1201. Sarcoidosis Candidate Microbes Identified by Next Generation Sequencing

Background

Sarcoidosis is an autoimmune disease characterized by granulomatous lung disease with very prominent mediastinal adenopathy. Acid-fast bacteria, fungi, and viruses have been considered as possible causes of sarcoidosis. We used next-generation or deep sequencing to characterize the microbial content of diseased mediastinal lymph nodes from 10 sarcoidosis patients compared to a set of 10 negative-controls.

Methods

RNA was extracted from fixed paraffinized mediastinal lymph nodes (MLN) from 12 diseased specimens taken from 10 sarcoidosis patients and 2 positive control subjects (TB, MAI), and normal appearing MLN from 10 negative-control subjects (mostly cancer patients). The extracted RNA was sequenced on the Illumina 2500, yielding 125-bp paired-end reads. These reads were aligned to the human genome, human transcriptome, and a nonredundant panmicrobial database. Each experimental sample were compared against the set of 10 negative-controls using the false discovery rate method (q-value). Directed qPCR was performed on all the samples.

Results

100-153 million read-pairs were obtained from the 24 sequenced samples (12 sarcoidosis, 10 negative-control, 2 positive-control). Among these, 0.01-1.32% of the reads were microbial, with a trend towards fewer microbial reads in the sarcoidosis group compared to controls (means 66K vs. 457K, p=0.09). Mycobacterial sequence was significantly enriched (q< 0.05) in the MAI but not the TB sample compared to the negative-controls. Among the 12 sarcoidosis samples, sequence mappings were significantly enriched (q< 0.05) for the following genera: fungal, Magnaporthe (N=4 samples) and Debaromyces (1); bacteria, Odoribacter (1) and Granulicella (1); and viral, Roseolovirus (6) and Mardivirus (6). Further metagenomic analysis eliminated Magnaporthe as a candidate. qPCR confirmed the presence of Odoribacter in 2 specimens and Debaromyces in 1. Roseolovirus (HHV6) could not be detected by qPCR in any of the samples.

Conclusion

We conclude that sequencing is a feasible method for identifying candidate microbes that might trigger sarcoidosis in human subjects. Further research is required to establish or refute the pathogenicity of these organisms in patients with sarcoidosis.

Disclosures

All Authors: No reported disclosures

Neuroendocrine tumors, version 1.2015

Neuroendocrine tumors (NETs) comprise a broad family of tumors that may or may not be associated with symptoms attributable to hormonal hypersecretion. The NCCN Clinical Practice Guidelines in Oncology for Neuroendocrine Tumors discuss the diagnosis and management of both sporadic and hereditary NETs. This selection from the guidelines focuses on sporadic NETs of the pancreas, gastrointestinal tract, lung, and thymus.

Eosinophilic esophagitis in adults is associated with IgG4 and not mediated by IgE

BACKGROUND & AIMS

Eosinophilic esophagitis is usually triggered by foods, by unclear mechanisms. We evaluated the roles of IgE and IgG4 in the development of eosinophilic esophagitis.

METHODS

We performed a prospective, randomized, double-blind, placebo-controlled trial of adults with eosinophilic esophagitis given an antibody against IgE (omalizumab, n = 16) or placebo (n = 14) every 2-4 weeks for 16 weeks, based on weight and serum level of IgE. Endoscopy was performed, esophageal biopsy specimens were collected, and symptoms were assessed at baseline and at 16 weeks. Maximum numbers of eosinophils/high-power field were determined. Homogenates of esophageal biopsy specimens from 11 subjects with eosinophilic esophagitis and 8 without (controls) were assessed for IgM, IgA, and IgG subclasses. In a retrospective analysis, we performed immunofluorescence analysis of IgG4 in fixed esophageal tissues from 2 patients with eosinophilic esophagitis who underwent esophagectomy and 47 consecutive autopsies (controls). We also performed immunofluorescence analysis of IgG4 in esophageal mucosal biopsy specimens from 24 subjects with eosinophilic esophagitis and 9 without (controls). Finally, sera were collected from 15 subjects with eosinophilic esophagitis and from 41 without (controls), and assayed for total and food-reactive IgG4.

RESULTS

Omalizumab did not alter symptoms of eosinophilic esophagitis or eosinophil counts in biopsy samples compared with placebo. Homogenates of esophageal tissues from patients with eosinophilic esophagitis had a 45-fold increase in IgG4 compared with controls (P < 3 × 10(-5)), but no significant increases in other IgG subclasses, IgM, or IgA. Sparse stromal deposits resembling immune complexes were found in 2 of 5 eosinophilic esophagitis biopsy specimens based on ultrastructural analysis. Esophagectomy samples from 2 patients with eosinophilic esophagitis contained 180 and 300 IgG4 plasma cells/maximal high-power field, mainly in the deep lamina propria; these levels were greater than in tissues from controls. Fibrosis essentially was exclusive to the lamina propria. Granular extracellular IgG4 was detected in biopsy specimens from 21 of 24 patients with eosinophilic esophagitis, but in none of the specimens from 9 controls (P = 6 × 10(-6)). The total serum level of IgG4 increased only slightly in patients with eosinophilic esophagitis, compared with controls. Subjects with eosinophilic esophagitis had increased serum levels of IgG4 that reacted with milk, wheat, egg, and nuts-the 4 foods that most commonly trigger this condition (P ≤ 3 × 10(-4) for each food).

CONCLUSIONS

In a prospective trial, omalizumab did not reduce symptoms of eosinophilic esophagitis or tissue eosinophil counts compared with placebo. This finding, along with observed granular deposits of IgG4, abundant IgG4-containing plasma cells, and serum levels of IgG4 reactive to specific foods, indicate that, in adults, eosinophilic esophagitis is IgG4-associated, and not an IgE-induced allergy. ClinicalTrials.gov number: NCT 00123630.

