDC and 3.8% in ILC (P&lt;0.0001). During a median follow-up of 24.3 months 19 (14.5%) and 17 (13.0%) IMPC patients developed local and distant recurrence, respectively. IMPC is an uncommon special type of invasive breast cancer but it is more aggressive in reference to IDC and ILC based on larger tumor size and more frequent the presence of LVI and LN metastases. The presence of IMPC features in breast cancers, even if present focally, should alert the clinician for the high likelihood of lymphatic tumor spread and an adverse biologic behavior.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-01-03.

Estimation of Risk of Recurrence of Early Stage Estrogen Receptor Positive Breast Carcinoma by Surgical and Medical Oncologists and Pathologists Compared to the Oncotype Dx® Recurrence Score

Background: The decision to use adjuvant chemotherapy in patients with early stage breast cancer is based in part on the estimation of risk of tumor recurrence by physicians, which traditionally relies heavily on tumor size, nodal status and a set of biologic tumor characteristics such as hormone receptor and HER2 expression. The Oncotype DX® assay is a 21-gene expression profile aiming to improve risk stratification, recurrence prediction and optimize selection of patients for adjuvant chemotherapy.Methods: We selected 154 consecutive patients with early stage estrogen receptor (ER) positive breast cancer and available Oncotype Dx® recurrence score (RS) for the study. Clinicopathologic data, including patient age, menopausal status, tumor size, histologic type, grade, mitotic activity, presence of lymphatic invasion (LVI), nodal status, hormone receptor and HER2 status on all patients were provided to four surgical oncologists, four medical oncologists and three pathologists, specializing in breast cancer diagnosis and management. Participants were asked to estimate the risk of recurrence of tumors based on available clinicopathologic data and to provide the three most important tumor features their risk estimates were based on. Risk estimates of participants were compared with RS results.Results: Based on the Oncotype Dx® results, 95 (61.7%), 45 (29.2%) and 14 (9.1%) tumors were of low (RS &lt;18), intermediate (RS 18-30) and high (RS ≥31) risk, respectively. RS values showed a highly significant correlation with tumor grade, mitotic activity, LVI, hormone receptor and HER2 status, while no correlation with patient age, menopausal status, tumor size and histologic type was found. Participants' risk estimates agreed with those of the Oncotype Dx® assay in 54.2 ± 2.3 % (mean ± SEM, range 41.6 - 63.0%) of cases, while the risk of recurrence was over- and underestimated compared to RS results in 31.8 ± 3.1% (16.2 - 43.5%) and 14.1 ± 1.4% (7.1 - 22.7%), respectively. The rates of overestimation were significantly higher than those of underestimation (p = 0.0003). Although medical oncologists tended to overestimate the risk more frequently (38.1 ± 2.0%) compared to surgeons (28.7 ± 5.9%) and pathologists (27.5 ± 7.8%), the difference did not reach statistical significance. Estimation of the agreement of participants' risk assessment with RS results showed a mean kappa value of 0.2955 (range 0.1506 - 0.4123). No statistically significant difference in overall concurrence with RS results was found between surgeons, medical oncologists and pathologists. Participants ranked tumor stage/nodal status, hormone receptor status and tumor size to be the most important features when estimating recurrence risk.Conclusions: Based on traditional clinicopathologic features alone, surgeons, medical oncologists and pathologists tend to overestimate the risk of tumor recurrence as compared to Oncotype Dx® assay results. The RS may provide additional information regarding the intrinsic biological features of ER positive breast cancers and help tailoring treatment recommendations.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4061.

The Effect of Oncotype Dx® Recurrence Score on Treatment Recommendations for Patients with Early Stage Estrogen Receptor Positive Breast Cancer

Background: Current guidelines recommend administration of chemotherapy for patients with breast carcinomas &gt;1 cm in size, with consideration for patient age, comorbidities and tumor grade. However, it is unknown which patients actually benefit from therapy and overtreatment of a significant proportion of patients is a major concern. We investigated the impact of the Oncotype Dx® Recurrence Score (RS) on chemotherapy recommendations in early stage estrogen receptor (ER) positive breast cancer patients.Methods: We selected 154 patients with early stage ER positive breast cancer and available RS for the study. Clinicopathologic data, including age, menopausal status, tumor size, type, grade, mitotic activity, presence of lymphatic invasion, nodal status, hormone receptor and HER2 status on all patients were provided to four surgical oncologists, four medical oncologists and three pathologists, specializing in breast cancer diagnosis and management. Assuming that all patients were in good general health and would receive endocrine therapy, participants were asked whether they would also advovate adjuvant chemotherapy based on clinicopathologic data with and without knowledge of the RS, and to provide the three salient clinicopathologic features on which their recommendations were based. Changes in recommendations of participants following inclusion of RS data were compared.Results: Based on RS results, 95 (61.7%), 45 (29.2%) and 14 (9.1%) tumors were of low (RS &lt;18), intermediate (RS 18-30) and high (RS ≥31) risk, respectively. The results are summarized in Table 1. Assuming that the hypothesis previously put forward that patients with low to intermediate risk RS are not likely to benefit from chemotherapy, 82.3 ± 1.3% (75.5 - 89.0%) and 69.0 ± 6.9% (5.9 - 85.7%) of patients for whom chemotherapy was recommended by the participants would be "overtreated" without and with the use of RS results (p = 0.0322). No statistically significant difference was found among surgeons, medical oncologists and pathologists. Participants ranked patient age/menopausal status, hormone receptor status and tumor stage/nodal status to be the most important features when recommending chemotherapy.Conclusions: Although current recommendations for adjuvant chemotherapy for early stage ER positive breast cancer patients are largely in line with published guidelines, inclusion of RS alters recommendations in about 25% of cases. While medical oncologists recommended chemotherapy more frequently compared to surgeons and pathologists, they were more likely to change recommendations in light of RS results.Table 1. Summary of results SurgeonsMedical oncologistsPathologistsp* Mean ± SEMRangeMean ± SEMRangeMean ± SEMRange Chemo without RS (%)29.2 ± 1.824.0 - 31.859.0 ± 5.046.8 - 70.846.8 ± 3.741.6 - 53.90.0156Chemo with RS (%)27.0 ± 5.611.0 - 36.438.6 ± 9.517.5 - 63.644.4 ± 5.833.8 - 53.90.1794No change (%)75.3 ± 7.054.5 - 85.766.7 ± 6.851.3 - 83.885.9 ± 6.478.6 - 98.70.3682Add chemo (%)11.2 ± 4.13.2 - 22.76.5 ± 1.93.2 - 11.75.8 ± 3.20.6 - 11.70.6882Avoid chemo (%)13.5 ± 3.94.5 - 22.726.8 ± 7.94.5 - 41.68.2 ± 4.50.6 - 16.20.2186*Kruskal-Wallis test

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4058.

