Normal Antigen Levels Research Articles

Long-Term Outcomes After Surgical Resection of Pulmonary Metastases From Colorectal Cancer

Surgical resection has been widely performed on patients with pulmonary metastases from colorectal cancer with favorable outcomes. However, there are currently no standard surgical indications for pulmonary metastases. We reviewed 94 patients who underwent complete resection of pulmonary metastases from colorectal cancer between November 1991 and April 2013. The cumulative survival rate after pulmonary metastasectomy was calculated, and prognostic factors for long-term survival were analyzed. There were 60 men and 34 women, and their median age was 66 years. The 5-year survival rate was 45.5% after pulmonary metastasectomy. The 5-year survival of patients with colon and rectal cancers was 62.4% and 33.8%, respectively (p = 0.030), and the 5-year survival of those with normal and high carcinoembryonic antigen (CEA) levels before pulmonary resection was 57.0% and 30.9%, respectively (p = 0.038). Multivariate analysis revealed the preoperative CEA level was an independent prognostic factor. Recurrence was identified in 65 of the 94 patients (69.1%) after pulmonary metastasectomy, and the patients who underwent surgical resection for recurrent lesions in the liver or lungs, or both, had better survival than those who received other treatments or palliative care. Surgical resection offers a chance to prolong survival in colorectal cancer patients with resectable pulmonary metastases. Owing to the high recurrence rate, careful postoperative follow-up for early detection is recommended, and even for recurrence, surgical resection should be considered for better survival if the lesions are limited to the liver or lungs, or both.

Domain Specificity and Mechanism of Action of Anti-ADAMTS13 Antibodies at Presentation and Relapse in Acquired Thrombotic Thrombocytopenic Purpura (TTP)

Acquired thrombotic thrombocytopenic purpura (TTP) is an autoimmune disease due to autoantibodies (Auto-Ab) against ADAMTS13, resulting in a severe deficiency in enzyme activity (<10%). Little is known about the pathogenicity of anti-ADAMTS13 IgG directed against different domains of the enzyme, or how domain specificity alters between presentation, remission or TTP relapse. We developed novel assays to explore domain specificity and inhibitory potential of anti-ADAMTS13 IgG using samples from the UK TTP Registry.Full-length ADAMTS13 and ADAMTS13 fragments (MD, MDTC and MDTCS - N-terminal domains; TSR2-8 and CUB1/2 - C-terminal domains) were expressed in HEK293T cells and purified. Microtitre plates were coated with ADAMTS13 or ADAMTS13 fragments, incubated with TTP plasmas and bound IgG detected. Domain specificity was further analysed by preincubation of patient samples with ADAMTS13 fragments, assessing the ability of fragments to compete for full-length ADAMTS13 binding on the plate. From a cohort of 92 acquired TTP patients at presentation, 100% (92/92) contained auto-Ab that recognised ADAMTS13 N-terminal domains (MDTCS). Of these, 39% (36/92) had auto-Ab recognising the N-terminal domains alone, 22% (20/92) also had anti-TSR2-8, and 39% (36/92) had anti-CUB1/2 auto-Abs. There was no correlation between auto-Ab domain specificity and mortality/disease severity (anti-ADAMTS13 IgG titre, plasma exchanges to remission, platelet count and cardiac involvement).There was no evidence for auto-Ab recognising MD or MDTC domains in 25 patients tested, suggesting immunoreactivity for MDTCS was primarily mediated through the spacer domain. Consistent with this, TTP IgG inhibited proteolysis of VWF115 (a recombinant VWF A2 domain fragment), but failed to inhibit VWF106 proteolysis (VWF A2 domain fragment lacking the spacer domain binding exosite).To examine the inhibitory potency of anti-ADAMTS13 auto-Ab, IgG isolated from TTP patient samples were titrated in reactions measuring MDTCS-mediated proteolysis of FRETS-VWF73. Twenty eight out of 43 presentation samples tested had inhibitory IgG (IC50 ranging from <0.2-5μM total IgG). Addition of excess of MDTC to 19/19 of these samples did not alter the IC50, confirming inhibition in these samples is mediated solely by anti-spacer antibodies. Intriguingly, 15/43 patients had no evidence of inhibitory auto-Ab, suggesting the pathogenic mechanism in these cases may be enhanced clearance of ADAMTS13. We therefore determined ADAMTS13 antigen concentrations by ELISA. All patients at presentation exhibited markedly reduced ADAMTS13 antigen levels (n=91, median 58ng/ml (range 0-450) vs. normal n=67, median 951ng/ml (515-1829); p<0.0001). Interestingly, patients with predominantly C terminal auto-Ab and no evidence of inhibitory auto-Ab had significantly lower ADAMTS13 antigen levels at first presentation than the rest of the cohort (median 2ng/ml (0-141) vs. 57ng/ml (0-356); p=0.006).Cases where rituximab failed to normalise ADAMTS13 activity despite clinical remission were associated with the persistence of inhibitory anti-N-terminal auto-Ab. Two patients with persistently high anti-ADAMTS13 IgG but normal ADAMTS13 activity and antigen levels during remission had non-pathogenic anti-TSR2-8 antibodies that seemingly had no effect upon ADAMTS13 function or clearance. Nine out of 16 patients exhibited altered auto-Ab domain specificity upon relapse, with either loss or development of anti-C-terminal auto-Ab.In conclusion, from our functional studies ADAMTS13 inhibition appears to be mediated exclusively by anti-spacer antibodies, with no evidence for the presence of auto-Ab that recognise/inhibit other N terminal domains. Importantly, we demonstrate ADAMTS13 antigen depletion is a crucial pathogenic mechanism in acquired TTP, accounting for a large proportion of the reduced ADAMTS13 activity detected in patient samples. Our results suggest that auto-Ab directed against the C-terminal domains of ADAMTS13 may be particularly important in mediating this clearance. There is continual development of the autoimmune response during treatment of TTP patients that can result in altered domain specificity at relapse. DisclosuresNo relevant conflicts of interest to declare.

