Therapeutic utility of the newly discovered properties of interleukin-21.

Since its discovery in 2000, interleukin-21 (IL-21) has been shown to display a broad spectrum of pleiotropic actions including the regulation of development, differentiation and function of lymphoid-myeloid cells. More specifically, IL-21 modulates the effector functions of T, B and NK cells, which not only have key roles in antitumoral and antiviral immunity but also in exerting major effects on inflammatory responses promoting the development of autoimmune diseases. Recent studies have unveiled an unexpected role for IL-21 in immune regulation and de novo T-cell development. While highlighting its critical role in immunity, this review will mainly focus on recent advances in IL-21 biology and how such newly discovered properties could potentially be exploited therapeutically in the establishment of future clinical trials.

Interleukin-21 administration to aged mice rejuvenates their peripheral T-cell pool by triggering de novo thymopoiesis.

The vaccination efficacy in the elderly is significantly reduced compared to younger populations due to thymic involution and age-related intrinsic changes affecting their naïve T-cell compartment. Interleukin (IL)-21 was recently shown to display thymostimulatory properties. Therefore, we hypothesized that its administration to ageing hosts may improve T-cell output and thus restore a competent peripheral T-cell compartment. Indeed, an increase in the production of recent thymic emigrants (RTEs) attributable to intrathymic expansion of early thymic progenitors (ETPs), double-negative (DN), and double-positive (DP) thymocytes as well as thymic epithelial cell (TEC) was observed in recombinant (r)IL-21-treated aged mice. In sharp contrast, no alterations in the frequency of bone marrow (BM)-derived progenitors were detected following rIL-21 administration. Enhanced production of naïve T cells improved the T-cell receptor (TCR) repertoire diversity and re-established a pool of T cells exhibiting higher levels of miR-181a and diminished amounts of the TCR-inhibiting phosphatases SHP-2 and DUSP5/6. As a result, stimulation of T cells derived from rIL-21-treated aged mice displayed enhanced activation of Lck, ZAP-70, and ERK, which ultimately boosted their IL-2 production, CD25 expression, and proliferation capabilities in comparison with T cells derived from control aged mice. Consequently, aged rIL-21-treated mice vaccinated using a tyrosinase-related protein 2 (Trp2)-derived peptide exhibited a substantial delay in B16 tumor growth and improved survival. The results of this study highlight the immunorestorative function of rIL-21 paving its use as a strategy for the re-establishment of effective immunity in the elderly.

Fetal dose measurements and shielding efficiency assessment in a custom setup of (192)Ir brachytherapy for a pregnant woman with breast cancer.

PURPOSE: To assess the radiation dose to the fetus of a pregnant patient undergoing high-dose-rate (HDR) (192)Ir interstitial breast brachytherapy, and to design a new patient setup and lead shielding technique that minimizes the fetal dose. METHODS: Radiochromic films were placed between the slices of an anthropomorphic phantom modeling the patient. The pregnant woman was seated in a chair with the breast over a table and inside a leaded box. Dose variation as a function of distance from the implant volume as well as dose homogeneity within a representative slice of the fetal position was evaluated without and with shielding. RESULTS: With shielding, the peripheral dose after a complete treatment ranged from 50 cGy at 5 cm from the caudal edge of the breast to <0.1 cGy at 30 cm. The shielding reduces absorbed dose by a factor of two near the breast and more than an order of magnitude beyond 20 cm. The dose is heterogeneous within a given axial plane, with variations from the central region within 50%. Interstitial HDR (192)Ir brachytherapy with breast shielding can be more advantageous than external-beam radiotherapy (EBRT) from a radiation protection point of view, as long as the distance to the uterine fundus is higher than about 10 cm. Furthermore, the weight of the shielding here proposed is notably lower than that needed in EBRT. CONCLUSIONS: Shielded breast brachytherapy may benefit pregnant patients needing localized radiotherapy, especially during the early gestational ages when the fetus is more sensitive to ionizing radiation.

