Pituitary surgery during Covid-19: a first hand experience and evaluation.

PURPOSE: During the Covid-19 pandemic every hospital has had to change its internal organization. Different institutions have highlighted the risks connected with endoscopic endonasal surgery. The goal of this paper is to illustrate the feasibility of pituitary region surgery during the SARS-CoV-2 pandemic. METHODS: After two negative Covid tests were obtained, three patients with macro GH-secreting tumors, and two patients with micro ACTH-secreting tumors resistant to medical treatment underwent surgery during the pandemic. During the surgery, every patient was treated as if they were positive. RESULTS: Neither operator, nor patient have developed Covid symptoms. The two neurosurgeons performing the operations underwent two Covid swab, which resulted negative. CONCLUSIONS: Pituitary surgery is a high risk non-urgent surgery. However, the method described has so far been effective and is safe for both patients and healthcare providers.

Stem cells based therapy in high grade glioma: why the intraventricular route should be preferred?

AIM: Mesenchymal stem cells (MSCs) migrate in response to chemokines and possess extensive tropism for experimental glioma. Antitumor effects have been reported following intracranial and intravenous administration of gene-modified MSCs. Among the different routes for cell transplant, the intraventricular (IV) approach found very little employment in comparison with intraparenchymal, intratumoral and intravenous administration protocols. Nevertheless, IV transplantation offers advantages in terms of cells viability and distribution toward target sites, opening interesting opportunities for its clinical application. METHODS: Using a rat glioma model, we investigated migratory capacity, tumor tropism, distribution and differentiation of MSCs following IV administration. RESULTS: Transplanted MSCs create niches of viable cells in the subventricular zone and can be stimulated to migrate to sites of tumor infiltration. MSCs seemed not to be involved in tumor growth and angiogenesis. CONCLUSION: We speculate that the IV route can be used to achieve a kind of reservoir of self-renewal cells, potentially active against the spread of cancer cells. Further studies are needed to shed light on MSCs distribution close to the ventricular wall, in order to define their lifespan and their capacity to migrate towards new-enhancing foci time after implantation.

A computational model to compare different investment scenarios for mini-stereotactic frame approach to deep brain stimulation surgery.

UNLABELLED: Deep brain stimulation (DBS) alleviates symptoms of many neurological disorders by applying electrical impulses to the brain by means of implanted electrodes, generally put in place using a conventional stereotactic frame. A new image guided disposable mini-stereotactic system has been designed to help shorten and simplify DBS procedures when compared to standard stereotaxy. A small number of studies have been conducted which demonstrate localization accuracies of the system similar to those achievable by the conventional frame. However no data are available to date on the economic impact of this new frame. AIM: The aim of this paper was to develop a computational model to evaluate the investment required to introduce the image guided mini-stereotactic technology for stereotactic DBS neurosurgery. METHODS: A standard DBS patient care pathway was developed and related costs were analyzed. A differential analysis was conducted to capture the impact of introducing the image guided system on the procedure workflow. The analysis was carried out in five Italian neurosurgical centers. RESULTS: A computational model was developed to estimate upfront investments and surgery costs leading to a definition of the best financial option to introduce the new frame. Investments may vary from Euro 1.900 (purchasing of Image Guided [IG] mini-stereotactic frame only) to Euro 158.000.000. Moreover the model demonstrates how the introduction of the IG mini-stereotactic frame doesn't substantially affect the DBS procedure costs.

Influence of basal ganglia on upper limb locomotor synergies. Evidence from deep brain stimulation and L-DOPA treatment in Parkinson's disease.