Targeted intraceptor nanoparticle therapy reduces angiogenesis and fibrosis in primate and murine macular degeneration

Monthly intraocular injections are widely used to deliver protein-based drugs that cannot cross the blood-retina barrier for the treatment of leading blinding diseases such as age-related macular degeneration (AMD). This invasive treatment carries significant risks, including bleeding, pain, infection, and retinal detachment. Further, current therapies are associated with a rate of retinal fibrosis and geographic atrophy significantly higher than that which occurs in the described natural history of AMD. A novel therapeutic strategy which improves outcomes in a less invasive manner, reduces risk, and provides long-term inhibition of angiogenesis and fibrosis is a felt medical need. Here we show that a single intravenous injection of targeted, biodegradable nanoparticles delivering a recombinant Flt23k intraceptor plasmid homes to neovascular lesions in the retina and regresses CNV in primate and murine AMD models. Moreover, this treatment suppressed subretinal fibrosis, which is currently not addressed by clinical therapies. Murine vision, as tested by OptoMotry, significantly improved with nearly 40% restoration of visual loss induced by CNV. We found no evidence of ocular or systemic toxicity from nanoparticle treatment. These findings offer a nanoparticle-based platform for targeted, vitreous-sparing, extended-release, nonviral gene therapy.

Neuroendocrine tumors

Neuroendocrine tumors comprise a broad family of tumors, the most common of which are carcinoid and pancreatic neuroendocrine tumors. The NCCN Neuroendocrine Tumors Guidelines discuss the diagnosis and management of both sporadic and hereditary neuroendocrine tumors. Most of the recommendations pertain to well-differentiated, low- to intermediate-grade tumors. This updated version of the NCCN Guidelines includes a new section on pathology for diagnosis and reporting and revised recommendations for the surgical management of neuroendocrine tumors of the pancreas.

Prognostic significance of PINCH signalling in human pancreatic ductal adenocarcinoma

OBJECTIVE

Prognostic markers for pancreatic ductal adenocarcinoma (PDA) have failed to accurately predict patient prognosis. Recently, interest has developed in the accuracy of integrin-associated PINCH protein expression in human cancers as a predictive marker of tumour status. The goal of this study was to define the expression of PINCH protein in PDA.

METHODS

Human PDA samples and orthotopic tumours from a murine model were analysed by immunohistochemistry for PINCH expression. In the animal model, PINCH expression was compared between primary and metastatic tumours. In the human samples, PINCH expression was correlated with stage, nodal involvement, margin status and overall survival.

RESULTS

In the murine model, there was greater PINCH expression in metastatic tumours than in primary tumours. In the human PDA samples, greater staining for PINCH in the tumour cells was correlated with higher T status. Additionally, high PINCH expression in the stroma was associated with decreased overall survival.

CONCLUSIONS

Findings of increased PINCH protein in more advanced stages of human PDA, as well as in metastatic tumours in the animal model, support the hypothesis that PINCH is an important controller of cell survival and migration. Additionally, the importance of the differential expression of PINCH in the human tumour and stroma warrants further evaluation.

Noninvasive evaluation of antiangiogenic effect in a mouse tumor model by DCE-MRI with Gd-DTPA cystamine copolymers

The efficacy of polydisulfide-based biodegradable macromolecular Gd(III) complexes, Gd-DTPA cystamine copolymers (GDCC), for assessing tumor microvascular characteristics and monitoring antiangiogenesis therapy was investigated in a mouse model using dynamic contrast-enhanced MRI (DCE-MRI). The mice bearing human colon tumor xenografts were intraperitoneally injected with an antiangiogenesis agent Avastin three times in a week at a dose of 200 mug/mouse. DCE-MRI with GDCC of 40 kDa (GDCC-40) was performed before and at 36 h after the first treatment with Avastin and at the end of treatment (7 days). Gd(DTPA-BMA) was used as a low molecular weight control. The tumor vascular parameters, endothelial transfer coefficient K(trans) and factional plasma volume f(PV), were calculated from the DCE-MRI data with a two-compartment model. The K(trans) and f(PV) in tumor periphery estimated by DCE-MRI with GDCC-40 before and after the antiangiogenesis treatment correlated well to tumor growth before and after the treatment in the tumor model. In contrast, the parameters estimated by Gd(DTPA-BMA) did not show significant correlation to the therapeutic efficacy. This study demonstrates that DCE-MRI with the biodegradable macromolecular MRI contrast agent can provide effective assessment of the antiangiogenic efficacy of Avastin in the animal tumor model based on measured vascular parameters in tumor periphery.

Application of a biodegradable macromolecular contrast agent in dynamic contrast-enhanced MRI for assessing the efficacy of indocyanine green-enhanced photothermal cancer therapy

PURPOSE

To investigate the effectiveness of a polydisulfide-based biodegradable macromolecular contrast agent, (Gd-DTPA)-cystamine copolymers (GDCC), in assessing the efficacy of indocyanine green-enhanced photothermal cancer therapy using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).

MATERIALS AND METHODS

Breast cancer xenografts in mice were injected with indocyanine green and irradiated with a laser. The efficacy was assessed using DCE-MRI with GDCC of 40 kDa (GDCC-40) at 4 hours and 7 days after the treatment. The uptake of GDCC-40 by the tumors was fit to a two-compartment model to obtain tumor vascular parameters, including fractional plasma volume (f(PV)), endothelium transfer coefficient (K(PS)), and permeability surface area product (PS).

