MLH1 Promoter Methylation Could Be the Second Hit in Lynch Syndrome Carcinogenesis

(1) Background: MLH1 hypermethylation is an epigenetic alteration in the tumorigenesis of colorectal cancer (CRC) and endometrial cancer (EC), causing gene silencing, and, as a consequence, microsatellite instability. Commonly, MLH1 hypermethylation is considered a somatic and sporadic event in cancer, and its detection is recognized as a useful tool to distinguish sporadic from inherited conditions (such as, Lynch syndrome (LS)). However, MLH1 hypermethylation has been described in rare cases of CRC and EC in LS patients. (2) Methods: A total of 61 cancers (31 CRCs, 27 ECs, 2 ovarian cancers, and 1 stomach cancer) from 56 patients referred to cancer genetic counselling were selected for loss of MLH1 protein expression and microsatellite instability. All cases were investigated for MLH1 promoter methylation and MLH1/PMS2 germline variants. (3) Results: Somatic MLH1 promoter hypermethylation was identified in 16.7% of CRC and in 40% of EC carriers of MLH1 germline pathogenic variants. In two families, primary and secondary MLH1 epimutations were demonstrated. (4) Conclusions: MLH1 hypermethylation should not be exclusively considered as a sporadic cancer mechanism, as a non-negligible number of LS-related cancers are MLH1 hypermethylated. Current flow charts for universal LS screening, which include MLH1 methylation, should be applied, paying attention to a patient's family and personal history.

Breast and Prostate Cancer Risks for Male BRCA1 and BRCA2 Pathogenic Variant Carriers Using Polygenic Risk Scores

BACKGROUND

Recent population-based female breast cancer and prostate cancer polygenic risk scores (PRS) have been developed. We assessed the associations of these PRS with breast and prostate cancer risks for male BRCA1 and BRCA2 pathogenic variant carriers.

METHODS

483 BRCA1 and 1318 BRCA2 European ancestry male carriers were available from the Consortium of Investigators of Modifiers of BRCA1/2 (CIMBA). A 147-single nucleotide polymorphism (SNP) prostate cancer PRS (PRSPC) and a 313-SNP breast cancer PRS were evaluated. There were 3 versions of the breast cancer PRS, optimized to predict overall (PRSBC), estrogen receptor (ER)-negative (PRSER-), or ER-positive (PRSER+) breast cancer risk.

RESULTS

PRSER+ yielded the strongest association with breast cancer risk. The odds ratios (ORs) per PRSER+ standard deviation estimates were 1.40 (95% confidence interval [CI] =1.07 to 1.83) for BRCA1 and 1.33 (95% CI = 1.16 to 1.52) for BRCA2 carriers. PRSPC was associated with prostate cancer risk for BRCA1 (OR = 1.73, 95% CI = 1.28 to 2.33) and BRCA2 (OR = 1.60, 95% CI = 1.34 to 1.91) carriers. The estimated breast cancer odds ratios were larger after adjusting for female relative breast cancer family history. By age 85 years, for BRCA2 carriers, the breast cancer risk varied from 7.7% to 18.4% and prostate cancer risk from 34.1% to 87.6% between the 5th and 95th percentiles of the PRS distributions.

CONCLUSIONS

Population-based prostate and female breast cancer PRS are associated with a wide range of absolute breast and prostate cancer risks for male BRCA1 and BRCA2 carriers. These findings warrant further investigation aimed at providing personalized cancer risks for male carriers and informing clinical management.

Filling the gap: A thorough investigation for the genetic diagnosis of unsolved polyposis patients with monoallelic MUTYH pathogenic variants

Backgrounds

MUTYH‐associated polyposis (MAP) is an autosomal recessive disease caused by biallelic pathogenic variants (PV) of the MUTYH gene. The aim of this study was to investigate the genetic causes of unexplained polyposis patients with monoallelic MUTYH PV. The analysis focused on 26 patients with suspected MAP, belonging to 23 families. Ten probands carried also one or more additional MUTYH variants of unknown significance.

Methods

Based on variant type and on the collected clinical and molecular data, these variants were reinterpreted by applying the ACMG/AMP rules. Moreover, supplementary analyses were carried out to investigate the presence of other variants and copy number variations in the coding and promoter regions of MUTYH, as well as other polyposis genes (APC, NTHL1, POLE, POLD1, MSH3, RNF43, and MCM9).

Results

We reclassified 4 out of 10 MUTYH variants as pathogenic or likely pathogenic, thus supporting the diagnosis of MAP in only four cases. Two other patients belonging to the same family showed a previously undetected deletion of the APC gene promoter. No PVs were found in the other investigated genes. However, 6 out of the 18 remaining families are still interesting MAP candidates, due to the co‐presence of a class 3 MUTYH variant that could be reinterpreted in the next future.

Conclusion

Several efforts are necessary to fully elucidate the genetic etiology of suspected MAP patients, especially those with the most severe polyposis/tumor phenotype. Clinical data, tumor molecular profile, family history, and polyposis inheritance mode may guide variant interpretation and address supplementary studies.

Lynch syndrome and Muir-Torre phenotype associated with a recurrent variant in the 3'UTR of the MSH6 gene

A MSH6 3'UTR variant (c.*23_26dup) was found in 13 unrelated families consulted for Lynch/Muir-Torre Syndrome. This variant, which is very rare in the genomic databases, was absent in healthy controls and strongly segregated with the disease in the studied pedigrees. All tumors were defective for MSH2/MSH6/MSH3 proteins expression, but only MSH2 somatic pathogenic mutations were found in 5 of the 12 sequenced tumors. Moreover, we had no evidence of MSH6 transcript decrease in carriers, whereas MSH2 transcript was downregulated. Additional evaluations performed in representative carriers, including karyotype, arrayCGH and Linked-Reads whole genome sequencing, failed to evidence any MSH2 germline pathogenic variant. Posterior probability of pathogenicity for MSH6 c.*23_26dup was obtained from a multifactorial analysis incorporating segregation and phenotypic data and resulted >0.999, allowing to classify the variant as pathogenic (InSiGHT Class 5). Carriers shared a common haplotype involving MSH2/MSH6 loci, then a cryptic disease-associated variant, linked with MSH6 c.*23_26dup, cannot be completely excluded. Even if it is not clear whether the MSH6 variant is pathogenic per se or simply a marker of a disease-associated MSH2/MSH6 haplotype, all data collected on patients and pedigrees prompted us to manage the variant as pathogenic and to offer predictive testing within these families.