Laboratory Assessment of Anti-Coagulant Properties of a Von Willebrand Factor Targeted Aptamer

Introduction: Many cardiovascular procedures including percutaneous coronary intervention, coronary bypass surgery, and peripheral vascular surgery require antithrombotic therapy during the procedure. Heparin is frequently used, due to low cost, ease of monitoring and reversibility with protamine. Antiplatelet agents such as aspirin and clopidogrel are also frequently used but these agents are not reversible. Alternative reversible antithrombotic strategies that interfere with platelet-mediated thrombosis are needed. We are investigating the use of a reversible agent that is specific for von Willebrand factor (VWF) for use during cardiovascular procedures.We previously developed an antidote-controlled 80 oligonucleotide RNA aptamer Ch-9.14-T10 (T10). (Nimjee, S.M., Lohrmann, Wang, H, et al. Molecular Therapy 2012; 2:391-397). T10 bound to VWF with high affinity and inhibited thrombosis in a murine carotid artery damage model. The aptamer also greatly increased bleeding in mice that were surgically challenged by tail transection and blood loss decreased when complementary antidote oligonucleotides were administered. In addition, T10 inhibited primary hemostasis in the PFA-100 assay and this inhibition was completely reversed by the antidote. This study further characterizes the T10 aptamer, as well as a truncated version of the T10 aptamer, using clinical laboratory assays that would be used to monitor antithrombotic therapies during cardiovascular procedures.Methods: We initiated our study with T10 and then developed a truncated version, T25, a 60 oligonucleotide with which we performed additional investigations. We recruited normal donors for analysis of aptamer and antidotes. All participants had normal platelet counts, VWF activity and antigen levels, and were not taking antiplatelet agents. Laboratory tests included: ristocetin induced platelet agglutination (RIPA), VWF activity, ristocetin cofactor activity, cone and plate(let) analyzer, thromboelastography (TEG) and thromboelastometry (ROTEM).Results: We first determined the effects of the VWF aptamers on RIPA, VWF activity, and ristocetin cofactor activity to confirm functional inhibition of VWF. We found that T10 (500-750 nM) and T25 (250-750nM) completely inhibited RIPA depending on the donor. T25 also inhibited VWF activity with a Ki of 160-320 nM and ristocetin cofactor activity with an IC50 of 3000 nM. Employing a cone and plate(let) analyzer we found that T25 (750 nm) reduced platelet adhesion by 33-49% on a polystyrene surface under arterial flow conditions (1800 s-1, for 2 minutes). The aggregate size was also reduced by 30%.As ACT and TEG are frequently used during cardiovascular procedures, we performed several measures with our VWF aptamer. T10 had no effect on the ACT (730-2000nM), TEG (1600 nM), or ROTEM (750 nM). Standard methods were used for the TEG (Kaolin activation followed by CaCl2) and ROTEM (EXTEM assay) Topf et al. reported a modified ROTEM protocol where they found that incubating citrated whole blood with ristocetin decreased the clot strength as measured by the maximum amplitude (Thromb.Haemost 2011; 105:1091). We reasoned that an aptamer that bound to VWF would inhibit the effect of ristocetin on the maximum amplitude. We found that T25 did inhibit the effect of ristocetin and titration studies showed that 200-400 nM T25 was needed to restore the maximum amplitude to at least 80% of its original value. An example of the ROTEM tracings is shown in figure 1.Conclusion: The VWF-specific aptamer T25 can be detected by several clinical assays, including the RIPA, VWF activity assays, and the cone and plate(let) analyzer. It is not detectable by an ACT or standard TEG or ROTEM, however. We are able to detect the aptamer using a modified ROTEM and are further defining the adaptability of this assay to facilitate monitoring during cardiovascular procedures.Citrated whole blood from was incubated with buffer or ristocetin (0.7 mg/ml) or ristocetin and T25 (300 nM) as indicated. Clotting was initiated with EXTEM (tissue factor pathway activation) and CaCl2. [Display omitted] DisclosuresBecker:Regado Biosciences: Membership on an entity’s Board of Directors or advisory committees.