Lymphatic vessel density is significantly increased in melanoma

BACKGROUND

Melanoma is well known for its ability to involve regional lymph nodes in the early stage. However, the presence of lymphangiogenesis in melanoma is still controversial due to lack of lymphatic-specific markers. The purpose of this study was to determine the intra- and peritumoral lymphatic vessel density (LVD) using a novel lymphatic vessel-specific marker D2-40 and compare it to general vessel density (GVD) as determined by CD31 immunostaining in a series of melanocytic lesions.

METHODS

The intra- and peritumoral GVD and LVD were examined by immunohistochemistry using D2-40 and CD31 antibodies in a series of melanocytic lesions.

RESULTS

We found significantly higher intratumoral LVD in melanomas as compared to either common acquired or dysplastic nevi (p < 0.01). Although peritumoral LVD in melanoma and malignant melanoma in situ was higher compared to nevi, the difference did not reach statistical significance (p = 0.059). There was no significant difference in GVD among the various groups of melanocytic lesions.

CONCLUSIONS

Our results show that intratumoral LVD is significantly increased in melanomas compared to benign nevi. The higher intratumoral lymphatic density in invasive melanomas suggests that melanoma cells might promote lymphangiogenesis. In addition, assessment of intratumoral LVD may be potentially useful in the differential diagnosis of melanocytic lesions.

Systemic and regional hemorheological consequences of warm and cold hind limb ischemia-reperfusion in a canine model

We have studied systemic and regional changes in hemorheological parameters after complete acute limb ischemia and reperfusion (I/R) in 24 mongrel dogs. Unilateral cooled and non-cooled vascular ischemia (3 h)-reperfusion (4 h), and sham-operations were performed. Blood samples were collected from the excluded region, during reperfusion and for 5 days. Whole blood and plasma viscosity (WBV, PV), relative cell transit time (RCTT) of erythrocytes, fibrinogen level and hematological parameters were determined. In I/R groups WBV of excluded blood was significantly higher compared to the base (p < 0.05), and RCTT increased during the reperfusion. On 2nd-3rd days RCTT increased significantly in both I/R groups. In each group PV and fibrinogen showed continuous increase during the postoperative period, prominently in cooled I/R group, and furthermore WBV corrected for hematocrit (40%) was the highest in cooled I/R group. These suggest that surgical acute limb I/R may cause hemorheological changes, which are more serious after cooling. (Grants: OTKA-T032571, 6003/1/2001/ETT.)

The influence of medical history on restorative procedure failure rates following dental rehabilitation

PURPOSE

This study evaluated the association between patient medical history and the outcomes of restorative procedures performed under general anesthesia.

METHODS

The dental records of patients who had dental rehabilitation under general anesthesia at Children's Hospital in Boston (1990-1992) and Children's National Medical Center in Washington, DC (1994-1998) were examined. Data regarding restorative outcomes and the association between patient medical history and restorative failures were assessed using chi-square tests with correction for continuity. T-tests were performed on parametric data.

RESULTS

Significantly higher stainless steel crown failure rates were found in young patients diagnosed with developmental disabilities when compared to patients without such disabilities (p<0.025, x2 = 5.50). However, there was no difference in the failure rates of SSCs in young patients with significant medical histories compared to patients without significant medical histories. Regarding amalgam and composite restorations, there were no differences in failure rates among patients with and without significant medical histories, including developmental disabilities.

CONCLUSIONS

SSC failures were higher in young children with developmental disabilities compared to children without these disabilities.

Perceived outcomes and parental satisfaction following dental rehabilitation under general anesthesia

PURPOSE

The objective of this study was to evaluate parents' perceptions of their child's quality of life following dental rehabilitation under general anesthesia and to assess their satisfaction with that treatment modality.

METHODS

A survey was sent to 400 parents of patients who had undergone dental rehabilitation. Quality of life outcomes, such as continued presence of pain and inability to eat or sleep, were assessed. Additionally, parental satisfaction with outcomes and processes was evaluated, as was outcome expectation. Descriptive statistics were collected on outcome measures. Contingency testing was employed to compare outcomes by medical or developmentally compromising conditions, gender, or continued use of the initial treatment facility for routine care.

RESULTS

Fifty seven percent of parents returned surveys. A descending hierarchy of improved treatment outcomes was noted, with improvement in pain the predominant outcome, followed by improved abilities to eat and sleep, reported by 86, 69, and 41% of parents, respectively, 72% perceived an improvement in their child's health. Children with medically or developmentally compromising conditions were significantly more likely to have improved abilities to eat and sleep, and had a significantly improved overall health status. Satisfaction and expectations were consistently achieved and were not related to continued use of the initial treatment facility.

CONCLUSIONS

Children with early childhood caries receiving comprehensive treatment under general anesthesia achieved improvements in their quality of life as well as overall health. A hierarchy of improvement was noted, with the greatest improvement noted in pain experience followed by improved abilities to eat and sleep. Parents were overwhelmingly satisfied with outcomes and the process of care, and reported that their expectations had been met.

A 20-year perspective on the changing use of hand over mouth (HOM) and restraint in postdoctoral pediatric dental education

PURPOSE

This study assessed the current teaching and utilization of the hand over mouth technique in advanced educational programs in pediatric dentistry and compared these results to previous surveys.

METHODS

A survey, identical to those used in 1979 and 1989, was sent to pediatric dentistry program directors. Descriptive and comparative statistics evaluated the use of HOM, HOMAR, and restraint. Additionally, changing patterns of responses for programs and directors that responded to both the 1989 and 1999 surveys were assessed.

RESULTS

Eighty-seven percent of directors returned surveys. There was a significant decrease in the number of programs utilizing the HOM technique in the past 10 years (P< 0.0001). Among respondents that returned surveys in 1989 and 1999, 50% of the previous HOM users discontinued its use (P<0.03). Technique non-users were significantly less likely to describe the technique consistent with AAPD guidelines (P<O.0001). Although the 1989 respondents expressed significantly decreased certainty that restraint techniques were free of psychological sequealae compared to 1979 respondents, the continuing decreasing trend observed between the 1989 and 1999 groups was not significant.

CONCLUSIONS

With continuing uncertainty regarding psychological sequealae associated with HOM, there was a significant decrease in the number of programs advocating its use.

Diabetic Mastopathy in Men: Imaging Findings in Two Patients

The classic imaging findings of diabetic mastopathy, an uncommon entity manifesting in patients with a history of long-standing insulin-dependent diabetes mellitus, have been reported in the literature in women but not, to the authors' knowledge, in men. Two men with diabetic mastopathy presented with palpable breast masses. The clinical histories of the men in whom this condition was diagnosed were similar to those reported for women with the condition. The mammographic findings in both men, at presentation, were suggestive of gynecomastia.

