Microdissection genotyping of archival fixative treated tissue for Gaucher disease

The genetic diagnosis of Gaucher disease by molecular methods is complicated by the existence of a highly homologous transcribed pseudogene (96% identity) that is found in close proximity to the true gene on chromosome 1q21. In addition, the pseudogene sequence can mimic disease-causing mutations in the true gene. Selective polymerase chain reaction (PCR) amplification of the true gene can be accomplished in extracted DNA from fresh-frozen samples by designing oligonucleotide primers to hybridize to defined regions that are not present in the pseudogene. This standard molecular approach, which entails amplification of relatively long segments of intact DNA, is not feasible in archival, paraffin-embedded, solid-tissue specimens in which the negative effects of chemical fixation result in DNA strand scission and breakdown of nucleic acid. A novel approach, specifically created for use with archival, fixative-treated tissue specimens, was developed for detection and characterization of common mutations of Gaucher disease. Three separate robust PCR reactions were formulated, 2 for selective amplification of portions of only the true gene exons 2 and 9, with a third reaction targeting exon 10, wherein both the true and pseudogene were coamplified. In the latter, DNA sequencing was used to determine the presence of true and pseudogene allele content in addition to identification of base sequence alterations. This method, requiring a single, 4-microm-thick histologic section, was successfully applied to archival paraffin block tissue specimens that had been in storage for up to 75 years. It was capable of accurately genotyping common Gaucher disease mutations as well as discovering a novel mutation and genetic polymorphism. We recommend our approach when only fixative-treated tis sue is available for molecular genotyping.     

Jejunal gastrointestinal stromal tumor: a cause of obscure gastrointestinal bleeding

In cases of obscure gastrointestinal bleeding, when a source for blood loss is not apparent from examination of the colon and upper gastrointestinal tract, the small bowel usually becomes the focus of investigation. A tumor with interesting pathologic features was found in a patient who presented with recurrent episodes of massive obscure gastrointestinal hemorrhage. This case highlights the importance of considering small intestinal tumors as the likely cause of obscure gastrointestinal hemorrhage in young patients and how a noninvasive test, eg, abdominal computed tomography scan, might obviate the need for more invasive testing.     

Evaluation of anticancer drug schedule dependency using an in vitro human tumor clonogenic assay

Summary A human tumor clonogenic assay (HTCA) has been used to evaluate standard and experimental anticancer drugs with respect to thrir inhibition of clonogenicity of both fresh human cancers and human tumor cell lines. By comparing the inhibitory effect on tumor colony-forming unit (TCFU) growth of 1-h and continuous drug exposures in the HTCA we were able to identify and separate schedule-dependent (e.g., bleomycin, vinblastine, and etoposide) and schedule-independent drugs (e.g., actinomycin D, adriamycin, basantrene, and cis-platinum). Vinblastine, bleomycin, and etoposide, which are known to have cell cycle-specific characteristics, caused exponential reduction in tumor colony formation when given by continuous exposure, whereas when given with a short exposure each of these drugs caused plateau-type dose-response curves. For comparison of the relative efficacy of the two dosing schedules, a ratio (1-h versus continuous exposures) was calculated of the drug concentrations which reduced growth of TCFU to 50% of the control values (ID₅₀) for fresh human tumors and human tumor cell lines. For fresh tumors, ID₅₀ ratios for adriamycin, actinomycin D, and bisantrene ranged between 2 and 60 (median 14), whereas the ID₅₀ ratios for bleomycin, vinblastine, and etoposide ranged between 100 and 3,000 (median 600). The fact that actinomycin D, adriamycin, and bisantrene (a new anthracene-type drug) had similarly shaped dose-response curves and very low ID₅₀ ratios suggests that the cytotoxicity of these compounds may not be schedule-dependent. On the other hand, the steep dose-survival curves we observed after continuous drug exposure and the high ID₅₀ ratios of bleomycin, vinblastine, and etoposide suggest that these drugs may possess schedule-dependent cytotoxicity characteristics. Before final conclusions are drawn concerning a drug's schedule dependency it is essential to evaluate its in vitro stability and protein-binding characteristics. Finally, it must be emphasized that unlike the results obtained with 1-h exposure studies, the in vitro continuous exposure schedules have yet to be shown to be predictive of clinical response for any agent or tumor type.     