RESULTS

GDCC-40 resulted in similar tumor vascular parameters at three doses, with larger standard deviations at lower doses. The values of f(PV), K(PS), and PS of the treated tumors were smaller (P < 0.05) than those of untreated tumors at 4 hours after the treatment and recovered to pretreatment values (P > 0.05) at 7 days after the treatment.

CONCLUSION

DCE-MRI with GDCC-40 is effective for assessing tumor early response to dye-enhanced photothermal therapy and detecting tumor relapse after the treatment. GDCC-40 has a potential to noninvasively monitor anticancer therapies with DCE-MRI.

Tumor characterization with dynamic contrast enhanced magnetic resonance imaging and biodegradable macromolecular contrast agents in mice

PURPOSE

To investigate the efficacy of polydisulfide-based biodegradable macromolecular contrast agents of different degradability and molecular weight for tumor characterization based on angiogenesis using dynamic contrast enhanced MRI (DCE-MRI).

METHODS

Biodegradable macromolecular MRI contrast agents, Gd-DTPA cystamine copolymers (GDCC) and Gd-DTPA cystine copolymers (GDCP), with molecular weight of 20 and 70 KDa were evaluated for tumor characterization. Gd(DTPA-BMA) and a prototype of macromolecular contrast agent, albumin-(Gd-DTPA), were used as controls. The DCE-MRI studies were performed in nude mice bearing MDA PCa 2b and PC-3 human prostate tumor xenografts. Tumor angiogenic kinetic parameters including endothelium transfer coefficient (K(trans)) and fractional tumor plasma volume (f(PV)) were calculated from the DCE-MRI data using a two-compartment model and compared between the two different tumor models for each contrast agent.

RESULTS

There was no significant difference in the f(PV) values between two tumor models estimated with the same agent except for GDCC-70. The K(trans) values in both tumor models decreased with the increase of molecular weight of contrast agents. With the same high molecular weight (70 KDa), GDCC-70 showed a higher K(trans) values than GDCP-70 due to high degradability of the former in both tumor models (p < 0.05). The K(trans) values of MDA PCa 2b tumors were significantly higher than those of PC-3 tumors estimated by Gd(DTPA-BMA), GDCC-20, GDCC-70, GDCP-70, and albumin-(Gd-DTPA) (p < 0.05).

CONCLUSIONS

The polydisulfide-based biodegradable macromolecular MRI contrast agents are promising in tumor characterization and differentiation with dynamic contrast enhanced MRI.

Characterization of tumor angiogenesis with dynamic contrast-enhanced MRI and biodegradable macromolecular contrast agents in mice

The efficacy of polydisulfide-based biodegradable macromolecular contrast agents for characterizing tumor angiogenesis was investigated in a mouse model using dynamic contrast-enhanced MRI (DCE-MRI). Biodegradable macromolecular MRI contrast agents, gadopentetate dimeglumine (Gd-DTPA) cystamine copolymers (GDCC), and Gd-DTPA cystine copolymers (GDCP), with molecular weights of 20 and 70 kDa were used in the study. Gadodiamide (Gd [DTPA-BMA]) and albumin labeled with Gd-DTPA [albumin-(Gd-DTPA)] were used as the controls. The DCE-MRI studies were performed in nude mice bearing prostate tumor xenografts from the MDA-PCa-2b cell line. Tumor angiogenic kinetic parameters, including endothelial transfer coefficient (K(PS)), fractional tumor plasma volume (f(PV)), and permeability surface area product (PS), were estimated from the DCE-MRI data using a two-compartment model. The K(PS) and f(PV) values estimated by the biodegradable macromolecular contrast agents were between those estimated by Gd(DTPA-BMA) and albumin-(Gd-DTPA). The parameters estimated by the agent with a slow degradation rate and high molecular weight, GDCP-70 (K(PS) = 2.09 +/- 0.50 ml/min/100 cc and f(PV) = 0.075 +/- 0.021), were closer to those by albumin-(Gd-DTPA) (K(PS) = 1.43 +/- 0.64 ml/min/100 cc and f(PV) = 0.044 +/- 0.007) than by other agents with relatively low molecular weight or rapid degradation rate. The polydisulfide-based biodegradable macromolecular contrast agents are promising for characterizing tumor vascularity and angiogenesis with DCE-MRI.

Contrast-enhanced MRI-guided photodynamic cancer therapy with a pegylated bifunctional polymer conjugate

PURPOSE

To study contrast-enhanced MRI guided photodynamic therapy with a pegylated bifunctional polymer conjugate containing an MRI contrast agent and a photosensitizer for minimally invasive image-guided cancer treatment.

METHODS

Pegylated and non-pegylated poly-(L-glutamic acid) conjugates containing mesochlorin e6, a photosensitizer, and Gd(III)-DO3A, an MRI contrast agent, were synthesized. The effect of pegylation on the biodistribution and tumor targeting was non-invasively visualized in mice bearing MDA-MB-231 tumor xenografts with MRI. MRI-guided photodynamic therapy was carried out in the tumor bearing mice. Tumor response to photodynamic therapy was evaluated by dynamic contrast enhanced MRI and histological analysis.

RESULTS

The pegylated conjugate had longer blood circulation, lower liver uptake and higher tumor accumulation than the non-pegylated conjugate as shown by MRI. Site-directed laser irradiation of tumors resulted in higher therapeutic efficacy for the pegylated conjugate than the non-pegylated conjugate. Moreover, animals treated with photodynamic therapy showed reduced vascular permeability on DCE-MRI and decreased microvessel density in histological analysis.

CONCLUSIONS

Pegylation of the polymer bifunctional conjugates reduced non-specific liver uptake and increased tumor uptake, resulting in significant tumor contrast enhancement and high therapeutic efficacy. The pegylated poly(L-glutamic acid) bifunctional conjugate is promising for contrast enhanced MRI guided photodynamic therapy in cancer treatment.

