Effects of rIL2/anti-IL2 antibody complex on chikungunya virus-induced chronic arthritis in a mouse model.

Chikungunya virus (CHIKV) is characterized by disabling joint pain that can cause persistent arthritis in approximately one-fourth of patients. Currently, no standard treatments are available for chronic CHIKV arthritis. Our preliminary data suggest that decreases in interleukin-2 (IL2) levels and regulatory T cell (Treg) function may play a role in CHIKV arthritis pathogenesis. Low-dose IL2-based therapies for autoimmune diseases have been shown to up-regulate Tregs, and complexing IL2 with anti-IL2 antibodies can prolong the half-life of IL2. A mouse model for post-CHIKV arthritis was used to test the effects of recombinant IL2 (rIL2), an anti-IL2 monoclonal antibody (mAb), and the complex on tarsal joint inflammation, peripheral IL2 levels, Tregs, CD4 + effector T cells (Teff), and histological disease scoring. The complex treatment resulted in the highest levels of IL2 and Tregs, but also increased Teffs, and therefore did not significantly reduce inflammation or disease scores. However, the antibody group, which had moderately increased levels of IL2 and activated Tregs, resulted in a decreased average disease score. These results suggest the rIL2/anti-IL2 complex stimulates both Tregs and Teffs in post-CHIKV arthritis, while the anti-IL2 mAb increases IL2 availability enough to shift the immune environment towards a tolerogenic one.

Effects of IL2/anti-IL2 antibody complex on chikungunya virus-induced arthritis in a mouse model.

Chikungunya virus (CHIKV) is characterized by disabling joint pain that can cause persistent arthritis in approximately one-fourth of patients. Currently, no standard treatments are available for chronic CHIKV arthritis. Our preliminary data suggest that decreases in interleukin-2 (IL2) levels and regulatory T cell (Treg) function may play a role in CHIKV arthritis pathogenesis. Low-dose IL2-based therapies for autoimmune diseases have been shown to up-regulate Tregs, and complexing IL2 with anti-IL2 antibodies can prolong the half-life of IL2. A mouse model for post-CHIKV arthritis was used to test the effects of IL-2, an anti-IL2 monoclonal antibody (mAb), and the complex on tarsal joint inflammation, peripheral IL2 levels, Tregs, effector (Teff) T cells, and histological disease scoring. The complex treatment resulted in the highest levels of IL2 and Tregs, but also increased Teffs, and therefore did not significantly reduce inflammation or disease scores. However, the antibody group, which had moderately increased levels of IL2 and activated Tregs, resulted in a decreased average disease score. These results suggest the IL2/anti-IL2 complex stimulates both Tregs and Teffs in post-CHIKV arthritis, while the anti-IL2 mAb increases IL2 availability enough to shift the immune environment towards a tolerogenic one.

A Mouse Model for Studying Post-Acute Arthritis of Chikungunya.

Chikungunya virus (CHIKV) was introduced to the Americas in 2013, causing two million infections across over thirty countries. CHIKV causes a chronic debilitating arthritis in one fourth of infected individuals and currently evidence-based targeted therapies for the treatment of CHIKV arthritis are lacking. Multiple mouse models of chikungunya have been developed to study acute CHIKV infection. In humans, post-CHIKV arthritis may persist for months to years after viremia from a CHIKV infection has resolved. Therefore, the development of a mouse model of post-acute arthritis of chikungunya may facilitate the study of potential novel therapeutics for this arthritis. In this article we describe the development of a wild-type immunocompetent C57BL/6 mouse model for post-acute arthritis of chikungunya, including a histologic inflammation scoring system, as well as suggestions for how this mouse model may be used to examine the efficacy of novel therapies for CHIKV arthritis.

The Association Between Race, Obesity, and Sperm Quality Among Men Attending a University Physician Practice in Washington, DC.