Presence of C1-inhibitor polymers in a subset of patients suffering from hereditary angioedema.

Hereditary angioedema (HAE) is a potentially life-threatening disease caused by mutations in the gene encoding the serine protease inhibitor (serpin) C1 inhibitor (C1-inh). The mutations cause decreased functional plasma levels of C1-inh, which triggers unpredictable recurrent edema attacks. Subjects suffering from HAE have been classified in type I patients with decreased functional and antigenic levels of C1-inh, and type II patients with decreased functional but normal antigenic C1-inh levels. However, a few reports have demonstrated that some mutations cause C1-inh polymerization in vitro, and it is speculated that C1-inh polymers may exist in patient plasma, challenging the current classification of HAE patients. To investigate the presence of C1-inh polymers in patient plasma samples, we developed an immunological method, where monoclonal antibodies produced against polymerized C1-inh were applied in native PAGE western blotting. Using this approach we analyzed genuine plasma samples from 31 Danish HAE families, and found that plasma samples from three genotypically distinct HAE type I families (classified upon C1-inh plasma concentrations) contained C1-inh polymers. Identical C1-inh polymerization phenotypes were observed in four affected family members from one of these families. Genotyping of the families revealed that the polymerogenic mutations of two families were located in proximity to the reactive center loop insertion site in C1-inh (p.Ile271Thr and p.Ser258_Pro260del),and one mutation affected helix C (p.Thr167Asn). In conclusion, we demonstrate that C1-inh polymers are present in the plasma of a subgroup of HAE type I patients.

A novel congenital dysprothrombinemia leading to defective prothrombin maturation

IntroductionProthrombin deficiency is a very rare disorder caused by mutations in the F2 gene that generate hypoprothrombinemia or dysprothrombinemia and is characterized by bleeding manifestations that can vary from clinically irrelevant to life-threatening. AimHere we characterize a patient with a novel missense mutation in F2, c.1090T/A (p.Val322Glu), that causes severe dysprothrombinemia. MethodsCoagulation assays, prothrombin Western Blotting, FII activation by Ecarin, fibrinogen degradation products quantification and thrombin generation assay were carried out to assess prothrombin expression and function. PCR followed by direct sequencing was carried out to characterize the mutation. In silico analysis for missense variant and molecular modeling were applied to predict the mechanism that leads to dysprothrombinemia. Results and conclusionsThe homozygous patient had a markedly prolonged prothrombin time, strongly reduced FII activity (0.82%) but normal antigen levels. In the thrombin generation assay the lag time and the peak height were unmeasurable, suggesting that the Val322Glu mutation results in the inability of the mutant prothrombin to be fully activated to thrombin. In fact, prothrombin activation by ecarin was defective, with a massive accumulation of the meizothrombin intermediate. Molecular modeling and dynamic simulation studies showed that the Val322Glu mutation interferes with protein flexibility at Arg271 and Arg320. This impairs the switch of the protein from zymogen to proteinase, thus preventing the formation of thrombin. Accumulated meizothrombin, however, maintains some fibrinogen-degrading activity, as shown by the formation of FDPs, and this probably explains the patient’s mild bleeding phenotype.

Functional characterization of a novel missense mutation, His147Arg, in A1 domain of FV protein causing type II deficiency

IntroductionCongenital factor V (FV) deficiency is a rare inherited disorder. Three compound heterozygous missense mutations, Asp68His, His147Arg, and Arg2074Cys, were observed in a Taiwanese patient with moderately severe FV deficiency. MethodThe novel His147Arg mutation in the A1 domain was investigated by protein modeling, followed by in vitro expression studies in COS-1 cells, to elucidate the molecular pathology associated with FV deficiency. ResultsThe His147Arg mutation was associated with normal antigen levels, both in cell lysates and conditioned media, whereas FV activity was significantly reduced to 63.5±17.0%. These observations correspond to a type II FV deficiency mutation. Protein modeling by short-duration molecular dynamics (MD) simulation showed that the His147Arg mutation was associated with a conformational change, which could disrupt the stability of FVa by interfering with His1817 coordination of the copper ion. In functional activation assays, the His147Arg mutation did not affect FV protein activation by thrombin; however, reduced cofactor activity of the FVa protein, due to an increased rate of dissociation of heavy and light chains, was observed. ConclusionOur results show that the His147Arg mutation in the A1 domain of FV does not impair synthesis or procoagulant activity. Instead, the His147Arg mutation appears to disrupt the stability of FVa, providing a potential explanation for the functional deficiency.