Squamous differentiation and cytokeratin expression in an osteosarcoma: a case report and review of the literature

Cytokeratin expression has been documented in a variety of sarcomas including synovial sarcomas, epithelioid sarcomas, Ewing's sarcomas and, rarely, osteosarcomas. In osteosarcomas immunohistochemically shown to expression cytokeratins, a component of epithelioid cells is generally present. These epithelioid cytokeratin positive cells raise the possibility of metastatic disease with prognostic and therapeutic implications differing from primary osteosarcoma. The cytokeratin-expressing cells of the cases reported in the literature have not shown definitive squamous differentiation with keratin pearl formation. We report a case of osteosarcoma in which islands of malignant squamous cells were present showing keratin pearl formation and expression of cytokeratins.

Subcutaneous tumor seeding following needle core biopsy of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary hepatic tumor and one of the most common cancers worldwide. At present, there are two widely used and accepted methods for obtaining diagnostic material for establishing the likelihood of malignancy in a hepatic mass, namely fine-needle aspiration (FNA) cytology and needle core biopsy (NCB). In recent years, however, tumor cell seeding along the needle tract has been shown to be a risk associated with using these procedures to obtain a pathologic diagnosis. We report a case of a patient who presented with a nodule in the anterior abdominal wall at the expected location of the previous NCB tract. FNA biopsy of the abdominal wall lesion confirmed the presence of malignant cells consistent with HCC. The finding of tumor seeding within a NCB tract raises the question of the role of NCB in the diagnostic workup of focal liver lesions.

Modification of Gd-DTPA cystine copolymers with PEG-1000 optimizes pharmacokinetics and tissue retention for magnetic resonance angiography

The purpose of this study was to investigate the effect of PEGylation of novel biodegradable macromolecular polydisulfide Gd(III) complexes, gadolinium diethylenetriaminepentaacetate (GdDTPA) cystine copolymers (GDCP), on their pharmacokinetics and long-term Gd(III) tissue retention, and to demonstrate the potential application of PEGylated GDCP (PEG-GDCP) for MR angiography (MRA). The pharmacokinetics, biodistribution, and metabolic excretion of PEG(1000)-GDCP (42.1-52.1 kDa; PEG: MW = 1000 Da) with three different PEG grafting degrees and GDCP (43.3 kDa) were investigated in Sprague-Dawley rats. Pharmacokinetic data were analyzed by means of an open two-compartment model. Initially all three PEG(1000)-GDCP contrast agents (CAs) had a higher plasma concentration than GDCP, but after 30 min the Gd(III) concentration from the PEGylated agents rapidly decreased, resulting in significantly lower elimination half-life values. All of the biodegradable macromolecular CAs demonstrated low long-term Gd(III) tissue accumulation, while PEG(1000)-GDCP had significantly lower accumulation in the liver than GDCP. In the rats, all CAs showed excellent vascular contrast enhancement in an MRA protocol with a long image acquisition time. Because PEG(1000)-GDCP remained intravascular for an acceptable period for effective contrast-enhanced (CE)-MRA, and then excreted rapidly from the vasculature with minimal tissue retention, PEG(1000)-GDCP shows a great promise as a blood-pool CA for MRA.

Adding to the controversy: pitfalls in the diagnosis of testosterone deficiency syndromes with questionnaires and biochemistry

PURPOSE

To determine the value of available questionnaires used for the diagnosis of testosterone deficiency syndromes (TDS) by correlating their ratings with a panel of hormonal determinations in a male population.

MATERIALS AND METHODS

Participants completed the ADAM questionnaire and underwent biochemical evaluation at the local site. Assessments determined entry into Group A (symptomatic) or Group B (non-symptomatic). After stratification, subjects provided a morning sample of blood, completed the Aging Male Survey (AMS) and the newly developed Canadian Society for the Study of the Aging Male (CSAM-Q) questionnaires. Serum aliquots were analysed at a central lab for 8 putative markers commonly associated with symptomatic testosterone deficiency associated with aging: total testosterone (T); bioavailable T (BT); dehydroepiandrosterone sulphate (DHEA-S); sex-hormone binding globulin (SHBG); luteinizing hormone (LH), prolactin (PRL); thyroid-stimulating hormone (TSH) and insulin-like growth factor-1 (IGF-1).

RESULTS

92 men were screened; of these 59 (mean age of 58+/-11 years) completed the study, 30 (51%) scored positively (mean 61.5 years) to the ADAM while 29 (49%) did not (mean 54.1 years). For the AMS the weight of the three domains (psychological, somato-vegetative and sexual) was significantly greater in Group A (p<0.001) than in Group B. Equally, for the CAS questionnaire, the scores for the variables energy, global performance, frequency of intercourse, mood and quality of sleep were lower in Group A than in their asymptomatic counterparts (p<0.001). The domain of memory assessment within the CSSAM-Q was not discriminatory. ADAM and AMS are self-administered and completed within 10 minutes. CSSAM-Q is more time consuming, requires an investigator to administer, and memory domain is biased in favour of specific professional training. No difference was found between the two groups in 6 of 8 biochemical tests. However, significant lower values (p<0.001) were found for DHEA-S and IGF-1 in the symptomatic group as compared with the non-symptomatic cohort.

CONCLUSIONS

This study confirms that newer, more complex tools perform similarly to the simpler ADAM questionnaire. The lack of correlation between the clinical picture and the most commonly used biochemical confirmatory tests, again, clearly points to the paramount importance of the clinical evaluation. An emphasis and reliance on serum T alone hinders the clinician's ability to manage testosterone deficiency syndromes (TDS).