Clinical evidence of impaired arm swing while walking in patients with Parkinson's disease suggests that basal ganglia and related systems play an important part in the control of upper limb locomotor automatism. To gain more information on this supraspinal influence, we measured arm and thigh kinematics during walking in 10 Parkinson's disease patients, under four conditions: (i) baseline (no treatment), (ii) therapeutic stimulation of the subthalamic nucleus (STN), (iii)L-DOPA medication and (iv) combined STN stimulation and L-DOPA. Ten age-matched controls provided reference data. Under baseline conditions the range of patients' arm motion was severely restricted, with no correlation with the excursion of the thigh. In addition, the arm swing was abnormally coupled in time with oscillation of the ipsilateral thigh. STN stimulation significantly increased the gait speed and improved the spatio-temporal parameters of arm and thigh motion. The kinematic changes as a function of gait speed changes, however, were significantly smaller for the upper than the lower limb, in contrast to healthy controls. Arm motion was also less responsive after L-DOPA. Simultaneous deep brain stimulation and L-DOPA had additive effects on thigh motion, but not on arm motion and arm-thigh coupling. The evidence that locomotor automatisms of the upper and lower limbs display uncorrelated impairment upon dysfunction of the basal ganglia, as well as different susceptibility to electrophysiological and pharmacological interventions, points to the presence of heterogeneously distributed, possibly partially independent, supraspinal control channels, whereby STN and dopaminergic systems have relatively weaker influence on the executive structures involved in the arm swing and preferential action on those for lower limb movements. These findings might be considered in the light of phylogenetic changes in supraspinal control of limb motion related to primate bipedalism.

Neuro-psychiatric therapy during chronic subthalamic stimulation in Parkinson's disease.

BACKGROUND: Neuro-psychiatric (NP) disturbances are highly prevalent in patients with Parkinson's disease (PD) and contribute to worsen quality of life. Deep brain stimulation of the subthalamic nucleus (STN-DBS) is commonly utilized as surgical treatment for advanced PD with motor complications. The effectiveness of the procedure on motor symptoms is well established whereas the effects of STN-DBS on NP symptoms are less clear. The aim of our study was to analyze the postoperative pharmacological therapy for NP symptoms in a group of STN-DBS treated PD patients. Such therapy provides indirect information about the evolution of underlying NP disturbances during the follow-up in this group of PD patients. METHODS: NP therapy (benzodiazepines, antidepressants, antipsychotics) was assessed in 48 consecutive PD patients treated by STN-DBS, preoperatively and postoperatively after 4 months, 1 year and 3 years. Motor symptoms were evaluated by the Unified PD Rating Scale (UPDRS) and levodopa equivalence daily dose (LEDD) was calculated. Cognitive, mood and anxiety assessments were performed with appropriate rating scales. RESULTS: The number of patients treated with antidepressant drugs gradually increased during the follow-up. The use of antipsychotic drugs was stable until 1 year, with a subsequent increase at 3 years. Benzodiazepines were given to fewer patients immediately after surgery. CONCLUSIONS: Pharmacological treatment supplies further information about NP symptoms in the follow-up of PD patients undergoing STN stimulation.

Antiparkinsonian therapy modifications in PD patients after STN DBS: a retrospective observational analysis.

OBJECTIVE: This study reports a retrospective analysis of 67 consecutive parkinsonian patients to assess changes in antiparkinsonian medications after Deep Brain Stimulation (DBS) of the Subthalamic Nucleus (STN). METHODS: All antiparkinsonian drugs, including levodopa, dopamine agonists, associated drugs such as COMT and MAO inhibitors, amantadine and anticholinergics, were evaluated pre- and post-operatively at 1 and 3 years follow-up. RESULTS: The levodopa mean daily dose was reduced approximately 60% after 1 year and remained stable after 3 years. Apomorphine, bromocriptine, tolcapone, entacapone and selegiline were withdrawn after STN DBS. Three years post-operatively, 9 patients (13.4%) no longer required levodopa and 6 patients (8.9%) completely stopped all dopaminergic medications. More patients were on monotherapy of either levodopa or dopamine agonist and fewer patients required a combined treatment of dopamine agonist and levodopa, compared to the pre-surgical condition. CONCLUSIONS: STN DBS treated PD patients experience a significant long-term reduction and simplification of the pharmacological treatment.

When words are painful: unraveling the mechanisms of the nocebo effect.

