Outcomes of active surveillance of EU-TIRADS 5 thyroid nodules

OBJECTIVE

Active surveillance of cytologically proven microcarcinomas has been shown as a safe procedure. However, fine needle aspiration biopsy (FNAB) is not recommended by European Thyroid Association (ETA) and American Thyroid Association (ATA) guidelines for highly suspicious nodules ≤ 10 mm. The aim of the study was to assess the outcomes of active surveillance of EU-TIRADS 5 nodules ≤ 10 mm not initially submitted to FNAB.

PATIENTS AND METHODS

80 patients with at least one EU-TIRADS 5 nodule ≤ 10 mm and no suspicious lymph nodes, accepting active surveillance, were included.

RESULTS

Mean baseline diameter and volume were 5.4 mm (±2.0) and 64.4 mm3 (±33.5), respectively. After a median follow-up of 36.1 months, a volumetric increase ≥ 50% occurred in 28 patients (35.0%) and a suspicious lymph node in 3 patients (3.8%). Twenty-four patients underwent an FNAB (30.0%) after at least a 1 year follow-up of which 45.8% were malignant, 8.3% benign, 33.3% undetermined and 8.3% nondiagnostic. Sixteen patients (20.0%) underwent conversion surgery after a median follow-up of 57.2 months, confirming the diagnosis of papillary carcinoma in 15/16 cases (not described in 1 histology report), all in remission at 6-12 months postoperative follow-up.

CONCLUSION

Applying ETA and ATA guidelines to avoid FNA of EU-TIRADS 5 sub-centimeter nodules and proceeding to active surveillance of such nodules in selected patients is a safe procedure. Thus, US-FNAB could be postponed until the nodule shows signs of progression or a suspicious lymph node appears, with no added risk for the patient.

TIRADS score is of limited clinical value for risk stratification of indeterminate cytological results

CONTEXT

Thyroid nodules with cytological indeterminate results represent a daily and recurrent issue for patient management.

OBJECTIVE

The primary aim of our study was to determine if TIRADS (Thyroid Imaging Reporting and Data System) could be used to stratify the malignancy risk of these nodules and to help in their clinical management. Secondary objective was to estimate if this risk stratification would change after reclassification of encapsulated non-invasive follicular variant of papillary carcinomas (FVPTC) as non-invasive follicular thyroid neoplasm (NIFTP).

PATIENTS AND METHODS

Single-center retrospective study of a cohort of 602 patients who were referred for ultrasound-guided fine-needle aspiration from January 2010 to December 2016 with an indeterminate cytological result and in whom histological results after surgery were available. TIRADS score was prospectively determined for all patients included. Nodules that had been classified as FVPTC were submitted to a rereading of histological report and reclassified as NIFTP when judged relevant. A table of malignancy risk crossing Bethesda and TIRADS results was built before and after this reclassification.

RESULTS

The study included 602 cytologically indeterminate nodules. TIRADS score was positively correlated with the malignancy rate (P < 0.0001). Risk stratification with TIRADS was significant only in Bethesda V nodules (P = 0.0004). However, the risk of malignancy in this Bethesda V category was always above 45%, whatever the TIRADS score.

CONCLUSION

For a clinician facing an indeterminate cytological result for a thyroid nodule, return to TIRADS score is of limited value in most conditions to rule in or rule out malignancy and to guide subsequent management of patients.

Early Conversion From Calcineurin Inhibitor- to Everolimus-Based Therapy Following Kidney Transplantation: Results of the Randomized ELEVATE Trial

In a 24-month, multicenter, open-label, randomized trial, 715 de novo kidney transplant recipients were randomized at 10-14 weeks to convert to everolimus (n = 359) or remain on standard calcineurin inhibitor (CNI) therapy (n = 356; 231 tacrolimus; 125 cyclosporine), all with mycophenolic acid and steroids. The primary endpoint, change in estimated glomerular filtration rate (eGFR) from randomization to month 12, was similar for everolimus versus CNI: mean (standard error) 0.3(1.5) mL/min/1.73² versus -1.5(1.5) mL/min/1.73² (p = 0.116). Biopsy-proven acute rejection (BPAR) at month 12 was more frequent under everolimus versus CNI overall (9.7% vs. 4.8%, p = 0.014) and versus tacrolimus-treated patients (2.6%, p < 0.001) but similar to cyclosporine-treated patients (8.8%, p = 0.755). Reporting on de novo donor-specific antibodies (DSA) was limited but suggested more frequent anti-HLA Class I DSA under everolimus. Change in left ventricular mass index was similar. Discontinuation due to adverse events was more frequent with everolimus (23.6%) versus CNI (8.4%). In conclusion, conversion to everolimus at 10-14 weeks posttransplant was associated with renal function similar to that with standard therapy overall. Rates of BPAR were low in all groups, but lower with tacrolimus than everolimus.

Evaluation of the effect of tofacitinib exposure on outcomes in kidney transplant patients

Tofacitinib fixed-dose regimens attained better kidney function and comparable efficacy to cyclosporine (CsA) in kidney transplant patients, albeit with increased risks of certain adverse events. This post-hoc analysis evaluated whether a patient subgroup with an acceptable risk-benefit profile could be identified. Tofacitinib exposure was a statistically significant predictor of serious infection rate. One-hundred and eighty six kidney transplant patients were re-categorized to above-median (AME) or below-median (BME) exposure groups. The 6-month biopsy-proven acute rejection rates in AME, BME and CsA groups were 7.8%, 15.7% and 17.7%, respectively. Measured glomerular filtration rate was higher in AME and BME groups versus CsA (61.2 and 67.9 vs. 53.9 mL/min) at Month 12. Fewer patients developed interstitial fibrosis and tubular atrophy (IF/TA) at Month 12 in AME (20.5%) and BME (27.8%) groups versus CsA (48.3%). Serious infections occurred more frequently in the AME group (53.0%) than in BME (28.4%) or CsA (25.5%) groups. Posttransplant lymphoproliferative disorder (PTLD) only occurred in the AME group. In kidney transplant patients, the BME group preserved the clinical advantage of comparable acute rejection rates, improved renal function and a lower incidence of IF/TA versus CsA, and with similar rates of serious infection and no PTLD.

