Differential utilization of Ras signaling pathways by macrophage colony-stimulating factor (CSF) and granulocyte-macrophage CSF receptors during macrophage differentiation.

Granulocyte-macrophage colony-stimulating factor (GM-CSF) and macrophage colony-stimulating factor (M-CSF) independently stimulate the proliferation and differentiation of macrophages from bone marrow progenitor cells. Although the GM-CSF and M-CSF receptors are unrelated, both couple to Ras-dependent signal transduction pathways, suggesting that these pathways might account for common actions of GM-CSF and M-CSF on the expression of macrophage-specific genes. To test this hypothesis, we have investigated the mechanisms by which GM-CSF and M-CSF regulate the expression of the macrophage scavenger receptor A (SR-A) gene. We demonstrate that induction of the SR-A gene by M-CSF is dependent on AP-1 and cooperating Ets domain transcription factors that bind to sites in an M-CSF-dependent enhancer located 4.1 to 4.5 kb upstream of the transcriptional start site. In contrast, regulation by GM-CSF requires a separate enhancer located 4.5 to 4.8 kb upstream of the transcriptional start site that confers both immediate-early and sustained transcriptional responses. Results of a combination of DNA binding experiments and functional assays suggest that immediate transcriptional responses are mediated by DNA binding proteins that are constitutively bound to the GM-CSF enhancer and are activated by Ras. At 12 to 24 h after GM-CSF treatment, the GM-CSF enhancer becomes further occupied by additional DNA binding proteins that may contribute to sustained transcriptional responses. In concert, these studies indicate that GM-CSF and M-CSF differentially utilize Ras-dependent signal transduction pathways to regulate scavenger receptor gene expression, consistent with the distinct functional properties of M-CSF- and GM-CSF-derived macrophages.

Dynamic changes in the clonal structure of MDS and AML in response to epigenetic therapy.

Traditional response criteria in myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) are based on bone marrow morphology and may not accurately reflect clonal tumor burden in patients treated with non-cytotoxic chemotherapy. We used next-generation sequencing of serial bone marrow samples to monitor MDS and AML tumor burden during treatment with epigenetic therapy (decitabine and panobinostat). Serial bone marrow samples (and skin as a source of normal DNA) from 25 MDS and AML patients were sequenced (exome or 285 gene panel). We observed that responders, including those in complete remission (CR), can have persistent measurable tumor burden (that is, mutations) for at least 1 year without disease progression. Using an ultrasensitive sequencing approach, we detected extremely rare mutations (equivalent to 1 heterozygous mutant cell in 2000 non-mutant cells) months to years before their expansion at disease relapse. While patients can live with persistent clonal hematopoiesis in a CR or stable disease, ultimately we find evidence that expansion of a rare subclone occurs at relapse or progression. Here we demonstrate that sequencing of serial samples provides an alternative measure of tumor burden in MDS or AML patients and augments traditional response criteria that rely on bone marrow blast percentage.

The peroxisome proliferator-activated receptor(PPARgamma) as a regulator of monocyte/macrophage function.

Peroxisome proliferator-activated receptors (PPARs) are ligand-dependent transcription factors of the nuclear hormone receptor super-family, which includes the steroid, retinoid, and thyroid hormone receptors. The PPARs can be activated by fatty acids and their eicosanoid metabolites, and have until recently been considered primarily to regulate genes involved in glucose and lipid homeostasis. In the past year there has been an explosive increase in research implicating PPARgamma in macrophage biology, cell cycle regulation, and atherosclerosis. This review describes recent insights into the role of PPARgamma in the macrophage lineage, and its potential function in the regulation of inflammatory responses and atherosclerosis.

The postirradiated breast.

High-energy irradiation is used increasingly as a part of breast conservation treatment of malignant disease. The response of the breast tissue encompassed by the treatment fields varies considerably, even in well-conducted therapeutic programs. Early and late changes in the tissues include redness, edema, pigmentation, fibrosis, and retraction. Fibrosis and retraction may cause suboptimal cosmetic results and occur most frequently in obese patients, large breasts, and breasts from which a large (greater than 4 cm) primary tumor has been excised. Combinations of treatment modalities, such as adjuvant chemotherapy, surgical excision, and irradiation, seem to produce fewer excellent cosmetic results than single-modality treatment. In patients who have undergone breast conservation treatment, careful follow-up is necessary for detection of possible local, regional, or distant recurrence of the malignant disease, as well as of other diseases related or unrelated to the earlier treatment.