A decades-long decline in sperm counts in Western countries has coincided with an increase in obesity rates, prompting study into their association. Few of these studies have incorporated men of color, the sperm health of whom is relatively unknown. The present exploratory study evaluated the association between body mass index (BMI), race, ethnicity, and sperm parameters among a diverse sample of U.S. men attending a Washington, DC physician practice. Semen samples were collected and processed at a single laboratory and sperm concentration, motility, morphology, and count were evaluated according to World Health Organization (WHO) 5th edition criteria. Multivariate models accounted for covariates related to sperm health. The study population (n = 128) was largely obese (45.3%) or overweight (34.4%), and 36.0% were black or Hispanic. Black men had lower adjusted sperm concentration compared to white men (75.0 million/mL to 107.4 million/mL, p = .01) and were more likely to have oligozoospermia (p = .01), asthenozoospermia (p = .004), and low sperm count (p < .0001). Hispanic men had higher adjusted sperm concentration compared to non-Hispanic men (124.5 million/mL to 62.1 million/mL, p = .007) and were less likely to have teratozoospermia (p = .001). Obesity and BMI were associated with lower sperm motility and count in crude models only. Given the study's sample size its findings should be interpreted with caution but align with the limited epidemiological literature to date that has evaluated racial and ethnic differences in semen quality. Heightened clinical research attention is needed to ensure men of color are included in representative numbers in studies of urologic and andrologic health.

Creating prognostic systems for cancer patients: A demonstration using breast cancer.

Integrating additional prognostic factors into the tumor, lymph node, metastasis staging system improves the relative stratification of cancer patients and enhances the accuracy in planning their treatment options and predicting clinical outcomes. We describe a novel approach to build prognostic systems for cancer patients that can admit any number of prognostic factors. In the approach, an unsupervised learning algorithm was used to create dendrograms and the C-index was used to cut dendrograms to generate prognostic groups. Breast cancer data from the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute were used for demonstration. Two relative prognostic systems were created for breast cancer. One system (7 prognostic groups with C-index = 0.7295) was based on tumor size, regional lymph nodes, and no distant metastasis. The other system (7 prognostic groups with C-index = 0.7458) was based on tumor size, regional lymph nodes, no distant metastasis, grade, estrogen receptor, progesterone receptor, and age. The dendrograms showed a relationship between survival and prognostic factors. The proposed approach is able to create prognostic systems that have a good accuracy in survival prediction and provide a manageable number of prognostic groups. The prognostic systems have the potential to permit a thorough database analysis of all information relevant to decision-making in patient management and prognosis.

The anatomy of the TNM for colon cancer.

BACKGROUND: To visualize the anatomy as revealed by dendrograms of the tumor, lymph node, and metastasis (TNM) staging system for colon cancer and compare it with the Dukes' system. METHODS: A hierarchical clustering algorithm generated tree-structured dendrograms that stratified patients according to survival only. The dendrograms were constructed with the same prognostic variables used for the TNM. Because combinations of prognostic factors were stratified only on survival, additional factors of any number and type could be integrated into the TNM without changing the TNM categories. RESULTS: The algorithm provided a step-by-step visualization of the TNM and the Dukes' system for colon cancer. Dendrograms and associated 5-year survival rates were generated for the T category only, the N category only, the T, N combination, and combinations of the T, N, and M, and the T, N, M with histological grade. Dendrograms revealed visual differences between the structure of TNM and the Dukes' system of staging. Dendrograms also revealed how variations in prognostic factors changed survival. By cutting dendrograms along their dissimilarity axis, multiple prognostic subgroups could be created for colon cancer that may reflect outcomes that are more accurate to estimate. CONCLUSIONS: Dendrograms provide a new way to view cancer patient staging. They reveal a visual step-by-step hierarchical relationship between survival rates and combinations of prognostic variables. The dendrograms also revealed fundamental differences between the TNM and the Dukes system of staging. By stratifying on survival only, additional factors including molecular factors can be added to the TNM, because it classifies patients according to survival rates only and not according to pre-set rules of prognostic factors and stage groups. The clinical implications of stratifying only survival are discussed.

Gouty Tenosynovitis of the Distal Biceps Tendon Insertion Complicated by Partial Rupture: First Case and Review of the Literature.