Large scale multifactorial likelihood quantitative analysis of BRCA1 and BRCA2 variants: An ENIGMA resource to support clinical variant classification

The multifactorial likelihood analysis method has demonstrated utility for quantitative assessment of variant pathogenicity for multiple cancer syndrome genes. Independent data types currently incorporated in the model for assessing BRCA1 and BRCA2 variants include clinically calibrated prior probability of pathogenicity based on variant location and bioinformatic prediction of variant effect, co-segregation, family cancer history profile, co-occurrence with a pathogenic variant in the same gene, breast tumor pathology, and case-control information. Research and clinical data for multifactorial likelihood analysis were collated for 1,395 BRCA1/2 predominantly intronic and missense variants, enabling classification based on posterior probability of pathogenicity for 734 variants: 447 variants were classified as (likely) benign, and 94 as (likely) pathogenic; and 248 classifications were new or considerably altered relative to ClinVar submissions. Classifications were compared with information not yet included in the likelihood model, and evidence strengths aligned to those recommended for ACMG/AMP classification codes. Altered mRNA splicing or function relative to known nonpathogenic variant controls were moderately to strongly predictive of variant pathogenicity. Variant absence in population datasets provided supporting evidence for variant pathogenicity. These findings have direct relevance for BRCA1 and BRCA2 variant evaluation, and justify the need for gene-specific calibration of evidence types used for variant classification.

Toward a better definition of EPCAM deletions in Lynch Syndrome: Report of new variants in Italy and the associated molecular phenotype

Background

Inherited epimutations of Mismatch Repair (MMR) genes are responsible for Lynch Syndrome (LS) in a small, but well defined, subset of patients. Methylation of the MSH2 promoter consequent to the deletion of the upstream EPCAM gene is found in about 1%–3% of the LS patients and represents a classical secondary, constitutional and tissue‐specific epimutation. Several different EPCAM deletions have been reported worldwide, for the most part representing private variants caused by an Alu‐mediated recombination.

Methods

712 patients with suspected LS were tested for MMR mutation in our Institute. EPCAM deletions were detected by multiplex ligation‐dependent probe amplification (MLPA) and then defined by Long‐Range polymerase chain reaction (PCR)/Sanger sequencing. A comprehensive molecular characterization of colorectal cancer (CRC) tissues was carried out by immunohistochemistry of MMR proteins, Microsatellite Instability (MSI) assay, methylation specific MLPA and transcript analyses. In addition, somatic deletions and/or variants were investigated by MLPA and next generation sequencing (NGS).

Results

An EPCAM deletion was found in five unrelated probands in Italy: variants c.556‐490_*8438del and c.858+1193_*5826del are novel; c.859‐1430_*2033del and c.859‐670_*530del were previously reported. All probands were affected by CRC at young age; tumors showed MSI and abnormal MSH2/MSH6 proteins expression. MSH2 promoter methylation, as well as aberrant in‐frame or out‐of‐frame EPCAM/MSH2 fusion transcripts, were detected in CRCs and normal mucosae.

Conclusion

An EPCAM deletion was the causative variant in about 2% of our institutional series of 224 LS patients, consistent with previously estimated frequencies. Early age and multiple CRCs was the main clinical feature of this subset of patients.

Prediction of Breast and Prostate Cancer Risks in Male BRCA1 and BRCA2 Mutation Carriers Using Polygenic Risk Scores

Purpose BRCA1/2 mutations increase the risk of breast and prostate cancer in men. Common genetic variants modify cancer risks for female carriers of BRCA1/2 mutations. We investigated-for the first time to our knowledge-associations of common genetic variants with breast and prostate cancer risks for male carriers of BRCA1/ 2 mutations and implications for cancer risk prediction. Materials and Methods We genotyped 1,802 male carriers of BRCA1/2 mutations from the Consortium of Investigators of Modifiers of BRCA1/2 by using the custom Illumina OncoArray. We investigated the combined effects of established breast and prostate cancer susceptibility variants on cancer risks for male carriers of BRCA1/2 mutations by constructing weighted polygenic risk scores (PRSs) using published effect estimates as weights. Results In male carriers of BRCA1/2 mutations, PRS that was based on 88 female breast cancer susceptibility variants was associated with breast cancer risk (odds ratio per standard deviation of PRS, 1.36; 95% CI, 1.19 to 1.56; P = 8.6 × 10-6). Similarly, PRS that was based on 103 prostate cancer susceptibility variants was associated with prostate cancer risk (odds ratio per SD of PRS, 1.56; 95% CI, 1.35 to 1.81; P = 3.2 × 10-9). Large differences in absolute cancer risks were observed at the extremes of the PRS distribution. For example, prostate cancer risk by age 80 years at the 5th and 95th percentiles of the PRS varies from 7% to 26% for carriers of BRCA1 mutations and from 19% to 61% for carriers of BRCA2 mutations, respectively. Conclusion PRSs may provide informative cancer risk stratification for male carriers of BRCA1/2 mutations that might enable these men and their physicians to make informed decisions on the type and timing of breast and prostate cancer risk management.