Accuracy of 18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography for Detection of Recurrent or Metastatic Colorectal Carcinoma in Patients with Rising Carcinoembryonic Antigen Levels

Objective: A rise in carcinoembryonic antigen level is commonly encountered during follow-up of patients with colorectal carcinoma. This study aimed to evaluate the diagnostic performance of 18 F-fluorodeoxyglucose positron emission tomography/computed tomography ( 18 F-FDG PET/CT) studies for detection of recurrent or metastatic colorectal carcinoma in patients with rising carcinoembryonic antigen levels. Methods: Patients with colorectal carcinoma in clinical remission with rising carcinoembryonic antigen levels who underwent PET/CT in Prince of Wales Hospital, Hong Kong from 2008 to 2011 were included. Patient demographics, carcinoembryonic antigen levels, and clinical follow-up data were recorded. Outcomes were determined by histopathological findings or at least 12-month follow-up. Results: Forty-two PET/CT studies of 37 patients (16 men and 21 women; mean [standard deviation] age, 65.8 [11.6] years) were included. Carcinoembryonic antigen levels ranged from 1.8 to 45 µg/l (9 patients had normal carcinoembryonic antigen levels of <5 µg/l, but serial carcinoembryonic antigen measurements showed a rising trend). Among the 42 events, 23 (55%) had a positive final diagnosis. The sensitivity, specificity, and positive and negative predictive values of PET/CT for recurrence or metastases were 91.3%, 89.5%, 91.3%, and 89.5%. Conclusion: 18 F-FDG PET/CT is a useful imaging modality to evaluate recurrence or metastases in patients with colorectal carcinoma in clinical remission but showing rising carcinoembryonic antigen levels.

Primary hepatic lymphoma in a patient with rheumatoid arthritis treated with methotrexate.

Primary hepatic lymphoma (PHL) has rarely been reported in patients with immunosuppression. We herein describe a case of Epstein-Barr virus- (EBV-) positive PHL in a 67-year-old Japanese woman receiving methotrexate (MTX) treatment for rheumatoid arthritis (RA). The patient, who had been receiving MTX therapy for more than 6 years, presented with low-grade fever and abdominal pain. Initial laboratory tests showed mildly elevated liver enzymes with normal levels of alpha-fetoprotein and carcinoembryonic antigen, and computed tomography scans revealed multiple hepatic tumors with no lymph-node swelling. Examination of liver specimens obtained via ultrasonography-guided needle biopsy indicated EBV-positive diffuse large B cell lymphoma; therefore, she was diagnosed with PHL. MTX was discontinued, and she was carefully monitored thereafter owing to the prolonged history of MTX administration for RA. Rapid progression of PHL was observed; therefore 10 days after the PHL diagnosis, she received 6 cycles of R-THP-COP (rituximab, cyclophosphamide, pirarubicin, vincristine, and prednisolone) therapy and achieved complete remission for more than 1 year. Although MTX-associated lymphoproliferative disorders often show remission after withdrawal of MTX, early diagnosis and treatment are essential for PHL in patients with RA treated with MTX, because of the aggressive nature of the disease.

Antithrombin-p.Ala416Pro: The Second Reported Case in Japan

A 42-year-old man was referred to our department due to recurrent deep venous thrombosis. He, his father and his aunt had low antithrombin (AT) heparin cofactor activity and progressive AT activity levels with normal AT antigen levels. A single nucleotide substitution of G to C was found at nucleotide position c.1246 in exon 7 of the patient's AT gene, resulting in a p.Ala416Pro mutation of AT. The same mutation was identified in his father and aunt, but not his sister, who had a normal AT level. These results show that the AT-p.Ala416Pro mutation was responsible for type IIa AT deficiency in this family.

Preferential autoimmune response in prostate cancer to cyclin B1 in a panel of tumor-associated antigens.

