Paroxysmal dystonic choreoathetosis with symptomatic seizures secondary to hypoglycemia caused by insulinoma

Neurological syndromes are not an uncommon presentation with insulinomas. Recurrent hypoglycemia associated with it can present with a variety of neurological symptoms that may include disturbances of consciousness, seizures, stroke-like presentation, movement disorder, dementia and chronic neuropathy. The myriad of presentations, resemblance with other neurological conditions and episodic nature often lead to misdiagnosis and a delay in definitive treatment. Rare cases of insulinoma presenting as combination of abnormal movements have been described. We report a patient who presented with both hypoglycemia induced symptomatic seizures and paroxysmal non-kinesiogenic dystonic choreoathetosis. Insulinoma is a potentially treatable disorder and early definitive intervention can prevent long term neurological disability in patients.     

A randomised controlled trial of a pilot intervention to encourage early presentation of oral cancer in high risk groups

Objective

Prognosis for oral cancer is substantially improved when diagnosed early. This research aimed to evaluate an intervention to promote early presentation of oral cancer.

Methods

Participants were randomly assigned to a leaflet group (n = 42), a one-to-one group (n = 46) or a control group (n = 24). Participants in the leaflet group read a theory-based (Extended Self-Regulatory Model; Social Cognitive Theory) leaflet on how to spot oral cancer early. Those in the one-to-one group received a brief, interactional discussion on early presentation of oral cancer and were then asked to read the leaflet. Participants in the control group received no information about oral cancer.

Results

The leaflet and the one-to-one instruction led to more accurate knowledge of oral cancer, decreased anticipated delay, and increased understanding, likelihood and confidence to perform self-examination. Neither intervention raised participants’ anxiety. There were minimal differences between the two interventions, yet both were superior to the control group.

Conclusion

This piloting indicates the initial effectiveness of an brief intervention purposefully designed for people at risk of developing oral cancer.

Practice implication

A low cost intervention may be a useful tool to encourage early detection of oral cancer. This could be embedded into routine consultations or an early detection programme.     

Patterns of differentiated thyroid cancer in Baluchistan Province of Pakistan: some initial observations

The incidence of thyroid cancer is increasing in several countries. The main objective of this retrospective study was to find and describe province-specific estimates of incidence in males and females by age groups for differentiated thyroid cancer (DTC). This study reports on 87 cases of DTC from Baluchistan province of Pakistan treated with post operative radioiodine at the Center for Nuclear Medicine and Radiotherapy (CENAR) Quetta from January 2003 to December 2009. The patient data has been collected from CENAR Quetta. Patients with DTC were confirmed by clinical examination, thyroid scintigraphy (Thyroid scan), blood tests (T3, T4, TSH) and histopathalogy tests and then treated with radioiodine. The Median age of the patients was 35.5 years (Range 12-70 years). The final histological diagnosis was papillary carcinoma in 71 (81.6 %) cases, follicular carcinoma in 6 (6.9%) cases while 10 (11.5%) cases presented with mixed papillary and follicular carcinoma. About 53 % cases were found in females with age 21-40 years. No strike predominance was observed in any age group for males. Four patients presented with recurrence while six patients showed metastasis in cervical lymph nodes. The small annual incidence did not follow any definite pattern. DTC has a small incidence in Baluchistan due to lack of education and health care facilities. The incidence of DTC is higher in females when compared with males as per this study. This preliminary study will provide an insight to incidence of DTC, its treatment facilities and future planning strategies in Baluchistan, Pakistan.     

Carprofen induction of p75NTR-dependent apoptosis via the p38 mitogen-activated protein kinase pathway in prostate cancer cells

The p75 neurotrophin receptor (p75(NTR)) functions as a tumor suppressor in prostate epithelial cells, where its expression declines with progression to malignant cancer. Previously, we showed that treatment with R-flurbiprofen or ibuprofen induced p75(NTR) expression in several prostate cancer cell lines leading to p75(NTR)-mediated decreased survival. Using the 2-phenyl propionic acid moiety of these profens as a pharmacophore, we screened an in silico database of 30 million compounds and identified carprofen as having an order of magnitude greater activity for induction of p75(NTR) levels and inhibition of cell survival. Prostate (PC-3 and DU-145) and bladder (T24) cancer cells were more sensitive to carprofen induction of p75(NTR)-associated loss of survival than breast (MCF-7) and fibroblast (3T3) cells. Transfection of prostate cell lines with a dominant-negative form of p75(NTR) before carprofen treatment partially rescued cell survival, showing a cause-and-effect relationship between carprofen induction of p75(NTR) levels and inhibition of survival. Carprofen induced apoptotic nuclear fragmentation in prostate but not in MCF-7 and 3T3 cells. Furthermore, small interfering RNA knockdown of the p38 mitogen-activated protein kinase (MAPK) protein prevented induction of p75(NTR) by carprofen in both prostate cell lines. Carprofen treatment induced phosphorylation of p38 MAPK as early as within 1 min. Expression of a dominant-negative form of MK2, the kinase downstream of p38 MAPK frequently associated with signaling cascades leading to apoptosis, prevented carprofen induction of the p75(NTR) protein. Collectively, we identify carprofen as a highly potent profen capable of inducing p75(NTR)-dependent apoptosis via the p38 MAPK pathway in prostate cancer cells.     

