Renal cell carcinoma classification: what matters?

Renal cell carcinoma classification may seem to be increasing dramatically in complexity over the last 10 years. Although integration of morphology, immunohistochemistry, and molecular features continues to refine different tumor types and dissect subgroups from long-established categories of renal cancer, only a select subset of these distinctions are of highest importance for clinical management. In the metastatic setting, distinction of clear cell from non-clear cell renal cancer is important, as there are different treatment pathways for these two groups. Another select handful of tumor types are highly aggressive (sarcomatoid, medullary, collecting duct, and fumarate hydratase-deficient carcinomas), which may necessitate different therapy from other non-clear cell carcinomas. A few tumor types are highly favorable, especially chromophobe carcinoma and clear cell papillary carcinoma (which is likely to be reclassified as a “tumor” rather than carcinoma soon). Still other tumor histologies often imply a hereditary syndrome solely based on their diagnosis, particularly succinate dehydrogenase-deficient and fumarate hydratase-deficient cancers. Although several eosinophilic tumor types with subtly different features have been recently recognized, it is not clear at present that discriminating them from chromophobe carcinoma is critical, as behavior appears to be largely favorable. Therefore, although some aspects of surgical pathology rely heavily on molecular diagnostics, histologic pattern and select immunohistochemical markers can resolve the differential diagnosis in most renal neoplasms, without need for complex molecular analysis.     

Hematopoietic stem cell transplantation for autoimmune diseases: what have we learned?

Numerous individuals and institutions throughout the world have contributed to the development of hematopoietic stem cell transplantation (HSCT) for autoimmune diseases. In this review, we will summarize what we have learned at our own institution (Northwestern University), and how it has guided our therapy. An emphasis will be placed on both the scientific basis for the development of autologous hematopoietic stem cell transplantation and a summary of the data in a variety of human diseases.     

Statin therapy for primary prevention in men: What is the role for coronary artery calcium?

Current cholesterol guidelines for primary prevention of atherosclerotic cardiovascular disease (ASCVD) base statin treatment decisions on multiple risk factor algorithms (e.g., Pooled Cohort Equations [PCEs]). By available PCEs, most older middle-aged men are statin eligible. But several studies cast doubt on predictive accuracy of available PCEs for ASCVD risk assessment. Recent studies suggest that accuracy can be improved by measurement of coronary artery calcium (CAC). This method has the advantage of identifying men at low risk in whom statin therapy can be delayed for several years, provided they are monitored periodically for progression of CAC. Thus, there are two approaches to statin therapy in men ≥ 55 years: first all men could be treated routinely, or second, treatment can be based on the extent of coronary calcium. The latter could allow a sizable fraction of men to avoid treatment for several years or indefinitely. Whether with initial CAC scan or with periodic rescanning, a CAC score ≥ 100 Agatston units is high enough to warrant statin therapy. In otherwise high-risk men (e.g., diabetes, severe hypercholesterolemia, 10-year risk by PCE ≥ 20%), a statin is generally indicated without the need for CAC; but in special cases, CAC measurement may aid in treatment decisions.     

Chronic inflammatory demyelinating polyradiculoneuropathy: a role for haematopoietic stem cell transplantation?

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a clinical syndrome of a chronic progressive or relapsing and remitting, symmetrical, sensory and motor radiculoneuropathy. The immune reaction in CIDP is characterised by selective inflammation of peripheral nerves and is probably due to the interaction of cellular and humoral responses. Only three treatments for CIDP have demonstrated benefit in randomised studies, corticosteroids, plasma exchange and intravenous immunoglobulin. 25% of patients fail to respond or do not respond adequately to these treatments. Experimental data in animal models have shown that several autoimmune disorders, either congenital or acquired, can be transferred and/or treated by the transplantation of bone marrow stem cells. Haematopoietic stem cell transplantation (HSCT) has been performed with varying success in over 700 patients with autoimmune disorders throughout Europe. The experience in CIDP is very limited. This article will review current understanding of CIDP and experience of the use of HSCT in refractory CIDP.     

Chronic inflammatory demyelinating polyradiculoneuropathy: A role for haematopoietic stem cell transplantation?

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a clinical syndrome of a chronic progressive or relapsing and remitting, symmetrical, sensory and motor radiculoneuropathy. The immune reaction in CIDP is characterised by selective inflammation of peripheral nerves and is probably due to the interaction of cellular and humoral responses. Only three treatments for CIDP have demonstrated benefit in randomised studies, corticosteroids, plasma exchange and intravenous immunoglobulin. 25% of patients fail to respond or do not respond adequately to these treatments. Experimental data in animal models have shown that several autoimmune disorders, either congenital or acquired, can be transferred and/or treated by the transplantation of bone marrow stem cells. Haematopoietic stem cell transplantation (HSCT) has been performed with varying success in over 700 patients with autoimmune disorders throughout Europe. The experience in CIDP is very limited. This article will review current understanding of CIDP and experience of the use of HSCT in refractory CIDP.     

Atherosclerosis,multiple sclerosis,and Alzheimer's disease: what role for Herpesviridae?

Herpesviridae are ubiquitous, and are commonly involved in well identified diseases as genital herpes, chickenpox and herpes zoster, infectious mononucleosis, exanthem subitum... They are responsible for latent and chronic infections after primary infection. Atherosclerosis, multiple sclerosis, Alzheimer's disease are diseases which are very different, and for which pathogenesis remains unknown. Several authors have hypothesized that Herpesviridae could play a role in such diseases. The present paper reviews arguments not only in favour but also against such hypothesis. Any formal conclusion is impossible, and more extensive studies are warranted.     

Dendritic cell CD83: a therapeutic target or innocent bystander?