Previous studies have demonstrated that sera from patients with prostate cancer (PCa) contain autoantibodies that react with tumor-associated antigens (TAAs). Autoantibodies to cyclin B1 and fourteen other TAAs were detected by enzyme-linked immunosorbent assay (ELISA) and Western blotting in 464 sera from patients with PCa, benign prostatic hyperplasia (BPH), and other controls. Autoantibodies to cyclin B1 were detected in 31.0% of sera from randomly selected patients with PCa versus 4.8% in sera with BPH. In the further analysis, 31.4% of sera from PCa patients at the early stage contained anti-cyclin B1 autoantibody, and even 29.4% of patients who had normal prostate-specific antigen (PSA) levels in their serum samples were observed anti-cyclin B1 positive. The cumulative positive rate of autoantibodies against seven selected TAAs (cyclin B1, survivin, p53, DFS70/LEDGFp75, RalA, MDM2, and NPM1) in PCa reached 80.5%, significantly higher than that in normal control sera. In summary, autoantibody to cyclin B1 might be a potential biomarker for the immunodiagnosis of early stage PCa, especially useful in patients with normal PSA level. This study further supports the hypothesis that a customized TAA array can be used for enhancing anti-TAA autoantibody detection, and it may constitute a promising and powerful tool for immunodiagnosis of PCa.

Transfusion Of RBCs With Low-Density KEL Induces Tolerance To The KEL Antigen

BackgroundPatients requiring repeat transfusion often develop RBC specific alloantibodies that decrease the therapeutic efficacy of transfused cells and limit the availability of compatible RBCs for future transfusion. However, not all RBC antigens possess equal ability to induce alloantibodies. While many factors likely influence this process, several studies suggest that antigen density may independently influence rates of RBC alloimmunization. To directly examine this, we generated transgenic founders with normal or lower levels of the human KEL antigen specifically on RBCs and examined the impact of RBC antigen levels on the development of anti-KEL antibodies following transfusion. Materials and methodsTransgenic C57BL/6 founders expressing the human KEL antigen specifically on RBCs were generated using the β-globin promoter and screened for levels of KEL antigen using monoclonal anti-KEL antibodies by flow cytometric analysis. The number of KEL antigens on RBCs isolated from different founders was estimated using QIFIKIT beads. The molecular weight of KEL on RBCs isolated from each founder was assessed by Western blot analysis. C57BL/6 recipients were transfused with RBCs that expressed normal levels of KEL (KEL RBCs) or reduced levels of KEL (KELlo RBCs), followed by harvesting blood on days 3, 5, 7, 14, 21 and 28 following transfusion and analysis of serum for anti-KEL antibodies by indirect immunofluorescence using flow cytometry with KEL and control C57BL/6 RBCs as targets. In addition, C57BL/6 recipients were transfused with KELlo RBCs followed by KEL RBCs and similar analysis for anti-KEL antibody formation on days 3, 5, 7, 14, 21 and 28 following KEL RBC transfusion. All experiments were completed at least three times with 3–5 recipients per group per experiment. ResultsWhile KEL RBCs express approximately 1200 antigens per cell, KELlo RBCs express fewer than 200 KEL antigens. However, each KEL transgenic expressed a KEL protein of the predicted molecular weight (83 kD) as assessed by Western blot analysis. Transfusion of KEL RBCs induced IgM anti-KEL antibodies as early as 3 days post transfusion followed by peak IgG anti-KEL antibody levels 14 days following transfusion. In contrast, transfusion of KELlo RBCs failed to induce detectable IgM or IgG anti-KEL antibody formation following transfusion. Similarly, while antibodies could be detected on the surface of KEL RBCs following the development of detectable anti-KEL antibodies in the serum, no antibodies could be detected on KELlo RBCs following transfusion, although anti-KEL generated following KEL RBC transfusion readily bound KELlo RBCs in vitro. Although subsequent KEL RBC exposure following initial KEL RBC transfusion induced considerable increases in anti-KEL antibody formation, KEL RBC transfusion following initial KELlo RBCs transfusion completely failed to induce detectable IgM or IgG anti-KEL antibody formation. (All the above differences achieved a p value of <0.05). ConclusionsThese results suggest that RBC alloantigen density may significantly impact the immunological outcome of RBC transfusion. KELlo RBC transfusion not only failed to induce anti-KEL antibodies, but also induced an apparent state of tolerance to KEL RBCs following subsequent KEL RBC transfusion. Thus, antigen density may not only influence whether RBC alloimmunization occurs, but may also alter a recipient's subsequent response to the same antigen. These results also suggest that manipulation of RBCs to express lower levels of RBC antigens may provide a unique tool to tolerize individuals against RBC alloantigens. Disclosures:Zimring:Immucor Inc.: Research Funding; Terumo: Research Funding; Haemonetics: Consultancy; Cerus: Honoraria.