Long-term results with oral fluoropyrimidines and oxaliplatin-based preoperative chemoradiotherapy in patients with resectable rectal cancer. A single-institution experience

INTRODUCTION: Neoadjuvant 5-FU-based chemoradiotherapy in resectable rectal cancer (RC) is a standard of treatment. The use of oral fluoropyrimidines and new agents such as oxaliplatin may improve efficacy and tolerance. MATERIAL AND METHODS: Between 1999 and 2009, 126 RC patients with T3-T4 and/or N+ disease were given three successive protocols: UFT (32), UFT-oxaliplatin (75) and capecitabine-oxaliplatin (19), alongside 45 Gy of radiotherapy; with surgery 4-6 weeks after. Adjuvant treatment was given in all patients. The primary objective was pathologic complete response (pCR). RESULTS: Preoperative therapy was well tolerated, with no toxic deaths and a 15% grade 3-4 toxicity rate. Eighty-five percent of patients received the full chemotherapy dose, 56% had an abdominoperineal resection, 6% reinterventions and 57% received the full adjuvant chemotherapy planned. The pCR rate was 13%. The downstaging rate was 80%; 8% had progression of disease. The relapse rate was 20%, with local relapse in 6%. By 5 years of followup, 92% of relapses had occurred. Median follow-up was 73 months, 5- and 10-year disease-free survival rates were 75% and 50%, and 5- and 10-year overall survival rates were 79% and 66% respectively. There was no benefit from the use of oxaliplatin regarding survival or pCR rates. Older patients had worse long-term outcomes. CONCLUSIONS: Neoadjuvant chemoradiotherapy with oral fluoropyrimidines and oxaliplatin is feasible and well tolerated. The risk of early progression is low. However, there was no added benefit with the use of oxaliplatin. There were no relapses in patients with pCR. The role of adjuvant chemotherapy is unclear (AU)

Multimodality management of a locally advanced primary oesophageal melanoma with radical surgery and adjuvant chemoimmunoradiotherapy.

We present the case of a 46-year-old woman diagnosed with a primary oesophageal melanoma (PEM), who was treated with radical surgery followed by combined chemoimmunotherapy (interferon, carboplatin, dacarbazine and external radiotherapy) and who achieved a complete response after this treatment. PEMs are rare malignancies, with less than 300 cases described in the literature. The main differential diagnosis is with metastases of skin or ocular malignant melanomas. They are usually diagnosed at advanced stages and prognosis is typically poor. The main treatment modality should be radical surgery. The role of adjuvant treatment is uncertain, although some long responses have been seen with the use of chemotherapy or immunotherapy alongside surgery.

Multimodality management of a locally advanced primary oesophageal melanoma with radical surgery and adjuvant chemoimmunoradiotherapy

We present the case of a 46-year-old woman diagnosed with a primary oesophageal melanoma (PEM), who was treated with radical surgery followed by combined chemoimmunotherapy (interferon, carboplatin, dacarbazine and external radiotherapy) and who achieved a complete response after this treatment. PEMs are rare malignancies, with less than 300 cases described in the literature. The main differential diagnosis is with metastases of skin or ocular malignant melanomas. They are usually diagnosed at advanced stages and prognosis is typically poor. The main treatment modality should be radical surgery. The role of adjuvant treatment is uncertain, although some long responses have been seen with the use of chemotherapy or immunotherapy alongside surgery (AU)

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Long-term results of neoadjuvant chemotherapy and combined chemoradiotherapy before surgery in the management of locally advanced oesophageal cancer: a single-centre experience