CD83 represents an intriguing target for immunotherapy due to its preferential expression on mature DCs, the most efficient of antigen presenting cells. Based on its restricted expression pattern, structure, and the paucity of CD4+ T cells in CD83-deficient mice, multiple immunologically important functions for CD83 during immune responses have been proposed. Indeed, several studies have reported that CD83 blockade using soluble receptor constructs inhibits T cell responses in vitro and in vivo, can affect autoimmune disease development and progression, and can inhibit transplant rejection. However, others have not been able to reproduce some of these findings, and antigen presenting cells deficient in CD83 expression or expressing a mutated form of CD83 induce normal T cell responses in vitro. This review examines the controversy surrounding CD83 function, alleged CD83 ligands, the potential therapeutic utility of recombinant proteins targeting CD83 function, and the importance of soluble serum CD83. While the validity of multiple previous studies needs to be confirmed, CD83 remains a fascinating cell surface molecule with a unique pattern of expression that has multiple confirmed functions in regulating immune system development and function.     

Macrophage activation syndrome in rheumatic disease: what is the role of the antigen presenting cell?

Macrophage Activation Syndrome (MAS), alternatively referred to as secondary hemophagocytic lymphohistiocytosis (HLH), is a complication of many rheumatic diseases, most commonly Systemic Juvenile Idiopathic Arthritis (SJIA). MAS consists of a fulminant picture of pan-cytopenia, hectic high fevers, hepatosplenomegaly, lymphadenopathy, rash, and central nervous systemic inflammation. It can arise from genetic defects in the cytotoxic effector response of CD8+ T-cells, resulting in an inability to terminate antigen presentation, which in turn leads to uncontrolled immune activation. However, in the case of most rheumatic diseases, no such defect in cytotoxic killing is present. Little is known about what the contributions from the antigen presenting cells are in the pathogenesis of MAS. In fact, macrophages may be playing a regulatory, anti-inflammatory in MAS. We review the proposed pathogenesis of MAS/HLH, what role macrophages may play in the disease, and the relationship of MAS to its most common associated rheumatic disease, SJIA.     

Are stem cell characteristics altered by disease state?

Autologous stem cell transplantation combined with gene therapy can potentially be used to treat genetically inherited diseases. However, characterization of multipotential cells from a disease state remains extremely limited. We have characterized adult bone marrow stromal cells (MSCs) derived from three retinal degenerative mouse models and compared them to marrow stromal cells derived from their normal strain counterparts. Despite similar profiles soon after harvest, at 30 days postisolation, marrow stromal cells derived from a disease origin were shown to contain a large pool (approximately 89-99%) of undifferentiated marrow stromal cells (CD90(+)/STRO-1(+)) as compared to their normal counterparts (approximately 19-43%). Fetal bovine serum appeared essential for marrow stromal cell proliferation and was not found to induce differentiation, although it could be substituted with other additives including epidermal growth factor (EGF), platelet-derived growth factor (PDGF), and leukemia inhibitory factor (LIF). We also showed that resulting CD90(+)/STRO(+) cells derived from both states could be directed into desired lineages expressing at the same rate and that they could be transduced with the same efficiency using different viral vehicles. This investigation has shown the existence of a large pool of undifferentiated stem cells derived from the disease state that have the potential to form the desired cell types when appropriately cued.     

Stem cell transplantation for autoimmune diseases: what can we learn from experimental models?

Using animal models for autoimmune diseases, we have previously shown that allogeneic bone marrow transplantation (allo BMT) can be used to treat autoimmune diseases. Using cynomolgus monkeys, we have recently developed new BMT methods for the treatment of autoimmune diseases. The methods include the perfusion method (PM) for the collection of bone marrow cells (BMCs), and intra-bone marrow (IBM)-BMT for the direct injection of collected whole BMCs into the bone marrow cavity. The PM, in comparison with the conventional aspiration method, can minimize the contamination of BMCs with T cells from the peripheral blood. Therefore, without removing T cells, no graft-versus-host disease (GvHD) develops in the case of the PM. Since BMCs collected by the PM contain not only hemopoietic stem cells (HSCs) but also mesenchymal stem cells (MSCs), the injection of both cells directly into the bone marrow cavity (IBM-BMT) facilitates the engraftment of donor hemopoietic cells. In organ allografts with IBM-BMT, no graft failure occurs even if the radiation dose is reduced. In addition, IBM-BMT is applicable to regeneration therapy and various age-associated diseases such as osteoporosis, since it can efficiently recruit donor-derived normal MSCs. We have also found that IBM-BMT in conjunction with donor lymphocyte infusion can prevent GvHD, but suppress tumor growth. We believe that this strategy heralds a revolution in the field of transplantation (BMT and organ allografts) and regeneration therapy.     

Knee osteoarthritis: a role for bradykinin?

Osteoarthritis (OA) is a painful and degenerating progressive disease of the joints which affects millions of patients worldwide. The cause of OA is largely unknown. Among the potential therapies for the symptomatic treatment of OA, the intra-articular administration of a specific bradykinin (BK) B(2) receptor antagonist has been reported to produce a long lasting analgesic effect in patients affected by knee OA. BK is a vasodilator and inflammatory nonapeptide which is generated in OA synovium. It contributes to the initiation and maintenance of inflammation, to exciting and sensitizing sensory nerve fibres, thus producing pain, and to activating synoviocytes and chondrocytes which are the main cells involved in the homeostasis of synovial fluid and cartilage, respectively. Moreover, BK synergistically potentiates the effects produced by pro-inflammatory cytokines. Biochemical and preclinical evidence supporting the therapeutic relevance of B(2) receptor blockade in OA pathophysiology are reviewed in this publication.