Erythropoietin and erythropoietin receptor expression in human cancer

Erythropoietin (EPO) stimulates the growth of erythroblasts in the bone marrow (C. Lacombe and P. Mayeux, NEPHROL: DIAL: TRANSPLANT:, 14 (SUPPL: 2): 22-28, 1999). We report basal and hypoxia-stimulated expression of EPO and its receptor, EPOR, in human breast cancer cells, and we demonstrate EPO-stimulated tyrosine phosphorylation and the proliferation of these cells in vitro. In 50 clinical specimens of breast carcinoma, we report high levels of EPO and EPOR associated with malignant cells and tumor vasculature but not with normal breast, benign papilloma, or fibrocystic tissue. Hypoxic tumor regions display the highest levels of EPO and EPOR expression. Enhanced EPO signaling may contribute to the promotion of human cancer by tissue hypoxia.

Loss of membrane expression of E-cadherin in leukemic erythroblasts

CONTEXT

The special societal relationships existing between various cell types in bone marrow suggests that there may be a link between the adhesive characteristics of hematopoietic cells and their maturation. Egress of the developing hematopoietic cells is also a highly regulated process governed by adhesive interactions. In leukemia, immature blasts are not retained within the marrow, suggesting a breakdown of adhesive mechanisms. Recent reports suggest that E-cadherin, an epithelial adhesion molecule, is expressed on erythroid precursors and megakaryocytes, but not on other hematopoietic marrow elements.

OBJECTIVE

To characterize the expression pattern of E-cadherin in normal and leukemic erythroid precursors by immunohistochemistry in paraffin-embedded tissue and bone marrow aspirate smears.

METHODS

Five normal bone marrow specimens from rib resections, 15 trephine bone marrow biopsy specimens, and 6 bone marrow aspirate smears from the iliac crest of patients with no known leukemia were selected. Fourteen bone marrow biopsy specimens from patients with erythroleukemia were also studied. Immunoperoxidase staining of paraffin-embedded tissue and air-dried aspirate smears for E-cadherin (1:200 dilution, HECD-1 clone) was performed using the avidin-biotin peroxidase technique.

RESULTS

In paraffin-embedded bone marrow biopsy and rib specimens and in air-dried bone marrow aspirate smears, strong membrane expression of E-cadherin was seen in the normal erythroid precursors in all cases. In contrast, no membrane expression of E-cadherin was present in any of the bone marrow biopsy specimens from patients with erythroleukemia.

CONCLUSIONS

Immunohistochemical detection of membrane expression of E-cadherin may be a useful tool for identification of erythroid precursors. Cells of erythroleukemia lack membrane expression of E-cadherin, in contrast to their normal counterparts. Further studies are needed to define the potential role of E-cadherin in the maturation of erythroid precursors and to ascertain the significance of loss of membrane expression of E-cadherin in erythroleukemia.

Differential expression of E-cadherin in lobular and ductal neoplasms of the breast and its biologic and diagnostic implications

We studied the pattern of E-cadherin expression in 183 invasive carcinomas (100 ductal, 42 lobular, 41 with mixed ductal and lobular features) and 198 in situ carcinomas (131 ductal, 53 lobular, 14 in situ with ductal and lobular features) by immunohistochemistry. We found a highly significant correlation of E-cadherin membrane expression with the histologic phenotype of the tumors. While moderate to strong membrane expression of E-cadherin was seen in all invasive and in situ ductal carcinomas, 41 of 42 invasive and 50 of 53 in situ lobular carcinomas showed complete loss of expression. All in situ carcinomas diagnosed histologically as showing mixed ductal and lobular features demonstrated complete loss of staining. Invasive carcinomas with ductal and lobular features showed 3 staining patterns: (1) complete or almost complete lack of membrane staining similar to that seen in lobular carcinomas, (2) uniform membrane expression throughout the tumor similar to ductal carcinomas, and (3) focal loss of E-cadherin staining, which correlated well with the histologic impression of focal lobular features. In tumors with histologically equivocal features, immunohistochemical detection of E-cadherin expression can be a useful diagnostic tool for the differentiation of ductal and lobular carcinomas of the breast.

Duodenal carcinoid tumor: report of a case diagnosed by endoscopic ultrasound-guided fine-needle aspiration biopsy with immunocytochemical correlation

Fine-needle aspiration biopsy is a reliable and accurate method for the endoscopic diagnosis of gastrointestinal malignancies and it is particularly well suited for evaluation of submucosal lesions. We report the cytopathologic findings of a case of malignant carcinoid tumor of a 44-year-old male who presented with melena and a nonhealing duodenal ulcer. Endoscopic ultrasound examination revealed a submucosal lesion in the pyloric region. Fine-needle aspiration revealed abundant cellularity with tumor cells arranged in sheets and loose groups and dispersed single cells in a clean background. Papillary fragments, capillaries cuffed by tumor cells, and rosette formation were also noted. The cells were moderate in size, round to oval, with a small subpopulation of spindle-shaped cells. The nuclei were uniform, round to oval, with smooth nuclear borders. The chromatin pattern was finely granular with a salt-and-pepper appearance. The cytoplasm of the cells was small to moderate in amount, pale, and showed fine granularity. The differential diagnosis included a neuroendocrine neoplasm vs. an epithelioid gastrointestinal stromal tumor. The tumor cells were focally positive for chromogranin and negative for CD34, supporting the diagnosis of a neuroendocrine neoplasm. The differential diagnosis of primary gastrointestinal carcinoid tumors from gastrointestinal stromal tumors can be very difficult in cytologic material. In cases when diagnostic material is scant, or only present on one smear, the use of smear division and cell transfer in order to perform immunocytochemical stains may be of considerable value to confirm the neuroendocrine nature of the neoplasms.

Cytomorphology of high-grade neuroendocrine carcinoma of the urinary tract

High-grade neuroendocrine carcinoma of the bladder is a rare malignant tumor with poor prognosis. We present the cytomorphologic features of six retrospectively identified cases which displayed high-grade tumors with neuroendocrine differentiation in bladder washings. Cytology specimens showed small-to-medium-sized tumor cells with powdery chromatin, inconspicuous nucleoli, and ill-defined nuclear membranes. Tumor fragments showed prominent nuclear molding and single-cell necrosis. All cases also revealed a varying proportion of tumor cells resembling the usual transitional-cell carcinoma. Biopsy specimens from five cases demonstrated high-grade transitional-cell carcinoma with areas resembling small-cell carcinoma. In one case the entire tumor consisted of classic small-cell carcinoma and failed to show any areas of transitional-cell differentiation. All cases were positive for neuroendocrine markers. Neuroendocrine carcinomas of the urinary bladder are rare, with cytological features similar to high-grade neuroendocrine carcinomas seen in other organs. They can be accurately diagnosed cytologically, and an awareness of the cytomorphologic features is important.