INTRODUCTION: Neoadjuvant chemoradiotherapy before surgery is an option in the treatment of locally advanced resectable oesophageal cancer (EC). However toxicity is substantial and the improvement in overall survival (OS) with this approach is controversial. METHODS: This was a prospective, single-centre study of neoadjuvant chemotherapy and concomitant chemoradiotherapy with CDDP and 5-FU and 50.4 Gy of external radiotherapy before possible radical surgery in patients with locally advanced resectable EC. If surgery was not possible, a second-phase radiotherapy boost of 10 Gy and one cycle of modified dose chemotherapy were used. RESULTS: Seventy-three patients included between 1998 and 2007: 96% males, median age 61, 83% squamous cell carcinomas, 23% lower third tumours, 36% stage II and 54% stage III and 47% local lymph node involvement. Eighty-six percent completed the combined protocol. Main grade 3-4 toxicities: mucositis (19%) and infections (8%); 4 toxic deaths. Clinical response rates: complete response 54%, partial response 27%, stable disease 8%. Twenty-five patients proceeded to surgery, with radical resection in 24. Pathological response rate: complete response 32%, partial response 52%, progression 16%. There were 7 postoperative deaths and 16 of 34 patients that did not have surgery received the second-phase RT boost. Survival analysis: Median follow-up of 64 months (range 6-134 months). Median OS of 10.33 months. 2-year and 5-year OS of 22 and 16%. The only significant prognostic factor in OS is the clinical complete response rate: 13.9 vs. 7.7 months (p=0.0049). CONCLUSIONS: Our protocol offers a high rate of clinical activity although it is relatively toxic and seems to increase the postoperative mortality, which would blunt any small improvement in survival. The achievement of a complete response is a powerful prognostic factor (AU)

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[Fever and cavitary infiltrate in a renal transplant recipient]. / Receptora de trasplante renal con fiebre y neumonía cavitada.

Aspergillus infection is a rare but devastating complication following organ transplantation with high mortality rate. Aspergillus fumigatus is the most common cause of invasive aspergillosis. This fungus is present in the environment worldwide. Aspergillus infection is mainly acquired by inhalation of spores and several nosocomial infections in transplant recipient have been associated with construction work at hospitals. Risk factors for invasive aspergillosis include administration of steroid boluses, history of cytomegalovirus infection, neutropenia and prolonged antibiotic use after transplantation. Successful treatment depends on three factors: early diagnosis, aggressive antifungal therapy and decrease or removal of immunosuppression. Amphotericin deoxycholate has been the standard treatment for many years but lipid preparations for amphotericin are now used due to their significantly fewer adverse effects. A number of new antifungal drugs are now being developed including new azoles such as voriconazol and echinocandin. Invasive aspergillosis has a high mortality rate more than 95% when cerebral dissemination is demonstrated. We report the case of a 47 years old woman who received a cadaveric renal graft and developed pulmonary aspergillosis with fulminant cerebral dissemination two months later. The diagnosis of pulmonary aspergillosis was by culture isolation obtained from bronchioalveolar lavage. Removal of immunosuppresive agents and liposomal amphotericin B therapy were started shortly after admission. Brain CT scan performed on the 12th day showed cerebral dissemination. The recipient died two days later. Our patient had several risk factors such as the administration of steroid boluses and cytomegalovirus infection. Invasive aspergillosis must be always included in the differential diagnosis of fever and pulmonary disease in the renal transplant recipient.

[Presence of hepatitis C virus in renal tissue in membranoproliferative glomerulonephritis and cryoglobulinemia]. / Presencia del virus de la hepatitis C en tejido renal en glomerulonefritis membranoproliferativa y crioglobulinemia.

Although hepatitis C virus infection has been documented in several extrahepatic diseases, the deposition of HCV RNA in glomerular structures has proved to be difficult to demonstrate. We report a patient with membranoproliferative glomerulonephritis, type III circulating cryoglobulins and hepatitis C virus infection with detection of HCV RNA in serum, cryoprecipitate and renal tissue using specific RT-PCR technique. These data confirm that HCV could have a direct role in renal damage.