The multifaceted effect of PB1-F2 specific antibodies on influenza A virus infection

PB1-F2 is a small influenza A virus (IAV) protein encoded by an alternative reading frame of the PB1 gene. During IAV infection, antibodies to PB1-F2 proteins are induced. To determine their function and contribution to virus infection, three distinct approaches were employed: passive transfer of anti-PB1-F2 MAbs and polyclonal antibodies, active immunization with PB1-F2 peptides and DNA vaccination with plasmids expressing various parts of PB1-F2. Mostly N-terminal specific antibodies were detected in polyclonal sera raised to complete PB1-F2. Passive and active immunization revealed that antibodies recognizing the N-terminal part of the PB1-F2 molecule have no remarkable effect on the course of IAV infection. Interestingly antibodies against the C-terminal region of PB1-F2, obtained by immunization with KLH-PB1-F2 C-terminal peptide or DNA immunization with pC-ter.PB1-F2 plasmid, partially protected mice against virus infection. To our knowledge, this is the first report demonstrating the biological relevance of humoral immunity against PB1-F2 protein in vivo.

2013 European thyroid association guidelines for cervical ultrasound scan and ultrasound-guided techniques in the postoperative management of patients with thyroid cancer

Cervical ultrasound scanning (US) is considered a key examination, by all major thyroid and endocrine specialist societies for the postoperative follow-up of thyroid cancer patients to assess the risk of recurrence. Neck US imaging is readily available, non-invasive, relatively easy to perform, cost-effective, and can guide diagnostic and therapeutic procedures with low complication rates. Its main shortcoming is its operator-dependency. Because of the pivotal role of US in the care of thyroid cancer patients, the European Thyroid Association convened a panel of international experts to review technical aspects, indications, results, and limitations of cervical US in the initial staging and follow-up of thyroid cancer patients. The main aim is to establish guidelines for both a cervical US scanning protocol and US-guided diagnostic and therapeutic procedures in patients with thyroid cancer. This report presents (1) standardization of the US scanning procedure, techniques of US-guided fine-needle aspiration, and reporting of findings; (2) definition of criteria for classification of malignancy risk based on cervical US imaging characteristics of neck masses and lymph nodes; (3) indications for US-guided fine-needle aspiration and for biological in situ assessments; (4) proposal of an algorithm for the follow-up of thyroid cancer patients based on risk stratification following histopathological and cervical US findings, and (5) discussion of the potential use of US-guided localization and ablation techniques for locoregional thyroid metastases.

PB1-F2 expedition from the whole protein through the domain to aa residue function

More than decade ago during systematic search for alternative reading frame derived peptides encoded by influenza A virus recognized by CD8+ T cells, PB1-F2 protein was discovered serendipitously by Chen et al. (2001). Since that time, an increasing body of evidence has continued to highlight the multifunctional meaning of this unusual influenza A protein. After twelve years of intensive research with 56 pubmed records for PB1-F2 in the title there is still a lot yet to explore. Is it a proapoptotic "explosive" protein that suppresses the mechanisms of early innate immune response or does it function as an NS1 antagonist? What is the root of its strain and cell specificity? What is the relationship between PB1-F2 and pathogenicity or secondary bacterial infection? Here we attempt to "take a trip" from the whole protein level through domains and regions to very particular aminoacid residues in correlation with its function in different virus isolates, cell type or animal model.

Sotrastaurin in calcineurin inhibitor-free regimen using everolimus in de novo kidney transplant recipients

Sotrastaurin, a novel selective protein-kinase-C inhibitor, inhibits early T cell activation via a calcineurin-independent pathway. Efficacy and safety of sotrastaurin in a calcineurin inhibitor-free regimen were evaluated in this two-stage Phase II study of de novo kidney transplant recipients. Stage 1 randomized 131 patients (2:1) to sotrastaurin 300 mg or cyclosporine A (CsA). Stage 2 randomized 180 patients (1:1:1) to sotrastaurin 300 or 200 mg or CsA. All patients received basiliximab, everolimus (EVR) and prednisone. Primary endpoint was composite efficacy failure rate of treated biopsy-proven acute rejection, graft loss, death or lost to follow-up. Main safety assessment was estimated glomerular filtration rate (eGFR) by MDRD-4 at Month 12. Composite efficacy failure rates at 12 months were higher in sotrastaurin arms (Stage 1: 16.5% and 10.9% for sotrastaurin 300 mg and CsA; Stage 2: 27.2%, 34.5% and 19.4% for sotrastaurin 200 mg, 300 mg and CsA). eGFR was significantly better in sotrastaurin groups versus CsA at most time points, except at 12 months. Gastrointestinal and cardiac adverse events were more frequent with sotrastaurin. Higher treatment discontinuation, deaths and graft losses occurred with sotrastaurin 300 mg. Sotrastaurin combined with EVR showed higher efficacy failure rates and some improvement in renal allograft function compared to a CsA-based therapy.

Polyomavirus BK replication in de novo kidney transplant patients receiving tacrolimus or cyclosporine: a prospective, randomized, multicenter study

Polyomavirus BK (BKV)-associated nephropathy causes premature kidney transplant (KT) failure. BKV viruria and viremia are biomarkers of disease progression, but associated risk factors are controversial. A total of 682 KT patients receiving basiliximab, mycophenolic acid (MPA), corticosteroids were randomized 1:1 to cyclosporine (CsA) or tacrolimus (Tac). Risk factors were analyzed in 629 (92.2%) patients having at least 2 BKV measurements until month 12 posttransplant. Univariate analysis associated CsA-MPA with lower rates of viremia than Tac-MPA at month 6 (10.6% vs. 16.3%, p = 0.048) and 12 (4.8% vs. 12.1%, p = 0.004) and lower plasma BKV loads at month 12 (3.9 vs. 5.1 log(10) copies/mL; p = 0.028). In multivariate models, CsA-MPA remained associated with less viremia than Tac-MPA at month 6 (OR 0.60; 95% CI 0.36-0.99) and month 12 (OR 0.33; 95% CI 0.16-0.68). Viremia at month 6 was also independently associated with higher steroid exposure until month 3 (OR 1.19 per 1 g), and with male gender (OR 2.49) and recipient age (OR 1.14 per 10 years) at month 12. The data suggest a dynamic risk factor evolution of BKV viremia consisting of higher corticosteroids until month 3, Tac-MPA compared to CsA-MPA at month 6 and Tac-MPA, older age, male gender at month 12 posttransplant.