Causes of death of patients with multiple injuries in Debrecen, Hungary

OBJECTIVE

To find out the main causes of death of people who had multiple severe injuries.

DESIGN

Retrospective study.

SETTING

Teaching hospital, Hungary.

SUBJECTS

86 people with severe multiple injuries, of whom 59 died and had necropsies.

MAIN OUTCOME MEASURE

Establishment of a database.

RESULTS

Consumption of alcohol was a common precursor. Head and chest injuries predominated. More pedestrians than people in vehicles were killed, and there were 8 suicides and 3 murders. There were no gunshot injuries.

CONCLUSIONS

Reduction of deaths from multiple injuries is as much a socioeconomic as a medical matter.

Glandular and squamous atypia and intraepithelial lesions in atrophic cervicovaginal smears. One institution's experience

OBJECTIVE

To review the cytologic features and follow-up histologic findings in atrophic cervicovaginal smears with the diagnoses of glandular or squamous atypia or intraepithelial lesion.

STUDY DESIGN

A total of 228 cases were included in the study. The selection criteria included: age > 48 years and a diagnosis of either atypical glandular cells (AGC) (51 cases), cellular changes suggestive of human papillomavirus (HPV) infection (S/O HPV, 97 cases), low grade squamous intraepithelial lesion (LSIL) (60 cases) or high grade squamous intraepithelial lesion (HSIL) (20 cases). Follow-up biopsy information was available for 103 cases (45%).

RESULTS

From the AGC group, 35 (69%) cases had tissue studies; 14 (40%) cases showed glandular lesions; 5 (14%) showed squamous intraepithelial lesion (SIL) and atypical cells. Follow-up information was available for 32 (33%) cases classified as S/O HPV; significant lesions (glandular/squamous) were found in 11 (34%). In the LSIL category, 22 (37%) cases had follow-up; 16 (73%) showed SIL. In the HSIL category, 14 cases (70%) underwent biopsy, and all showed SIL (four LSIL and nine HSIL) or squamous cell carcinoma.

CONCLUSION

Even though atrophy-related epithelial changes often pose diagnostic difficulties in the interpretation of postmenopausal smears, application of reproducible and established cytologic criteria in diagnosing SIL and/or glandular lesions can improve diagnostic accuracy and result in selection of patients for follow-up tissue studies.

The effect of dental rehabilitation on the body weight of children with early childhood caries

PURPOSE

The purpose of this study was to determine the effect of comprehensive dental rehabilitation on the percentile weight and percentile growth velocity of children with early childhood caries (ECC).

METHODS

The percentile weight categories of children with noncontributory medical histories and ECC were compared to caries free comparison patients, before and after comprehensive dental treatment under general anesthesia.

RESULTS

Prior to dental rehabilitation, test subjects' percentile weight categories were significantly less than that of comparison counterparts (P < 0.001). Of the ECC patients, 13.7% weighed less than 80% of their ideal weight, thereby satisfying one of the criteria for the designation of failure to thrive, while none of the comparison patients did so (P < 0.05). Following therapeutic intervention, ECC children exhibited significantly increased growth velocities through the course of the follow-up period (P < 0.001), reflecting the phenomenon of catch up growth. The average length of follow-up for the test and comparison groups were 1.58 and 1.36 years, respectively. At the end of the follow-up period there were no longer any statistically significant differences noted in the percentile weight categories of the test and comparison groups.

CONCLUSION

Comprehensive dental rehabilitation resulted in catch-up growth, such that children with a history of nursing caries no longer differed in percentile weights from comparison patients.

The effect of disabilities on exits from AFDC

The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 replaces AFDC, the largest means-tested cast assistance program for low-income families, with the Temporary Assistance for Needy Families (TANF) block grant. Unlike AFDC, assistance under TANF is limited to five years in a lifetime, and states are required to move families from the assistance rolls into jobs. But not all adult welfare recipients can easily move to work because either they themselves are disabled or they have a child with disabilities requiring special care. This article examines the extent and impact of disability among families on AFDC to gain insight into the potential impact of changes under TANF. Using data from the 1990 Survey of Income and Program Participation (SIPP), we find that in nearly 30 percent of the families on AFDC either the mother or child has a disability. Furthermore, we find that having a disability significantly lowers the probability that a woman leaves AFDC for work but not for other reasons, such as a change in living arrangements. Finally, we find little evidence that having a child with a disability affects the probability of leaving AFDC for any reason.

Characterization of functional vanilloid receptors expressed by mast cells

Capsaicin and its ultrapotent analog resiniferatoxin (RTX) act through specific vanilloid receptors on sensory neurons. The C-type receptor is coupled to 45Ca uptake, whereas the R-type is detectable by [3H]RTX binding. We describe here specific vanilloid responses in murine mast cells (MCs). In the MC lines and in bone marrow-derived mast cells, capsaicin and RTX induced 45Ca uptake similarly to that observed for cultured rat dorsal root ganglion neurons (DRGs). This response was antagonized by the antagonists capsazepine and ruthenium red. As in DRGs, pretreatment of MCs with capsaicin or RTX induced desensitization to subsequent stimulation of 45Ca uptake. The potency for desensitization by RTX in the MCs corresponded to that for 45Ca uptake, whereas in DRGs it occurred at significantly lower concentrations corresponding to that for the high-affinity [3H]RTX binding site. Consistent with this difference, in MCs we were unable to detect [3H]RTX binding. Vanilloids were noncytotoxic to the MCs, in contrast to the DRGs. Although vanilloids did not cause degranulation in MCs, in the P815 clone capsaicin evoked selective interleukin-4 release. We conclude that certain MCs possess vanilloid receptors, but only the C-type that functions as a channel. Our finding that MCs can respond directly to capsaicin necessitates a reevaluation of the in vivo pathway of inflammation in response to vanilloids.

The effect of dental rehabilitation on the body weight of children with failure to thrive: case reports

Four case reports of children with nursing caries and failure to thrive are presented. Without regard to the condition of the dentition, the various cases could be classified as organic, mixed, or nonorganic in etiology. After dental rehabilitation, all patients exhibited an acceleration of weight velocity that resulted in weights above the 5th percentile. During the period of observation, the weight velocity continued to increase with time, consistent with the "catch-up" phenomenon of growth that is observed in nutritionally deprived children.