Presencia del virus de la hepatitis C en tejido renal en glomerulonefritis membranoproliferativa y crioglobulinemia / Detection of hepatitis C virus in renal tissue in membranoproliferative glomerulonephritis and cryglobulinemia

Aunque la infección por el virus de la hepatitis C se asocia con varias enfermedadesextrahepáticas, la detección de RNA viral en las estructuras glomerulareses difícil. No obstante, algunos autores lo han encontrado, con resultados dispares.Describimos un paciente con glomerulonefritis membranoproliferativa,crioglobulinemia mixta tipo III e infección por virus de la hepatitis C con presenciade RNA VHC en suero, crioprecipitado y tejido renal mediante RT-PCR.Estos hallazgos apoyan el papel directo del VHC en el daño renal

Although hepatitis C virus infection has been documented in several extrahepaticdiseases, the deposition of HCV RNA in glomerular structures has proved to be difficultto demonstrate. We report a patient with membranoproliferative glomerulonephritis,type III circulating cryoglobulins and hepatitis C virus infection with detectionof HCV RNA in serum, cryoprecipitate and renal tissue using specific RT-PCRtechnique. These data confirm that HCV could have a direct role in renal damage

Further studies on RpoS in enterobacteria: identification of rpoS in Enterobacter cloacae and Kluyvera cryocrescens.

RpoS, the alternative sigma factor sigma(s), is important for bacterial survival under extreme conditions. Many enterobacteria are opportunistic human pathogens and their ability to survive in a changing environment could be an essential step for their virulence. To determine the presence of this gene in enteric bacteria, an Escherichia coli rpoS probe was constructed and used to detect the presence of this gene in different species. A gene homologous to rpoS was found in Citrobacter amalonaticus, Enterobacter cloacae, Klebsiella planticola, Kluyvera cryocrescens, Serratia rubidaea, Shigella sonnei, and Yersinia ruckeri. Providencia stuartii and Proteus vulgaris were the only tested enterobacteria that did not show any signal with the E. coli rpoS probe or that did not lead to amplification of an rpoS fragment using specific primers. The rpoS gene from E. cloacae and from K. cryocrescens was cloned and sequenced and a mutant allele was constructed in E. cloacae. Survival rates under different harsh conditions were followed in order to determine the effect of rpoS inactivation in exponential- and stationary-phase cells of both strains. E. cloacae rpoS mutants were more sensitive to extreme pH, high osmolarity, and high temperature than the wild-type.

Carcinoma epidermoide de conducto anal: revisión de 15 años de experiencia / Squamous cell carcinoma of the anal review of a fifteen-year experience

Introducción: El carcinoma epidermoide de conducto anal es una neoplasia poco frecuente. La cirugía (CIR) según la técnica de Miles (amputación abdomino-perineal) fue el tratamiento más utilizado hasta hace unos años. El uso de radioterapia (RT) solo o combinado con quimioterapia (QT) es en estos momentos el tratamiento de elección. Material y método: Hemos realizado un estudio retrospectivo para conocer las características clínicas y los tratamientos empleados en los pacientes diagnosticados de carcinoma epidermoide de conducto anal en nuestro centro. La supervivencia se analizó mediante el método de Kaplan y Meier. Resultados: Entre enero de 1983 y octubre de 1998 se diagnosticaron un total de 16 pacientes (1 mujeres y 5 varones), con una mediana de edad de 65 años (extremos 52-85). El síntoma inicial más frecuente fue farectorragia (8 enfermos) seguido de la tumoración perianal y la ulceración (3 pacientes en cada caso). La clasificación por estadios al diagnóstico fue: estadio 1, cinco pacientes; estadio II, seis pacientes; estadio 111-A, dos pacientes; estadio Ill-B tres pacientes. El tratamiento inicial consistió en CIR sola en seis ocasiones (3 amputaciones de Miles y tres resecciones locales), RT exclusiva en cuatro pacientes, CIR/RT en tres pacientes y QT/RT en tres. En el momento del análisis ocho pacientes habían recaído [siete recaídas locales y una sistémica) y ocho no presentaban recidiva. Del total de enfermos analizados 11 permanecían vivos (8 sin enfermedad y 3 con enfermedad) y cinco habían fallecido (4 por progresión tumoral y 1 par otras causas). Con una mediana de seguimiento de 84 meses (extremos 14-116); la supervivencia proyectada a los 5 años es de un 45 porciento con una mediana de supervivencia de 29 meses. Conclusiones: Nuestros resultados coinciden con los datos epidemiológicos de otras series publicadas. Se confirma la escasa incidencia de metástasis sistémicas. El tratamiento más utilizado ha sido la RT sola o en combinación con QT y CIR Una mayoría de los pacientes en nuestra serie se diagnosticó en estadios iniciales (1 y 11). La supervivencia es superponible a otros trabajos de la bibliografía (AU)