Background: Given the appreciable prevalence of gout, gout-induced tendon ruptures in the upper extremity are extremely rare. Although these events have been reported only 5 times in the literature, all in patients with a risk factor for or history of gout, they have conspicuously never been diagnosed in the shoulder or elbow. Methods: A 45-year-old, right-hand-dominant man with a history of gout presented with pain in his right anterior elbow and weakness in his forearm after a trivial injury. Results: Here, we report the first case of gouty tenosynovitis of the distal biceps tendon insertion complicated by partial rupture, a composite diagnosis supported by both intraoperative and histological observations. Conclusions: In patients who are clinically diagnosed with biceps tendon rupture and have a history of gout, it is important to consider the possibility of a gout-related pathological manifestation causing or simulating tendon rupture.

An Algorithm for Creating Prognostic Systems for Cancer.

The TNM staging system is universally used for classification of cancer. This system is limited since it uses only three factors (tumor size, extent of spread to lymph nodes, and status of distant metastasis) to generate stage groups. To provide a more accurate description of cancer and thus better patient care, additional factors or variables should be used to classify cancer. In this paper we propose a hierarchical clustering algorithm to develop prognostic systems that classify cancer according to multiple prognostic factors. This algorithm has many potential applications in augmenting the data currently obtained in a staging system by allowing more prognostic factors to be incorporated. The algorithm clusters combinations of prognostic factors that are formed using categories of factors. The dissimilarity between two combinations is determined by the area between two corresponding survival curves. Groups from cutting the dendrogram and survival curves of the individual groups define our prognostic systems that classify patients using survival outcomes. A demonstration of the proposed algorithm is given for patients with breast cancer from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute.

An algorithm for expanding the TNM staging system.

AIM: We describe a new method to expand the tumor, lymph node, metastasis (TNM) staging system using a clustering algorithm. Cases of breast cancer were used for demonstration. MATERIALS & METHODS: An unsupervised ensemble-learning algorithm was used to create dendrograms. Cutting the dendrograms produced prognostic systems. RESULTS: Prognostic systems contained groups of patients with similar outcomes. The prognostic systems based on tumor size and lymph node status recapitulated the general structure of the TNM for breast cancer. The prognostic systems based on tumor size, lymph node status, histologic grade and estrogen receptor status revealed a more detailed stratification of patients when grade and estrogen receptor status were added. CONCLUSION: Prognostic systems from cutting the dendrogram have the potential to improve and expand the TNM.

Histologic grade remains a prognostic factor for breast cancer regardless of the number of positive lymph nodes and tumor size: a study of 161 708 cases of breast cancer from the SEER Program.

CONTEXT: The appropriate staging of breast cancers includes an evaluation of tumor size and nodal status. Histologic grade in breast cancer, though important and assessed for all tumors, is not integrated within tumor staging. OBJECTIVE: To determine whether the histologic grade remains a prognostic factor for breast cancer regardless of tumor size and the number of involved axillary lymph nodes. DESIGN: By using a new clustering algorithm, the 10-year survival for every combination of T, N, and the histologic grade was determined for cases of breast cancer obtained from the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute. There were 36 combinations of TN, defined according to the American Joint Committee on Cancer, and grade. RESULTS: For each combination of T and N, a categorical increase in the histologic grade was associated with a progressive decrease in 10-year survival regardless of the number of involved axillary lymph nodes or size of the primary tumor. Absolute survival differences between high and low grade persisted despite larger tumor sizes and greater nodal involvement, though trends were apparent with increasing breast cancer stage. Statistical significance depended on the number of cases for each combination. CONCLUSIONS: Histologic grade continues to be of prognostic importance for overall survival despite tumor size and nodal status. Furthermore, these results seem to indicate that the assignment of the histologic grade has been consistent among pathologists when evaluated in a large data set of patients with breast cancer. The incorporation of histologic grade in TNM staging for breast cancer provides important prognostic information.

The clinical implications of integrating additional prognostic factors into the TNM.