In vivo evaluation of argon plasma coagulation in a porcine model

BACKGROUND

Argon plasma coagulation (APC) is a noncontact form of monopolar electrocautery. One purported advantage of APC includes a limit to the depth of injury. It is unclear from previous studies whether the depth of injury is limited to superficial tissue layers with the settings used in clinical practice.

OBJECTIVE

To evaluate the depth and the area of APC-induced injury by using new modes of APC delivery in an in vivo porcine model in the setting of colonoscopy.

DESIGN

Blinded quasi-experiment.

SUBJECTS

Six swine.

INTERVENTION

Colonoscopy with the swine under general anesthesia, with application of APC in 2 different pulsed modes and varying power settings and duration of application.

MAIN OUTCOME MEASUREMENTS

Surface area and depth of colonic mucosal injury. Qualitative histologic analysis of each site of APC application was performed on formalin-fixed specimens after euthanizing the swine.

RESULTS

Muscularis propria injury occurred in 22% of lesions with 10 W, 62% of lesions with 20 W, 86% of lesions with 40 W, and 80% of lesions with 60 W. Muscularis propria injury occurred in 42% of lesions at 1 second, 66% of lesions at 3 seconds, and 69% of lesions at 5 seconds. Depth of injury was significantly correlated with total energy delivered (P = .001, r = 0.75). Surface area was significantly associated with total energy delivered (P < .001, r = 0.81).

LIMITATIONS

This study was performed in distal swine colon rather than human colon. Colon tissue response to APC injury may differ from swine to human colon. The application distance from the APC probe to the colonic tissue may have varied between applications.

CONCLUSIONS

Muscularis propria injury occurs across a broad range of clinically used APC settings. The frequency of deep injury and the surface area of the lesion increases with total energy delivered. The lowest power settings (10-20 W) and the shortest durations have the lowest risk of deep tissue injury.

Adenocarcinoma arising in association with gastric heterotopic pancreas: A case report and review of the literature

We report a case of adenocarcinoma arising in a focus of heterotopic pancreas, occurring in the stomach of a 52-year-old man. The patient presented with gastric outlet obstruction. Radiographic studies revealed thickening of the gastric wall, but endoscopy failed to reveal a mucosal abnormality. A 50% distal gastrectomy was performed, along with vagotomy. Microscopic examination revealed extensive involvement of the muscularis propria of the distal stomach by heterotopic pancreas. The ectopic pancreas had a microscopic appearance consistent with Heinrich's class III, in which the majority of the heterotopic pancreas was characterized by cystically dilated duct structures. Occasional islets were present. Intimately associated with the cystically dilated ducts was a prominent number of small infiltrating ducts lined by columnar or cuboidal cells with enlarged hyperchromatic nuclei containing prominent nucleoli. These were consistent with a well-differentiated invasive adenocarcinoma. Despite multiple sectioning, no connection between the adenocarcinoma and the overlying gastric mucosa was seen. Adenocarcinoma arising within ectopic pancreas is a rare occurrence with fewer than 30 well-documented cases reported in the world literature to our knowledge.

Malignant islet cell tumor with sarcomatous differentiation

Malignant mesenchymal neoplasms of the pancreas are rare and malignant islet cell tumors with sarcomatous dedifferentiation are rarer still. We present a case of malignant islet cell tumor with sarcomatous differentiation, which to our knowledge is only the second reported case showing such a combination of morphologic features. Clinically, the neoplasm was not hormonally active and immunohistochemical staining was negative for gastrin, glucagon, insulin and somatostatin. The sarcomatous component strongly reacted with an antibody directed against vimentin, and a minority of cells stained strongly with antisera directed against desmin and smooth muscle actin. The spindle cell component was nonreactive with antibodies directed against Factor VIII. The myogenous direction of differentiation in the present tumor is similar to that seen in the prior case report of malignant islet cell tumor with rhabdomyosarcomatous differentiation.

Treatment of refractory interstitial cystitis

Interstitial cystitis is the most therapeutically frustrating condition of the urinary tract. The vast array of treatments available clearly indicates that none is particularly effective. As the majority of patients fail to experience a significant and prolonged response to standard treatments, new options are frequently being developed. These include the oral administration of cimetidine, the intravesical use of hyaluronic acid and BCG, and total cystectomy with the formation of a continent urinary diversion. Unfortunately, the acceptance of many new treatments is based on incomplete evaluation, and this has resulted in a confusing array of disparate alternatives. Effective and durable treatment will not be available until the nature of the disease is better understood and the mechanisms of action of current therapies are elucidated.

Neutralization of cardiac toxins oleandrin, oleandrigenin, bufalin, and cinobufotalin by digibind: monitoring the effect by measuring free digitoxin concentrations

Oleandrin plant poisoning is common in children and the plant extract is used in Chinese medicines. The toxicity is due to oleandrin and the deglycosylated metabolite oleandrigenin. Bufalin and cinobufotalin (toad cardiac toxins) are also widely used in Chinese medicines like Chan SU, and Lu-Shen -WU. Severe toxicity from bufalin after consumption of toad soup has been reported. Taking advantage of structural similarities of these toxins with digitoxin, we demonstrated that these compounds can be rapidly detected in blood by the fluorescence polarization immunoassay for digitoxin. The cross reactivities of these compounds with digoxin assay were much lower. For example, when a drug free serum was supplemented with 10 microg/ml of oleandrin, we observed 127.7 ng/ml of digitoxin equivalent but only 2.4 ng/ml of digoxin equivalent concentration. Digibind neutralized all cardiac toxins studied as evidenced by significant fall of free concentrations. When aliquots of serum pool containing 50.0 microg/ml of oleandrin were supplemented with 0, 10.0, 25.0, 50.0, 100, and 200 microg/ml of digibind, the mean free concentrations were 30.6, 23.3, 16.0, 10.7, 7.8 and 5.5 microg/ml respectively. Similarly, with 50.0 microg/ml of oleandrigenin (total concentration: 36.2 ng/ml), the free concentration was 14.5 ng/ml digitoxin equivalent in the absence of digibind and 5.4 ng/ml in the presence of 200 microg/ml of digibind. In another specimen containing 500 ng/ml bufalin (total concentration: 156.9 ng/ml), the free concentration was 8.6 ng/ml in the absence of digibind and none detected in the presence of 100.0 microg/ml digibind. Because such neutralization may also occur in vivo, digibind may be useful in treating patients exposed to these toxins.