The nocebo effect is a phenomenon that is opposite to the placebo effect, whereby expectation of a negative outcome may lead to the worsening of a symptom. Thus far, its study has been limited by ethical constraints, particularly in patients, as a nocebo procedure is per se stressful and anxiogenic. It basically consists in delivering verbal suggestions of negative outcomes so that the subject expects clinical worsening. Although some natural nocebo situations do exist, such as the impact of negative diagnoses upon the patient and the patient's distrust in a therapy, the neurobiological mechanisms have been understood in the experimental setting under strictly controlled conditions. As for the placebo counterpart, the study of pain has been fruitful in recent years to understand both the neuroanatomical and the neurochemical bases of the nocebo effect. Recent experimental evidence indicates that negative verbal suggestions induce anticipatory anxiety about the impending pain increase, and this verbally-induced anxiety triggers the activation of cholecystokinin (CCK) which, in turn, facilitates pain transmission. CCK-antagonists have been found to block this anxiety-induced hyperalgesia, thus opening up the possibility of new therapeutic strategies whenever pain has an important anxiety component. Other conditions, such as Parkinson's disease, although less studied, have been found to be affected by nocebo suggestions as well. All these findings underscore the important role of cognition in the therapeutic outcome, and suggest that nocebo and nocebo-related effects might represent a point of vulnerability both in the course of a disease and in the response to a therapy.

Apathy and verbal fluency in STN-stimulated PD patients. An observational follow-up study.

OBJECTIVE: To evaluate apathy and its relation to verbal fluency tasks in a consecutive series of 19 patients with Parkinson's disease (PD) submitted to deep brain stimulation of the subthalamic nucleus (DBS of STN). METHODS: 19 consecutive PD patients submitted to bilateral DBS of STN were studied for apathy pre-operatively and 17 months after surgery. The PD patients underwent a battery of cognitive tests assessing reasoning, memory and frontal executive functions, including phonemic and categorial fluency tasks. The Beck Depression Inventory (BDI) was used for depression. Apathy was assessed by means of the Apathy Scale (AS). In order to quantify changes among individual patients, the clinical criterion of more or less than 1 SD (standard z-score) was used to register a patient as improved or worsened, respectively. RESULTS: After surgery, apathy scores did not change and mood improved (p < 0.02), while a significant worsening was found in the phonemic fluency (p < 0.001). The percentage of patients with an apathy score above the recommended cut-off value (14) was 42% both before and after DBS of STN. Individual outcomes on the apathy scale (1 SD criterion) evidenced that 53% of the patients remained stable, 16% improved, while 31% worsened. This last percentage reduced to 21% (4/19) when considering only the PD patients with an apathy score > or =14 after surgery. No significant correlation was found between the apathy scores variation and any of the neurological variables considered, and, in particular, no correlation was found between apathy and verbal fluency. CONCLUSIONS: The results of the present study suggest that DBS of STN does not necessarily induce apathy even if individual patients show a moderate post-operative worsening of apathetic symptoms.

Fine mapping of 28S rRNA sites specifically cleaved in cells undergoing apoptosis.

Bona fide apoptosis in rat and human leukemia cells, rat thymocytes, and bovine endothelial cells was accompanied by limited and specific cleavage of polysome-associated and monosome-associated 28S rRNA, with 18S rRNA being spared. Specific 28S rRNA cleavage was observed in all instances of apoptotic death accompanied by internucleosomal DNA fragmentation, with cleavage of 28S rRNA and of DNA being linked temporally. This indicates that 28S rRNA fragmentation may be as general a feature of apoptosis as internucleosomal DNA fragmentation and that concerted specific cleavage of intra- and extranuclear polynucleotides occurs in apoptosis. Apoptosis-associated cleavage sites were mapped to the 28S rRNA divergent domains D2, D6 (endothelial cells), and D8. The D2 cuts occurred in hairpin loop junctions considered to be buried in the intact ribosome, suggesting that this rRNA region becomes a target for RNase attack in apoptotic cells. D8 was cleaved in two exposed UU(U) sequences in bulge loops. Treatment with agents causing necrotic cell death or aging of cell lysates failed to produce any detectable limited D2 cleavage but did produce a more generalized cleavage in the D8 region. Of potential functional interest was the finding that the primary cuts in D2 exactly flanked a 0.3-kb hypervariable subdomain (D2c), allowing excision of the latter. The implication of hypervariable rRNA domains in apoptosis represents the first association of any functional process with these enigmatic parts of the ribosomes.

Telomerase targeting by retinoids in cells from patients with myeloid leukemias of various subtypes, not only APL.