Expression of the antifeeding gene anfA1 in Serratia entomophila requires rpoS.

The rpoS gene of Serratia entomophila BC4B was cloned and used to create rpoS-mutant strain BC4BRS. Larvae of the New Zealand grass grub Costelytra zealandica infected with BC4BRS became amber colored but continued to feed, albeit to a lesser extent than infected larvae. Subsequently, we found that expression of the antifeeding gene anfA1 in trans was substantially reduced in BC4BRS relative to that in the parental strain BC4B. Our data show that a functional rpoS gene is vital for full expression of anfA1 and for development of the antifeeding component of amber disease.

[Pre-operative radiotherapy, conventional or accelerated, for invasive bladder cancer. Objectives and radiation modalities. Results and complications]. / Radioterapia pre-operatoria, convencional o acelerada, en el cáncer vesical invasor. Objectivos y modalidades de irradiación. Resultados y complicaciones.

OBJECTIVE: To present the experience of La Fe Hospital and the Institute of Oncology of Valencia with preoperative radiotherapy for bladder cancer and review the literature. METHODS: The principles of radiotherapy are discussed and the most important series reported in the English literature (Memorial Sloan Kettering, M.D. Anderson, London Institute of Urology and Rotterdam Radiotherapy Institute) and the largest published Spanish series (Ramón y Cajal Hospital) are reviewed. Furthermore, the results achieved in 123 patients treated between 1982 and 1989 at the Urology and Radiotherapeutic Oncology services of La Fe Hospital and the IVO experience with accelerated radiotherapy (20 Gy in 5 fractions) immediately followed by radical cystectomy are presented. RESULTS: The five-year survival ranged from 39% to 66%. Distant metastasis, which occurred in more than 50% of the patients, was the most common cause of failure. Comparison of the complication rates of the different series is difficult to perform. The operative mortality ranged from 2.4% to 10% and was 8% in our series. Preoperative radiotherapy does not appear to increase the number of postoperative complications. By multivariate analysis, lymph node involvement was the only significant factor that influenced survival in our series. CONCLUSIONS: It cannot be concluded from the analysis of the prospective and randomized studies that preoperative radiotherapy improves survival in patients with invasive bladder cancer. However, some authors have reported that patients with T3b tumor might benefit from this therapeutic modality.

[Identification of emergencies for asthma and chronic obstructive pulmonary disease in the emergency rooms of a hospital. A reliability study]. / Identificación de urgencias por asma y enfermedad pulmonar obstructiva crónica en el servicio de urgencias de un hospital. Estudio de concordancia.