Polyomavirus BK replication in de novo kidney transplant patients receiving tacrolimus or cyclosporine: a prospective, randomized, multicenter study

Polyomavirus BK (BKV)-associated nephropathy causes premature kidney transplant (KT) failure. BKV viruria and viremia are biomarkers of disease progression, but associated risk factors are controversial. A total of 682 KT patients receiving basiliximab, mycophenolic acid (MPA), corticosteroids were randomized 1:1 to cyclosporine (CsA) or tacrolimus (Tac). Risk factors were analyzed in 629 (92.2%) patients having at least 2 BKV measurements until month 12 posttransplant. Univariate analysis associated CsA-MPA with lower rates of viremia than Tac-MPA at month 6 (10.6% vs. 16.3%, p = 0.048) and 12 (4.8% vs. 12.1%, p = 0.004) and lower plasma BKV loads at month 12 (3.9 vs. 5.1 log(10) copies/mL; p = 0.028). In multivariate models, CsA-MPA remained associated with less viremia than Tac-MPA at month 6 (OR 0.60; 95% CI 0.36-0.99) and month 12 (OR 0.33; 95% CI 0.16-0.68). Viremia at month 6 was also independently associated with higher steroid exposure until month 3 (OR 1.19 per 1 g), and with male gender (OR 2.49) and recipient age (OR 1.14 per 10 years) at month 12. The data suggest a dynamic risk factor evolution of BKV viremia consisting of higher corticosteroids until month 3, Tac-MPA compared to CsA-MPA at month 6 and Tac-MPA, older age, male gender at month 12 posttransplant.

Polyomavirus BK replication in de novo kidney transplant patients receiving tacrolimus or cyclosporine: a prospective, randomized, multicenter study

Polyomavirus BK (BKV)-associated nephropathy causes premature kidney transplant (KT) failure. BKV viruria and viremia are biomarkers of disease progression, but associated risk factors are controversial. A total of 682 KT patients receiving basiliximab, mycophenolic acid (MPA), corticosteroids were randomized 1:1 to cyclosporine (CsA) or tacrolimus (Tac). Risk factors were analyzed in 629 (92.2%) patients having at least 2 BKV measurements until month 12 posttransplant. Univariate analysis associated CsA-MPA with lower rates of viremia than Tac-MPA at month 6 (10.6% vs. 16.3%, p = 0.048) and 12 (4.8% vs. 12.1%, p = 0.004) and lower plasma BKV loads at month 12 (3.9 vs. 5.1 log(10) copies/mL; p = 0.028). In multivariate models, CsA-MPA remained associated with less viremia than Tac-MPA at month 6 (OR 0.60; 95% CI 0.36-0.99) and month 12 (OR 0.33; 95% CI 0.16-0.68). Viremia at month 6 was also independently associated with higher steroid exposure until month 3 (OR 1.19 per 1 g), and with male gender (OR 2.49) and recipient age (OR 1.14 per 10 years) at month 12. The data suggest a dynamic risk factor evolution of BKV viremia consisting of higher corticosteroids until month 3, Tac-MPA compared to CsA-MPA at month 6 and Tac-MPA, older age, male gender at month 12 posttransplant.

The ORION study: comparison of two sirolimus-based regimens versus tacrolimus and mycophenolate mofetil in renal allograft recipients

Safety and efficacy of two sirolimus (SRL)-based regimens were compared with tacrolimus (TAC) and mycophenolate mofetil (MMF). Renal transplantation recipients were randomized to Group 1 (SRL+TAC; week 13 TAC elimination [n = 152]), Group 2 (SRL + MMF [n = 152]) or Group 3 (TAC + MMF [n = 139]). Group 2, with higher-than-expected biopsy-confirmed acute rejections (BCARs), was sponsor-terminated; therefore, Group 2 two-year data were limited. At 1 and 2 years, respectively, graft (Group 1: 92.8%, 88.5%; Group 2: 90.6%, 89.9%; Group 3: 96.2%, 95.4%) and patient (Group 1: 97.3%, 94.4%; Group 2: 95.2%, 94.5%; Group 3: 97.0%, 97.0%) survival rates were similar. One- and 2-year BCAR incidence was: Group 1, 15.2%, 17.4%; Group 2, 31.3%, 32.8%; Group 3, 8.2%, 12.3% (Group 2 vs. 3, p < 0.001). Mean 1- and 2-year modified intent-to-treat glomerular filtration rates (mL/min) were similar. Primary reason for discontinuation was adverse events (Group 1, 34.2%; Group 2, 33.6%; Group 3, 22.3%; p < 0.05). In Groups 1 and 2, delayed wound healing and hyperlipidemia were more frequent. One-year post hoc analysis of new-onset diabetes posttransplantation was greater in TAC recipients (Groups 1 and 3 vs. 2, 17% vs. 6%; p = 0.004). Between-group malignancy rates were similar. The SRL-based regimens were not associated with improved outcomes for kidney transplantation patients.

N-terminal region of the PB1-F2 protein is responsible for increased expression of influenza A viral protein PB1

Influenza A virus (IAV) PB1-F2 protein is encoded by an alternative reading frame (+1) within the PB1 gene. PB1-F2 has been shown to contribute to the pathogenesis of influenza virus infection as well as to the secondary bacterial infection. More recently has been shown that PB1-F2 protein may regulate a viral RNA (vRNA) polymerase activity by the interaction with PB1 protein. We proved that PB1-F2 protein increased the level of expression of PB1 protein and vRNA in the infected cells. Moreover, we demonstrated that a higher level of vRNA expression resulted in the increase of expression of multiple viral proteins, including NP, M1, and NS1. Finally, we used plasmids expressing N-terminal (1-50 aa) or C-terminal (51-87 aa) region of the PB1-F2 molecule for transfection of MDCK cells co-infected with influenza A/Puerto Rico/8/34 (H1N1) virus deficient in the PB1-F2 protein expression (PR8ΔPB1-F2). These experiments clearly showed that N-terminal region of PB1-F2 protein was responsible for the increase in PB1 protein expression. C-terminal region of PB1-F2 protein had no effect. Thus, we have identified the important function for N-terminal region of PB1-F2 protein.

