Successful fertility restoration after allogeneic hematopoietic stem cell transplantation.

OBJECTIVE: Myeloablative conditioning regimens given prior to hematopoietic stem cell transplantation (HSCT) frequently cause permanent sterility in men. In patients with sickle cell disease (SCD) we use a nonmyeloablative regimen with sirolimus, alemtuzumab, and low-dose total-body irradiation (300 centigrays) with gonadal shielding preceding allogeneic HSCT. We report here the restoration of azoospermia in a patient with SCD after allogeneic HSCT. We discuss the impact of our patient's underlying chronic medical conditions and the therapies he had received (frequent blood transfusions, iron chelating drugs, ribavirin, hydroxyurea, opioids), as well as the impact of the nonmyeloablative conditioning regimen on male gonadal function, and we review the literature on this topic. METHODS: We determined the patient's reproductive hormonal values and his semen parameters before, during, and after HSCT and infertility treatment. In addition, we routinely measured his serum laboratory parameters pertinent to SCD and infertility, such as iron and ferritin levels. A karyotype analysis was performed to assess the potential presence of Klinefelter syndrome. Finally, imaging studies of the patient's brain and testes were done to rule out further underlying pathology. RESULTS: A 42-year-old man with SCD, transfusional iron overload, and hepatitis C underwent a nonmyeloablative allogeneic HSCT. One year later he desired to father a child but was found to be azoospermic in the context of hypogonadotropic hypogonadism. Restoration of fertility was attempted with human chorionic gonadotropin (2,000 IU) plus human menopausal gonadotropin (75 IU follicle-stimulating hormone) injected subcutaneously 3 times weekly. Within 6 months of treatment, the patient's serum calculated free testosterone value normalized, and his sperm count and sperm motility improved. After 10 months, he successfully initiated a pregnancy through intercourse. The pregnancy was uncomplicated, and a healthy daughter was delivered naturally at term. CONCLUSION: Despite exposure to several gonadotoxins, transfusional iron overload and nonmyeloablative conditioning with radiation causing severe testicular atrophy suggesting extensive damage to seminiferous tubules and possibly Leydig cells, gonadotropins were efficacious in restoring our patient's reproductive capability.

Metastatic methicillin-sensitive Staphylococcus aureus infection.

Staphylococcus aureus bacteremia (SAB) is a common and increasingly recognized hospital- and community-acquired infection. To minimize morbidity and mortality, it is essential to determine which patients are at high risk for metastatic SAB. The risk-scoring system described by Fowler et al and the APACHE II scoring system can be helpful in identifying the clinical predictors of metastatic SAB. Herein we describe a case of metastatic methicillin-sensitive SAB in a previously healthy 19-year-old woman that was complicated by a disseminated pneumonia, an ischemic toe, and an acute intracranial hemorrhage. We also discuss the clinical factors associated with increased risk for complications from SAB and the currently available treatment options.

Thymic epithelial tumors and metastasis to the brain: a case series and systematic review.

BACKGROUND: Thymic epithelial tumors (TETs) rarely metastasize to the brain. Clinico-pathologic features of TET patients with brain metastasis are not well described. METHODS: TET patients referred for consultation or screening for clinical trials are included. Imaging to evaluate for brain metastases was performed when clinically indicated or if required for screening. Tumor tissue from brain metastases was obtained for analysis, when available. Clinical characteristics and survival was evaluated and a systematic review of the literature on brain metastases associated with TETs was performed. RESULTS: Fourteen TET patients with brain metastasis were identified. Median age at TET diagnosis was 53 years (range: 31-71 years). Twelve patients had thymic carcinoma and two patients had World Health Organization B3 thymoma. Median time from TET diagnosis to discovery of brain metastases was 2.5 years (range: 9 months-8.3 years). Eleven patients had extracranial, extrathoracic metastases during presentation with brain metastases. Three patients underwent surgery and radiation therapy, eight patients received radiation therapy alone, and one patient had surgery alone. One patient with thymoma died 11 months after diagnosis of brain metastases and another patient died but with unknown date of diagnosis of brain metastases. Among 12 patients with thymic carcinoma, 11 of whom had a known date of brain metastases diagnosis, the median potential follow-up is 35.8 months, and median overall survival (OS) from diagnosis of brain metastases is 13.1 months. CONCLUSIONS: Although uncommon, patients with advanced thymic carcinoma can develop brain metastases. Appropriate imaging and aggressive treatment should be considered for these patients.