BACKGROUND AND OBJECTIVES: The management of solid tumors is governed by host and tumor factors that traditionally have incorporated TNM staging with additional pathologic, biologic, and clinical host factors. Beyond the anatomic-based TNM, increasingly new prognostic and predictive factors are being discovered that have important survival and treatment implications. However, because the TNM is based on a "bin" model, additional prognostic factors would rapidly overwhelm the current system. This communication demonstrates the clinical implications and improved patient prognosis derived from a new algorithmic model based on clustering analysis. METHODS: A new algorithm is described that integrates additional factors into the TNM and calculates survival. RESULTS: The results indicate that additional factors can be integrated into the TNM staging system providing additional patient stratification without changing the TNM definitions. Adding prognostic factors to traditional TNM staging increases substratification of given stages and identifies and separates favorable and unfavorable clinical outcomes for specific TNM stages. CONCLUSION: Integration of additional prognostic factors into the TNM by a clustering algorithm can change the stratification of patient outcome. This may guide the clinician to select a more rational management program based on the additional factors and improve cohort selection for clinical trials.

Surgical pathology of lung cancer.

The diagnosis, treatment, and management of lung tumors represent a complex set of decision algorithms and require the cooperation and interaction of a team of experts and support systems. The surgical pathologist, an early, important member of the diagnostic team, uses clinical and radiological evidence to differentiate benign from malignant tumors and renders a unique diagnosis that provides both prognostic and treatment information. Using routine histopathologic criteria, histochemical and immunohistochemical stains, and molecular and genetic testing, surgical pathologists and cytopathologists may distinguish between small cell and other bronchogenic carcinomas, separate adenocarcinomas from squamous cell carcinomas, differentiate between pleural carcinomas and diffuse malignant mesotheliomas, and discriminate among the varieties of neuroendocrine carcinomas. Among adenocarcinomas, the pathological examination stratifies those tumors with absent or minimal central invasive cores that have an excellent prognosis from the more common adenocarcinomas with larger invasive components. These distinctions are necessary based on differences in tumor biology, response to therapy, and prognosis for these different histological types. Histopathologic analysis should attempt to provide a precise diagnosis and limit the usage of the term non-small cell carcinoma. The team approach also enables the optimal use of tumor tissue for diagnostic purposes as well as molecular genetic testing and the discovery of targetable sites for therapeutic management. Though low-stage tumors tend to be initially treated with surgical resection, more advanced stages will be approached with limited tissue acquisition, necessitating a strategy for best practices of scarce tissue resources. The awareness of diagnostic modalities and tissue handling by all members of the team ensures the best patient-centered care.

Diagnostic surgical pathology in lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.

BACKGROUND: This article provides evidence-based background and recommendations for the development of American College of Chest Physicians guidelines for the diagnosis and management of lung cancer. Specific population, intervention, comparison, and outcome questions were addressed to arrive at consensus recommendations. METHODS: A systematic search of the medical and scientific literature using MEDLINE and PubMed was performed for the years 1990 to 2011 and limited to literature on humans and articles written in English. Our approach to examining the evidence and formulating recommendations is described in the "Methodology for Lung Cancer Evidence Review and Guideline Development: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (2nd Edition)" and updated in "Methodology for Development of Guidelines for Lung Cancer: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines." RESULTS: Pathologic examination results of lung cancers should be recorded in a synoptic form to include important prognostic features of histologic type, tumor size and location, involvement of visceral pleura, extension to regional and distant lymph nodes, and metastatic spread to visceral organs and bone to increase completeness of recording. It is important for the surgical pathologist to make distinctions between malignant mesothelioma and pleural adenocarcinomas, small cell and non-small cell carcinomas, adenocarcinomas and squamous cell carcinomas, and primary and metastatic carcinomas of the lung. In challenging cases of pathologic differential diagnosis, additional studies may enable the separation of distinct tumor types. CONCLUSIONS: Pathologic assessment of lung cancers is a crucial component for the diagnosis, management, and prognosis of lung cancer, making the pathologist a critical member of the clinical and management team. Selective diagnostic techniques, including limited designed immunohistochemical panels, and decision analysis will increase diagnostic accuracy.

