[Companion diagnostics in the era of personalized medicine--chairmen's introductory remarks].

Personalized medicine is a medical model that proposes the customization of treatment for individual patients. In this model, diagnostic tests are essential for selecting safer and more efficacious treatments. The term "companion diagnostics" has been used to describe these tests, whereby molecular assays that measure the levels of proteins or specific gene mutations are used to provide a specific therapy for an individual by stratifying the disease status, selecting the proper medication, and tailoring dosages. Examples of companion diagnostics in the field of cancer medicine for molecular targeted therapy include tests for the ALK-fusion gene in non-small cell lung cancer and expression of CCR4 in adult T-cell leukemia. For breast cancer, the expression of HER2 protein is evaluated by immunohistochemistry (IHC), and gene amplification of HER2 is tested by fluorescence in situ hybridization (FISH); both tests consist of pre-analysis, analysis, and post-analysis processes that require quality control to ensure the reliability of the results. This symposium includes: 1) future aspects of companion diagnostics addressing many of the problems that must be overcome, 2) companion diagnostics using FISH focusing on HER2 amplification and ALK alteration, 3) newly developed diagnostic tests using tumor specimens and cell-free DNA in serum, and 4) CCR4 expression detected by IHC and flow cytometry.

Significance of the vascular concentration of angiotensin II-receptor blockers on the mechanism of lowering blood pressure in spontaneously hypertensive rats.

To clarify the hypotensive mechanism of angiotensin II receptor-blockers (ARBs), drug concentrations in plasma and vascular tissues were measured using matrix-assisted laser desorption ionization time-of-flight mass spectrometry and imaging mass spectrometry. In spontaneously hypertensive rats, systolic blood pressure (SBP) was measured 2 and 24 h after administration of candesartan cilexetil (0.3, 1, or 3 mg/kg) or azilsartan (0.3, 1, or 3 mg/kg). SBP was similarly lowered 2 h after administration of azilsartan or candesartan cilexetil, but it was significantly lower in the azilsartan-treated group than in the candesartan cilexetil-treated group at 24 h. Angiotensin II-induced vascular contractions were similarly attenuated 2 h after administration of these drugs, and the contractions were significantly lower in the azilsartan-treated group at 24 h. Although plasma concentration was significantly lower in the azilsartan-treated group at 24 h, vascular concentration of azilsartan was significantly greater than that of candesartan. Significant correlations between SBP and vascular concentrations were observed both at 2 and 24 h, while no significant correlation was observed between plasma and vascular concentrations. In conclusion, the mechanism of ARB-induced hypotension is likely to depend on vascular concentrations rather than plasma concentrations.

[Acquisition of accreditation ISO 15189 and view of the future--case of a private college].

We received ISO 15189 accreditation (International Organization for Standardization 15189) in 2009. Several effects from the subjective points are shown below, 1. The reliability of the test results has improved. 2. Skill or knowledge level of staff has improved. 3. Internal recognition has improved. 4. Procedures to prevent accidents have been enforced. 5. Management system has improved. 6. Effective management tool for the manager. In addition to high costs for qualification and maintenance, extensive human resources are required to prepare documents. We need to make further efforts to aim at better cost-effectiveness.

[Clinical applications of MALDI imaging using sliced sections of formalin-fixed paraffin-embedded tissues and longitudinal sliced hairs].

MALDI-imaging MS (IMS) with MSMS analysis is a new powerful tool for the identification of not only disease-related proteins in formalin-fixed paraffin-embedded (FFPE) tissue sections but also protein/peptides/drugs/medicine in fresh-frozen tissues. IMS is used to reveal the mass profiles and spatial distribution of proteins in tissue sections and/or digested peptides derived from deposited protein in pathologic organs and then MSMS analysis identifies the amino acid sequence of the detected proteins in the tissue section. Moreover, on-tissue digestion combined with the MALDI-IM-TOF-IMS approach allows a proteomics "bottom-up" strategy with clinical samples, especially perioperative isolated tissues and FFPE tissues conserved for a long time in a clinical sample bank. The mass barcode-like image (MBI) on a longitudinal sliced hair by IMS is used in the selected reaction monitoring mode for serially chronological monitoring and traceability every few hours after drug and medicine intake. The advances of quantitative MBI for sliced sections of hair allow a new universal standardized assessment of drugs and medicines throughout the drug history.