Massive bleeding from a ruptured metastatic hepatic melanoma treated by hepatic lobectomy. Case report and review of the literature.

An unusual case is reported of an occult, spontaneously rupturing, hemorrhagic, metastatic melanoma of the liver treated by hepatic lobectomy, resulting in short-term survival. A long, symptom-free interval (13 years) after excision of the primary cutaneous lesion (stage I) preceded the appearance of the hepatic metastasis. This case illustrates the need for a careful and thorough history as well as the benefit of prompt hepatic resection for bleeding from ruptured hepatic malignancies.

Linitis plastica caused by metastatic lobular carcinoma of the breast.

We describe herein the syndrome of linitis plastica caused by metastatic lobular carcinoma of the breast. In 14 of our 31 patients, gastric involvement, alone or concurrent with other metastasis, provided the first sign of tumor dissemination. The distinction of primary and secondary gastric malignancies in patients with a history of breast cancer is most important for successful management of patients. At a time when primary gastric carcinoma is decreasing nationally, an awareness of the association of lobular breast tumors with linitis plastica due to metastases may modify diagnostic evaluation and treatment planning in patients who present with symptoms of this syndrome.

Fine-needle aspiration of the breast.

One of the numerous controversial issues related to the clinical management of breast cancer is the role of fine-needle aspiration (FNA). Despite its enthusiastic use in the diagnosis of thyroid nodules, its application to breast abnormalities has been accepted reluctantly. Breast FNA necessitates technical and interpretative skill and continual practice and is not 100% accurate. It also entails an additional, although moderate, expense. To assess the accuracy and determine the possible role of FNA at our institution, we performed both FNA and excisional biopsy in 100 unselected women with palpable breast nodules and correlated the cytologic and histologic findings. Our results were similar to those in previously published studies. FNA had a false-negative rate of 6%, no false-positive results, and an accuracy of 94%. After reviewing the potential assets and liabilities of this technique, we believe that breast FNA may add a measure of confidence in the diagnosis of benign breast lesions, provides a safeguard for preventing misdiagnosis of malignant lesions, and might expedite and reduce the cost of managing both primary and recurrent breast cancer.

Proximal gastric vagotomy. Initial experience.

Proximal gastric vagotomy was performed in 223 patients with chronic duodenal ulceration between 1973 and 1977. The follow-up ranged from 6 to 78 months with a mean of 39 months. There was no operative mortality. Adverse postoperative sequelae, including delayed gastric emptying, dumping, diarrhea, and reflux gastritis, were seen in less than 3% of patients. Ulcers recurred in 11 patients (4.9%). We conclude that proximal gastric vagotomy is an effective, safe, and satisfactory operation for chronic duodenal ulcer over the short term.

Surgical considerations after chemotherapy and radiation therapy for inflammatory breast cancer.

Eighteen patients seen between 1974 and 1982 with the clinical diagnosis of inflammatory breast carcinoma underwent modified radical mastectomy after preoperative chemotherapy and radiation therapy. In 17 of the 18 patients (94%), residual carcinoma was detected in either the resected breast or the axillary nodes. All mastectomies were accomplished without major technical difficulty. Seven wound complications, including three infections, occurred. Local recurrence was noted in 29% (five of 17 patients) and distant metastasis was detected in 89% (16 of 18 patients). Only three patients are presently alive without evidence of disease 19, 21, and 21 months since the onset of symptoms. Eleven patients have died, the median survival being 23 months since the development of symptoms, and four are alive with distant metastasis. Modified radical mastectomy can be accomplished in patients with inflammatory breast cancer after preoperative chemotherapy and radiation therapy and may have a role in reducing local tumor burden.

Clean air bench. Use for sterile maintenance of unwrapped surgical instruments.