Assessment of K-Ras mutant frequency and micronucleus incidence in the mouse duodenum following 90-days of exposure to Cr(VI) in drinking water.

Chronic exposure to high concentrations of hexavalent chromium [Cr(VI)] as sodium dichromate dihydrate (SDD) in drinking water induces duodenal tumors in mice, but the mode of action (MOA) for these tumors has been a subject of scientific debate. To evaluate the tumor-site-specific genotoxicity and cytotoxicity of SDD in the mouse small intestine, tissue pathology and cytogenetic damage were evaluated in duodenal crypt and villus enterocytes from B6C3F1 mice exposed to 0.3-520mg/L SDD in drinking water for 7 and 90 days. Allele-competitive blocker PCR (ACB-PCR) was used to investigate the induction of a sensitive, tumor-relevant mutation, specifically in vivo K-Ras codon 12 GAT mutation, in scraped duodenal epithelium following 90 days of drinking water exposure. Cytotoxicity was evident in the villus as disruption of cellular arrangement, desquamation, nuclear atypia and blunting. Following 90 days of treatment, aberrant nuclei, occurring primarily at villi tips, were significantly increased at ≥60mg/L SDD. However, in the crypt compartment, there were no dose-related effects on mitotic and apoptotic indices or the formation of aberrant nuclei indicating that Cr(VI)-induced cytotoxicity was limited to the villi. Cr(VI) caused a dose-dependent proliferative response in the duodenal crypt as evidenced by an increase in crypt area and increased number of crypt enterocytes. Spontaneous K-Ras codon 12 GAT mutations in untreated mice were higher than expected, in the range of 10(-2) to 10(-3); however no treatment-related trend in the K-Ras codon 12 GAT mutation was observed. The high spontaneous background K-Ras mutant frequency and Cr(VI) dose-related increases in crypt enterocyte proliferation, without dose-related increase in K-Ras mutant frequency, micronuclei formation, or change in mitotic or apoptotic indices, are consistent with a lack of genotoxicity in the crypt compartment, and a MOA involving accumulation of mutations late in carcinogenesis as a consequence of sustained regenerative proliferation.

Alternate estrogen receptors promote invasion of inflammatory breast cancer cells via non-genomic signaling.

Although Inflammatory Breast Cancer (IBC) is a rare and an aggressive type of locally advanced breast cancer with a generally worst prognosis, little work has been done in identifying the status of non-genomic signaling in the invasiveness of IBC. The present study was performed to explore the status of non-genomic signaling as affected by various estrogenic and anti-estrogenic agents in IBC cell lines SUM149 and SUM190. We have identified the presence of estrogen receptor α (ERα) variant, ERα36 in SUM149 and SUM190 cells. This variant as well as ERß was present in a substantial concentration in IBC cells. The treatment with estradiol (E2), anti-estrogenic agents 4-hydroxytamoxifen and ICI 182780, ERß specific ligand DPN and GPR30 agonist G1 led to a rapid activation of p-ERK1/2, suggesting the involvement of ERα36, ERß and GPR30 in the non-genomic signaling pathway in these cells. We also found a substantial increase in the cell migration and invasiveness of SUM149 cells upon the treatment with these ligands. Both basal and ligand-induced migration and invasiveness of SUM149 cells were drastically reduced in the presence of MEK inhibitor U0126, implicating that the phosphorylation of ERK1/2 by MEK is involved in the observed motility and invasiveness of IBC cells. We also provide evidence for the upregulation of p-ERK1/2 through immunostaining in IBC patient samples. These findings suggest a role of non-genomic signaling through the activation of p-ERK1/2 in the hormonal dependence of IBC by a combination of estrogen receptors. These findings only explain the failure of traditional anti-estrogen therapies in ER-positive IBC which induces the non-genomic signaling, but also opens newer avenues for design of modified therapies targeting these estrogen receptors.