FANCM c.5791C>T nonsense mutation (rs144567652) induces exon skipping, affects DNA repair activity and is a familial breast cancer risk factor

Numerous genetic factors that influence breast cancer risk are known. However, approximately two-thirds of the overall familial risk remain unexplained. To determine whether some of the missing heritability is due to rare variants conferring high to moderate risk, we tested for an association between the c.5791C>T nonsense mutation (p.Arg1931*; rs144567652) in exon 22 of FANCM gene and breast cancer. An analysis of genotyping data from 8635 familial breast cancer cases and 6625 controls from different countries yielded an association between the c.5791C>T mutation and breast cancer risk [odds ratio (OR) = 3.93 (95% confidence interval (CI) = 1.28-12.11; P = 0.017)]. Moreover, we performed two meta-analyses of studies from countries with carriers in both cases and controls and of all available data. These analyses showed breast cancer associations with OR = 3.67 (95% CI = 1.04-12.87; P = 0.043) and OR = 3.33 (95% CI = 1.09-13.62; P = 0.032), respectively. Based on information theory-based prediction, we established that the mutation caused an out-of-frame deletion of exon 22, due to the creation of a binding site for the pre-mRNA processing protein hnRNP A1. Furthermore, genetic complementation analyses showed that the mutation influenced the DNA repair activity of the FANCM protein. In summary, we provide evidence for the first time showing that the common p.Arg1931* loss-of-function variant in FANCM is a risk factor for familial breast cancer.

Association of SULT1A1 Arg²¹³His polymorphism with male breast cancer risk: results from a multicenter study in Italy

Male breast cancer (MBC) is rare and poorly understood. Like female breast cancer (FBC), MBCs are highly sensitive to hormonal changes, and hyperestrogenism, specifically, represents a major risk factor for MBC. MBC is considered similar to late-onset, post-menopausal estrogen/progesteron receptors positive FBC (ER+/PR+). Sulfotransferase 1A1 (SULT1A1) is an enzyme involved in the metabolism of estrogens. Recently, SULT1A1 common functional polymorphism Arg(213)His (638G>A) variant has been found to be associated with increased breast cancer (BC) risk, particularly in post-menopausal women. For this reason, we decided to explore whether SULT1A1 Arg(213)His could exert an effect on MBC development. The primary aim of this study was to evaluate the influence of the SULT1A1 Arg(213)His polymorphism on MBC risk. The secondary aim was to investigate possible associations with relevant clinical-pathologic features of MBC. A total of 394 MBC cases and 786 healthy male controls were genotyped for SULT1A1 Arg(213)His polymorphism by PCR-RFLP and high-resolution melting analysis. All MBC cases were characterized for relevant clinical-pathologic features. A significant difference in the distribution of SULT1A1 Arg(213)His genotypes was found between MBC cases and controls (P < 0.0001). The analysis of genotype-specific risk showed a significant increased MBC risk in individuals with G/A (OR 1.97, 95% CI 1.50-2.59; P < 0.0001) and A/A (OR 3.09, 95% CI 1.83-5.23; P < 0.0001) genotypes in comparison to wild-type genotype, under co-dominant model. A significant association between SULT1A1 risk genotypes and HER2 status emerged. Results indicate that SULT1A1 Arg(213)His may act as a low-penetrance risk allele for developing MBC and could be associated with a specific tumor subtype associated with HER2 overexpression.

Changes in autonomic regulation and ventricular repolarization induced by subclinical hyperthyroidism

The aim of the present study was to evaluate the effect of subclinical hyperthyroidism (SHT) on cardiovascular autonomic function and ventricular repolarization.

METHODS

Thirty subjects (25 females; mean age 49.6 ± 9.8 years) with SHT, as judged by reduced TSH serum levels and normal free T4 and T3 serum levels, and 30 age and sex-matched control subjects underwent standard 12-lead ECG, and 24h ambulatory ECG monitoring. The dispersion of the QT interval, an index of inhomogeneity of repolarization, and the heart rate variability (HRV), a measure of cardiac autonomic modulation, were studied.

RESULTS

Patients with SHT showed higher QT dispersion (p<0.001) and lower HRV measures (0.01>p<0.001) than controls. In SHT patients, QT dispersion was inversely related to HRV (r=-0.47, p<0.01).

CONCLUSION

The results of the present study demonstrated that SHT is associated with a sympathovagal imbalance, characterized by increased sympathetic activity in the presence of diminished vagal tone, and with an increased inhomogeneity of ventricular recovery times. The assessment of HRV and QT dispersion in patients with SHT may represent a useful tool in monitoring the cardiovascular risk of this condition.

Phase II trial of weekly intravenous gemcitabine administration with interferon and interleukin-2 immunotherapy for metastatic renal cell cancer

PURPOSE

Since metastatic renal cell carcinoma has a poor prognosis and treatment strategies, including hormone therapy, chemotherapy and immunotherapy, have little impact on the quality of life and global survival statistics, new interest has recently focused on the combination of immuno-chemotherapy using pyrimidine analogues, such as gemcitabine.

MATERIALS AND METHODS

In a phase II study 16 patients with metastatic renal cell carcinoma were treated with 1,000 mg./m. gemcitabine intravenously on days 1, 8, 15 and 28 for 6 months, 3 MU (1 MU = 1 x 10(6) IU) interferon (IFN)-alpha intramuscularly 3 times a week and 4.5 million IU interleukin (IL)-2 subcutaneously daily for 5 days a week for 2 consecutive weeks every month for 6 months. Responding and nonprogressing cases were maintained on immunotherapy consisting of IFN-alpha and IL-2 for further 6 months.

RESULTS

In 15 evaluable patients overall response rate (1 complete response plus 3 partial response) was 28% while stable disease was achieved in 7 (47%). Median survival duration was 20 months (range, 9 to 26+) and median time to tumor progression was 14 months (6 to 26+). The complete response lasted 24+ months and partial response lasted 16 months. The regimen was well tolerated with only 1 case of neutropenia (WHO grade 3), while anorexia, fatigue and flu-like symptoms were the most common toxicity problems but were never greater than grade 2.