Numerous strategies have been proposed to specifically inhibit telomerase (human telomerase reverse transcriptase (hTERT)) but to date only a few are clinically relevant in anticancer therapy. Recently, we have shown that long-term treatment with all-trans retinoic acid (ATRA), a compound clinically approved for differentiation therapy of acute promyelocytic leukemia (APL), represses hTERT in differentiation-resistant APL cell lines leading to telomere shortening and death. This signaling requires the co-activation of the retinoic acid receptor alpha (RARalpha) and the retinoic X receptor (RXR). In contrast to differentiation-therapy, which is only successful in this subtype of leukemia, the telomerase-targeted pathway could also be of use in non-APL. Here, we demonstrate that repression of hTERT occurs in fresh blasts cells from patients with myeloid leukemias of various subtypes exposed ex vivo to ATRA or synthetic retinoids. These results support the idea that, by hTERT targeting, retinoids can induce telomere shortening and cell death and their integration in therapy protocols for myeloid leukemias refractory to maturation should be considered.

Telomeres and telomerase: Pharmacological targets for new anticancer strategies?

Telomeres are located at the ends of eukaryotic chromosomes. Human telomerase, a cellular reverse transcriptase, is a ribonucleoprotein enzyme that catalyzes the synthesis and extension of telomeric DNA. It is composed of at least, a template RNA component (hTR; human Telomerase RNA) and a catalytic subunit, the telomerase reverse transcriptase (hTERT). The absence of telomerase is associated with telomere shortening and aging of somatic cells, while high telomerase activity is observed in over 85% of human cancer cells, strongly indicating its key role during tumorigenesis. Several details regarding telomere structure and telomerase regulation have already been elucidated, providing new targets for therapeutic exploitation. Further support for anti-telomerase approaches comes from recent studies indicating that telomerase is endowed of additional functions in the control of growth and survival of tumor cells that do not depend only on the ability of this enzyme to maintain telomere length. This observation suggests that inhibiting telomerase or its synthesis may have additional anti-proliferative and apoptosis inducing effect, independently of the reduction of telomere length during cell divisions. This article reviews the basic information about the biology of telomeres and telomerase and attempts to present various approaches that are currently under investigation to inhibit its expression and its activity. We summarize herein distinct anti-telomerase approaches like antisense strategies, reverse transcriptase inhibitors, and G-quadruplex interacting agents, and also review molecules targeting hTERT expression, such as retinoids and evaluate them for their therapeutic potential. "They conceive a certain theory, and everything has to fit into that theory. If one little fact will not fit it, they throw it aside. But it is always the facts that will not fit in that are significant". "Death on the Nile". Agatha Christie.

A survey of Italian cases of dystonia treated by deep brain stimulation.

AIM: The aim of this study was to report on Italian cases of dystonia treated by deep brain stimulation up to the end of 2005. METHODS: Retrospective survey. Presentation of data collection among all Italian neurosurgical institutions. RESULTS: Seven out of 123 Italian neurosurgical centres were enrolled. Sixty-nine patients were operated. According to different classification criteria, cases were grouped as follows: 37 primary and 32 secondary dystonia; 61 generalized and 8 focal dystonia; 16 patients aged at onset <2 years, 22 aged 3-12 years, 14 aged 13-20 years, 17 aged >20 years. Primary dystonia (DYT) mutation 1 was identified in 21% of primary generalized dystonia. Age at surgery was <15 years in 21.7% of cases (N.=15). Mean time between clinical onset and surgery was 17 years. Globus pallidus internus (GPi) was chosen for implantation in all cases. Type of anesthesia, method of target localization, lead and implanted pulse generator (IPG) model differed among centres. Surgical complications occurred in 19% of patients, but at a higher rate (33%) in the pediatric subgroup. Stimulation parameters varied among centres, but the main scheme was 90-120 micros and 130 Hz. Follow-up duration ranged from 3 to 84 months (longer than 24 months in 50% of patients). Mean Burke-Fahn-Marsden scale (BFM) improvement was 42% for both severity and disability score, ranging from 0% to 92%. Improvement of at least 50% in BFM severity score has been reached by 45% of primary and 37% of secondary dystonia. Clinical results were better in the DYT1 subgroup, with 60% of cases improving more than 50%. Among secondary dystonia, the drug-induced group had very good results too. On the contrary delayed surgery and presence of comorbidity were negatively correlated to the outcome. CONCLUSION: In this series, primary generalized dystonia has a better outcome, especially if associated to DYT1 mutation. Among secondary dystonia, the drug-induced group has very good RESULTS: Correlation analysis of time to surgery and associated comorbidity suggests that earlier surgery is advisable.