OBJECTIVE: To analyse the reliability of the obtained results in the identification of cases of asthma and chronic obstructive pulmonary disease (COPD) diagnosed in the medical records of the emergency rooms of the <> of Valencia, Spain. METHODS: In the context of a study on the relationship between emergency rooms for asthma and COPD and specific environmental risks, we revised all the emergency rooms medical records of people aged over 14 attended at the <> of Valencia, Spain, during 1993 and 1994. The observers were two nurses who received previous training in the identification of cases. One observer revised the year 1993 and the other one 1994. To evaluate the reliability of the results we obtained a 24 days sample for each year and we estimated the inter-observer agreement using the Proportion of Observed Agreement (POA) and the Kappa Index (KI) and the 95 % confidence intervals (95% CI). We also carried out a specific analysis for each study category estimating the specific Kappa Index and the Proportions of Specific Agreement (PSA). To assess the inter-observer agreement we used the first 59 days of 1994, to estimate the same indexes mentioned above. RESULTS: In the total of emergency rooms, the POA for both observers was 0.99 and the KI was 0.91 (95% CI: 0.88-0.94) for the first observer and 0.79 (0.76-0.82) for the second one. In the specific analysis the PSA for <> versus <> were 0.92 (0.75-1) and 0.48 (0.31-0. 66) respectively. For the analysis of <> versus <> the PSA were 0.78 (0.69-0.87) and 0.75 (0.64-0.86). In the inter-observer agreement study we obtained, for the overall analysis, a POA equal to 0.99 and a KI to 0.87 (0.86-0.88). In the specific study the PSA for <> versus <> were 0.64 (0.53-0. 74) and 0.82 (0.77-0.87) for <> versus <>. CONCLUSIONS: The consistency of the results is good for both observers, but better for the first observer, particularly for asthma. For the COPD category the results are more homogeneous, showing a good concordance for both observers. The results for the inter-observer study also show a good reliability.

Role of the Escherichia coli SurA protein in stationary-phase survival.

SurA is a periplasmic peptidyl-prolyl isomerase required for the efficient folding of extracytoplasmic proteins. Although the surA gene had been identified in a screen for mutants that failed to survive in stationary phase, the role played by SurA in stationary-phase survival remained unknown. The results presented here demonstrate that the survival defect of surA mutants is due to their inability to grow at elevated pH in the absence of sigmaS. When cultures of Escherichia coli were grown in peptide-rich Luria-Bertani medium, the majority of the cells lost viability during the first two to three days of incubation in stationary phase as the pH rose to pH 9. At this time the surviving cells resumed growth. In cultures of surA rpoS double mutants the survivors lysed as they attempted to resume growth at the elevated pH. Cells lacking penicillin binding protein 3 and sigmaS had a survival defect similar to that of surA rpoS double mutants, suggesting that SurA foldase activity is important for the proper assembly of the cell wall-synthesizing apparatus.

Sigma s regulates pLS1 maintenance in stationary-phase Escherichia coli.

We have studied the influence of sigma s on the stability and number of copies of the promiscuous plasmid pLS1 in Escherichia coli. Our results indicate that pLS1 is less stable and has a lower number of copies in a rpoS mutant than in a wild-type strain during stationary phase. This behaviour does not seem to be due to differences in the expression of pLS1 replication regulators, but to be related to plasmid topology.

VIP gene expression in rat thymus and spleen.

Vasoactive intestinal peptide (VIP) is a neuropeptide with immunomodulatory properties. In the present study, we demonstrate VIP gene expression in cells of both thymus and spleen in the rat by in situ hybridization. In thymus sections, hybridization signal for VIP mRNA was found in cells in corticomedullary and medulla regions. In the spleen, cells were labeled at the outer area on the periarteriolar lymphoid sheath of the white pulp. Hybridization signal appeared to be in lymphoid cells. These findings suggest that lymphoid cells might produce VIP, which, if released, could exert a paracrine action on central and peripheral lymphoid organs. We suggest that VIP participates in the bidirectional communication between the nervous and the immune systems.

Sigma s-dependent promoters in Escherichia coli are located in DNA regions with intrinsic curvature.

Expression of a number of genes during stationary phase in Escherichia coli is controlled by the alternative sigma factor sigma s (KatF). Promoters recognized by sigma s do not present a well-defined consensus sequence in their -10 and -35 regions. By polyacrylamide gel electrophoresis of DNA fragments performed at different temperatures, and by computer prediction analyses, we have found that sigma s-regulated promoters are located in regions where DNA shows intrinsic curvatures. This feature does not appear in a stationary-phase-induced promoter which is not controlled by sigma s. We propose that DNA bending may help in recognition and/or binding of sigma s to stationary-phase-induced promoters.