Microbiologic sterility of unwrapped surgical instruments has been maintained for long periods by the use of an operating room instrument cabinet that continuously circulates high-flow, "particle-free" air. Use of this clean air bench has had excellent acceptance by operating room nurses and by surgeons because fewer instrument storage procedures are needed and setup time, takedown time, and case turnover time in the operating room are diminished. It has been found to be effective in operating rooms having busy schedules for both elective and emergency procedures.

Therapeutic oophorectomy in disseminated carcinoma of the breast.

Of 145 women with metastatic breast carcinoma who survived palliative surgical castration, 40.7% had objective remission and another 11.0% had subjective improvement. Favorable response was more frequent in ovulating patients who had small masses of recurrent tumor in fewer locations, with skeletal spread especially well tolerated. Palliation appeared to be related to the site of metastatic disease and numbers (mass) of metastatic sites, but not to the age of the patient, tumor histology, or the disease-free interval. Survival was better for the patients who showed improvement after castration. Such improvement may predict continued relief from the use of other modalities of systemic treatment.

Immunodiagnosis of parasitic zoonoses: comparative efficacy of three immunofluorescence tests using antigens purified by affinity chromatography.

Three immunofluorescent antibody assays were developed during this study: the direct (DFAT) and indirect (IFAT) fluorescent antibody tests using frozen worm sections, and the cyanogen bromide indirect fluorescent antibody test (CNBr-IFAT) using helminth antigens purified by affinity chromatography bound on to commercially prepared CNBr-Sepharose 4B beads. Purified antigens used in the CNBr-IFAT gave greater specificity and sensitivity than either the DFAT or IFAT. Dirofilaria immitis, Toxocara canis, Angiostrongylus cantonensis and Ascaris lumbricoides infections were studied in natural and zoonotic hosts and in rabbits immunized with antigens prepared from these parasites. In addition, a serological survey of Aboriginal Australians from Queensland was made.

Immunodiagnosis of parasitic zoonoses: sensitivity and specificity of in vitro lymphocyte proliferative responsiveness using nematode antigens purified by affinity chromatography.

The sensitivity of in vitro lymphocyte proliferative responsiveness using antigens purified by affinity chromatography, was greater than that of three serological tests and allowed the specific identification of Dirofilaria immitis, Toxocara canis, Angiostrongylus cantonensis and Ascaris lumbricoides in animals sensitized with parasite antigens, and the diagnosis of natural (D. immitis, T. canis and Angiostrongylus cantonensis) and zoonotic nematode infections. Lymphocytes remained viable in whole blood suspensions in RPM 1640 in a polystyrene insulation box at air temperature for at least 12 hours and reacted in the cell-mediated immunity test (CMIT) without loss of response. The CMIT proved useful in the early immunodiagnosis of nematode infections and showed that parasite antigens purified by affinity chromatography retained a high degree of specificity and sensitivity in both the CMIT and serological tests.

Angiostrongylus cantonensis in East New Britain, Papua New Guinea.

The first case of angiostrongyliasis (eosinophilic meningitis) to be diagnosed in Papua New Guinea in 1977, led to a survey of adult Melanesian residents of East New Britain province where the case occurred, to assess the level of immunological responsiveness to Angiostrongylus cantonensis. In 104 subjects tested using an indirect fluorescent antibody test, the serum antibody titres to A. cantonensis equalled or exceeded 1:16 in 50.7% and ranged from 1:32 to 1:64 in 17.3% of subjects. No individual tested showed evidence of active or recent angiostrongyliasis but in a patient suspected to have ocular angiostrongyliasis, the antibody titre of A. cantonensis was 1:128 in the single serum specimen obtained. In a programme to determine the distribution of this parasite in the natural hosts, 19 rats were trapped; one had adult A. cantonensis in its pulmonary arteries. Examination of 200 Achatina fulica snails revealed Angiostrongylus larvae in 62 (31%) and when these larvae were fed to laboratory rats, adult A. cantonensis were subsequently recovered from their pulmonary arteries.

Immunodiagnosis and seroepidemiology of Angiostrongylus cantonensis zoonoses in man.