CONCLUSIONS

Despite the small sample size, this study demonstrates that gemcitabine combined with standard doses of IFN-alpha and low doses of IL-2 is effective treatment for metastatic renal cell carcinoma. This biotherapy was well tolerated and resulted in an optimum objective response and relatively long-term survival.

Phase II trial of weekly intravenous gemcitabine administration with interferon and interleukin-2 immunotherapy for metastatic renal cell cancer

PURPOSE

Since metastatic renal cell carcinoma has a poor prognosis and treatment strategies, including hormone therapy, chemotherapy and immunotherapy, have little impact on the quality of life and global survival statistics, new interest has recently focused on the combination of immuno-chemotherapy using pyrimidine analogues, such as gemcitabine.

MATERIALS AND METHODS

In a phase II study 16 patients with metastatic renal cell carcinoma were treated with 1,000 mg./m. gemcitabine intravenously on days 1, 8, 15 and 28 for 6 months, 3 MU (1 MU = 1 x 10(6) IU) interferon (IFN)-alpha intramuscularly 3 times a week and 4.5 million IU interleukin (IL)-2 subcutaneously daily for 5 days a week for 2 consecutive weeks every month for 6 months. Responding and nonprogressing cases were maintained on immunotherapy consisting of IFN-alpha and IL-2 for further 6 months.

RESULTS

In 15 evaluable patients overall response rate (1 complete response plus 3 partial response) was 28% while stable disease was achieved in 7 (47%). Median survival duration was 20 months (range, 9 to 26+) and median time to tumor progression was 14 months (6 to 26+). The complete response lasted 24+ months and partial response lasted 16 months. The regimen was well tolerated with only 1 case of neutropenia (WHO grade 3), while anorexia, fatigue and flu-like symptoms were the most common toxicity problems but were never greater than grade 2.

CONCLUSIONS

Despite the small sample size, this study demonstrates that gemcitabine combined with standard doses of IFN-alpha and low doses of IL-2 is effective treatment for metastatic renal cell carcinoma. This biotherapy was well tolerated and resulted in an optimum objective response and relatively long-term survival.

Gemcitabine plus Epi-doxorubicin as first-line chemotherapy for bladder cancer in advanced or metastatic stage: a phase II

Combination chemotherapy with newer, more active drugs in patients with advanced and/or metastatic bladder cancer might show improved response rate and survival. Gemcitabine (GEM) and Epidoxorubicin (EPI) have demonstrated activity in this disease. In addition, experimental studies in vitro have shown that the two agents have additive-synergistic effects when used in combination. Our prior phase I dose-finding study in previously untreated patients with advanced or metastatic bladder cancer defined recommended doses for further trials of GEM 1000 mg/m2 and EPI 25 mg/m2 on days 1, 8 and 15 every 28 days. A phase II trial at this dose level was initiated in previously untreated patients to assess efficacy and toxicity. Eligible patients had measurable disease; Karnofsky performance status (PS) of > 40; no prior chemotherapy; and adequate bone marrow reserve, cardiac, hepatic and renal function. Thirty- one patients (22 males, 9 females) with median age of 64 (range 44-75) and median PS of 80 were accrued, and all were eligible. Twelve patients had T4N1-2 M0, 8 had lymph node only metastases, while 11 had visceral metastases (liver, bone, lung). A total of 181 cycles was administered (range 3-7 per patient). Major toxicities (WHO grade > or = 3) were: neutropenia in 5 patients, thrombocytopenia in 2 patients, and anemia in 2 patients. Three patients had febrile neutropenic episodes and only 3 patients required dose reduction. Grade 1-2 non-hematological toxicities included nausea/vomiting, stomatitis and alopecia. No cardiac toxicity was observed. Of the 30 response evaluable patients, 17 (57%) demonstrated a major response (3 complete and 14 partial) (95% CI: 39%-75%), 7 had stable disease (23%) and 6 progressed (20%). These preliminary results confirm the phase I observation that the combination of GEM--EPI is highly active in the treatment of advanced and metastatic bladder cancer with a favourable toxicity profile.

Weekly gemcitabine plus Epirubicin as effective chemotherapy for advanced pancreatic cancer: a multicenter phase II study

The current role of chemotherapy in pancreatic carcinoma is limited, and progress in the treatment of this disease represents a significant challenge to medical oncology. The most promising drug under study is gemcitabine, a relatively new antimetabolite that represents an attractive candidate for combination chemotherapy because of its excellent side-effect profile and the absence of overlapping toxicities with other chemotherapeutic agents. Combined administration of gemcitabine and anthracyclines could result in the induction of DNA breaks that are not easily repaired by the cell's machinery, thus enhancing the apoptotic signals triggered by these lesions. Forty-four patients with locally advanced and/or metastatic pancreatic adenocarcinoma were enrolled in this multicenter study. Patients received Epirubicin 20 mg m(-2) for 3 weeks followed by 1 week of rest (1 cycle) and gemcitabine 1000 mg m(-2) after Epirubicin on the same day. All were assessable for toxicity and response, 11 patients responded to treatment with one complete response and 10 partial responses, for an overall response rate of 25%. Median survival was 10.9 months (range, 2-26 months). Therapy was well tolerated, with a low incidence of haematologic grade >2 toxicity. A total of 12 of 27 (44.4%) eligible patients attained a clinical benefit response. Our findings suggest that the gemcitabine-epirubicin schedule is active and well tolerated in patients with advanced pancreatic cancer.

Randomized trial of adjuvant chemotherapy versus control after curative resection for gastric cancer: 5-year follow-up

Adjuvant chemotherapy of gastric cancer after curative resection is still subject to discussion. In this study 137 patients with gastric adenocarcinoma, all with positive nodes, were randomized after curative resection so that 69 received epidoxorubicin (EPI), leucovorin (LV) and 5-fluorouracil (5-FU) on days 1-3 every 3 weeks for 7 months, whereas the remaining 68 did not. After a follow-up period of 5 years, 21 of the 69 treated patients (30%) and nine controls (13%) were still alive; median survival time was 18 months for the controls and 31 months for the patients treated with adjuvant chemotherapy (P< 0.01).