The aryl propionic acid R-flurbiprofen selectively induces p75NTR-dependent decreased survival of prostate tumor cells

Epidemiologic studies show that patients chronically consuming nonsteroidal anti-inflammatory drugs (NSAID) for arthritis exhibit a reduced incidence of prostate cancer. In addition, some NSAIDs show anticancer activity in vitro. NSAIDs exert their anti-inflammatory effects by inhibiting cyclooxygenase (COX) activity; however, evidence suggests that COX-independent mechanisms mediate decreased prostate cancer cell survival. Hence, we examined the effect of selected aryl propionic acid NSAIDs and structurally related compounds on the decreased survival of prostate cancer cell lines PC-3, DU-145, and LNCaP by induction of the p75(NTR) protein. p75(NTR) has been shown to function as a tumor suppressor in the prostate by virtue of its intracellular death domain that can initiate apoptosis and inhibit growth. The most efficacious compounds for induction of p75(NTR) and decreased survival, in rank-order, were R-flurbiprofen, ibuprofen, oxaprozin, fenoprofen, naproxen, and ketoprofen. Because R-flurbiprofen and ibuprofen exhibited the greatest efficacy, we examined their dose-dependent specificity of induction for p75(NTR) relative to other members of the death receptor family. Whereas treatment with R-flurbiprofen or ibuprofen resulted in a massive induction of p75(NTR) protein levels, the expression of Fas, p55(TNFR), DR3, DR4, DR5, and DR6 remained largely unchanged. Moreover, transfection of either cell line before R-flurbiprofen or ibuprofen treatment with a dominant negative form of p75(NTR) to antagonize p75(NTR) activity or p75(NTR) small interfering RNA to prevent p75(NTR) protein expression rescued both cell lines from decreased survival. Hence, R-flurbiprofen and ibuprofen selectively induce p75(NTR)-dependent decreased survival of prostate cancer cells independently of COX inhibition.     

Early expression of mature αβ TCR in CD4−CD8− T cell progenitors enables MHC to drive development of T-ALL bearing NOTCH mutations

During normal T cell development in mouse and human, a low-frequency population of immature CD4⁻CD8⁻ double-negative (DN) thymocytes expresses early, mature αβ T cell antigen receptor (TCR). We report that these early αβ TCR+ DN (EADN) cells are DN3b-DN4 stage and require CD3δ but not major histocompatibility complex (MHC) for their generation/detection. When MHC - is present, however, EADN cells can respond to it, displaying a degree of coreceptor-independent MHC reactivity not typical of mature, conventional αβ T cells. We found these data to be connected with observations that EADN cells were susceptible to T cell acute lymphoblastic leukemia (T-ALL) transformation in both humans and mice. Using the OT-1 TCR transgenic system to model EADN-stage αβ TCR expression, we found that EADN leukemogenesis required MHC to induce development of T-ALL bearing NOTCH1 mutations. This leukemia-driving MHC requirement could be lost, however, upon passaging the tumors in vivo, even when matching MHC was continuously present in recipient animals and on the tumor cells themselves. These data demonstrate that MHC:TCR signaling can be required to initiate a cancer phenotype from an understudied developmental state that appears to be represented in the mouse and human disease spectrum.