S-sulfonation of transthyretin is an important trigger step in the formation of transthyretin-related amyloid fibril.

Senile systemic amyloidosis and familial amyloid polyneuropathy are caused by oxidative deposition of conformationally altered transthyretin (TTR). We identified oxidative modification of the 10th cysteine of TTR through S-sulfonation in vitro. Based on mass spectrometric analysis, we determined the spectrophotometric, western blotting, and fluorescent microscopic properties of TTR incubated with and without cysteine-S-sulfonate in acidic (pH 4) and alkaline (pH 8) conditions at 37 degrees. The absorption of the aggregated TTR molecules increased more with incubation time and the concentration of cysteine-S-sulfonate at pH 4 than at pH 8. The Congo red binding to the S-sulfonated TTR at pH 4 was saturated with an apparent Bmax of 2.01 mol per mole of the S-sulfonated TTR and apparent KD of 7.75x10(-6) M. On the other hand, the Bmax of cysteinyl TTR was 1.38, and its KD was 3.52x10(-6) M while the Bmax of reduced TTR was 0.86, and its KD was 2.86x10(-6) M. Moreover, we detected positive amyloid fibril staining using Thioflavin T and Congo red with the S-sulfonated TTR but not with untreated or reduced TTR by microscopic fluorescent analysis. After modification of TTR in vitro, oligomers resisted reduction and denaturation was irreversibly induced, and which contributed differences in the Western blotting patterns obtained with four anti-TTR antibodies. In conclusion, this study showed that the formation of S-sulfonation of TTR through oxidative modifications of the thiol residue on the 10th cysteine of TTR is an important trigger step in the formation of transthyretin-related amyloid fibril.

An operative case of hepatic pseudolymphoma difficult to differentiate from primary hepatic marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue.

Hepatic pseudolymphoma (HPL) and primary hepatic marginal zone B cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) are rare diseases and the differential diagnosis between these two entities is sometimes difficult. We herein report a 56-year-old Japanese woman who was pointed out to have a space occupying lesion in the left lateral segment of the liver. Hepatitis viral-associated antigen/antibody was negative and liver function tests including lactic dehydrogenase, peripheral blood count, tumor markers and soluble interleukin-2 receptor were all within normal limit. Imaging study using computed tomography and magnetic resonance imaging were not typical for hepatocellular carcinoma, cholangiocarcinoma, or other metastatic cancer. Fluorodeoxyglucose-positron emission tomography examination integrated with computed tomography scanning showed high standardized uptake value in the solitary lesion in the liver. Under a diagnosis of primary liver neoplasm, laparoscopic-assisted lateral segmentectomy was performed. Liver tumor of maximal 1.0 cm in diameter was consisted of aggregation of lymphocytes of predominantly B-cell, containing multiple lymphocyte follicles positive for CD10 and bcl-2, consistent with a diagnosis of HPL rather than MALT lymphoma, although a definitive differentiation was pending. The background liver showed non-alcoholic fatty liver disease/early non-alcoholic steatohepatitis. The patient is currently doing well with no sign of relapse 13 months after the surgery. Since the accurate diagnosis is difficult, laparoscopic approach would provide a reasonable procedure of diagnostic and therapeutic advantage with minimal invasiveness for patients. Considering that the real nature of this entity remains unclear, vigilant follow-up of patient is essential.

[In a disaster, what should medical technologists at a university hospital do? What do they have?].

"Disaster medicine" involves "cases that cannot be supported by the normal medical service system of the hospital because many injuries have occurred by an explosion/chemical pollution/radioactive pollution or a pandemic caused deliberately as well as natural disasters". In "disaster medicine", university hospitals should become the base for advanced medical services and wide area transportation. Also, the clinical laboratory/medical technologists of the university hospital should offer high quality laboratory analysis. On the other hand, one of the advantages of a university hospital is an experimental medicine laboratory (integrated universities also have a Department of Science and Department of Engineering). Development of testing equipment to cover all the functions necessary for disaster medicine may be a possibility. A system to conduct simple testing is expected at the actual location of the emergency, and an identification system must be established. "Emergency medicine" and "disaster medicine" have different aspects, but the essence is the same, and medical technologists must have knowledge/techniques to report and interpret results quickly. Because a university hospital is the core of logistical support, daily training is important.