Activation of HLA-G expression by 5-aza-2 - deoxycytidine in malignant hematopoetic cells isolated from leukemia patients

Human leukocyte antigen - G (HLA-G) is a non-classical HLA class I antigen with restricted distribution in normal tissues. Ectopic HLA-G expression observed at some pathological circumstances as malignant transformation might be triggered by epigenetic modifications such as DNA demethylation. Recently it was demonstrated that DNA methyltransferase inhibitor 5-aza-2 - deoxycytidine (AdC) induces/enhances HLA-G transcription in many leukemia cell lines of different origin. Here we investigated the effect of AdC on HLA-G expression in malignant hematopoetic cells isolated from patients with acute myeloid leukemia (AML) and chronic lymphocytic leukemia (B-CLL). We detected HLA-G expression in untreated cells from some patients. Nevertheless treatment with 5-aza-2 - deoxycytidine enhanced HLA-G transcription and concomitantly HLA-G protein synthesis in some leukemia cells.

Pharmacokinetics for once- versus twice-daily tacrolimus formulations in de novo kidney transplantation: a randomized, open-label trial

Tacrolimus, a cornerstone immunosuppressant, is widely available as a twice-daily formulation (Tacrolimus BID). A once-daily prolonged-release formulation (Tacrolimus QD) has been developed that may improve adherence and impart long-lasting graft protection. This study compared the pharmacokinetics (PK) of tacrolimus in de novo kidney transplant patients treated with Tacrolimus QD or Tacrolimus BID. A 6-week, open-label, randomized comparative study was conducted in centers in Europe and Australia. Eligible patients received Tacrolimus QD or Tacrolimus BID. PK profiles were obtained following the first tacrolimus dose (day 1), and twice under steady-state conditions. As secondary objectives, efficacy and safety parameters were also evaluated. Sixty-six patients completed all PK profiles (34 Tacrolimus QD, 32 Tacrolimus BID). Mean AUC(0-24) of tacrolimus on day 1 was approximately 30% lower for Tacrolimus QD than Tacrolimus BID (232 and 361 ng.h/mL, respectively), but was comparable by day 4. There was a good correlation and a similar relationship between AUC(0-24) and C(min) for both formulations. Efficacy and safety data were also comparable over the 6-week period. Tacrolimus QD can be administered once daily in the morning on the basis of the same systemic exposure and therapeutic drug monitoring concept as Tacrolimus BID.

Where did we leave off in 2008? Conclusions from the 8th International Symposium

Although short-term outcomes following kidney transplantation have improved in recent years, allograft viability beyond 1 year has changed little since the introduction of cyclosporine (CsA)-based immunosuppression. Chronic allograft nephropathy (CAN) is a continuing threat to improved long-term outcomes, and regimens that involve calcineurin inhibitors (CNI) are implicated as a result of the progressive fibrosis they promote in renal allografts. Although strategies to reduce the nephrotoxic effects of CNI exposure have shown some success, alternative approaches to reducing nephrotoxicity and graft failure are needed. Sirolimus (SRL) suppresses immune reactions in a mechanism distinct from that of other immunosuppressants and may therefore hold potential for reducing the risk of CAN and improving long-term graft survival. The Rapamune Maintenance Regimen study randomized patients at 3 months either to continue with a regimen of SRL, CsA, and steroids or to have CsA withdrawn and the dose of SRL increased. Patients who were randomized to CsA withdrawal had superior graft and patient survival, demonstrated improved renal function, better blood pressure control, and a lower rate of skin and nonskin posttransplantation malignancy. A key barrier to the wider clinical implementation of SRL in kidney transplantation has, however, been the understanding of its optimal incorporation into standard immunosuppressive protocols. The CONVERT study examined the late conversion (approximately 3 years posttransplantation) from CNI to SRL. Late conversion was associated with inferior outcomes in patients with poor graft function or significant proteinuria following conversion. In addition, a number of short-term adverse events, such as prolongation of delayed graft function and abnormal wound healing, have been more commonly associated with de novo approaches. In designing the optimal approach to achieving long-term CNI-free immunosuppression with SRL, it should therefore be considered how these adverse events may be avoided or minimized. This brings into focus the optimal timing for the introduction of SRL and the potential for a two-stage approach to immunosuppression, minimizing the different short- and long-term risks to both the graft and the patient.

Oxaliplatin, irinotecan, and cetuximab in advanced gastric cancer. First efficacy results of a multicenter phase II trial (AGMT Gastric-2) of the Arbeitsgemeinschaft Medikamentoese Tumortherapie (AGMT)

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Background: Patients (pts.) suffering from advanced gastric cancer have still a poor prognosis and treatment options are limited. In our previous phase II trial (AGMT-Gastric-1) we could show that the combination of oxaliplatin and irinotecan was well tolerated and showed an objective response rate of 58% (Anticancer Res 28:2901–2906, 2008). This chemotherapy regimen was tested in combination with cetuximab in a multicenter phase II trial. Methods: Oxaliplatin 85 mg/m2 biweekly and irinotecan 125 mg/m2 biweekly were combined with cetuximab 400 mg/m2 loading dose and subsequently weekly 250 mg/m2. 51 patients with histological proven unresectable and/or metastatic gastric adenocarcinoma were treated in a first line setting. Median age: 62 years (range 19–79 years), PS 0: 25 patients, PS 1+2 26 patients, single metastatic site: 24 patients, multiple metastases: 27 patients. Results: Frequently reported adverse events (more than 20% of pts.) were predominantly grade 1 or 2 and included neutropenia (35% of pts.), thrombocytopenia (33%), anemia (73%), nausea (45%), diarrhea (57%), alopecia (22%), and fatigue (37%). Grade 3 and 4 toxicities included neutropenia in 9/1 pts., thrombocytopenia in 1/0 pts., anemia in 3/1 pts., nausea in 2/0 pts., and diarrhea in 7/2 pts. Sensory neuropathy occurred mostly as grade 1 and 2 in 37% of pts., in 7 pts. grade 3 neurotoxicity was observed. Acneiform skin rash grade 1 / 2 / 3 / 4 was reported in 31% / 20% / 6% / 2% of pts. respectively. 16 pts. went off-study due to neutropenia (n=5), nausea/vomiting (n=1), diarrhea (n=1), progressive disease (n=3), toxic colon (n=2), and allergic reaction to cetuximab at first (n=2), second (n=1) or third infusion (n=1). 35 patients are assessable for response with 1 pt. (3%) showing a CR, 21 pts. (60%) a PR, 7 pts. (20%) a SD and PD in 6 pts. (17%). A disease control rate was achieved in 83%. Median time to progression was 24.8 weeks (n=29), median overall survival 38.1 weeks (n=32). Conclusions: The combination of oxaliplatin and irinotecan with cetuximab is feasible, safe and active in advanced gastric cancer.