Motor and nonmotor symptom follow-up in parkinsonian patients after deep brain stimulation of the subthalamic nucleus.

OBJECTIVE: To evaluate motor and nonmotor symptoms in patients with Parkinson's disease undergoing bilateral deep brain stimulation of the subthalamic nucleus (STN DBS). METHODS: Thirty-six consecutive patients receiving bilateral STN stimulation implants were evaluated preoperatively as well as 12 and 24 months after surgery. Motor symptoms were assessed through the Unified Parkinson's Disease Rating Scale (UPDRS). Data concerning nonmotor symptoms were collected from items of the UPDRS and 2 additional questions from clinical charts regarding constipation and urological dysfunction. RESULTS: STN DBS was effective in controlling motor symptoms; concerning nonmotor symptoms, sleep quality and constipation improved after surgery as compared to baseline. Salivation, swallowing and sensory complaints were ameliorated to a comparable degree by the medication on state, whether preoperatively or postoperatively. With a lower dose of dopaminergic medication, however, the medication on state appeared to be a much larger percentage of the day postoperatively. No significant variations were detected in intellectual impairment, depression, thought disorders, motivation, falling unrelated to freezing, nausea, orthostatic hypotension and urological dysfunction. CONCLUSIONS: STN DBS effectively controls motor symptoms, while nonmotor features of advanced Parkinson's disease patients are mostly unchanged after surgery, even though some specific aspects, notably sleep complaints and constipation, are ameliorated.

Retinoid/arsenic combination therapy of promyelocytic leukemia: induction of telomerase-dependent cell death.

Acute promyelocytic leukemia (APL) is efficiently treated with a cell differentiation inducer, all-trans retinoic acid (ATRA). However, a significant percentage of patients still develop resistance to this treatment. Recently, arsenic trioxide (As2O3), alone or in combination with ATRA, has been identified as an alternative therapy in patients with both ATRA-sensitive and ATRA-resistant APL. Previous investigations restricted the mechanism of this synergism to the modulation and/or degradation of PML-RARalpha oncoprotein through distinct pathways. In this study, using several ATRA maturation-resistant APL cell lines, we demonstrate in vitro that the success of ATRA/As2O3 treatment in APL pathology can be explained, at least in part, by a synergistic effect of these two drugs in triggering downregulation of telomerase efficient enough to cause telomere shortening and subsequent cell death. Such long-term low-dose combinatorial therapy strategies, developed also to avoid acute side effects, reinforce the notion that the antitelomerase strategy, based on a combination of active agents, should now be considered and evaluated not only in APL but also in other malignancies.

Granulocytic differentiation of human NB4 promyelocytic leukemia cells induced by all-trans retinoic acid metabolites.