Primary cutaneous diffuse large B-cell lymphoma, leg type, with features simulating POEMS syndrome.

A 91-year-old woman presented with a rapidly proliferative cutaneous lesion on the left lower limb, which was identified as a primary cutaneous diffuse large B-cell lymphoma (PCLBCL), leg type, on biopsy. The patient also showed complications of hepatomegaly, endocrinopathy, edema, skin change, and polyneuropathy without monoclonal plasma cell proliferative disorder, and was therefore diagnosed with POEMS-like syndrome owing to the lack of monoclonal plasma cell proliferative disorder. Levels of serum vascular endothelial growth factor (VEGF) and interleukin-6 (IL-6) were high with the lymphoma cells immunostained positively for VEGF and IL-6. To the best of our knowledge, this is the first case report of PCLBCL, leg type, with POEMS-like syndrome. The findings in this case suggest that the symptoms of POEMS-like syndrome might be caused by the cytokines produced by the lymphoma cells. Furthermore, a wider range of diagnostic criteria associated with the result of abnormal secretion of cytokine may have to be considered for the diagnosis and evaluation of patients with possible POEMS syndrome, as against the present criteria specifying monoclonal plasma cell proliferative disorder as the essential criterion.

[Proteomic analysis of changes in the serum protein profile by anti-TNF-alpha therapy].

We analyzed the alternation in serum protein by infliximab therapy using proteomics-based technique. More than 50 gel spots were seen to increase or decrease in correlation with clinical improvements of rheumatoid arthritis (RA). Spots of interest were identified by two dimensional electrophoresis and mass spectrometry. Infliximab therapy reduced the inflammatory proteins such as C-reactive protein, serum amyloid protein A, serum amyloid protein P, and alpha1-acid glycoprotein, while the therapy increased Apo A-I, retinol-binding protein, vitamin D-binding protein, and gelsolin. This suggested that infliximab therapy shifted the inflammatory status of serum protein profile of RA patients to normal and modified the extracellular actin-scavenging system as well as vitamin and lipid profile.

Flow cytometric immunophenotyping of peripheral T cell neoplasms using CD3 gating.

Peripheral T cell neoplasms (PTCNs) such as peripheral T cell lymphoma, adult T cell leukemia/lymphoma, and mycosis fungoides are associated with poorer prognoses compared to B cell neoplasms. Hence, an accurate and early diagnosis is necessary for the successful treatment of PTCNs; however, this can be difficult to achieve. In this study, flow cytometric immunophenotyping using CD3 gating was performed retrospectively on 56 samples from 52 patients diagnosed with PTCNs, and the analytical data were compared with the immunohistochemical findings. Abnormal CD3 T cell populations were distinguishable from the normal T cell population, using this CD3 gating strategy.

[In vitro susceptibilities to levofloxacin and various antibacterial agents of 12,919 clinical isolates obtained from 72 centers in 2007].