The development of serum and cellular assays to measure responses to Angiostrongylus cantonensis antigen, purified by affinity chromatography, formed the basis of this study. The specificity and sensitivity of these techniques were established in immunized rabbits and in naturally and laboratory-infected rats. The assays were then used to determine levels of immunological responsiveness to A. cantonensis in four Australian populations. There was a direct correlation between the prevalence of the parasite in rodents and the proportion of human reactors to A. cantonensis antigen in each population studied. Five patients with similar clinical histories and presenting symptoms suggesting eosinophilic meningitis were investigated; three were admitted to hospital. Haematological examination demonstrated hypereosinophilia in all five while three had, in addition, a cerebrospinal fluid eosinophilia. Serological tests and assays of cell-mediated responses to A. cantonensis antigen showed elevated immunological reactivity during the acute phase of illness with a subsequent decrease in reactivity corresponding with the progressive recovery of the patient.

Immunodiagnosis of Entamoeba histolytica and Ascaris lumbricoides infections in Caucasian and aboriginal Australians.

The immunodiagnostic efficiency of an indirect immunofluorescence test (IFAT) and in vitro lymphocyte proliferative responsiveness (cell mediated immunity test, CMIT) used to measure the immunological responses of individuals with known natural Entamoeba histolytica and Ascaris lumbricoides infections, was studied under survey conditions. E. histolytica was common among Aborigines from Cherbourg, Kowanyama and Central Australia, but it was not found in Brisbane Caucasians. The protozoan was selected for the study because it was prevalent and purified antigen was commercially available. Immunodiagnosis for A. lumbricoides was made using an antigen prepared by affinity chromatography. Diagnosis based on frequency distribution of immunological data gave valid assessment of the number of infected individuals in each population studied.

Monoclonal antibodies directed against Brucella abortus cell surface antigens.

A panel of monoclonal antibodies (MAb) has been raised against Brucella abortus cell surface antigens from mice immunized with either heat/phenol treated or UV killed bacterial suspensions of B. abortus. The hybridomas were screened by either a microagglutination procedure or by an indirect enzyme immunoassay (EIA) on sonicated bacterial preparations. From a large number of MAb generated by various procedures, two distinct types of MAb emerged. The most numerous type was capable of agglutinating B. abortus and reacting with a soluble preparation of lipopolysaccharide (LPS). A second type was not capable of agglutinating the bacterial suspensions or of binding to the soluble LPS preparation but reacted with an antigen present in bacterial sonicates. Two MAb of this type react differentially with sonicates prepared from virulent and avirulent strains of B. abortus. There appeared to be sufficient evidence from our analysis of the relative degree of cross reaction with antigens present on a range of B. abortus strains and Brucella and xenogenic bacterial species to conclude that each of the seven MAb was recognising a separate antigenic site on the B. abortus cell surface.

State of the art in myeloid sarcoma.

INTRODUCTION: Myeloid sarcomas are extramedullary lesions composed of myeloid lineage blasts that typically form tumorous masses and may precede, follow, or occur in the absence of systemic acute myeloid leukemia. They most commonly involve the skin and soft tissues, lymph nodes, and gastrointestinal tract and are particularly challenging to diagnose in patients without an antecedent history of acute myeloid leukemia. METHODS: We conducted a search of the English language medical literature for recent studies of interest to individuals involved in the diagnosis of myeloid sarcoma. RESULTS: The differential diagnosis includes non-Hodgkin lymphoma, blastic plasmacytoid dendritic cell neoplasm, histiocytic sarcoma, melanoma, carcinoma, and (in children) small round blue cell tumors. The sensitivity and specificity of immunohistochemical markers must be considered when evaluating a suspected case of myeloid sarcoma. A high percentage of tested cases have cytogenetic abnormalities. CONCLUSION: A minimal panel of immunohistochemical markers should include anti-CD43 or anti-lysozyme as a lack of immunoreactivity for either of these sensitive markers would be inconsistent with a diagnosis of myeloid sarcoma. Use of more specific markers of myeloid disease, such as CD33, myeloperoxidase, CD34 and CD117 is necessary to establish the diagnosis. Other antibodies may be added depending on the differential diagnosis. Identification of acute myeloid leukemia-associated genetic lesions may be helpful in arriving at the correct diagnosis.