[Table: see text]

Antibodies induced by the HA2 glycopolypeptide of influenza virus haemagglutinin improve recovery from influenza A virus infection

The haemagglutinin (HA) of influenza A virus consists of two glycopolypeptides designated HA1 and HA2. Antibodies recognizing HA1 inhibit virus haemagglutination, neutralize virus infectivity and provide good protection against infection, but do not cross-react with the HA of other subtypes. Little is known regarding the biological activities of antibodies against HA2. To study the role of antibodies directed against HA2 during influenza virus infection, two vaccinia virus recombinants (rVVs) were used expressing chimeric molecules of HA, in which HA1 and HA2 were derived from different HA subtypes. The KG-11 recombinant expressed HA1 from A/PR/8/34 (H1N1) virus and HA2 from A/NT/60 (H3N2) virus, whilst KG-12 recombinant expressed HA1 from A/NT/60 virus and HA2 from A/PR/8/34 virus. Immunization of BALB/c mice with rVV expressing HA2 of the HA subtype homologous to the challenge virus [A/PR/8/34 (H1N1) or A/Mississippi/1/85 (H3N2)] did not prevent virus infection, but nevertheless resulted in an increase in mice survival and faster elimination of virus from the lungs. Passive immunization with antibodies purified from mice immunized with rVVs confirmed that antibodies against HA2 were responsible for the described effect on virus infection. Based on the facts that HA2 is a rather conserved part of the HA and that antibodies against HA2, as shown here, may moderate virus infection, future vaccine design should deal with the problem of how to increase the HA2 antibody response.

Kidney transplant rejection in Australia and New Zealand: relationships between rejection and graft outcome

Although acute rejection rates have fallen over time, how this relates to graft outcomes is not known. Using data from the ANZDATA Registry, we examined associations of rejection within six months of transplantation with graft and patient outcomes among kidney-only transplants performed between April 1997 and December 2004 in Australia and New Zealand. Associations of biopsy histology with outcomes of the rejection episode were also examined. Outcomes were examined among 4325 grafts with 1961 rejection episodes in total. Crude rejection rates have fallen by one-third over that time, but rates of graft survival are constant. The occurrence of acute rejection was associated with an increased risk of graft loss after 6 months (HR, adjusted for donor and recipient characteristics, 1.69 [1.36-2.11], p<0.001). Late rejection (first rejection >or=90 days) was associated with higher risk of graft loss (adjusted HR 2.46 [1.70-3.56], p<0.001). Vascular rejection was also associated with a higher risk of graft loss 2.07 [95% CI 1.60-2.68], p<0.001. The occurrence of acute rejection is associated with an ongoing increased risk of graft loss, particularly if that episode occurred late or included vascular rejection. The reduced rates of rejection have not been associated with improved graft survival.

The transmission of donor-derived malignant melanoma to a renal allograft recipient

The transmission to organ transplant recipients of donor origin malignancy in the allograft has been described. Here we report the transmission of malignant melanoma in a renal allograft transplanted from a multiorgan donor. The lung transplant recipient presented with an allograft lesion that was proven to be melanoma and of donor-origin based on human leukocyte antigen (HLA)-DR typing. One renal allograft recipient was undergoing his second deceased donor renal transplant, having lost his first graft from recurrent IgA nephropathy. He was unsensitized and immunosuppression consisted of tacrolimus, mycophenolate and prednisolone. He achieved stable graft function and there were no episodes of rejection. Four and a half months post-transplant a diagnosis of donor origin melanoma in the lung recipient was made and his immunosuppression was stopped. He presented with clinical rejection two wk later and a transplant nephrectomy was undertaken. Histology demonstrated vascular and cellular rejection and there was a 3-mm melanoma deposit with no evidence of tumour infiltrating lymphocytes. Three years post-transplant he remained clinically well with no evidence of melanoma and received his third deceased donor renal transplant. This was complicated by cellular rejection in the first week treated with methylprednisolone and vascular rejection at day 10 treated with anti-thymocyte globulin. Three months post-transplant he has achieved good allograft function and remains well with no evidence clinically or on imaging of metastatic melanoma. The other renal allograft recipient was receiving his first deceased donor transplant, having end-stage renal failure of uncertain aetiology. His immunosuppression was not stopped until melanoma was proven in the renal allograft pair six months post-transplant and he then presented with clinical rejection six wk later. Transplant nephrectomy was undertaken and histology did not demonstrate melanoma, but severe vascular and cellular rejection was evident. At three-yr post-transplant he remains disease free clinically and on imaging. At present, the cardiac allograft recipient has no evidence of transmitted melanoma. The highest risk of transmission of donor origin melanoma appears to be from donors who are older and have died from an intracerebral haemorrhage. It is likely these donors have metastatic melanoma and their intracerebral haemorrhage is not primary but has occurred in an unrecognized metastatic cerebral deposit. While the occurrence of donor-transmitted malignancy is not common, the outcome is often fatal.

Influenza a virus PB1-F2 protein

PB1-F2 protein (PB1-F2) is encoded by the alternative (+1) ORF in the PB1 gene of influenza A viruses (IAVs). This protein has a number of unique features, namely its absence from some animal IAV isolates, variable expression in individual infected cells, rapid proteasome-dependent degradation, mitochondrial localization, and apoptotic or pro-apoptotic properties. Localization of PB1-F2 to mitochondria is mediated via C-terminal basic amphipathic alpha-helix. PB1-F2 affects apoptosis and may contribute to the pathogenicity and lethality of IAVs. Sequence analysis showed that, in addition to the strains with an ORF for full-length PB1-F2, there are some with an ORF for different truncated forms of PB1-F2. Several other viruses encode proteins with structure and function similar to PB1-F2 of IAVs.