Analysis of prognostic factors in patients with stage IV lung adenocarcinoma after failure of second-line EGFR-TKIs therapy

背景与目的表皮生长因子受体酪氨酸激酶抑制剂（epidermal growth factor receptor-tyrosine kinases inhibitors, EGFR-TKIs）普遍应用后，其治疗失败后预后情况引起学界的关注。本研究旨在回顾性分析Ⅳ期肺腺癌患者的临床资料，探讨EGFR-TKIs治疗失败后影响预后的相关因素。方法收集2009年1月-2012年2月体能状态评分（performance status, PS）为0分-2分的Ⅳ期肺腺癌患者，随访至死亡。主要观察指标为EGFR-TKIs治疗失败后的生存时间（overall survival, OS）。结果共81例患者入组，中位OS为9.6个月（QL-QU: 5.4-19.2）。单因素分析显示，PS评分、多部位的转移及靶向药物治疗后出现中/大量胸水对预后有影响（P < 0.05），靶向治疗失败后血CEA水平正常及曾有手术史也表明患者更能得到生存时间获益的趋势。多因素分析显示，PS评分、多部位转移及靶向药物治疗后出现中/大量胸水可以作为Ⅳ期肺腺癌患者独立的预后因素（P < 0.05）。结论晚期肺腺癌PS评分为0分-1分、单脏器的转移及靶向药物治疗后出现无或少量胸水可获得较好的生存时间，应采取积极的化学药物治疗。

Unusual presentations of prostate cancer: A review and case reports

ObjectiveTo report our institutional experience with some rare presentations of prostate cancer, as prostate cancer is a common problem and affects a large group of men during their lifetime, but a few studies report unusual presentations of metastatic prostate cancer. MethodsAll possible clinical and pathological data were collected for six relevant patients with prostate cancer and unusual metastases who were identified at our institution. PubMed was searched for unusual presentations of prostate cancer in the last 20years (1982–2012) and all relevant publications were assessed. The authors discussed the reports and selected those articles of major clinical significance to include in a review. ResultsWe identified 19 reports of major clinical significance and reviewed them. As in the cases from our institution, supraclavicular lymphadenopathy, isolated upper ureteric obstruction and severe obstructing constipation were some of the rare presentations encountered at other institutions, and reported mostly as sporadic case-reports. ConclusionProstate cancer should be always considered in the differential diagnosis of elderly men presenting with supraclavicular lymphadenopathy, hydroureteronephrosis or constipation, even in the presence of a normal digital rectal examination and low serum total prostate-specific antigen (PSA) levels. PSA immunohistochemical staining should be used in doubtful cases.

A Rare Case of Small Bowel Angioedema with Normal C4 Level

Introduction: Angioedema is self-limited, localized subcutaneous (or submucosal) swelling, which results from extravagation of fluid into interstitial tissues. Angioedema may occur in isolation, accompanied by urticaria, or as a component of anaphylaxis. We describe a case of isolated angioedema of the bowel, a rare presentation, occurring in a man with normal C4 and C1q level. Case Description: A 23-year-old male with H/O no medical problems was admitted to our hospital for nausea, vomiting and abdominal pain for one day duration. He ate a large omelet for breakfast and few hours later developed urticaria, nausea and severe heartburn. He went to the nearest ER, where he was discharged on Benadryl and proton pump inhibitors. In the evening his symptoms progressed and nausea/vomiting worsened. He also had a colicky abdominal pain and diarrhea. The recent allergic triggers like tattoos, soaps, new foods, parenteral injections, detergents, medications like angiotensin-converting enzyme inhibitors, could not be identified. Family history was significant for allergic reaction in his father that caused him to break out in hives. Examination shows multiple urticarial lesions on both arms and shoulders. Lips are swollen and abdomen is soft with epigastric tenderness. CT scan of abdomen shows mild enteritis with mildly distended small bowel. Patient did not improve to initial conservative treatment consisting of nasogastric tube and antiemetics, but improved markedly with the steroid treatment. The patient work up including C4 level; C1 inhibitor antigenic level; C1q level was negative. Discussion: Angioedema affecting the bowel wall presents as colicky abdominal pain, sometimes accompanied by nausea, vomiting and/or diarrhea. Bowel wall edema can often be visualized by abdominal CT. It is seen in patients on ACE inhibitors and in those with hereditary or acquired C1 inhibitor deficiency. The particular case was unique because of normal C4 and C1 inhibitor antigenic level. The patient improved on antihistamines and steroids. High degree of suspicion for bowel wall angioedema is needed in a patient presenting with urticaria, severe nausea and vomiting, who is not improving with conservative treatment.