Kinase inhibitors and monoclonal antibodies in oncology: clinical implications.

Molecularly targeted cancer therapies, such as small-molecule kinase inhibitors and monoclonal antibodies, constitute a rapidly growing and an important part of the oncology armamentarium. Unlike conventional (cytotoxic) chemotherapeutics, targeted therapies were designed to disrupt cancer cell pathogenesis at specific biological points essential for the development and progression of the tumour. These agents were developed to disrupt specific targets with the aim of minimizing treatment burden compared with conventional chemotherapy. Nevertheless the increasingly common use of targeted therapies has revealed some unanticipated, often clinically significant toxic effects, as well as compromising effective palliative and end-of-life management approaches. Although patients and clinicians welcome improvements in cancer prognosis, these changes can also impact patient quality-of-life. Therefore, as demand for oncology expertise increases, physicians need to apprise themselves of targeted therapies and their clinical implications, including drug-specific side effects, impact on quality of life, and cost issues, especially in relation to end-of-life care. This Review provides a useful summary and guide for professionals treating patients with malignant diseases.

Female fertility following dose-adjusted EPOCH-R chemotherapy in primary mediastinal B-cell lymphomas.

We assessed fertility/gonadal function in premenopausal women treated with dose-adjusted EPOCH-Rituximab for untreated primary mediastinal B-cell lymphoma (PMBL). Eligible patents were ≤ 50 years and premenopausal. Serial reproductive histories were obtained and hormonal assays were performed on serum samples before, at the end of treatment and 4-18 months later. Twenty-eight eligible women had a median age (range) of 31 (21-50) years and were followed a median of 7.3 years. Of 23 patients who completed a questionnaire, 19 (83%) were and four were not menstruating prior to chemotherapy. Amenorrhea developed in 12 patients during chemotherapy. At > 1-year follow-up, 14/19 (74%) patients were menstruating, all < 35 years old, and six (43%) of these patients delivered healthy children. Hormonal assays showed ovarian dysfunction during chemotherapy in all patients with varying recovery at 4-18 months after treatment. Fertility was preserved in most women with ovarian failure confined to patients > 40 years old.

The role of reproductive hormones in epithelial ovarian carcinogenesis.

Epithelial ovarian cancer comprises ∼85% of all ovarian cancer cases. Despite acceptance regarding the influence of reproductive hormones on ovarian cancer risk and considerable advances in the understanding of epithelial ovarian carcinogenesis on a molecular level, complete understanding of the biologic processes underlying malignant transformation of ovarian surface epithelium is lacking. Various hypotheses have been proposed over the past several decades to explain the etiology of the disease. The role of reproductive hormones in epithelial ovarian carcinogenesis remains a key topic of research. Primary questions in the field of ovarian cancer biology center on its developmental cell of origin, the positive and negative effects of each class of hormones on ovarian cancer initiation and progression, and the role of the immune system in the ovarian cancer microenvironment. The development of the female reproductive tract is dictated by the hormonal milieu during embryogenesis. Intensive research efforts have revealed that ovarian cancer is a heterogenous disease that may develop from multiple extra-ovarian tissues, including both Müllerian (fallopian tubes, endometrium) and non-Müllerian structures (gastrointestinal tissue), contributing to its heterogeneity and distinct histologic subtypes. The mechanism underlying ovarian localization, however, remains unclear. Here, we discuss the role of reproductive hormones in influencing the immune system and tipping the balance against or in favor of developing ovarian cancer. We comment on animal models that are critical for experimentally validating existing hypotheses in key areas of endocrine research and useful for preclinical drug development. Finally, we address emerging therapeutic trends directed against ovarian cancer.

Alterations of immune cell subsets in relapsed, thymoma-associated minimal change disease: A case report.

The most frequently described glomerulopathy in patients with thymoma is minimal change disease (MCD). The present study reports the case of a 63-year-old female with recurrent thymoma and poorly-controlled paraneoplastic MCD, who was enrolled on a phase I/II clinical trial (no. NCT01100944) and treated with the histone deacetylase inhibitor, belinostat, in combination with cisplatin, doxorubicin and cyclophosphamide. Treatment resulted in a complete radiological response, a dramatic reduction in proteinuria and changes in immune cell subset composition, consisting of a reduction in the number of T helper (Th)1, Th2, Th17 and regulatory T cells. Changes in T-cell polarization were also observed with an increase in the Th1/Th2 ratio. To the best of our knowledge, the current study is the first to provide a detailed description of changes in immune cell subset composition in thymoma-associated MCD. Early administration of effective antitumor therapy should be considered in these cases, particularly when proteinuria is poorly controlled despite the use of steroids and other immunosuppressive therapies.