Relative efficacy of various exogenous glycosaminoglycans in providing a bladder surface permeability barrier

PURPOSE

To investigate the relative efficacy of heparin (H), pentosanpolysulfate (PPS) and hyaluronic acid (HA) in preventing the absorption of 14C labeled urea in protamine pretreated bladders compared with saline pretreated control bladders.

MATERIALS AND METHODS

Control Group - Rabbit bladders were pretreated with phosphate buffered saline (PBS) followed by instillation of 14C-urea. Radioactivity was determined in blood, bladder and fluid drained from the bladder. Protamine Group - Bladders were pretreated with of PBS followed by protamine sulfate. The bladders were then treated with 14C-urea and radioactivity determined as above. GAG Groups - Bladders were pretreated with saline and protamine as described above followed by instillation of: Group 3A - HA, Group 3B - H and Group 3C - PPS. The bladders were then treated with 14C-urea and radioactivity determined as described above.

RESULTS

Protamine treated bladders demonstrated significantly more radioligand uptake in bladder tissue compared with control bladders. There was no significant difference in radioligand uptake in bladders treated with PPS and H compared with control. While not significantly different, there was considerably more radioligand concentration in the blood of rabbits with bladders treated with protamine and protamine-HA compared with those of control rabbits and those treated with protamine-PPS and protamine-H.

CONCLUSIONS

Exogenous GAG's are effective in providing an epithelial permeability barrier in protamine pretreated bladders. There is a difference in the relative efficacy of the various GAG's in producing this effect.

Rapid detection of bladder cancer: a comparative study of point of care tests

PURPOSE

We assessed sensitivity, specificity, accuracy, positive predictive value and negative predictive value of the bladder tumor antigen (Bard BTA), fibrinogen/fibrin degradation products (AuraTek FDP), urinary cytology and hemoglobin dipstick tests in the urine of patients presenting to a urology clinic.

MATERIALS AND METHODS

A total of 130 patients (60 with bladder cancer) provided a urine sample, which was divided into appropriate aliquots for each of the tests cited above. The endoscopist, pathologist, cytologist and the person performing the BTA/FDP/hemoglobin dipstick were blinded as to the results of the other tests, and the tests were read independently by a second blinded evaluator.

RESULTS

Comparative results demonstrate a clear superiority of FDP in sensitivity (81%) and overall accuracy in bladder cancer detection (p = 0.0001) while cytology and BTA were marginally better than FDP in specificity.

CONCLUSIONS

The anticipated lack of specificity of the hemoglobin dipstick was confirmed as well as the inadequacy of urinary cytology, particularly in the well differentiated tumors. Our findings with BTA were disappointing. The superiority of the FDP, first demonstrated here, was particularly striking in its ability to detect even well differentiated tumors. The simplicity and significantly better overall performance of FDP make it a reliable test for detection of transitional cell carcinoma of the bladder and a potential alternative to urinary cytology with important implications for clinical practice and health economics.

Intralesional administration of biological response modifiers in the treatment of localized cancer of the prostate: a feasibility study

OBJECTIVES

The primary aims of this pilot study were to establish the feasibility of intraprostatic administration of biological response modifiers (BRMs) and to investigate the toxicity and side effects of recombinant interferon (IFN)-alpha-2b injected into prostate glands harboring cancer. A secondary goal was to perform a preliminary assessment of the antitumor effect of this treatment.

METHODS

Nine patients with histologically documented carcinoma of the prostate participated in the study. IFN was administered weekly for 5 weeks, under transrectal ultrasound visualization, with a modified gun that permitted the controlled injection of small volumes initially into the area of the tumor and later into the whole gland. Total doses of IFN ranged between 15 and 100 MU.

RESULTS

The procedure resulted in minor local discomfort, comparable to a prostatic biopsy. Side effects from the drug were those anticipated from most BRMs (chills, fever, malaise, headache, fatigue), and in every case they were minor and self-limiting to several hours. Local adverse events were limited to gross hematuria (2 patients [22%]) and hematospermia (1 patient [11%]) and resolved spontaneously within 2 weeks. Antitumor activity, a secondary goal of the study, was noted in 3 (33%) patients with limited follow-up (mean 22.5 months).

CONCLUSIONS

The results of this pilot study indicate that the intraprostatic administration of IFN-alpha-2b can be readily accomplished by the method described here and is associated with minor, self-limited toxicity. With the regimen and doses used, IFN demonstrated modest antineoplastic activity. Modifications of the schedule, routes, and amounts administered may result in enhanced therapeutic value.

Intravesical hyaluronic acid in the treatment of refractory interstitial cystitis

OBJECTIVES

On the assumption that interstitial cystitis (IC) is the result of a defective mucous lining of the bladder epithelium, a study was carried out to investigate the activity of hyaluronic acid (HA) in the treatment of IC. HA is an important glycosaminoglycan (GAG) present in all connective tissues, including the GAG layer of the vesical mucosa. It exhibits a variety of pharmacologic properties that enhance its appeal for the therapy of IC.