Modulation of HLA-G expression

Recent studies demonstrated that HLA-G transcription is in some cells silenced by epigenetic mechanisms as DNA methylation and histone modification. Accordingly HLA-G gene transcriptions can be activated in such cells by demethylating agent or by inhibitors of histone deacetylation. In addition to epigenetic alterations HLA-G gene transcription can be activated by stress. In the present study these aspects of HLA-G expression are re-examined and a new inhibitor of histone deacetylation (valproic acid) and hypoxia mimetic chemical (CoCl2) are included. The highest activation of HLA-G transcription was achieved by treatment of choriocarcinoma JAR and lymphoblastoid RAJI cell lines with demethylating agent 5-aza-2 - deoxycytidine. Treatment of JAR and RAJI cells with histone deacetylase inhibitors (sodium butyrate and valproic acid) also enhanced HLA-G transcription. Nevertheless this increase in HLA-G expression was low as compared with activation by 5-aza-2 - deoxycytidine. The hypoxia mimetic agents (desferrioxamine or CoCl2) had no detectable effect on HLA-G gene transcription in examined cells. Relatively high increase of HLA-G transcription was detected in JAR and RAJI cells exposed to heat shock treatment. Interestingly heat shock induced high expression of HLA-G6 transcript in JAR cells. Heat shock treatment had no effect on alternative splicing of constitutively expressed HLA-G mRNA in choriocarcinoma cell line JEG-3. HLA-G1 protein expression was induced in JAR and RAJI cell lines by 5-aza-2 - deoxycytidine. In agreement with the differences in the levels of HLA-G transcripts JAR cells express more of HLA-G1 protein than RAJI cells.

FTY720/cyclosporine regimens in de novo renal transplantation: a 1-year dose-finding study

FTY720 is a novel immunomodulator being investigated for rejection prophylaxis in renal transplantation when combined with full-dose cyclosporine (CsA; FDC). This 1-year phase II study compared FTY720 plus FDC (Neoral) with FTY720 plus reduced-dose CsA (RDC) and mycophenolate mofetil (MMF) plus FDC in de novo renal transplant patients. Patients were randomized 2:2:2:1 to FTY720 5 mg plus RDC (n = 72); FTY720 2.5 mg plus RDC (n = 74); FTY720 2.5 mg plus FDC (n = 76); or MMF plus FDC (n = 39) for 12 months. CsA exposure in the RDC group was reduced on average by 50% as assessed by C(2) monitoring. The primary efficacy endpoint was the composite incidence of biopsy-proven acute rejection (BPAR), graft loss, death or premature study discontinuation. The incidences for this composite endpoint were 24% and 22%, respectively, for FTY720 5 mg plus RDC and FTY720 2.5 mg plus FDC versus 39% for MMF plus FDC. Patients receiving FTY720 2.5 mg plus RDC were discontinued from treatment due to risk of under-immunosuppression. FTY720 2.5 mg plus FDC and FTY720 5 mg plus RDC were safe and effective in de novo renal transplant patients over 12 months.

Effect of proteasome inhibitors on expression of HLA-G isoforms

HLA-G primary transcript is alternatively spliced into a number of mRNAs. In addition to full length HLA-G1 protein isoform these mRNAs might also encode truncated HLA-G protein isoforms lacking one or two extracellular domains. Whereas HLA-G1 protein isoform is regularly identified, truncated HLAG protein isoforms are not detected even if all alternative spliced mRNAs are present in cells. The absence of entire domain(s) renders the truncated HLA-G protein isoforms incapable of binding peptide and beta2-microglobulin. These features of truncated HLA-G protein isoforms may result in their rapid degradation by proteasomes. Here we show that despite the presence of all alternatively spliced HLA-G transcripts in JEG-3 cells pretreated with proteasome inhibitors only a full length HLA-G1 protein isoform was regularly detected. Interestingly, immunoblot analysis showed slight increase of HLA-G1 protein in cells pretreated with proteasome inhibitors, although the expression of HLA-G1 transcript was basically not affected. Expression of HLA-G3 transcript increased in JEG-3 cells pre-incubated with LLL, however, neither HLA-G3 nor other HLA-G short protein isoform was regularly detected. In K562 transfectants proteasome inhibitor LLL greatly enhanced expression of the HLA-G1 and -G2 transcripts as well as corresponding protein isoforms. Flow cytometry analysis showed that in cells pre-treated with proteasome inhibitors cell surface expression of HLA-G1 protein decreased but the quantity of intracellularly localized HLA-G antigens increased. Altogether our results suggest that truncated HLA-G proteins isoforms are not detected in JEG-3 cells as a result of their instability and the low translation efficiency of truncated HLA-G transcripts.

PB1-F2 gene in influenza a viruses of different hemagglutinin subtype

The second ORF frame (+1) of PB1 polymerase gene of Influenza A virus (IAV) encodes the PB1-F2 protein. The length of PB1-F2 encoded by the A/Puerto Rico/8/34 (H1N1) (PR8) virus is 87 aa. The analysis of nucleotide sequences of PB1 gene of 626 IAV isolates available in GenBank and Influenza Sequence Database revealed that this gene has mostly the capacity to encode a putative protein of 90 aa. The predicted extra three amino acids in the 90-aa PB1-F2 are to a great extent conservative. Some IAV isolates, particularly human, avian and swine with hemagglutinin (HA) of H1 subtype can potentially encode a C-terminally truncated PB1-F2 of various lengths. The C-terminally truncated PB1-F2 in H1 isolates is lacking the region responsible for mitochondrial targeting and apoptosis. About 50% of avian isolates of H9 subtype possess an ORF for truncated PB1-F2. Eighteen aa, 10 at the N-terminus and 8 at the C terminus are strictly conservative in all 148 human isolates.

Immunity in latent Herpes simplex virus infection

Immune responses against productive Herpes simplex virus 1 (HSV-1) and/or Herpes simplex virus 2 (HSV-2) (HSV) infection together with associated immune escape mechanisms are to a great degree understood. Due to a limited RNA expression and lacking a convincing evidence for production of virus proteins during latency, HSV in latently infected neurons had been for a long period considered invisible to immune system. This review analyzes currently accumulating data indicating an important role of immune response to HSV-1 latency and/or to early steps of HSV-1 reactivation process. Although this review focuses on HSV-1, it is likely that general concepts apply to both HSV-1 and HSV-2, since they share a great deal of similarity in their biological features including a high degree of sequence similarity at the nucleic acid level.

Phase II Study of Single-Agent Pegylated Liposomal Doxorubicin HCl (PLD) in Metastatic Breast Cancer After First-Line Treatment Failure

OBJECTIVES

Aim of this study was to evaluate the clinical benefit and the toxicity of pegylated liposomal doxorubicin.