Advances in gene transfer into haematopoietic stem cells by adenoviral vectors.

Until recently, the cells of haematopoietic origin were not considered good adenoviral (Adv) targets, primarily because they lacked the specific Adv receptors required for productive and efficient Adv infections. In addition, because of limitations inherent in Adv infections, such as short-term expression and a non-integrating nature, their application has been precluded from haematopoietic stem cell (HSC) and bone marrow transduction protocols where long-term expression has been required. Therefore, limited research utilising Adv-mediated gene transfer into haematopoietic cells had been conducted. With recent insights into the critical interactions between adenovirus (Adv) and cells, new Adv-mediated gene transduction strategies have now been reported that may overcome these limitations. These new strategies include Adv possessing synthetic polymer coatings, genetically modified capsid proteins or antibody-redirected fibres that can efficiently redirect and retarget Adv to transfer genes into HSC. Additionally, new hybrid Advs, engineered with both modified capsid proteins and novel cis-acting integration sequences, are also being developed which can efficiently deliver and integrate Adv delivered genes into HSC. This is an area of research that is now rapidly gaining momentum in terms of techniques and applications. Here we review the current status of adenovirus-based vectors as a means to achieve high-level gene transfer into haematopoietic cell types.

Bortezomib-based chemotherapy for light chain deposition disease presenting as acute renal failure.

We report a case of kappa light chain deposition disease (LCDD) associated with multiple myeloma in a patient presenting with acute renal failure, 2+ proteinuria and hypercalcemia. Serum protein electrophoresis showed an M-spike at 0.1 g/dL. 24-h urine protein electrophoresis showed Bence-Jones proteinuria of 3.8 g. Serum-free light chain assay found excess kappa chains at 3080 mg/L, with normal lambda and an elevated kappa:lambda ratio of 124.7. A kidney biopsy revealed kappa light chain nephropathy with PAS-negative tubular casts in the cortex and outer medulla. Bone marrow biopsy showed 15% kappa-restricted plasma cells. Serum beta-2 microglobulin level was elevated at 7.94 mg/dL. The patient received a 3-day course of plasmapheresis followed by eight cycles of bortezomib (Velcade®), liposomal doxorubicin, and dexamethasone (VDD) and did not require hemodialysis. As partial response was not achieved, treatment was continued with three cycles of bortezomib, cyclophosphamide, dexamethasone, and thalidomide, followed by thalidomide maintenance at 100 mg daily. Thirty-two months after the diagnosis, the patient's renal function was improved and he achieved a partial response. This case underlines the feasibility and effectiveness of bortezomib-based chemotherapy in the treatment of LCDD with severe renal dysfunction.

Seborrheic keratoses of florid eruption.

We report the case of a 79-year-old Caucasian man, who developed numerous pruritic seborrheic keratoses on his chest and back within one year. An underlying malignant disease was suspected. Upper and lower endoscopies were performed and the patient was diagnosed with adenocarcinoma of the ascending colon. We discuss the clinical significance of his cutaneous symptoms/signs, and review the medical literature on the paraneoplastic sign of Leser-Trélat.

Acrometastasis as the Initial Presentation of a KRAS-Positive Colon Cancer.

The propensity of colon cancer to metastasize to bones is very low compared to prostate, breast or lung cancer. The reason for this is not yet understood, although an explanation for the osteotropism of certain primaries has been offered by the 'seed and soil' concept, suggesting that the bone microenvironment provides a favorable 'soil' for metastasis and proliferation of some tumor cells ('seeds') [1]. Here, we report an unusual case of colon cancer with metastasis to the finger at initial presentation, and exophytic sclerotic lesions to other bones. The incidence of metastases to fingers/toes (acrometastases) is reported to be only 0.1%, even after including involvement of primary sites other than the colon. The etiology and characteristics of acrometastases are reviewed in this case report.

Transduction of human embryonic stem cells by foamy virus vectors.