METHODS

A total of 25 patients, with the characteristic picture of IC and refractory to other medical treatments, participated in a trial of HA. Patients received 40 mg of HA intravesically on a weekly basis for 4 weeks, then monthly. Response to therapy was evaluated by symptom score, voiding diaries, and visual analog scales.

RESULTS

An initial positive (complete+partial) response of 56% at week 4 increased to 71% by week 12. This response was maintained until week 20; beyond week 24 there appears to be a moderate decrease in the effectiveness of the medication. There was no significant toxicity attributable to the presence of HA in the bladder.

CONCLUSIONS

The response of refractory IC patients to the intravesical administration of HA was gratifying. In the past, many therapies for IC that were initially considered promising failed the test of a controlled study. Further studies will establish the effectiveness of this particular preparation of HA in the treatment of IC.

Prostatic microwave therapy: A pilot study for technology assessment

Objective. The Genemed Genetherm S 150 is an easy to use and comparatively inexpensive device for administering prostatic microwave therapy. This study was aimed at testing the efficacy and safety of this machine in a pilot study. Methods. Sixteen patients with benign prostatic hypertrophy participated in the study, but only fourteen were evaluable. All received one hour of microwave therapy where the mean temperature was 45.7±0.2 °C. Symptom scores (International Prostate Symptom Score and Quality of Life Assessment), peak flow rates and post void residuals were used to evaluate participants prior to and three months following their treatment. Results. The results of this study show a statistically significant improvement in mean symptom scores. There was no significant change in mean peak flow rates while a statistically significant increase in mean post void residual occurred. Individually, however, only one patient experienced an improvement in all of the above parameters. There were no undesirable side effects during or after treatment. Conclusions. We conclude that the results of this pilot study do not warrant further study of this device, despite its practicality and safety.

Interaction of valproic acid with nonsteroidal antiinflammatory drugs mefenamic acid and fenoprofen in normal and uremic sera: lack of interaction in uremic sera due to the presence of endogenous factors

Valproic acid is an anticonvulsant that is strongly bound to serum albumin. The nonsteroidal antiinflammatory drugs mefenamic acid and fenoprofen are also strongly bound to albumin. We observed significant displacement of valproic acid from protein binding by mefenamic acid and fenoprofen at both therapeutic and slightly above therapeutic concentrations. The concentration of free valproic acid was higher in the uremic serum, as expected, but we observed no further displacement of valproic acid in the presence of mefenamic acid and fenoprofen. Known uremic compounds, hippuric acid and indoxyl sulfate, did not inhibit the interactions between valproic acid and mefenamic acid or fenoprofen. Treatment of uremic serum with activated charcoal at pH 3.0 removes endogenous interfering factors and corrects the binding defect of uremic serum for valproic acid. We observed significant displacement of valproic acid from protein binding by both mefenamic acid and fenoprofen in uremic serum after charcoal treatment. We conclude that endogenous factors are present in uremic sera that block interaction of valproic acid with mefenamic acid and fenoprofen.

Intravesical hyaluronic acid in the treatment of refractory interstitial cystitis

PURPOSE

Based on the assumption that interstitial cystitis results from a defective mucous lining of the bladder epithelium, we investigated the activity of hyaluronic acid in the treatment of this disease. Hyaluronic acid is an important glycosaminoglycan present in all connective tissues, including the glycosaminoglycan layer of the vesical mucosa. It exhibits a variety of pharmacological properties that enhance its appeal for the therapy of interstitial cystitis.

MATERIALS AND METHODS

A total of 25 patients with characteristic findings of interstitial cystitis refractory to other medical treatments participated in a trial of intravesical hyaluronic acid at a dose of 40 mg. weekly for 4 weeks and then monthly. Response to therapy was evaluated by symptom score, voiding diaries and visual analog scales.

RESULTS

An initial 56% positive (complete plus partial) response rate at week 4 increased to 71% by week 12 and response was maintained until week 20. Beyond week 24 there was a moderate decrease in the effectiveness of the medication. There was no significant toxicity attributable to hyaluronic acid in the bladder.

CONCLUSIONS

The response of patients with refractory interstitial cystitis to the intravesical administration of hyaluronic acid was gratifying. In the past many therapies for interstitial cystitis which were initially considered promising failed the test of a controlled study. Such a study to determine the activity of hyaluronic acid in patients with interstitial cystitis is currently under way.

Biofeedback: a noninvasive treatment for incontinence after radical prostatectomy

OBJECTIVE

Will a program using biofeedback help patients with post radical prostatectomy incontinence to achieve continence by increasing their ability to contract pelvic floor muscles?

STUDY DESIGN

Twenty-seven patients who had undergone incontinent radical prostatectomy were evaluated for urinary incontinence and treated at the Urology Biofeedback Laboratory at our institution. Patients were assessed by urodynamic studies including uroflow, postvoid residual measurement, and cystometrogram before biofeedback was initiated. The protocol provided for 10 weekly sessions of 15 minutes' duration with additional reinforcement sessions at 1, 3, 6, and 12 months. Subjective symptoms related to urgency, frequency, nocturia, and number of pad changes were reported by patients before treatment and at each visit. Digital evaluation of the pelvic floor muscle contraction was objectively graded from 0 to 3 (nil to strong) and was completed before and after treatment. These subjective and objective findings were used to determine success of treatment.

RESULTS

Of the 27 patients completing the full treatment course, 13 (48%) had complete success, 7 (26%) had significant improvement but were not completely dry, and 7 (26%) had failure, for a total improvement rate of 74%.

CONCLUSIONS

A biofeedback training program is an effective, minimally invasive, and well-accepted method that can be offered as a first-line option to patients who have undergone radical prostatectomy and want to improve the postsurgical problem of urinary incontinence. Patient motivation is an important factor in success. Nurses have an opportunity to use their expertise in this program to assist these patients to return to continence.