Insulin resistance and hyperinsulinemia: No independent relation to left ventricular mass in humans

BACKGROUND

Hyperinsulinemia and insulin resistance may contribute to the development of cardiac hypertrophy. In humans, however, the evidence is inconclusive.

METHODS AND RESULTS

We studied 50 nondiabetic subjects covering a wide range of age (20 to 65 years), body mass index (BMI, 19 to 40 kg x m(-2)), and mean blood pressure (72 to 132 mm Hg). Plasma insulin concentrations and secretory rates were measured at baseline and during an oral glucose tolerance test; insulin sensitivity was measured by the insulin clamp technique. Left ventricular mass (LVM) (by 2D M-mode echocardiography) was distributed normally and was higher in obese (BMI >/=27 kg x m(-2), n=16) or hypertensive patients (blood pressure >140/90 mm Hg, n=21) (50+/-8 and 55+/-10 g x m(-2.7), respectively) than in 13 nonobese, normotensive subjects (40+/-8 g x m(-2.7), P:=0.0004). In a multivariate model adjusting for sex, age, BMI, and blood pressure, neither insulin concentrations (fasting or postglucose) nor insulin sensitivity or secretory rates were significant correlates of LVM. Systolic blood pressure (P:=0.003) and BMI (P:=0.01) were the only independent correlates of LVM. From the regression, the impact of hypertension (as a systolic pressure of 180 versus 140 mm Hg=+20%) was twice as large as that of obesity (as a BMI of 35 versus 25 kg x m(-2)=+11%), the two factors being additive.

CONCLUSIONS

When adequate account is taken of body mass and blood pressure, insulin, as concentration, secretion, or action, is not an independent determinant of LVM in nondiabetic subjects.

Melatonin's growth-inhibitory effect on hepatoma AH 130 in the rat

We tested the effects of daily melatonin treatment on the growth of the ascites hepatoma in rats, determining survival time, cell number and cell cycle phases at various stages of tumor development. Melatonin inhibited cellular proliferation, doubled mean life-time and increased survival. Thymidine incorporation in hepatoma cells from treated rats decreased significantly without changes in the apoptotic index. Flow cytometric analysis showed that melatonin slowed cell cycle progression by increasing the number of cells in phase G0G1. Thus, similar to in vitro models, melatonin's oncostatic action in vivo appears to be directed to specific cell cycle mechanisms, which remain to be elucidated.

Melatonin as biological response modifier in cancer patients

The neuroendocrine system modulates the immune response through neuropeptides and neurohormones, findings which point to the existence of a neuro-endocrine-immune system regulatory axis. At the same time, there is growing evidence that the pineal gland has anti-neoplastic properties, which include the action of its principal hormone, melatonin (MLT), on the immune system through the release of cytokines by activated T-cells and monocytes. The present study was carried out on 31 patients (19 males and 12 females, age range 46-73 years) with advanced solid tumors (7 gastric, 9 enteric, 8 renal, 5 bladder, 2 prostate) who either failed to respond to chemotherapy and radiotherapy or showed insignificant responses and were therefore shifted to MLT therapy (10 mg/die orally for 3 months). We obtained blood samples just before the start of MLT administration and after 30 days of therapy. Plasma was collected in EDTA tubes on ice, immediately centrifuged at 4 degrees C and stored frozen at -80 degrees C; samples were measured by immunoradiometric assays (Medgenix-Fleurus, Belgium) for tumor necrosis factor alpha (TNF), interleukin-1, 2 and 6 (IL-1, IL-2, IL-6) and interferon gamma (IFN). We used Student's paired t-test to compare each patient's cytokine circulating levels before and after MLT administration and found a significant differences (p < 0.05). After 3 months of therapy, none of our patients displayed adverse reactions to MLT or had to discontinue treatment. Nineteen patients (61%) showed disease progression. The other 12 (39%), however, achieved disease stabilization with no further growth of either the primary tumor or of secondaries; moreover, they experienced an improvement in their general well-being, in terms of Tchekmedyian's criteria, associated with a significative decrease of IL-6 circulating levels. These findings are consistent with the hypothesis that MLT modulates immune function in cancer patients by activating the cytokine system which exerts growth-inhibitory properties over a wide range of tumor cell types. Furthermore, by stimulating the cytotoxic activity of macrophages and monocytes, MLT plays a critical role in host defence against the progression of neoplasia.

Adjuvant chemotherapy after gastric resection in node-positive cancer patients: a multicentre randomised study

After curative resection for gastric adenocarcinoma, 103 patients, all with positive nodes, were randomised so that 48 received adjuvant chemotherapy of epidoxorubicin (EPI) 75 mg m-2 on day 1, leucovorin (LV) 200 mg m-2 on days 1-3 and 5-fluorouracil (5-FU) 450 mg m-2 on days 1-3, every 21 days for 7 months, whereas the remaining 55 did not. During the first year of observation, 21 control patients (38%) and five treated patients had recurrences. After a follow-up period of 36 months, 12 of the treated patients (25%) and only seven controls (13%) were still alive. At that point, the median survival was 13.6 months for the 55 untreated patients and 20.4 months for the 48 treated patients, a significant difference. We found a survival advantage for patients treated with the EPI-LV-5-FU regimen and a consistent delay in the appearance of recurrent or metastatic cancer. Acute toxicity was mild and treatment was well accepted by all patients. There was no long-term toxicity or any cardiac toxicity. We conclude that this particular chemotherapy, administered shortly after gastric resection, improves survival rate in node-positive gastric cancer patients, even although final assessment of this particular adjuvant approach must await completion of the trial.

[Effects of rehabilitation on cardiovascular autonomic function in ischemic cardiopathy]

METHODS

Twenty patients with uncomplicated myocardial infarction randomized in two groups (group 1 and 2) of ten patients were investigated. Only group 1 trained four months according to a protocol of rehabilitation, whereas patients of group 2 followed their usual activity (control group). The autonomic cardiovascular function was estimated by Ewing's tests, that evaluate the variations of heart rate and blood pressure during deep breathing.