The metabolism of all-trans retinoic acid (ATRA) has been reported to be partly responsible for the in vivo resistance to ATRA seen in the treatment of human acute promyelocytic leukemia (APL). However, ATRA metabolism appears to be involved in the growth inhibition of several cancer cell lines in vitro. The purpose of this study was to evaluate the in vitro activity of the principal metabolites of ATRA [4-hydroxy-retinoic acid (4-OH-RA), 18-hydroxy-retinoic acid (18-OH-RA), 4-oxo-retinoic acid (4-oxo-RA), and 5,6-epoxy-retinoic acid (5,6-epoxy-RA)] in NB4, a human promyelocytic leukemia cell line that exhibits the APL diagnostic t(15;17) chromosomal translocation and expresses the PML-RAR alpha fusion protein. We established that the four ATRA metabolites were indeed formed by the NB4 cells in vitro. NB4 cell growth was inhibited (69-78% at 120 h) and cell cycle progression in the G1 phase (82-85% at 120 h) was blocked by ATRA and all of the metabolites at 1 microM concentration. ATRA and its metabolites could induce NB4 cells differentiation with similar activity, as evaluated by cell morphology, by the nitroblue tetrazolium reduction test (82-88% at 120 h) or by the expression of the maturation specific cell surface marker CD11c. In addition, nuclear body reorganization to macropunctated structures, as well as the degradation of PML-RAR alpha, was found to be similar for ATRA and all of its metabolites. Comparison of the relative potency of the retinoids using the nitroblue tetrazolium reduction test showed effective concentrations required to differentiate 50% of cells in 72 h as follows: ATRA, 15.8 +/- 1.7 nM; 4-oxo-RA, 38.3 +/- 1.3 nM; 18-OH-RA, 55.5 +/- 1.8 nM; 4-OH-RA, 79.8 +/- 1.8 nM; and 5,6-epoxy-RA, 99.5 +/- 1.5 nM. The ATRA metabolites were found to exert their differentiation effects via the RAR alpha nuclear receptors, because the RAR alpha-specific antagonist BMS614 blocked metabolite-induced CD11c expression in NB4 cells. These data demonstrate that the principal ATRA Phase 1 metabolites can elicit leukemia cell growth inhibition and differentiation in vitro through the RAR alpha signaling pathway, and they suggest that these metabolites may play a role in ATRA antileukemic activity in vivo.

Maturation sensitive and resistant t(15;17) NB4 cell lines as tools for APL physiopathology: nomenclature of cells and repertory of their known genetic alterations and phenotypes.

Chromosomal translocations, leading to gene rearrangements that generate chimerical proteins, represent one of the initiating events of leukemia. Preleukemia cells eventually develop into overt leukemia by occurrence of secondary genetic alterations (tumor progression). The physiopathology of leukemia has made considerable progress during the last two decades, due to molecular biology investigations on the role played by the altered genes, during neoplasic hemopoiesis. In vitro studies have been facilitated by the establishment of stable leukemia cell lines bearing these gene rearrangements and secondary gene mutations. Investigations on acute promyelocytic leukemia (APL) have benefited from maturation sensitive and resistant cell lines (NB4 and UF-1) derived from APL patient's leukemia cells and bearing the t(15;17). The information concerning the NB4 cell line (responsiveness to retinoid/rexinoid, cAMP, arsenic, mutations causing resistance) is spread in an abundant literature. In this paper, we briefly recapitulate the cellular and molecular features of this cell line and its subclones with the aim of facilitating investigators in their choice of the most appropriate tool for their studies. As redundancy of several names given to NB4 sublines has sometimes created difficulties, we propose a nomenclature for the various NB4 sublines that most investigators certainly would be agreed with.

Differential changes of retinoid-X-receptor (RXR alpha) and its RAR alpha and PML-RAR alpha partners induced by retinoic acid and cAMP distinguish maturation sensitive and resistant t(15;17) promyelocytic leukemia NB4 cells.

The expression of retinoid receptors (RXRalpha, RARalpha and the chimeric form PML-RARalpha) was analysed both at the mRNA and protein level in the maturation sensitive NB4 and resistant NB4-R1 cell lines of t(15;17) promyelocytic leukemia (APL). All-trans RA and cAMP which show synergistic activity in inducing maturation of NB4 cells and maturation triggering of the RA 'primed' NB4-R1 resistant cells, distinctly modulate RXRalpha, RARalpha and PML-RARalpha mRNA. In the NB4 and NB4-R1 cells, RXRalpha mRNA was downregulated by RA, but only in RA-primed NB4-R1 cells a release from RXRalpha mRNA downregulation was obtained by cAMP treatment. RXRalpha protein (53 kDa) was decreased to the western-blot detection limit (97.5%) by RA in NB4 cells, but in NB4-R1 cells although it was frankly decreased (85%), the signal for RXRalpha protein remained very significant. More importantly, while cAMP slightly upregulated RXRalpha protein in RA-treated NB4 cells, it caused an increase of RXRalpha protein in RA-treated NB4-R1 cells bringing RXRalpha to the initial control level. RXRalpha partners in heterodimers (PML-RARalpha, RARalpha) were also analysed. In contrast to RXRalpha, RARalpha and PML-RARalpha mRNA were not modulated by RA and/or cAMP, while significant changes were observed at the protein levels. A putatively phosphorylated form of RARalpha (52 kDa) decreased during maturation of NB4 cells, but was unchanged in resistant NB4-R1 cells. Conversely, while PML-RARalpha remained stable during RA-induced NB4 maturation, RA treatment which failed to induce maturation of NB4-R1 cells significantly down-regulated the chimeric receptor (120 kDa). These differences most likely results from translational and post-translational regulation. This work reveals complex pattern of subtle changes at the protein level distinguishing RA-sensitive and RA-resistant cells. Our data show that the RA-cAMP synergistic effect on NB4 cell maturation and cooperation in triggering maturation of RA-primed NB4-R1 cells operate changes in the RXR/PML-RARalpha ratio which are both favouring RXRalpha. In both cell lines, variations of PML-RARalpha and RXRalpha may result in a decrease in the formation of the PML-RARalpha/RXRalpha heterodimers which are supposed involved in the block of maturation. This may prove crucial to embark cells on maturation.