We have reported in this journal in vitro susceptibilities of clinical isolates to antibiotics every year since 1992. In this paper, we report the results of an analysis of in vitro susceptibilities of 12,919 clinical isolates from 72 centers in Japan to selected antibiotics in 2007 compared with the results from previous years. The common respiratory pathogens, Streptococcus pyogenes, Streptococcus pneumoniae, Moraxella catarrhalis and Haemophilus influenzae maintained a high susceptibility to fluoroquinolones (FQs). The resistance of S. pyogenes to macrolides has been increasing every year and this was especially clear this year. Most strains of Enterobacteriaceae except for Escherichia coli showed a high susceptibility to FQs. Almost 30% of E. coli strains were resistant to FQs and the resistance increased further this year. FQs resistance of methicillin-resistant Staphylococcus aureus (MRSA) was approximately 95% with the exception of 45% for sitafloxacin (STFX). FQs resistance of methicillin-susceptible S. aureus (MSSA) was low at about 10%. FQs resistance of methicillin-resistant coagulase negative Staphylococci (MRCNS) was higher than that of methicillin-susceptible coagulase negative Staphylococci (MSCNS), but it was lower than that of MRSA. However, FQs resistance of MSCNS was higher than that of MSSA. FQs resistance of Enterococcus faecalis was 22.5% to 29.6%, while that of Enterococcusfaecium was more than 85% except for STFX (58.3%). In clinical isolates of Pseudomonas aeruginosa derived from urinary tract infections, FQs resistance was 21-27%, which was higher than that of P. aeruginosa from respiratory tract infections at 13-21%, which was the same trend as in past years. Multidrug resistant strains accounted for 5.6% in the urinary tract and 1.8% in the respiratory tract. Acinetobacter spp. showed high susceptibility to FQs. The carbapenem resistant strains, which present a problem at present, accounted for 2.7%. Neisseria gonorrhoeae showed high resistance of 86-88% to FQs. The results of the present survey indicated that although methicillin-resistant Staphylococci, Enterococci, E. coli, P. aeruginosa, and N. gonorrhoeae showed resistance tendencies, and other species maintained high susceptibility rates more than 90% against FQs, which have been used clinically for over 15 years.

Toll-like receptor 4 promoter polymorphisms in a familial mediterranean fever patient with asymptomatic bacteriuria.

A periodic fever, due to inherited inflammatory disorders, can be misdiagnosed as a common infection, when a possible pathogen is detected from a patient. TLR4 SNPs that are responsible for asymptomatic bacteriuria might disturb the pathophysiology of familial Mediterranean fever without MEFV mutations.

Ectopic expression of band 3 anion transport protein in colorectal cancer revealed in an autoimmune hemolytic anemia patient.

Cancer patients occasionally have anemia with high mean corpuscular volume in addition to iron deficiency anemia. Secondary autoimmune hemolytic anemia (AIHA) following cancer is also observed with low frequency. To date, no causal mechanisms for these disease states have been reported. Here, we present the case of an 80-year-old woman with AIHA that was resistant to prednisolone. Further examinations revealed primary adenocarcinoma of the sigmoid colon and primary squamous cell carcinoma in the right lung. After resections of these tumors, her anemia partially improved until a colon cancer-derived metastatic tumor was detected in the left lung. Immunoprecipitation of erythrocyte membrane proteins with an autoantibody followed by mass spectrometry/Western blotting identified band 3 as the target of the autoantibody. Immunohistochemical analysis revealed ectopic expression of band 3 in the colon adenocarcinoma. To our knowledge, this is the first report that identifies the cause in a case of anemia without bleeding in a cancer patient and that defines a mechanism underlying secondary AIHA following cancer progression.

Proteomics-based identification of autoantibody against heat shock protein 70 as a diagnostic marker in esophageal squamous cell carcinoma.

Detection of novel tumor-related antigens and autoantibodies in cancer patients is expected to facilitate the diagnosis of early-stage malignant tumor and establish effective new immunotherapies. The purpose of this study was to identify novel tumor antigens in an esophageal squamous cell carcinoma (ESCC) cell line (TE-2) and related autoantibodies in sera from patients with ESCC using a proteomics-based approach. TE-2 proteins were separated by two-dimensional polyacrylamide gel electrophoresis, followed by Western blot analysis in which sera from patients with ESCC, healthy controls and patients with other cancers were tested for primary antibodies. Positive spots were excised from silver-stained gels and analyzed by matrix-assisted laser disorption/ionization time-of-flight mass spectrometry (MALDI-TOF/TOF-MS). Sera from patients with ESCC yielded multiple spots, one of which was identified as heat shock protein 70 (Hsp70) by MALDI-TOF/TOF-MS. Concentrations of serum Hsp70 autoantibody were significantly higher for patients with ESCC (mean, 0.412+/-0.096 mg/ml) than for patients with gastric (0.236+/-0.112 mg/ml, P<0.001) or colon cancer (0.231+/-0.120 mg/ml, P<0.001) or healthy individuals (0.207+/-0.055 mg/ml, P<0.001) by enzyme-linked immunosorbent assay. We have identified an autoantibody against Hsp70 in ESCC patients. The proteomic approach implemented herein offers a powerful tool for identifying novel serum markers that may display clinical utility against cancer.