PATIENTS AND METHODS

Patients with metastatic breast cancer (n = 30) who failed a prior chemotherapy regimen for metastatic disease received 45 mg/m2 pegylated liposomal doxorubicin (PLD) every 4 weeks following prophylactic administration of metoclopramide (10 mg) and dexamethasone (8 mg).

RESULTS

29 of 30 patients were assessed for clinical benefit and time to progression. All patients were assessed for toxicity and analysis of overall survival. 9 patients (31%) had a partial response, and 16 patients (55%) responded with stable disease, resulting in a clinical benefit rate of 86% (n = 25). Median time to progression was 4 months (95% CI: 2.8-5.2), median duration of response was 7 months (95% CI: 4.7-8.2), and median survival was 12 months (95% CI: 6.7-17.2). Skin toxicity was the most common adverse event (30%, all < or = grade 2). Other toxicities were remarkably low in occurrence.

CONCLUSION

PLD is a well-tolerated, second-line monotherapy with a high rate of clinical benefit.

Sexually transmitted infections among prostitutes in Bratislava, Slovakia

Sera from 18 prostitutes from Bratislava were examined for the presence of antibodies to several sexually transmitted pathogens, namely Herpes simplex virus 2 (HSV-2), Human immunodeficiency viruses 1 and 2 (HIV-1 and HIV-2), Hepatitis B and C viruses (HBV and HCV), Chlamydia trachomatis, and Treponema pallidum. Results of this screening indicated that 11 prostitutes (61%) carried 1 or more sexually transmitted infections. The most prevalent antibodies were directed against HSV-2 (9 cases, i.e. 50%), which represents the most common sexually transmitted infection agent.

Binding analysis of HLA-G specific antibodies to hematopoietic cells isolated from leukemia patients

Expression of HLA-G on the surface of malignant hematopoietic cells isolated from leukemia patients was analyzed by flow cytometry using monoclonal antibodies (mAbs) recognizing both, intact HLA-G complex (87G, 01G and MEM-G9) as well as HLA-G free heavy chain (4H84, MEM-G/1 and MEM-G/2). Prerequisite of HLA-G detection by mAbs specific to free heavy chain was mild acid treatment, which dissociates intact HLA-G complex. All mAbs, with the exception of 4H84 mAb, did not indicate the presence of HLA-G antigen in leukemia cells. Positive staining with 4H84 mAb was detected in acid-treated cells isolated from 16 out of 30 patients. Intensity of staining increased after IFN-g pre-incubation in most cases. Immunoblot analyses and RT-PCR, however, failed to detect HLA-G antigen or HLA-G transcripts in cells that bind 4H84 mAb after acid-treatment. The binding of 4H84 mAb can be explained by the acid-induced cross-reactivity of this HLA-G specific mAb with classical HLA class I molecules [15]. The results described here further demonstrate that the HLA-G molecule is not expressed in freshly isolated human leukemia cells.

Live donor renal transplantation in Australia 1964-1999: an evolving practice

BACKGROUND

Australia has a low cadaver organ donor (CD) rate by international standards, leading to the increasing use of live donor (LD) renal grafts.

AIMS

To review the Australian experience with LD transplants from 1964 to 1999.

METHODS

Data were obtained from the Australian and New Zealand Dialysis and Transplant Registry. Survival was assessed by the Kaplan-Meier method.

RESULTS

A total of 1584 LD and 10 252 CD transplants was performed between 1964 and 1999. While the CD rate dropped over the last decade, the LD rate increased, maintaining the overall transplantation rate. Only 3.6% of grafts before 1980 were LD, increasing to 28.4% during 1995-1999. Patient and graft survival of LD grafts was superior to CD grafts. Most LD grafts were from live related donors (LRD), most commonly parents or siblings. The number of transplants from live unrelated donors (LURD) has risen (1980-1989, n = 6; 1990-1999, n = 143), primarily due to more spousal donation, with no difference in survival between LRD and LURD groups. Grafts from older donors (> 50 years of age) increased, with no graft survival difference between donors < 50 years and donors > 50 years. LD transplants performed prior to commencement of dialysis increased, with survival similar to grafts performed after dialysis.

CONCLUSION

The pattern of renal transplantation in Australia has changed, with increasing numbers of LD transplants, growing use of unrelated and older donors, and more transplants before dialysis commences. Long-term patient and graft survival advantages have been maintained, supporting the growing use of live donors to expand the donor pool.

Analysis of the extracellular processing of HIV-1 gp160-derived peptides using monoclonal antibodies specific to H-2Dd molecule complexed with p18-I10 peptide

The immunodominant peptide of human immunodeficiency virus 1 gp 160 for murine cytotoxic T cells of H-2d haplotype, has been originally identified as a 15 amino acid residue peptide P18IIIB (RIQRGPGRAFVTIGK) (Takahashi et al., 1988). Further studies have indicated that a more active form of the peptide is generated by removal of the C-terminal dipeptide by angiotensin-I-converting enzyme (ACE), and additional detailed studies have shown that the actual immunodominant peptide is a decamer P18-I10 (RGPGRAFVTI) (Kozlowski et al., 1993). The effect of proteolytic processing on the antigenicity of P18IIIB peptide and its analogs was investigated by functional T cell assays based on the ability of T cell receptor (TCR) to recognize a specific major histocompatibility complex class I (MHC-I)/peptide complex. Recently we described a new monoclonal antibody (MAb) KP15 directed against the MHC-I molecule H-2Dd complexed with the 10-mer peptide P18-I10. Using this MAb, the cell surface H-2Dd/P18-I10 complex can be easily detected by flow cytometry (Polakova et al., 2000). Here we examined whether peptides longer than P18-I10 decamer form H-2Dd complexes recognized by KP15 MAb. Further we also analyzed how the ACE processing of P18IIIB-related peptides of different length affects their ability to form complexes with H-2Dd recognized by MAb KP15. These experiments confirmed that the ACE digestion of 15-mer peptide P18IIIB is the most effective in the production of a peptide capable of forming complex with H-2Dd recognized by KP15 MAb. The ACE digestion of longer peptides (16-mer to 19-mer) did not produce a significant quantity of peptides, capable of forming H-2Dd complexes recognizable with by MAb KP15. Peptides shorter than P18IIIB (13-mer to 10-mer), notably the optimally sized P18-I10 peptide lost most of their capacity to form H-2Dd complexes recognized by KP15 MAb. Our results show that the extracellular processing of MHC-I-restricted peptides, which cannot be overlooked in designing peptide-based vaccines, can be also studied by as simple and rapid assay as flow cytometry, provided MAbs specific to a particular MHC-I/peptide complex are available.