Splenic autotransplantation after abdominal trauma in childhood. Clinical and experimental data

Splenectomy is known to increase the risk of overwhelming bacterial infection. There is a decrease in immunoglobulin IgM and T-lymphocytes, primary antibody response to antigen challenge is impaired, altered opsonic function an Tuftsin deficiency are noted. Splenic autotransplantation has been suggested as a method of preserving function and this concept is supported by experiments in animals. Prior to operation on humans the technique was thoroughly elaborated and practised in animal experiments (dogs). After splenectomy, 6-8 thin segments (Furka's "spleen chip") are placed in between the plates of the major omentum. Within the period of ten years out of 52 patients 11 children (4 girls, 7 boys) suffered from abdominal trauma underwent total splenectomy, and than autotransplantation in the Kenézy Hospital in Debrecen, Hungary. In several patients the postoperative follow-up radionuclide imaging, IgM, and Tuftsin levels, and the haematological changes (leukocytes, differential blood count, platelet count, iron level in serum) unambiguously confirmed the function of the splenic tissue.

Recent advances in understanding of vanilloid receptors: a therapeutic target for treatment of pain and inflammation in skin

C-fiber sensory afferent neurons, which contain neuropeptides such as calcitonin-gene related peptide and substance P, mediate a wide variety of physiologic responses, including chemogenic pain, thermoregulation, and neurogenic inflammation. Capsaicin, the pungent constituent in red pepper, functions to activate and then, at higher doses and longer times, desensitize this class of neurons. This latter response provides the basis for the therapeutic application of capsaicin. A major advance in the field has been the identification of resiniferatoxin, a phorbol-related diterpene, as an analog of capsaicin that is ultrapotent but with differential selectivity. In particular, resiniferatoxin is only similar in potency for induction of pain but is much more effective for desensitization. Structure-activity analysis in whole animal experiments provides further evidence for dissociation of biologic endpoints, strongly arguing for the existence of vanilloid receptor subclasses. Using resiniferatoxin, we have been able to define specific, high-affinity receptors for capsaicin both in animal models such as rats and in man. Of great importance, the pharmacologic characterization in cultured dorsal root ganglion cells of the high-affinity resiniferatoxin-binding site and of the physiologic response believed to be directly coupled to the receptor, viz. calcium uptake, differed in structure-activity and in cooperativity. We conclude that multiple high-affinity vanilloid receptor subclasses mediate vanilloid response; moreover, the resiniferatoxin-selective subclass of vanilloid receptors is not the voltage-independent, cation-nonselective ion channel as previously believed. Optimization of ligands for the individual vanilloid receptor subclasses should revolutionize this therapeutic area.

Differential activation and desensitization of sensory neurons by resiniferatoxin

Recently, with use of rat dorsal root ganglion (DRG) neurons we have been able to dissociate the binding affinities of vanilloids from their potencies to induce 45Ca uptake, which suggests the existence of distinct classes of the vanilloid receptor (). In the present study, we have demonstrated that the ultrapotent capsaicin analog resiniferatoxin (RTX) desensitized rat DRG neurons to the subsequent induction of 45Ca uptake by capsaicin and RTX with affinity and cooperativity similar to that found for [3H]RTX binding, contrasting with a approximately 10-fold weaker potency and lack of cooperativity to induce 45Ca uptake. Likewise, the competitive antagonist capsazepine inhibited RTX-induced desensitization with potency similar to that for inhibition of specific [3H]RTX binding, whereas the potency of capsazepine was approximately 10-fold higher for inhibiting RTX-induced 45Ca uptake. Finally, the noncompetitive antagonist ruthenium red inhibited both the RTX-induced desensitization and 45Ca uptake but showed approximately 60-fold selectivity for inhibiting RTX-induced desensitization. The RTX-induced desensitization was not associated with loss of specific [3H]RTX binding, suggesting lack of gross cell toxicity. In contrast to RTX, capsaicin caused desensitization with a potency corresponding to that for 45Ca uptake and did so in a noncooperative manner. Unlike the RTX-induced desensitization, the desensitization by capsaicin was blocked by ruthenium red only at doses that blocked 45Ca uptake and depended on external calcium. Our findings provide further support for the existence of vanilloid receptor subtypes on DRG neurons with distinct pharmacology and distinct patterns of desensitization.

The effect of acetaminophen on tooth movement in rabbits

Orthodontic patients have reported the use of analgesics during therapy. However, common anti-inflammatory analgesics, such as aspirin and ibuprofen, have been shown to slow the rate of tooth movement. Acetaminophen, another common analgesic, does not possess anti-inflammatory properties. The effect of acetaminophen on tooth movement was studied using New Zealand white rabbits. Experimental animals were matched to a control animal of the same sex and weight. Under anesthesia, springs were ligated between the lower first molar and incisor, resulting in approximation of these teeth. Under blinded conditions, seven of the rabbits received 1000 mgs of acetaminophen daily. Seven control animals received water. The animals were sacrificed after 21 days. The movement of incisors and molars was measured. Results showed considerable movement within both the experimental and control groups, but no significant difference in tooth movement between them. Acetaminophen has no effect on the rate of tooth movement in rabbits undergoing orthodontic treatment.

Specific binding of [3H]resiniferatoxin by human and rat preoptic area, locus ceruleus, medial hypothalamus, reticular formation and ventral thalamus membrane preparations

Specific [3H]resiniferatoxin (RTX) binding detects the vanilloid (capsaicin) receptors and provides a biochemical means for exploring their pharmacology. In the present study we demonstrate specific vanilloid (RTX) binding sites in various brain areas not known to be innervated by primary afferent neurons. Specific high-affinity binding of [3H]RTX could be detected in membrane preparations of the posterior ("hypothalamic") and anterior ("septal") parts of the preoptic area, locus ceruleus, medial hypothalamus, brainstem reticular formation and ventral thalamic nuclei from naive rats. The determined levels of binding at 4 nM [3H]RTX were 23.0 +/- 4.5, 7.1 +/- 1.6, 29.9 +/- 2.3, 23.5 +/- 2.4, 9.9 +/- 2.2 and 8.1 +/- 1.9 fmol/mg, respectively; unfortunately, the high levels of non-specific binding (higher than 80%) in the present experiments made it impossible for us to characterize fully the binding properties of the receptors. However, no detectable specific [3H]RTX binding was present in membranes of brain nuclei from rats pretreated with 300 mg/kg capsaicin, a treatment which causes loss of response to capsaicin. Significant specific [3H]RTX binding was also absent in membrane preparations of the midbrain central gray matter, somatosensory cortex and cerebellum either from naive or capsaicin treated rats. In human brain specific [3H]RTX binding measured at 4 nM [3H]RTX showed a pattern of distribution similar to that in the rat brain. The corresponding levels of specific [3H]RTX binding in the preoptic area, locus ceruleus, medial hypothalamus, reticular formation and ventral thalamus were 44.9 +/- 2.4, 50.6 +/- 3.0, 36.1 +/- 2.9, 9.4 +/- 2.8 and 8.4 +/- 2.4 fmol/mg, respectively. Our findings corroborate previous biological evidence that vanilloid receptors are present in brain as well as in sensory afferent neurons.