Identification of L-plastin autoantibody in plasma of patients with non-Hodgkin's lymphoma using a proteomics-based analysis.

BACKGROUND: The diagnosis of malignant lymphoma (ML) such as non-Hodgkin's lymphoma (NHL) and Hodgkin's lymphoma (HL) was mainly performed by morphological examination and gene analysis. There are only a few serum/plasma biomarkers such as lactate dehydrogenase and soluble interleukin-2 receptor alpha to diagnose ML. The classifications are various, and therefore the cell surface markers using flow cytometry or lymph node biopsy have been examined. It is difficult, however, to distinguish the two diseases, NHL and HL, from each other. METHODS: In order to identify the haematological malignancy-associated autoimmunoreactivity (autoantibodies) in patients' plasma, a novel proteomics-based approach using electrophoresis/mass spectrometry was applied. Solubilized proteins from a Burkitt's lymphoma cell line (Raji) were separated by sodium dodecyl sulphate-polyacrylamide gel electrophoresis and Western blotting analysis, in which the plasma of individual patients with haematological malignancies was tested for primary antibodies, followed by visualization with anti-IgG antibody conjugated with horseradish peroxidase. RESULTS: Two proteins, L-plastin and alpha-enolase, capable of reacting with the antibodies in plasma of patients with NHL, were detected using matrix-assisted laser desorption ionization/time-of-flight mass spectrometry and tandem mass spectrometry. The rates of the detections of an anti L-plastin autoantibody were significantly higher: 0.84 (21/25) in patients with NHL; 0.00 (0/4) in HL; 0.38 (5/13) in autoimmune diseases; 0.20 (2/10) in leukaemia; and 0.13 (1/8) in healthy controls. In contrast, those of anti alpha-enolase antibody were not specific to NHL. CONCLUSIONS: We first identified autoantibody against L-plastin in plasma of patients with NHL, suggesting that the autoantibody can be a new diagnostic biomarker for NHL.

Identification of phosphotyrosyl proteins in vitreous humours of patients with vitreoretinal diseases by sodium dodecyl sulphate-polyacrylamide gel electrophoresis/Western blotting/matrix-assisted laser desorption time-of-flight mass spectrometry.

BACKGROUND: It is important to explain target proteins for the understanding of the pathogenesis of vitreoretinal diseases. In a previous study, we identified more than 100 proteins including seven angiogenic-modulated factors in vitreous humours (VHs). Although there have been many reports of expressed protein profiles in VHs, only a few of these are modified proteins, such as those undergoing phosphorylation and oxidation. METHODS: We applied Western blotting (WB), selective staining of phosphoproteins and mass spectrometry to detect and identify phosphoproteins in VHs of patients with vitreoretinal diseases. After the removal of albumin and immunoglobulins A/G in VHs, the proteins were separated by sodium dodecyl sulphate-polyacrylamide gel electrophoresis and reacted with anti-PY-20 monoclonal antibody on transfer membranes, and treated proteins were visualized with Phos-tag and identified by matrix-assisted laser desorption time-of-flight mass spectrometry (MALDI-TOFMS). RESULTS: WB analysis detected four positive bands, 20, 30, 35 and 55 kDa, in VHs of patients with vitreoretinal diseases. One of them, 55 kDa, was frequently detected in VHs of patients with macular hole (MH) and retinal detachment (RD), but the band was not found in patients with proliferative diabetic retinopathy (PDR). alpha-1 antitrypsin (alpha-1 AT) was identified in excised gel pieces of this band. CONCLUSIONS: We identified five phosphorylated proteins such as alpha-1 AT in VHs of patients with vitreoretinal diseases by MALDI-TOFMS and WB analysis. Phosphotyrosyl alpha-1 AT was neither detected in PDR patients nor in any plasma. Phosphotyrosyl alpha-1 AT may be a new biomarker of MH and RD.

Detection of citrullinated proteins in synovial fluids derived from patients with rheumatoid arthritis by proteomics-based analysis.