Human embryonic stem cells (hESCs) are important tools for the study of stem cell biology and may ultimately be used in cellular therapies and regenerative medicine. For hESCs to achieve their potential, stable genetic modification of the hESC genome will be required. Here we have studied the transduction of hESCs by vectors based on foamy virus (FV), an integrating retrovirus with no known pathogenicity. We find that hESCs and also ESCs derived from rhesus monkeys can be efficiently transduced by FV vectors at frequencies of 14-48%. Integration of FV vector DNA was demonstrated by Southern blot analysis, and stable expression was observed from a single integrated provirus in several clones. Transduced hESCs expressed markers characteristic of undifferentiated cells, differentiated and expressed markers from all three germ layers after serum exposure, and formed teratomas with persistent transgene expression in differentiated cells. Thus, FV vectors are promising tools for the genetic modification of hESCs.

The interaction between the fiber knob domain and the cellular attachment receptor determines the intracellular trafficking route of adenoviruses.

Most of the presently used adenovirus (Ad) vectors are based on serotype 5. However, the application of these vectors is limited by the native tropism of Ad5. To address this problem, a series of fiber chimeric vectors were produced to take advantage of the different cellular receptors used by Ad of different subgroups. In this study we utilize an Ad5-based chimeric vector containing sequences encoding the Ad35 fiber knob domain instead of the Ad5 knob (Ad5/35L) to analyze factors responsible for selection of intracellular trafficking routes by Ads. By competition analysis with recombinant Ad5 and Ad35 knobs we showed that the Ad5/35L vector infected cells through a receptor different from the Ad5 receptor. Intracellular trafficking of Ad5 and Ad5/35L viruses was analyzed in HeLa cells by tracking fluorophore-conjugated Ad particles, by immunostaining for capsid hexon protein, by electron microscopy, and by Southern blotting for viral DNA. These studies showed that the interaction with the Ad35 receptor(s) predestines Ad5/35L vector to intracellular trafficking pathways different from those of Ad5. Ad5 efficiently escaped from the endosomes early after infection. In contrast, Ad5/35L remained longer in late endosomal/lysosomal compartments and used them to achieve localization to the nucleus. However, a significant portion of Ad5/35L particles appeared to be recycled back to the cell surface. This phenomenon resulted in significantly less efficient Ad5/35L-mediated gene transfer compared to that of Ad5. We also demonstrated that the selection of intracellular trafficking routes was determined by the fiber knob domain and did not depend on the length of the fiber shaft. This study contributes to a better understanding of the mechanisms that govern the infection of retargeted, capsid-modified vectors which have potential application for hematopoietic stem cell and tumor gene therapy.

Genome size and structure determine efficiency of postinternalization steps and gene transfer of capsid-modified adenovirus vectors in a cell-type-specific manner.

Adenovirus serotype 5 (Ad5) vectors containing Ad B-group fibers have become increasingly popular as gene transfer vectors because they efficiently transduce human cell types that are relatively refractory to Ad5 infection. So far, most B-group fiber-containing vectors have been first-generation vectors, deleted of E1 and/or E3 genes. Transduction with these vectors, however, results in viral gene expression and is associated with cytotoxicity and immune responses against transduced cells. To circumvent these problems, we developed fiber-chimeric Ad vectors devoid of all viral genes that were produced either by the homologous recombination of first-generation vectors or by using the Cre/lox-based helper virus system. In this study we compared early steps of infection between first-generation (35-kb genome) and Ad vectors devoid of all viral genes with genome sizes of 28 kb and 12.6 kb. All vectors possessed an Ad35-derived fiber knob domain, which uses CD46 as a primary attachment receptor. Using immortalized human hematopoietic cell lines and primary human CD34-positive hematopoietic cells, we found that the Ad genome size did not affect the efficiency of virus attachment to and internalization into cells. Furthermore, independently of the genome length and structure, all vectors migrated to the nucleus through late endosomal and lysosomal cellular compartments. However, the vector containing the short 12.6-kb genome was unable to efficiently escape from endosomes and deliver its DNA into the nucleus. Moreover, compared to other vectors, these Ad particles were less stable and had an abnormal capsid protein composition, including a lack of capsid-stabilizing protein IX. Our data indicate that the size and structure of the packaged viral genomes can affect the integrity of Ad particles, which in turn results in lower infectivity of Ad vectors.