RESULTS

Our data showed an increase of parasympathetic tone in group 1 (Valsalva ratio 1.55 +/- 0.28 vs 1.36 +/- 0.28, p < 0.01; variation in heart rate during deep breathing 17.3 +/- 4.6 vs 13.3 +/- 4.2). The sympathetic activity tests showed no significant difference after training. On the other hand, group 2 showed no significant difference in sympathetic and parasympathetic activity.

CONCLUSIONS

In patients with uncomplicated myocardial infarction physical training increases the parasympathetic activity; as shown in the literature, such an increase can have clinical and prognostic importance, since improves cardiac performance and reduces the risk of sudden death from arrhythmic events.

[The ultrasonic characterization of myocardial hypertrophy: new prospects]

The extensive use of ultrasound imaging in cardiology has greatly contributed to expand both its diagnostic possibilities and its utility in the interpretation of physiopathologic mechanisms. Conventional echocardiography is the more specific technique for the diagnosis of myocardial hypertrophy which, in turn, is one of the most important cardiovascular risk factors. The improvement of ultrasound technology may expand the possibility of noninvasive characterization of left ventricular hypertrophy by adding to the already known information about left ventricular mass and function, and that relative to the degree of hypertrophy-related fibrosis. In the present paper the authors reviewed the knowledge about biological and hemodynamic factors which contribute to the development and regression of myocardial hypertrophy. The possible role of new ultrasonic technology in the tissue characterization of myocardial hypertrophy is also discussed.

[Cardiovascular effects of amitriptyline in therapeutic dosages. Echocardiographic study]

The authors studied the cardiovascular effects of amitriptyline at therapeutic plasma concentrations in 15 depressed patients (6 M. 9 F.) without cardiovascular disease both before treatment and after six months of therapy. The cardiovascular effects were evaluated by means of electrocardiographic and 2D-echocardiographic examinations in basal conditions and after hand-grip stress test. The effects of isometric hand-grip exercise (IHG) on left ventricular size and performance were studied non invasively in all patients at rest and after 3 min. of IHG at 30% of maximum contraction. Left ventricular internal diameter was measured at end-diastole and end-systole on LV echograms, and blood pressure was measured by sphygmomanometer. Our data confirmed the depressant effect of amitriptyline even on healthy myocardium, an effect that becomes manifest only at handgrip stress with a significant reduction of ejection fraction (form 70.6 to 66.4%; p < 0.001), while ECG and arterial blood pressure did not change throughout the study. This goes to show that treatment with tricyclic antidepressants always has a latent depressant effect on myocardial contractility that becomes clinically evident under stress, as well as in subjects with heart disease and in the elderly. Hence the need to monitor left ventricular function, as well as ECG and blood pressure, and to exercise great caution in prescribing tricyclic antidepressants to subjects with a history of myocardial failure.

Dilation of venous vessels at the splenic hilum in normal sized spleens as an indication of pathologic splenic involvement: preliminary results

Twelve hundred patients without liver or heart disease, having a normal sized spleen without focal lesions, were examined by ultrasonography to measure the inner diameter of the splenic vein in relation to possible current or recent recovery from pathologic processes. SVD was measured at the hilum of the spleen with the patients supine. Ten of the patients in whom dilation of the SVD was found, together with a group of healthy controls (25), were subsequently studied with a duplex Doppler analysis to measure the venous outflow from the spleen. The results showed 1,175 spleens (98%) with SVD at the hilum of < 8 mm and 25 spleens (2%) with SVD of > 8 mm. Twenty-three of 25 patients (92%) with enlarged SVD had recent histories of hematopoietic or infectious diseases. Ten of 23 patients with enlarged SVD were studied further with a Doppler analysis. They demonstrated a rapid splenic blood flow with maximum flow velocities ranging from 14 to 27 cm/sec and high outflow volumes (from 430 to 1,227 ml/min, averaging 786 ml/min +/- 266), both significantly increased in comparison with controls (outflow volume from 200 to 355 ml/min, averaging 274 +/- 40; P < 0.0001). We conclude that dilation of the SVD accompanied by an increased intrasplenic blood flow volume without splenic enlargement would indicate a state of increased perfusion of splenic tissue associated with an immune response, reflecting reaction of the spleen to disease.

[The pancreas in diabetes mellitus. The echographic aspects]

Forty patients with diabetes mellitus (25 with insulin-dependent and 15 with non-insulin dependent diabetes) were studied by means of US in order to evaluate possible volumetric alterations in the pancreas and their eventual progression over time. Thirty healthy subjects were also studied as a control group. The following variables were recorded: thickness of the head, body and tail of the pancreas and area of its head. The patients were also divided into 5 groups according to the age of diabetes (< 1, > 1, > 7, > 14, > 21 years). The results showed 25 IDDM patients to exhibit significant reduction in these variables relative to controls (p < = 0.01), especially in the body (average reduction -40%) and tail (average reduction -20%) of the pancreas. NIDDM patients exhibited non-significant reductions in pancreatic size. The study of the 5 groups of IDDM patients, divided according to the duration of diabetes, revealed all pancreatic variables to reduce more than in controls within a year since diagnosis, to exhibit relative increase during the next 7 years and finally to reduce again in the following years. These results show that anatomic damage to the pancreas occurs within the first year of diabetes. Moreover, IDDM was seen to alter the normal proportions among the single anatomic structures forming the pancreas, especially relative to two anatomic ratios--i.e., head/body and tail/body pancreatic thickness. The relative values in IDDM patients were markedly higher than those in controls (p < 0.001). The patients were again divided into 5 groups according to the age of diabetes: the values of the above ratios in the course of diabetes greatly differed from those observed in controls--i.e., they increased within the first year of diabetes, were steady during the next 7 years, and returned to normal values after 21 years of diabetes, which meant the return to the normal anatomic ratios among the three parts of the pancreas.