The stimulation of capsaicin-sensitive neurones in a vanilloid receptor-mediated fashion by pungent terpenoids possessing an unsaturated 1,4-dialdehyde moiety

1. The irritant fungal terpenoid isovelleral caused protective eye-wiping movements in the rat upon intraocular instillation and showed cross-tachyphylaxis with capsaicin, the pungent principle in hot pepper. 2. Isovelleral induced a dose-dependent calcium uptake by rat dorsal root ganglion neurones cultured in vitro with an EC50 of 95 nM, which was fully inhibited by the competitive vanilloid receptor antagonist capsazepine. 3. Isovelleral inhibited specific binding of [3H]-resiniferatoxin (RTX), an ultrapotent capsaicin analogue, to rat trigeminal ganglion or spinal cord preparations with an IC50 of 5.2 microM; in experiments in which the concentration of [3H]-RTX was varied, isovelleral changed both the apparent affinity (from 16 pM to 37 pM) and the co-operativity index (from 2.1 to 1.5), but not the Bmax. 4. The affinity of isovelleral for inducing calcium uptake or inhibiting RTX binding was in very good agreement with the threshold dose (2.2. nmol) at which it provoked pungency on the human tongue. 5. For a series of 14 terpenoids with an unsaturated 1,4-dialdehyde, a good correlation was found between pungency on the human tongue and affinity for vanilloid receptors on the rat spinal cord. 6. The results suggest that isovelleral-like compounds produce their irritant effect by interacting with vanilloid receptors on capsaicin-sensitive sensory neurones. Since these pungent diterpenes are structurally distinct from the known classes of vanilloids, these data provide new insights into structure-activity relations and may afford new opportunities for the development of drugs targeting capsaicin-sensitive pathways.

A novel agonist, phorbol 12-phenylacetate 13-acetate 20-homovanillate, abolishes positive cooperativity of binding by the vanilloid receptor

Capsaicin binds to a specific recognition site, referred to as the vanilloid receptor, which it shares with the natural, ultrapotent agonist resiniferatoxin and with the competitive antagonist capsazepine. Upon binding to its receptor, capsaicin opens a cation channel leading to Ca2+ influx. The binding of capsaicin or resiniferatoxin by the vanilloid receptor follows a sigmoidal saturation curve, indicative of positive cooperativity. The biological significance of this positive cooperative behaviour is unknown, as is the mechanism responsible for it. We have developed a novel ligand, phorbol 12-phenylacetate 13-acetate 20-homovanillate (PPAHV), which binds to cultured rat sensory neurons (with a Ki of 3.1 +/- 0.4 microM), and induces Ca2+ uptake by them (with an ED50 of 1.8 +/- 0.3 microM) with similar affinities and in a non-cooperative manner (Hill coefficients are 0.99 and 1.06 for binding and Ca2+ uptake, respectively). The behaviour of PPAHV thus contrasts with resiniferatoxin or capsaicin not only in the lack of cooperativity but also in the relative potencies for resiniferatoxin binding versus Ca2+ uptake (resiniferatoxin is less potent and capsaicin is more potent for induction of Ca2+ uptake than for binding). In further experiments in which the concentration of [3H]resiniferatoxin was varied, 1 microM PPAHV likewise reduced the cooperativity index that characterizes resiniferatoxin binding to rat spinal cord membranes from 2.3 +/- 0.1 to 1.1 +/- 0.2; in parallel experiments, neither capsaicin nor capsazepine (both at a concentration of 2 microM) affected binding cooperativity. Moreover, PPAHV (1 microM) turned the bi-phasic dissociation curve of resiniferatoxin into a monophasic curve, eliminating the second, slow-dissociation phase. The present results suggest that positive cooperativity is a ligand-induced feature rather than an inherent property of vanilloid receptors. A comparison of the spectrum of biological activity of ligands which bind to vanilloid receptors with different degrees of cooperativity may provide an approach to explore the functional significance of this binding behaviour.

Self-insured employer health plans: prevalence, profile, provisions, and premiums

Data from three recent surveys indicate that about 40 percent of workers with employment-based health insurance are enrolled in plans that their employers self-insure. Despite the considerable differences between federal regulation of these self-insured plans and state regulation of employer plans purchased from an insurance company, we find striking similarities in the populations they serve, the benefits they offer, and their premium costs. Implications for health policy are discussed.

Distinct structure-activity relations for stimulation of 45Ca uptake and for high affinity binding in cultured rat dorsal root ganglion neurons and dorsal root ganglion membranes

The [3H]resiniferatoxin (RTX) binding assay using membrane preparations has been used to identify and characterize the vanilloid receptors in the central and peripheral nervous system of different species. In the present study, using cultured adult rat dorsal root ganglion neurons either in suspension or attached to the tissue culture plates, we developed an assay to measure specific [3H]RTX binding by the intact cells. We were able to characterize the vanilloid binding characteristics of the neurons and compared those to the properties of vanilloid binding sites present in rat dorsal root ganglia membrane preparations. We found that [3H]RTX bound with similar affinity and positive cooperativity to attached neurons (cultured for 5 days before being assayed), neurons in suspension (using a filtration assay) and dorsal root ganglion membrane preparations. Dissociation constants obtained in the three assays were 47.6 +/- 3.5 pM, 38.4 +/- 3.1 pM and 42.6 +/- 3.1 pM, respectively. The cooperativity indexes determined by fitting the data to the Hill equation were 1.73 +/- 0.11, 1.78 +/- 0.12 and 1.78 +/- 0.09, respectively. The maximal binding capacity was 0.218 +/- 0.026 fmol/10(3) cells and 0.196 +/- 0.021 fmol/10(3) cells in the case of the attached cells and cells in suspension, respectively. Nonradioactive RTX, capsaicin, capsazepine and resiniferonol 20-homovanillylamide fully displaced specifically bound [3H]RTX from cells in suspension with Ki and Hill coefficient values of 42.5 +/- 5.3 pM, 2.06 +/- 0.16 microM, 3.16 +/- 0.21 microM and 32.4 +/- 4.1 nM and 1.79 +/- 0.17, 1.68 +/- 0.06, 1.72 +/- 0.11 and 1.81 +/- 0.12, respectively. Structure-activity analysis of different vanilloid derivatives revealed that the various compounds have distinct potencies for receptor binding and inducing 45Ca uptake in rat dorsal root ganglion neurons. Affinities for receptor binding and stimulation of 45Ca uptake of RTX, resiniferonol 20-homovanillylamide, RTX-thiourea, tinyatoxin, phorbol 12,13-dibenzoate 20-homovanillylamide and capsaicin were 38.5 +/- 2.9 pM, 25.7 +/- 3.0 nM, 68.5 +/- 3.8 nM, 173 +/- 25 pM, 7.98 +/- 0.83 microM and 4.93 +/- 0.35 microM as compared to 0.94 +/- 0.12 nM, 26.5 +/- 3.5 nM, 149 +/- 30 nM, 1.46 +/- 0.25 nM, 1.41 +/- 0.48 microM and 340 +/- 57 nM. Computer fitting of the data yielded Hill coefficient values indicating positive cooperativity of receptor binding; however, stimulation of 45Ca uptake appeared to follow a non-cooperative mechanism of action. The competitive capsaicin antagonist capsazepine inhibited specific binding of [3H]RTX by rat dorsal root ganglion membrane preparations with Ki and Hill coefficient values of 3.89 +/- 0.38 microM and 1.74 +/- 0.11. On the other hand it inhibited the induction of 45Ca uptake into the cells induced by capsaicin and RTX in a non-cooperative fashion with Ki values of 271 +/- 29 nM and 325 +/- 47 nM. Our results show that the membrane binding assay relates to the reality of receptor function in the intact, cultured neurons, both in terms of affinity and positive cooperativity. However the different vanilloid derivatives displayed markedly distinct structure-activity relations for high affinity receptor binding and stimulation of 45Ca uptake into rat dorsal root ganglion neurons. Among various explanations for this discrepancy, we favor the possibility that the two assays detect distinct classes of the vanilloid (capsaicin) receptor present in primary sensory neurons.