Cimetidine in the treatment of interstitial cystitis

OBJECTIVES

To assess the effect of the H2-antagonist cimetidine in the treatment of patients with interstitial cystitis (IC) refractory to other conservative therapies.

METHODS

A group of 9 patients previously treated conservatively for IC without success were entered in the study. They were thoroughly investigated and treated with cimetidine at the dose of 300 mg orally twice a day for 1 month.

RESULTS

Six of the 9 patients (66%) experienced various degrees of symptomatic relief while on the drug. Of these, 4 (44%) have noted a complete and sustained response to the medication.

CONCLUSIONS

The encouraging results observed in this pilot study together with the simplicity and tolerance of the treatment makes it an alternative when other options have been exhausted. Its use as a first-line monotherapy remains speculative.

The bladder mucus (glycosaminoglycan) layer in interstitial cystitis

The thin mucus or glycosaminoglycan layer of the bladder may be implicated in the pathogenesis of interstitial cystitis. We developed a specific anti-mucus, antisera stabilization technique to study the ultrastructural morphological appearance of the layer, and have used this technique to compare the surface morphology of 10 control and 10 interstitial cystitis patients. The electron micrographs demonstrate the ultrastructural characteristics of the pathological changes seen in interstitial cystitis but they did not show any significant difference in the morphological appearance of the mucus or glycosaminoglycan layer between the 2 groups.

Endoscopic balloon dilation of the prostate: early experience

Coaxial balloon dilation catheters recently have been introduced for transurethral dilation of the prostate. We applied endoscopically a specially designed high pressure, large diameter balloon catheter to patients with benign prostatic hyperplasia or primary bladder neck hyperplasia who presented with symptomatic, cystoscopic and urodynamic evidence of obstruction. We report our preliminary experience with 42 patients: 28 with benign prostatic hyperplasia and 14 with bladder neck hyperplasia. Six months after dilation 46% of the patients demonstrated at least a 25% improvement in subjective (symptom score) and objective (corrected peak flow rate) parameters, while 6 (21%) experienced excellent (greater than 50%) symptomatic improvement despite unchanged corrected peak flow rates and 3 (11%) showed significant (greater than 50%) improvement in corrected flow rate alone. At 1, 3, 6 and 12 months the symptom scores decreased by 70, 67, 61 and 59% (median) from pre-treatment levels. Men with benign prostatic hyperplasia fared better than those with primary bladder neck hyperplasia (74 versus 58% decrease at 6 months). Objective evaluation by corrected peak flow rates demonstrated 25, 24, 28 and 2% median improvement at 1, 3, 6 and 12 months, respectively. Patients with primary bladder neck hyperplasia had substantially greater increases than those with benign prostatic hyperplasia (47 versus 27% at 6 months). Immediately after dilation the serum prostate specific antigen level increased by at least 1.5 ng. per ml. in 16 of 22 patients, indicating significant tissue trauma. Complications included mild bleeding and pain for the initial 24 hours and transient urinary retention in 2 patients. Our experience demonstrates the safety of an endoscopic approach to balloon dilation of the prostate that allows the urologist to maintain a central role in the assessment of a new approach to the treatment of obstructed voiding dysfunction.

The mechanisms of continence in the Indiana pouch: a video-urodynamic study

The ileocecal reservoir (Indiana pouch) is a large volume, low pressure continent reservoir well suited for urinary diversion. The mechanism of continence is believed to be the result of several factors, including the natural ileocecal valve resistance, resistance produced by the plication of the ileal segment and normal peristalsis of the ileum. We report the results of a video-urodynamic study in patients with an Indiana pouch, aimed at establishing the factors that contribute to continence and their relative significance. Video-urodynamic studies clearly demonstrate that continence in this type of urinary reservoir is dependent upon a synergism of the aforementioned factors in combination with the low intraluminal pressure of the detubularized bowel. Video-urodynamic studies offer an objective demonstration of the reservoir dynamics and its continence mechanisms, and provide an insight into the possible etiology of incontinence. Such studies also offer an objective means for critical comparison of the different continent urinary reservoirs.

Maturation and degeneration of the fat body in the Drosophila larva and pupa as revealed by morphometric analysis

Using morphometric and cytochemical techniques we have described changes taking place in the fat body cells during three different stages of development. The cell number remains constant at about 2200 cells during larval life and then decreases gradually and continuously throughout metamorphosis and the first 3 days of the adult stage until no more cells can be observed. Cell size increases rapidly during the larval period and decreases steadily during metamorphosis and adult stage. The size of the nuclei increases during the larval instars and decreases during the pupal interval. The change in nuclear size is correlated with the amount of DNA present throughout development implying the nuclear DNA is synthesized during the larval period and degraded gradually during metamorphosis. The cell size changes are due in large part to accumulation or loss of reserve substances: lipid droplets, glycogen deposits and protein granules. During metamorphosis the amount of lipid decreases slightly whereas glycogen experiences two loss cycles. The protein granules in the form of lysosomes continue to increase in amount during the first day of metamorphosis because of a short period of massive autophagy. Then the lysosomes decrease in amount throughout the remainder of metamorphosis. The lysosomes stain positively for lipofuscin.

Urodynamic studies in interstitial cystitis

Urodynamics, although not diagnostic of IC, are useful in the differential diagnosis of painful voiding disorders and provide a convenient way to quantitate response to therapy. They may prove useful as prognostic indicators of response to treatment and are of value in those patients in whom surgery is considered. Our studies suggest that IC is a progressive disease if not treated and that early diagnosis may improve response to treatment. Although similar information can be gathered by other means, we find urodynamics reliable, reproducible, and quantifiable and a valuable tool in the diagnosis, treatment, and follow-up of patients with IC.