T cell acute lymphoblastic leukemia (T-ALL) is an aggressive hematologic malignancy arising from transformed immature T cell precursors (1). It represents ∼15% of pediatric and ∼25% of adult ALLs (2). Identification of subgroups with varied biological features, including overall relapse risk and responses to standard therapies, has allowed stratification of patients to the most appropriate therapeutic regimens that maximize efficacy, and has led to generally improved survival. However, prognosis remains poor for patients with treatment-refractory primary disease or relapse (3, 4). Clinical T-ALL can show inter- and intrapatient heterogeneity in the differentiation stage of tumor cells, implying that multiple pathways of cancer development exist (1, 5). Despite the heterogeneity, a unifying oncogenic network hub required for most or all T-ALL in humans and mice is hyperactivated (often mutated) NOTCH (6). Among the best understood causal drivers is developmentally early CD3 signaling at the pre-T cell antigen receptor (TCR)/γδTCR lineage bifurcation checkpoint, without a role for major histocompatibility complex (MHC)-based ligand (7–9). In contrast, a requirement for MHC and mature αβTCR to drive thymic leukemogenesis, resulting in mutant NOTCH-bearing tumors, has not been previously demonstrated.This makes sense based on the known relationship between T-ALL and T cell development. While there is overlap in NOTCH and developmentally early CD3 signals, cessation of NOTCH prior to MHC-restricted positive/negative selection signals mediated by αβTCR largely prevents simultaneous activity of the two receptors. Most conventional thymocytes rearrange first TCRβ and later TCRα loci in separate, ordered developmental stages. NOTCH signaling is required for early CD4⁻CD8⁻ double negative (DN) thymocyte development (10) while rearrangement of TCRβ and pre-TCR expression mediate β-selection, clonal expansion, and advancement to CD4⁺CD8⁺ double-positive (DP) stage (11). NOTCH signaling is then turned off (12), while DP thymocytes rearrange TCRα, express mature αβTCR, and test self-peptide-MHC reactivity in positive/negative selection (13).However, outside of this well-described sequence of events, a low-frequency, natural subset of DN thymocytes was once shown to rearrange and prematurely express the full αβTCR in wild-type mice (14). The cells were first detected in pre-Tα^−/− mice, where early TCRα replaced pre-Tα to provide β-selection signaling to generate DP cells. Conventional αβ T cell development potential was retained as proven in positive selection assays, but subsequent to the initial report little information on biological roles for these cells has followed. While pursuing developmental stages and signals in T-ALL leukemogenesis, we found that early αβTCR-expressing DN (EADN) cells can be generated in mouse and human thymus at a similar rate, and they are susceptible to T-ALL transformation in both species. We present a mouse model in which EADN oncogenesis requires MHC to drive development of T-ALL bearing NOTCH-mutations, highlighting a novel developmental state with unique signaling rules for a cancer phenotype that appears to be represented in the clinical, human disease spectrum.     

IgM monoclonal gammopathies of clinical significance: diagnosis and management

IgM monoclonal gammopathy of undetermined significance is a pre-malignant condition for Waldenström macroglobulinemia and other B-cell malignancies, defined by asymptomatic circulating IgM monoclonal protein below 30 g/L with a lymphoplasmacytic bone marrow infiltration of less than 10%. A significant proportion, however, develop unique immunological and biochemical manifestations related to the monoclonal protein itself in the absence of overt malignancy and are termed IgM-related disorders or, more recently, monoclonal gammopathy of clinical significance. The indication for treatment in affected patients is dictated by the pathological characteristics of the circulating IgM rather than the tumor itself. The clinical workup and treatment options vary widely and differ from those for Waldenström macroglobulinemia. The aim of this review is to alert clinicians to IgM monoclonal gammopathy of clinical significance and to provide practical guidance on when to screen for these phenotypes. We discuss clinical characteristics, the underlying clonal profile, diagnostic workup and treatment considerations for five important subtypes: cold agglutinin disease, type I and II cryoglobulinemia, IgM-associated peripheral neuropathy, Schnitzler syndrome and IgM-associated AL amyloidosis. The inhibition of the pathogenic effects of the IgM has led to great success in cold agglutinin disease and Schnitzler syndrome, whereas the other treatments are centered on eradicating the underlying clone. Treatment approaches in cryoglobulinemia and IgM-associated peripheral neuropathy are the least well developed. A multidisciplinary approach is required, particularly for IgM-related neuropathies and Schnitzler syndrome. Future work exploring novel, clone-directed agents and pathogenic IgM-directed therapies is welcomed.     

Prevention and management of secondary central nervous system lymphoma

Secondary central nervous system (CNS) lymphoma (SCNSL) is defined by the involvement of the CNS, either at the time of initial diagnosis of systemic lymphoma or in the setting of relapse, and can be either isolated or with synchronous systemic disease. The risk of CNS involvement in patients with diffuse large B-cell lymphoma is approximately 5%; however, certain clinical and biological features have been associated with a risk of up to 15%. There has been growing interest in improving the definition of patients at increased risk of CNS relapse, as well as identifying effective prophylactic strategies to prevent it. SCNSL often occurs within months of the initial diagnosis of lymphoma, suggesting the presence of occult disease at diagnosis in many cases. The differing presentations of SCNSL create the therapeutic challenge of controlling both the systemic disease and the CNS disease, which uniquely requires agents that penetrate the blood-brain barrier. Outcomes are generally poor with a median overall survival of approximately 6 months in retrospective series, particularly in those patients presenting with SCNSL after prior therapy. Prospective studies of intensive chemotherapy regimens containing high-dose methotrexate, followed by hematopoietic stem cell transplantation have shown the most favorable outcomes, especially for patients receiving thiotepa-based conditioning regimens. However, a proportion of patients will not respond to induction therapies or will subsequently relapse, indicating the need for more effective treatment strategies. In this review we focus on the identification of high-risk patients, prophylactic strategies and recent treatment approaches for SCNSL. The incorporation of novel agents in immunochemotherapy deserves further study in prospective trials.