Early detection of high‐grade prostate cancer using digital rectal examination (DRE) in men with a prostate‐specific antigen level of &lt;2.5 ng/mL and the risk of death

Study Type--Prognosis (inception cohort) Level of Evidence 2a. What's known on the subject? and What does the study add? There is little data on the utility of digital rectal examination (DRE) as a diagnostic tool in the era of prostate-specific antigen (PSA) testing. Using a population-based database, we found that detection of prostate cancer while still localized among men with high-grade PSA-occult disease may result in survival benefit. • To determine whether detection of high-grade prostate cancer while still clinically localised on digital rectal examination (DRE) can improve survival in men with a normal prostate-specific antigen (PSA) level. • From the Surveillance, Epidemiology and End Results database, 166,104 men with prostate cancer diagnosed between 2004 and 2007 were identified. • Logistic regression was used to identify factors associated with the occurrence of palpable, PSA-occult (PSA level of <2.5 ng/mL), Gleason score 8-10 prostate cancer. • Fine and Gray's and Cox multivariable regressions were used to analyse whether demographic, treatment, and clinicopathological factors were associated with the risk of prostate cancer-specific mortality (PCSM) and all-cause mortality (ACM), respectively. • Both increasing age (adjusted odds ratio [aOR] 1.02, 95% confidence interval (CI) 1.01-1.03; P < 0.001) and White race (aOR 1.26, 95% CI 1.03-1.54; P = 0.027) were associated with palpable, Gleason 8-10 prostate cancer. Of 166,104 men, 685 (0.4%) had this subset of prostate cancer. • Significant factors associated with risk of PCSM included PSA level (adjusted hazard ratio [aHR] 0.71, 95% CI 0.51-0.99; P = 0.04), higher Gleason score (aHR 2.20, 95% CI 1.25-3.87; P = 0.006), and T3-T4 vs T2 disease (aHR 3.11, 95% CI 1.79-5.41; P < 0.001). • Significant factors associated with risk of ACM included age (aHR 1.03, 95% CI 1.01-1.06; P = 0.006), higher Gleason score (aHR 2.05, 95% CI 1.36-3.09; P < 0.001), and T3-T4 vs T2 disease (aHR 2.11, 95% CI 1.38-3.25, P < 0.001) • Clinically localised disease on DRE among men with PSA-occult high-grade prostate cancer was associated with improved PCSM and ACM, suggesting that DRE in this cohort (older age and White race) may have the potential to improve survival.

Clinicoradiologic characteristics of patients with lung adenocarcinoma harboring EML4-ALK fusion oncogene

IntroductionThe fusion oncogene of echinoderm microtubule-associated protein like 4 (EML4) and anaplastic lymphoma kinase (ALK) defines a new molecular subset of non-small-cell lung cancer. We explored the EML4-ALK gene in a relatively large cohort and reviewed the clinicoradiologic background of the patients. MethodsWe studied 720 patients with lung adenocarcinoma. The clinicopathological characteristics of each patient were compared among the subgroups stratified by the EML4-ALK gene status. For radiographic evaluation, we scored the proportion of the ground-glass opacity (GGO) component and calculated the tumor disappearance rate (TDR) in each tumor in the cohort of 168 patients that were extracted by using a case-matching procedure. ResultsTwenty-eight (3.9%) patients harbored the EML4-ALK gene. Younger age (p=0.001), no or light history of smoking (p=0.05) and normal serum carcinoembryonic antigen (CEA) level (p=0.04) were characteristics of the patients with EML4-ALK. No significant difference was observed for overall and disease free survival between the two groups. All but one tumor in the EML4-ALK-positive group exhibited no GGO, whereas half of the tumors (69/140 patients) in the EML4-ALK-negative group exhibited some GGO (p=0.0004). The mean TDRs were 0.33 and 0.54, respectively, which was significantly lower in the positive group (p=0.0006). ConclusionsWe identified younger age, no or light history of smoking, and normal serum CEA as clinical features of patients with EML4-ALK-positive lung adenocarcinoma. In addition, EML4-ALK-positive tumors exhibited a solid pattern on CT. These features may be of value in predicting for patient selection for ALK inhibition therapy in the absence of genetic screening.