Colorectal cancer in patients with chronic renal failure: the effect of dialysis or renal transplantation

OBJECTIVE: This study reports the characteristics and surgical outcome of colorectal cancer in patients with chronic renal failure treated either by renal transplantation or dialysis. METHODS: Two thousand four hundred and seventeen patients with CRF (1387 transplant and 1030 dialysis) were treated at The Queen Elizabeth Hospital, South Australia, between January 1967 and September 2000. RESULTS: Fourteen have developed colorectal cancer and had their clinical records reviewed. Nine patients were renal transplant recipients and 5 patients were treated with dialysis. Eight patients had surgery. Chemotherapy was given palliatively to 3 patients. One patient died in hospital postoperatively. Seven patients with a renal transplant had notes available. Six presented with late stage disease and all were dead within 9 months of presentation from their disease. In the dialysis patients, tumour stage at presentation was not so advanced and although all the patients have died, the cause of death was secondary to the colorectal cancer in only 2 patients. CONCLUSIONS: This study highlights the poor outcome of patients who have had renal transplant and develop colorectal cancer. Immunosuppression and late diagnosis are implicated in this poor outcome.

Expression of the non-classical HLA-G antigen in tumor cell lines is extremely restricted

It has been proposed that tumor cells frequently associated with partial or total loss of HLA class Ia expression may abnormally express HLA-G class Ib antigen. Such peculiar HLA class I expression would allow tumor cells to escape not only from CD8+T but also from NK-cell cytotoxicity. We studied the cell surface expression of HLA-G using flow cytometry with two HLA-G specific monoclonal antibodies (87G, 01G). The JEG-3 choriocarcinoma cell line, which constitutively expresses HLA-G antigens was used as a positive control. We did not detect the cell-surface HLA-G antigens in the following 75 tumor cell lines: melanoma (22), neuroblastoma (7), retinoblastoma (1), glioma (2), breast carcinoma (3), ovarian carcinoma (3), cervical carcinoma (1), colon carcinoma (3), bladder carcinoma (2), hepatocarcinoma (1), sarcoma (2) and leukemia cell lines: T-lymphocytes (6), B-lymphocytes (13) and myelo-monocytes (9). We found that some myelomonocytic cell lines express on their surface high affinity FcgammaRI (CD64) that may result in the binding of HLA-G specific mabs to their cell surface even in the absence of HLA-G molecules. Our panel of HLA-G negative tumor cell lines accommodated 62 cell lines for which similar analysis have not been reported and also contained 13 cell lines with total or partial loss of HLA class Ia molecules. Our observation imply that under normal culture conditions the cell surface HLA-G reactive with 87G and 01G mabs is absent in most tumor cell lines of different origin.

The strong positive correlation between effective affinity and infectivity neutralization of highly cross-reactive monoclonal antibody IIB4, which recognizes antigenic site B on influenza A virus haemagglutinin

Monoclonal antibody (MAb) IIB4 displays a rare combination of virus neutralization (VN) activity and broad cross-reactivity with influenza A virus strains of the H3 subtype isolated in a period from 1973 to 1988. The epitope of this antibody has been identified as around HA1 residues 198, 199 and 201. Here we report that residues 155, 159, 188, 189 and 193 also influence the binding of this antibody. We have used this antibody to study the relationship between antibody affinity and VN activity. Using one MAb and a single epitope on the haemagglutinin (HA) of different influenza viruses we found a strong positive correlation between effective affinity and VN activity of MAb IIB4. A 10-fold increase in effective affinity corresponded to the 2000-fold increase in VN titre. It follows from the law of mass action that for an effective affinity K=9x10(8) l/mol, 50% VN was achieved at approx. 10% occupation of HA spikes with antibody. In contrast, for an effective affinity K=6x10(7) l/mol, to achieve 50% VN, occupation of up to 98% of HA spikes was required. An effective affinity about K=6x10(7) l/mol thus represents the limiting value for VN because a further decrease in the affinity cannot be compensated by a higher concentration of antibody.

Prevalence of antibodies to herpes simplex virus 2 among homosexual men either positive or negative for human immunodeficiency viruses in Slovakia

We determined the prevalence of antibodies to herpes simplex virus 2 (HSV-2, HSV-2 antibodies) in sera of homosexual men either positive for human immunodeficiency virus 1 (HIV-1, HIV+, a group of 27 sera) or negative for HIV-1 and HIV-2 (HIV-, a group of 52 sera) in Slovakia. Antibodies to HSV-2 glycoprotein G-2 (gG-2, gG-2 antibodies) were determined by a double-antibody sandwich enzyme-linked immunosorbent assay (DAS-ELISA) and immunoblot analysis. We found that 40% of HIV+ and 23% of HIV- homosexual men were positive for the gG-2 antibodies, what is 3.6 and 2.1 times higher incidence, respectively, than that in the control heterosexual population (Bystrická et al., Acta Virol. 42, 319-324, 1998). Identification of individuals infected with genital herpes among HIV+ and HIV- homosexual men should be succeeded by antiviral therapy in order to prevent transmission of HSV-2 and HIV as well in this community.

Monoclonal antibodies suitable for type-specific identification of herpes simplex viruses by a rapid culture assay

Eight monoclonal antibodies (MAbs) to herpes simplex viruses 1 and/or 2 (HSV-1, HSV-2) were tested for their reactivity with 190 previously typed HSV-positive clinical specimens in order to determine their suitability for use as type-specific reagents. Using a rapid culture assay we found that two MAbs (T51 and T96) identified HSV-1 in all the 94 specimens, previously found HSV-1-positive, but did not react with the 96 specimens, previously found HSV-2-positive. In contrast, one MAb (303) confirmed the presence of HSV-2 in all the specimens, previously found HSV-2-positive, but did not react with any of the 94 specimens, previously found HSV-1-positive. These three type-specific MAbs allow for a rapid type-specific identification of HSV in infected cultures. One type-common MAb (T111) reacted with all HSV-positive cultures. This MAb can be used as an excellent reagent for detection of HSV infection.