Slow-releasing nicardipine in the treatment of Raynaud's phenomena without underlying diseases

Calcium channel blockers have been used in the treatment of primary and secondary Raynaud's phenomenon (RP), and a beneficial effect was often recorded. The efficacy of slow-releasing nicardipine was assessed in a clinically homogeneous series of RP without underlying diseases in a randomized, double blind, cross-over and placebo controlled trial. Out of twenty-one selected patients (18 women and 3 men, mean age 46 +/- 12 yrs) eighteen completed the study and three dropped out, one for inadequate compliance and two due to headache. After a three-week period, slow-releasing nicardipine (20 mg two times daily) was significantly more useful than placebo: the number of RP episodes per week decreased (p less than 0.02), severity of discomfort and hand disability scores, evaluated after single RP attack, clearly improved (p less than 0.005 and p less than 0.02, respectively). According to clinical improvement, time of peak flow after postischemic reactive hyperaemia test was significantly reduced only after nicardipine (p less than 0.01). These results show that slow-releasing nicardipine is generally well tolerated and can provide effective improvement in RP patients without underlying diseases.

[Echocardiographic parameters and systolic times in arterial hypertension in the elderly]

In 40 subjects, 15 mean age 70.7 +/- 5.6 with systolic-diastolic hypertension, 15 mean age 75.5 +/- 6.8 years with systolic hypertension and 10 mean age 73.6 +/- 5.1 normotensive control group we have analyzed with M-mode 2D echocardiography and echophonocardiography the following parameters: diastolic--EDD--and systolic diameter--SD--of left ventricle, diastolic thickness of septum--SSD--and posterior wall--SPPD--of left ventricle, left ventricular ejection fraction--EF--(Theicholtr. formula), radius posterior wall thickness--R/SPPD--, left ventricular mass--LVM--(Devereux' formula), and systolic time intervals (Q-A2, LVET, PEP and PEP/LVET). The differences between groups are: systolic-diastolic hypertensive patients have increased EDD, SPPD and LVM, reduction of EF and increased PEP/LVET ratio in comparison with B and C groups; systolic hypertension doesn't increase EDD; SSD and PEP/LVET increase, while the EF remains within normal limits. In the healthy aged subjects SSD, SPPD and LVM are normal.

Cardiovascular adjustments induced by training evaluated during semisupine isotonic exercise and recovery period: an echocardiographic study

Two groups of subjects were examined: trained athletes (group A) and a sedentary control group (group B). The subjects performed submaximal bicycle exercise in the semisupine position to evaluate the differences between the two groups with regard to cardiovascular response during exercise and recovery and to point out all the changes due to training. During the first part of exercise, cardiac output increased contemporary with heart rate and myocardial contractility as shown by the trend of the ejection fraction, higher in group A, under the same level of total vascular peripheral resistances. Later there was an increase of cardiac output for a further increase of heart rate and cardiac inotropism due to the homeometric mechanism. During recovery the heart rate and peripheral vascular resistance reduction led to an increase of venous return which set up the Frank-Starling mechanism via an increase of left ventricular dimensions. These adjustments were more efficient in group A. During exercise and recovery the heart rate-pressure product was constantly lower in group A with a significant difference to group B. Therefore, trained athletes' myocardium is more efficient than that of the sedentary group because it performs an external work load with a lower oxygen consumption.

Asymmetric septal hypertrophy and sympathetic overactivity in normotensive hemodialyzed patients

Sympathetic activity has been evaluated in 23 chronic uremic normotensive patients on long-term hemodialysis. M-mode and bidimensional echocardiographic finding of asymmetric septal hypertrophy (ASH) was shown in seven (30.4%). Sympathetic function was assessed by determining arterial plasma norepinephrine (plasma NE) and epinephrine (plasma E) in supine and upright positions, both before and after dialysis. After dialysis standing caused a significant increase in plasma NE levels in the patients with ASH in comparison to the patients without ASH and the control group. A significant decrease in mean blood pressure (mBP) and a sharp heart rate (HR) increase were detected in the patients without ASH, whereas mBP and HR were unchanged in the patients with ASH. Predialysis serum creatinine and fasting triglycerides were found to be significantly higher in the group with ASH. These results suggest that sympathetic overactivity may play a role in the development of interventricular septum hypertrophy. This increased neurosympathetic responsiveness is probably related to the counteraction of the postural dialysis-induced hypotension.

Asymmetric septal hypertrophy in uremic-normotensive patients on regular hemodialysis. An M-mode and two-dimensional echocardiographic study

We have observed a high incidence (36.4%) of asymmetric septal hypertrophy (ASH), detected with the use of M-mode (MME) and two-dimensional echocardiography (2DE), in normotensive patients with chronic renal failure on maintenance hemodialysis without signs of cardiac diseases. ASH was detected by conventional MME in 11 cases and was confirmed with the use of 2DE in 8 cases showing a diagnostic concordance of 72.7% between the two methods. After dialysis the MME study of the left ventricular (LV) performance showed an evident impairment of cardiac index (CI) due to reduction of LV volume in addition to an abnormality of septal function. The presence of ASH does not impair the percentage of fractional shortening (FS%), the mean circumferential shortening (mean Vcf) and the ejection fraction (EF%), probably because of a compensatory performance of the LV posterior wall. Predialysis serum creatinine and fasting triglycerides have been found significantly higher in the group with ASH. ASH may be considered as a focal and early form of myocardial involvement in uremic patients on regular hemodialytic treatment.