cAMP signalling is decisive for recovery of nuclear bodies (PODs) during maturation of RA-resistant t(15;17) promyelocytic leukemia NB4 cells expressing PML-RAR alpha.

We analysed the expression of retinoid receptors and PML in relation to the morphology of PML-containing nuclear bodies (PODs) in maturation sensitive (NB4) and resistant subclones (NB4-R1 and R2) of the promyelocytic NB4 cell line. The basal level of RARalpha, RXRalpha and PML mRNA and protein were roughly the same in the three cell lines. While NB4 and NB4-R1 cells express comparable amounts of PM-RARalpha mRNA and 120 kDa protein, NB4-R2 cells despite normal mRNA levels the 120 kDa protein was not detectable. In NB4-R2 cells however, two novel PML-related entities of 65 kDa and 85 kDA were detected with a anti-PML antibody, in addition to the two PML isoforms of 78 and 97 kDa found in any NB4 cells. Despite the 120 kDa PML-RARalpha defect, NB4-R2 cells show micropunctuated nuclear bodies typical of APL cells. Contrasting with NB4 cells, neither NB4-R1 cells which express PML-RARalpha, nor NB4-R2 cells lacking the 120 kDa PML-RARalpha reorganised nuclear bodies (PODs) in response to RA. Importantly, in RA-primed NB4-R1 cells, a secondary event triggered by cAMP restored PODs, concomitant to maturation. This indicates that the recovery of nuclear bodies in APL is dissociated from the early action of RA in cell maturation. Finally, the key finding of this work is that cAMP signalling ultimately determines the recovery of nuclear bodies associated to cell maturation.

The transcriptional repressor ICER and cAMP-induced programmed cell death.

The cAMP pathway plays a central role in the response to hormonal signals for cell proliferation, differentiation and apoptosis. In IPC-81 leukaemia cells, activation of the cAMP pathway by prostaglandin E1 treatment, or other cAMP-elevating agents, induces apoptosis within 4-6 h. Inhibition of mRNA or protein synthesis during the first 2 h of cAMP induction protects cells from apoptosis, suggesting a requirement for early gene expression. cAMP-dependent protein kinase phosphorylates a class of nuclear factors and thereby regulates the transcription of a specific set of genes. Here we show that CREM (cAMP Responsive Element Modulator) expression is induced rapidly upon prostaglandin E1 treatment of IPC-81 cells. The induced transcripts correspond to the early product ICER (Inducible cAMP Early Repressor). ICER expression remains elevated until the burst of cell death. Protein synthesis inhibitors which prevent cAMP-induced apoptosis also block de novo ICER synthesis. Transfected IPC-81 cell lines, constitutively expressing high level of ICER are resistant to cAMP-induced cell death. In these transfected cells, cAMP fails to upregulate the ICER transcripts demonstrating that ICER exerts strongly its repressor function on CRE-containing genes. That an early expression of ICER blocks apoptosis, suggests that gene repression by endogenous ICER in IPC-81 is insufficient or occurs too late to protect cells against death. ICER transfected cells rescued from cAMP-induced apoptosis are growth arrested. It shows for the first time that CREM activation directly participates to the decision of the cell to die. ICER, by sequentially repressing distinct sets of CRE-containing genes could modulate cell fate.