Trifluoperazine modulates [3H]resiniferatoxin binding by human and rat vanilloid (capsaicin) receptors and affects 45Ca uptake by adult rat dorsal root ganglion neurones

Optimum treatment of neuropathic pain includes the use of adjuvant analgesics such as antipsychotic drugs and tricyclic antidepressants. Although the mechanism of their analgesic action is not known, it is possible that such agents act directly on pain pathways. The ability of capsaicin and its analogs to selectively deactivate primary afferent neurons provides a basis for their use in human therapy to relieve a number of chronic pain conditions. We examined whether the phenothiazine antipsychotic drug trifluoperazine (TFP) as well as other neuroleptics and tricyclic antidepressants have an effect on the agonist binding properties and the activation of the human and rat vanilloid receptors. Binding of [3H]resiniferatoxin (RTX) to membrane preparations of human dorsal horn and rat whole spinal cord was affected by TFP in a biphasic fashion, with an initial 25 and 65% enhancement of [3H]RTX binding, respectively, preceding inhibition. The apparent Ki values for inhibition were 3.93 +/- 0.13 microM for human dorsal horn and 7.91 +/- 0.62 microM for rat spinal cord. Scatchard analyses revealed that TFP affected both the affinity and the cooperativity of [3H]RTX binding by the receptors, leaving the receptor density unaltered. Similar effects on [3H]RTX binding to rat spinal cord membranes were also induced by other antipsychotic phenothiazines and other types of antipsychotics, by phenothiazines without antipsychotic actions, as well as by tricyclic antidepressants. In cultures of dorsal root ganglion neurones, TFP at concentrations that increased [3H]RTX binding (1-3 microM) also induced an increase in 45Ca uptake; this increase was absent in cultures prepared from capsaicin desensitized animals.(ABSTRACT TRUNCATED AT 250 WORDS)

Resiniferatoxin-amide and analogues as ligands for protein kinase C and vanilloid receptors and determination of their biological activities as vanilloids

The naturally occurring diterpene resiniferatoxin (RTX) is an ultrapotent analogue of capsaicin. Acting on polymodal afferent neurons, RTX induces a generally similar pattern of responses as does capsaicin. However, the two compounds, as well as other vanilloid derivatives, display different relative potencies for different responses. In the present study, we examined the vanilloid-like activities of two new derivatives, the amide analogue of RTX and phorbol 12,13-dibenzoate 20-homovanillylamide. Structurally, RTX-amide resembles capsaicin more closely than does RTX, and after cleavage of the amide bond the resulting amine would be predicted to not bind to protein kinase C in contrast to resiniferonol 9,13,14-orthophenylacetate, the parent diterpene of RTX. In contrast to our expectations the binding potency of the RTX-amide for the vanilloid receptor present in rat spinal cord was 450-fold lower than that of RTX (Ki values for the RTX-amide and RTX were 10.4 +/- 0.7 nM and 23.1 +/- 3.2 pM, respectively). In the case of phorbol 12,13-dibenzoate 20-homovanillylamide, there was a further loss of affinity for the vanilloid receptor compared with RTX; nonetheless, the Ki (8.56 +/- 0.61 microM) was comparable with that of capsaicin (5.31 +/- 0.37 microM). Computer fitting of the binding data yielded Hill coefficient values of 2.25 +/- 0.03, 2.33 +/- 0.03, and 1.84 +/- 0.05 for RTX, RTX-amide, and phorbol 12,13-dibenzoate 20-homovanillylamide, respectively, indicating that both new compounds induced apparent positive cooperativity among vanilloid binding sites.(ABSTRACT TRUNCATED AT 250 WORDS)

Protein kinase C in cell signaling: strategies for the development of selective inhibitors

Protein kinase C plays a central role in the cellular signaling pathway for the lipophilic second messenger sn-1,2-diacylglycerol, which is involved in many biological responses, including tumor promotion and inflammation. A major effort has been directed at understanding diversity within this system in order to develop strategies for selective inhibition. Two classes of ligands for the regulatory domain of protein kinase C have been identified which, although they function in vitro as activators of the enzyme, paradoxically behave in vivo as partial antagonists. Identification of targets for the phorbol esters distinct from protein kinase C argues that antagonists acting on the regulatory and catalytic domains of protein kinase C will have different spectra of action.

A constellation of dental anomalies in a chromosomal deletion syndrome (7q32): case report

A case is reported of a patient with deletion of the long arm of chromosome 7 at a highly specific locus (7q32). In addition to significant craniofacial stigmata and global developmental delay, the patient presented with numerous clinical and radiographic dental anomalies observed over a 10-year period. Hypodontia, accessory roots, dens invaginatus, hypoplastic enamel, and numerous pulpal anomalies all were noted. Some of these dental findings suggest trichodentoosseous syndrome (TDO), although the other stigmata do not. The wide variety of dental findings in this patient may help to define the role of chromosome 7q32 in dental development.