Carbohydrate antigen 19-9 is a valuable prognostic factor in colorectal cancer patients with normal levels of carcinoembryonic antigen and may help predict lung metastasis

We retrospectively analyzed preoperative levels of carbohydrate antigen (CA) 19-9 in colorectal cancer (CRC) patients to determine the prognostic value of CA19-9 in CRC patients with normal carcinoembryonic antigen (CEA) levels. A total of 639 patients who underwent curative surgery at Taipei Veterans General Hospital between 2002 and 2006 were enrolled. We excluded 254 patients (39.7%) with high preoperative CEA levels and analyzed 385 patients with normal CEA levels. The measured endpoint was the postoperative disease-free survival (DFS). The prognostic value of CA19-9 was determined using log-rank test and Cox regression analysis. High CA19-9 levels were significantly associated with advanced disease and were detected in 5.8% of patients with stage I disease, 11.7% of those with stage II disease, and 22.5% of those with stage III disease (P < 0.001). The 5-year DFS in patients with normal CA19-9 levels was 82.0%, which was significantly higher than that in patients with high CA19-9 levels (68%; P < 0.001). In a multivariate analysis, the most important independent factor affecting the 5-year DFS was tumor-node-metastasis stage (95% CI, 1.26-2.36; HR = 1.72). After stratification by other factors, high CA19-9 level remained an independent prognostic factor for patients with normal CEA levels. Patients with high CA19-9 levels also showed a higher incidence of lung metastasis (23.1%) than those with normal CA19-9 levels (7.2%). CA19-9 may be a prognostic factor for CRC patients with normal CEA levels. An aggressive follow-up protocol for lung metastasis should be used for these patients.

Adjuvant Chemotherapy With or Without Pelvic Radiotherapy After Simultaneous Surgical Resection of Rectal Cancer With Liver Metastases: Analysis of Prognosis and Patterns of Recurrence

To investigate the outcomes of adjuvant chemotherapy (CT) or chemoradiotherapy (CRT) after simultaneous surgical resection in rectal cancer patients with liver metastases (LM). One hundred and eight patients receiving total mesorectal excision for rectal cancer and surgical resection for LM were reviewed. Forty-eight patients received adjuvant CRT, and 60 were administered CT alone. Recurrence patterns and prognosis were analyzed. Disease-free survival (DFS) and overall survival (OS) rates were compared between the CRT and CT groups. The inverse probability of the treatment-weighted (IPTW) method based on the propensity score was used to adjust for selection bias between the two groups. At a median follow-up period of 47.7 months, 77 (71.3%) patients had developed recurrences. The majority of recurrences (68.8%) occurred in distant organs. By contrast, the local recurrence rate was only 4.7%. Median DFS and OS were not significantly different between the CRT and CT groups. After applying the IPTW method, we observed no significant differences in terms of DFS (hazard ratio [HR], 1.347; 95% confidence interval [CI], 0.759-2.392; p = 0.309) and OS (HR, 1.413; CI, 0.752-2.653; p = 0.282). Multivariate analyses showed that unilobar distribution of LM and normal preoperative carcinoembryonic antigen level (<6 mg/mL) were significantly associated with longer DFS and OS. The local recurrence rate after simultaneous resection of rectal cancer with LM was relatively low. DFS and OS rates were not different between the adjuvant CRT and CT groups. Adjuvant CRT may have a limited role in this setting. Further prospective randomized studies are required to evaluate optimal adjuvant treatment in these patients.

Treatment of an acute attack of type III hereditary angioedema with ecallantide

Hereditary angioedema (HAE) is a rare genetic condition characterized by recurrent attacks of nonpruritic, localized edema involving the face, extremities, gastrointestinal tract, and upper respiratory tract. Laryngeal attacks may be life-threatening. The 2 classic subtypes of HAE are caused by mutations in the C1 esterase inhibitor (C1-INH) gene, resulting in either a deficiency of C1-INH (type I HAE) or dysfunctional C1-INH (type II HAE).1 Type III HAE is a newly identified and extremely rare subtype of HAE that is characterized by normal C1-INH antigenic and functional levels.

Acquired von Willebrand syndrome in multiple myeloma

Acquired von Willebrand syndrome (AvWS) is an uncommon complication of multiple myeloma (MM), and it is believed to be connected with paraprotein. The aim of this study was to determine the incidence of AvWS in patients with MM, and estimate the role of paraprotein in its occurrence. The study included 40 patients with MM. The plasma level of paraprotein, platelet adhesion on glass pearls, plasma von Willebrand factor antigen concentration, and ristocetin-induced platelet aggregation (RIPA) were measured initially. Absence of RIPA was found in six patients with MM (15%); however, all six of them had normal levels of von Willebrand factor antigen. Paraprotein was isolated from the serum of these patients. Platelet aggregation was measured in six healthy donors before and after addition of the isolated paraprotein. RIPA was significantly decreased in healthy donors in the presence of paraprotein (P<0·001). The same test was repeated with added human immunoglobulins for intravenous use without any change in RIPA. A significant negative correlation between plasma paraprotein level and RIPA was found (P<0·001). These investigations have shown that paraprotein is associated with AvWS in patients with MM.