[Correlation between electrocardiographic and echocardiographic findings in chronic aortic insufficiency]

Echocardiographic indices of left ventricular volume and mass and electrocardiographic indices of left ventricular hypertrophy have evaluated in 25 patients with chronic aortic regurgitation and in 10 normal subjects. When the patients with aortic regurgitation were subdivided in three groups with increasing evidence of left ventricular hypertrophy, the echocardiographic measures of left ventricular dimension and mass were also found to be increased, with statistically significant differences between patients and controls and among the three groups of patients as well. A specially constructed cumulative electrocardiographic index of left ventricular hypertrophy (Sokolow and Lyon's index plus Lewis' index plus strain pattern) is correlated with the left ventricular end-diastolic diameter (r = 0.65; P less than 0.001), cross-sectional area (r = 0.65; p less than 0.001) and mass (r = 0.75; p less than 0.001) better than the isolated electrocardiographic indexes.

[Relation between asymmetrical hypertrophy of the interventricular septum and plasma levels of catecholamines in normotensive chronic uremic patients undergoing hemodialysis treatment]

Sympathetic-adrenergic activity has been evaluated in 23 chronic uremic, normotensive patients on regular hemodialysis, 7 of which (30.4%) with M-mode and bidimensional echocardiographic finding of asymmetric septal hypertrophy. The sympathetic function has been assessed by measuring arterial plasma norepinephrine and epinephrine levels before and after postural activation, just before and after dialysis. After dialysis, standing caused a significant increase of plasma norepinephrine levels in patients with asymmetric septal hypertrophy in comparison with patients without asymmetric septal hypertrophy and with the control non uremic group. Moreover, a significant decrease in blood pressure and a sharp heart rate increase were noted in the patients without asymmetric septal hypertrophy, whereas mean blood pressure and heart rate were unchanged in the patients with asymmetric septal hypertrophy. These results suggest that increased plasma norepinephrine concentration may have a role in the development of interventricular septal hypertrophy.

[Analysis of variations in cardiac performance induced by tilt and hand-grip in athletes and in untrained subjects]

The aim of the present study is to analyze variations of external cardiac work and of indices of myocardial oxygen consumption induced by upright tilting and hand-grip in volley-ball athletes (group A) in comparison with a group of normal subjects (group N). For this purpose we have used impedance cardiography, a simple, reproducible and non invasive technique, which is very reliable in evaluating both systolic time intervals and hemodynamic parameters such as stroke volume and cardiac output. No significant differences, of external cardiac work, double and triple product were observed between group A and N upon upright tilting. Hand-grip test, on the other hand, can differentiate the myocardial behaviour of trained people from that of the control group. The double product was significantly reduced in group A in comparison with group N (P less than 0.001 and the end of the test, P less than 0.05 after 30", P less than 0.001 after 1' and 3"). The triple product was significantly reduced in group A in comparison with group N at the end of the test (P less than 0.005). External cardiac work was always higher in group A in comparison with group N (P less than 0.02, at the stop P less than 0.05 after 30", P less than 0.01 after 1', P less than 0.0001 after 3'). Therefore in volleyball athletes the myocardium exhibits better mechanical performance than in normal subjects.

Acute respiratory distress syndrome in an adult patient with a myelodysplastic disorder

A 58-year-old man was diagnosed to have refractory anaemia with excessive blasts. After 3 1/2 years of relative control on periodic blood transfusions, the patient developed an acute leukaemia. Although the blastic crisis was not extreme (WBC counts less than 100 X 10(9)/l), a severe, intractable respiratory distress syndrome set in and brought the patient to the exitus in a few days. Overt signs of septic shock were absent, as was evidence of any other known cause of adult respiratory distress. Acute pulmonary failure can be the cause of death in leukaemic patients even in the absence of overwhelming sepsis or hyperleucocytosis.

[Essential monolateral hematuria: to operate or not to operate? Description of a case and review of the literature]

The case of a 31 years old female with monolateral essential hematuria is reported. Histological examination of the removed kidney showed only minute hemorrhagic spots beneath the epithelium of the calyces and the pelvis. The literature is reviewed; the benign character of this type of gross hematuria and attention for saving the kidneys was stressed.

Echocardiographic hemodynamic study during ultrafiltration sequential dialysis

4 patients on regular dialysis were studied by the echocardiographic method during ultrafiltration and dialysis performed sequentially according to two different protocols. Blood pressure, heart rate, cardiac output, stroke volume, systolic and diastolic dimension of the left ventricle, systolic and diastolic volumes of the left ventricle, ejection fraction, shortening fraction and total peripheral vascular resistance index were measured. During ultrafiltration there is an increase of the total peripheral vascular resistance index. Myocardial contractility improves only during dialysis. Physiopathologic implications are discussed.

Hypokalaemia as the only clinical symptom of ACTH ectopic secretion in a case of small cell carcinoma of the lung with very rapid evolution

A patient with heavy hypokalaemia is described: hypokalaemia and its effects were the unique clinical manifestations of small cell carcinoma of the lung, associated with ACTH ectopic secretion. The rapid unfavourable evolution denotes the explosive behaviour of the syndrome.

Duodenal plasmacytoma. A rare primary extramedullary localization simulating a carcinoma

A patient with duodenal plasmacytoma is described. The extramedullary localization preceded the complete humoural picture of multiple myeloma by 15 months. The previously reported cases of myeloma of primary gastrointestinal localization are reviewed.

[Multivariate analysis of aminoacyl-tRNA synthetase activities of liver and hepatomas (author's transl)]

Data on the aminoacyl-tRNA synthetase activities in normal liver and in three transplantable rat hepatomas, viz Yoshida's AH 130 and Morris's 5123C and 7793, were studied by means of factor analysis, a powerful technique of multivariate analysis particularly suitable foridentifying factors which theoretically may account for the pattern of interrelations between several variables. The analysis has been performed on 51 patterns of enzyme activities, covering 17 out of the 20 aminoacyl-tRNA synthetases; 80% on average of the total variability of the 17 enzyme activities may be accounted for by the first 4 factors extracted. The enzymes seem to fall into different groups, depending on their relationship with the factors thus identified. The results suggest that enzymes belonging to the same group share a common control mechanism, and are independent of the enzymes belonging to different groups, both in normal liver and in hepatomas.