BACKGROUND: Rheumatoid arthritis (RA) is the most common inflammatory joint disease. The aetiology of RA remains unknown, but autoimmune responses are considered to play an important role in the disease pathophysiology. Currently available data suggests that the process of diagnosing RA may benefit from testing for anticyclic citrullinated peptides. Identification of the presence of citrullinated proteins in rheumatoid synovial fluids is important for the elucidation of the aetiology of RA as well as in the differential diagnosis of rheumatic-related diseases. METHODS: A proteomics-based approach using electrophoresis/mass spectrometry was applied to identify the citrullinated proteins in synovial fluids from patients with RA. Synovial fluids from patients with RA were subjected to sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western blot analysis to detect the citrullinated proteins. Identification bands were then subjected to mass spectrometry. RESULTS: Three proteins - citrullinated fibrinogen, citrullinated fibronectin and citrullinated vimentin - in synovial fluids from RA patients were identified by matrix-assisted laser desorption ionization time-of-flight mass spectrometry. CONCLUSIONS: Proteomics-based analysis can be used to detect citrullinated proteins in synovial fluids from RA patients.

[Megaloblastic anemia associated with salazosulfapyridine treatment for rheumatoid arthritis].

A 70-year-old man was diagnosed as having rheumatoid arthritis (RA) in 2005. He was treated with 1 g salazosulfapyridine (SASP) daily for two years. Hematological investigations conducted since 2005 demonstrated hemoglobin concentrations of 8 approximately 9 g/dl, which then dropped to 4.9 g/dl on November 21, 2007, following which he was admitted to our hospital. Megaloblastic anemia associated with SASP treatment and anemia of chronic disorders were diagnosed on the basis of folate deficiency and bone marrow examination. This report describes a case of megaloblastic anemia, which developed two years after starting SASP and promptly recovered after its withdrawal and treatment with folic acid and prednisolone. The doses of SASP prescribed for RA in Japan are less than those prescribed abroad. Megaloblastic anemia associated with SASP treatment for RA is not usually detected in Japan. Currently, SASP is widely used and one of the key drugs in the treatment of RA. This case suggests that SASP therapy in RA might result in megaloblastic anemia.

Mean platelet component and mean platelet volume as useful screening markers for myelodysplastic syndrome.

BACKGROUND: Hematologic disorders, including myelodysplastic syndrome (MDS), are difficult to identify in routine hematologic examinations using automated hematology analyzers. However, the practical uses of mean platelet component and mean platelet volume (MPV) measured by these analyzers as screening markers for MDS, remain unclear. METHODS: Mean platelet component and MPV values were measured in the peripheral blood of patients with MDS, aplastic anemia, idiopathic thrombocytopenic purpura, myeloproliferative neoplasms, and in healthy controls using an automated hematologic analyzer. Cutoff values for discriminating between the MDS group and healthy controls were determined by recursive partitioning analysis. RESULTS: Mean platelet component was significantly lower in MDS patients compared with controls, while MPV was significantly higher. Combined cutoff values for MDS diagnosis of <25.3 g/dL for mean platelet component and >10.0 fL for MPV showed a specificity and positive predictive value of 99.9% and 99.1%, respectively. These cutoff values also differentiated between MDS and diagnoses of aplastic anemia, idiopathic thrombocytopenic purpura, and myeloproliferative neoplasms. CONCLUSION: Mean platelet component and MPV may, thus, be useful and convenient screening markers for MDS.

Serum protein profile of rheumatoid arthritis treated with anti-TNF therapy (infliximab).

We analyzed the changes in the serum protein profile by infliximab using two-dimensional gel electrophoresis and mass spectrometry. More than 50 gel spots were seen to increase or decrease in correlation with clinical improvements of RA. The spots corresponding to CRP, C3, and Apo J showed reduced staining intensity, while the spots corresponding to Apo A-I, RBP, and transthyretin were enhanced. The protein profile of RA patients treated with infliximab was mostly similar to that of normal healthy controls except for several protein spots. This suggested that infliximab normalized the serum protein profile of RA patients, leading to modification in the serum lipid profile and antioxidant status in RA.