[3H]resiniferatoxin binding by the human vanilloid (capsaicin) receptor

We report here that we were able to detect the human vanilloid receptor in all three major central endings of primary afferent neurons--in the dorsal horn of the spinal cord, in the cuneate and gracile nuclei and in the spinal nucleus of the trigeminal nerve--and to characterize the binding properties of the receptor in the dorsal horn. Specific [3H]resiniferatoxin (RTX) binding is thought to represent the vanilloid (capsaicin) receptor. [3H]RTX binding to membranes obtained from total human spinal cord and dorsal horn followed sigmoidal saturation kinetics indicating apparent positive cooperativity. The cooperativity index determined by fitting the data to the Hill equation was 1.37 +/- 0.02 in the total spinal cord and 1.77 +/- 0.16 in the dorsal horn. The apparent dissociation constants in whole spinal cord and dorsal horn membranes were 915 +/- 12 and 532 +/- 27 pM; the receptor densities were 140 +/- 6 and 227 +/- 15 fmol/mg protein, respectively. Membrane preparations from the spinal nucleus of the trigeminal nerve and the cuneate and gracile nuclei also bound [3H]RTX in a similar fashion. In parallel experiments, rat spinal cord membranes bound [3H]RTX with 20- to 40-fold higher affinity, somewhat greater positive cooperativity, but at a 3-fold lower receptor density. As predicted by the modified Hill equation, non-radioactive RTX at low receptor occupancy produced biphasic competition curves.(ABSTRACT TRUNCATED AT 250 WORDS)

[3H]resiniferatoxin binding to pig dorsal horn membranes displays positive cooperativity

In the present report we have reevaluated specific [3H]resiniferatoxin (RTX) binding, thought to represent the vanilloid (capsaicin) receptor, to whole spinal cord and dorsal horn membranes of the pig using a modified [3H]RTX binding assay. The high nonspecific [3H]RTX binding of the original protocol was reduced by the addition of alpha 1-acid glycoprotein (AGP), a plasma protein that binds RTX, to the assay mixture after the binding reaction had been terminated. Specific [3H]RTX binding to pig whole spinal cord and dorsal horn membranes followed sigmoidal saturation kinetics indicating apparent positive cooperativity. The cooperativity index determined by fitting the data to the Hill equation was 2.31 +/- 0.24 in the spinal cord and 2.27 +/- 0.13 in the dorsal horn. The apparent dissociation constants in spinal cord and dorsal horn membranes were 87.8 +/- 2.7 and 103.9 +/- 1.9 pM; the receptor densities were 23 +/- 3 and 203 +/- 5 fmol/mg protein, respectively. In parallel experiments, rat spinal cord membranes bound [3H]RTX with 2 - 3 fold higher affinity, equal positive cooperativity, and a 49 +/- 6 fmol/mg receptor density. As predicted by the modified Hill equation, at low receptor occupancy nonradioactive RTX produced biphasic competition curves. Capsaicin and the competitive antagonist capsazepine also fully displaced specifically bound [3H]RTX from pig dorsal horn membranes with Ki values of 9.7 +/- 1.7 microM and 6.8 +/- 0.7 microM, respectively; the corresponding Hill coefficients were 1.81 +/- 0.17 and 2.32 +/- 0.11. [3H]RTX binding was not inhibited by resiniferonol 9, 13, 14-orthophenylacetate, the biologically inactive parent diterpene of RTX. These findings suggest that the vanilloid receptor present in the dorsal horn of the pig, like those present in human and in the rat, is a receptor cluster in which the subunits cooperate.

Comparison of [3H]resiniferatoxin binding to spinal cord and dorsal root ganglia of newborn and adult rats

Capsaicin is frequently used in neurobiological investigations to selectively inhibit response by the primary sensory afferent neurons. The effectiveness of treatment depends significantly on the age of the animals; newborns are both quantitatively and qualitatively more sensitive than adults. In the present study, we used the [3H]resiniferatoxin binding assay to determine whether this different susceptibility to capsaicin between newborns and adult animals may reflect differences either in receptor affinity or density. We report here that whole spinal cord membranes of neonates bound [3H]RTX with similar affinity and positive cooperativity as did the spinal cord membranes from adult animals (Kd values were 24.8 +/- 3.7 and 26.8 +/- 4.8 pM, respectively; Hill coefficients were 2.25 +/- 0.03 and 2.17 +/- 0.05, respectively). However, the receptor density was three-fold higher in the spinal cord membranes of neonates than of adult rats (Bmax values were 142 +/- 13 and 43 +/- 3 fmol/mg protein, respectively). We found no significant difference in the [3H]RTX binding properties of dorsal root ganglia membranes of newborn and adult animals. Our results suggest that a higher density of the vanilloid receptor in the spinal cord (but not in the dorsal root ganglia) of newborn animals may contribute to the quantitative differences between the sensitivity of adult animals and neonates.

Comparison of [3H]resiniferatoxin binding by the vanilloid (capsaicin) receptor in dorsal root ganglia, spinal cord, dorsal vagal complex, sciatic and vagal nerve and urinary bladder of the rat

In the present report we compared the properties of [3H]resiniferatoxin (RTX) binding by the vanilloid receptors present at different parts of the primary afferent neurons of the rat. We found no major differences in either the affinity or the cooperativity of [3H]RTX binding by vanilloid receptors on the cell body, central terminals, peripheral terminals or axons. Specific binding of [3H]RTX to dorsal root ganglia, whole spinal cord, dorsal vagal complex, urinary bladder, and sciatic and vagal nerves all followed sigmoidal saturation kinetics indicating positive cooperativity among the binding sites. The cooperativity indexes determined by fitting the data to the Hill equation were 1.82 +/- 0.11, 2.21 +/- 0.04, 2.55 +/- 0.01, 1.91 +/- 0.11, 2.03 +/- 0.09 and 2.27 +/- 0.04, respectively. The dissociation constants in dorsal root ganglia, spinal cord, dorsal vagal complex, urinary bladder, and sciatic and vagal nerve membranes were 46.5 +/- 2.7, 29.3 +/- 5.1, 28.2 +/- 1.2, 60.8 +/- 4.4, 59.9 +/- 1.9 and 45.2 +/- 0.7 pM; the receptor densities were 219 +/- 14, 48 +/- 5, 67 +/- 1, 32 +/- 7, 61 +/- 9, and 100 +/- 20 fmol/mg protein, respectively. We could not show any major differences in the affinities of capsaicin and capsazepine in inhibition of [3H]RTX binding by the different membrane preparations either. In all cases the initial enhancement of [3H]RTX binding by nonradioactive RTX, capsaicin, and capsazepine confirmed the existence of positive cooperativity among the binding sites. We were unable to detect specific [3H]RTX binding sites in membrane preparations of the preoptic area, locus ceruleus, substantia nigra, striatum and paraventricular nuclei of the rat brain under our present conditions. Our results suggest the uniformity of the vanilloid receptors present at different parts of the primary afferent neuron.