Comparison of benign and malignant insulinoma

BackgroundHow malignant insulinomas present relative to benign insulinomas is unknown.MethodsA single-institution retrospective study identified patients with insulinoma. Malignancy was defined by distant metastases, positive lymph node(s), T stage of 4, direct invasion into surrounding peripancreatic tissue, or presence of lymphovascular invasion. Wilcoxon Rank Sum tests and Kaplan-Meier analysis were used.ResultsA total of 311 patients were identified: 51 malignant and 260 benign. Patients with malignant insulinoma presented with higher levels of insulin, proinsulin, and c-peptide. Malignant lesions were larger: 4.2 ± 3.2 vs 1.8 ± 0.8 cm in benign lesions, p < 0.01. Overall survival at 5 years was 66.8% vs 95.4% for malignant and benign insulinoma respectively, p < 0.01.ConclusionsLarger size of insulinoma and increased serum β-cell polypeptide concentrations were associated with malignancy. Malignant insulinoma has poorer survival. Further work-up to rule out malignancy may be indicated for larger pancreatic lesions and for patients with higher pre-operative insulin and pro-insulin.     

Is same-day discharge associated with increased 30-day postoperative complications and readmissions in patients undergoing laparoscopic adrenalectomy?

BackgroundAdvances in minimally invasive surgery and perioperative care have decreased substantially the duration of time that patients spend recovering in hospital, with many laparoscopic procedures now being performed on an ambulatory basis. There are limited studies, however, on same-day discharge after laparoscopic adrenalectomy. The objectives of this study were to investigate the outcomes and trends of ambulatory laparoscopic adrenalectomy in a multicenter cohort of patients.MethodsAdult patients who underwent elective laparoscopic adrenalectomy between 2005 and 2016 were identified in the database of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Baseline demographics and 30-day outcomes were compared between patients who underwent ambulatory laparoscopic adrenalectomy and those who were discharged after an inpatient stay. Multivariable logistic regression and Cox proportional hazards modelling were used to investigate the association between same-day discharge and 30-day complications and unplanned readmissions.ResultsOf the 4,807 patients included in the study, 88 (1.8%) underwent ambulatory laparoscopic adrenalectomy and 4,719 (98.2%) were admitted after the adrenalectomy. The same-day discharge group contained fewer obese patients (37.2% vs 50%; P = .04), a lesser proportion of American Society of Anesthesiologists class III patients (45.5% vs 61%; P = .003), and more patients with primary aldosteronism (14.8% vs 6%; P = .002) compared with the inpatient group. After adjustment for confounders, same-day discharge was not associated with 30-day overall complications (OR 1.17, 95% CI 0.35–3.85; P = .80) or unplanned readmissions (HR 2.77, 95% CI 0.86–8.96; P = .09). The percentage of laparoscopic adrenalectomies performed on an ambulatory basis at hospitals participating in the ACS NSQIP remained low throughout the study period (0–3.1% per year) with no evidence of an increasing trend over time (P = .21).ConclusionAmbulatory laparoscopic adrenalectomy is a safe and feasible alternative to inpatient hospitalization in selected patients. Further study is needed to determine the cost savings, barriers to uptake, and optimal selection criteria for this approach.     

Phase II evaluation of esorubicin (4′ deoxydoxorubicin) in pancreatic adenocarcinoma: A Southwest Oncology Group study

Summary Esorubicin (4 deoxydoxorubicin) is a new analogue of the anthracycline, doxorubicin. This compound lacks the hydroxyl group at 4 position on the amino sugar of the anthracycline. Phase II study was designed to determine the clinical response rate and to define the qualitative and quantitative toxicities of esorubicin in patients with adenocarcinoma of the pancreas. Fifty-eight patients with inoperable adenocarcinoma of the pancreas were entered on the study, 47 were evaluable for response, and 57 were evaluable for toxicity. The dose of esorubicin was 30 mg/m² for good risk patients and 25 mg/m² for poor risk patients every 21 days and administered IV push through a side arm of a running IV. Diphenhydramine, 50 mg is administered IM prior to the administration of the drug to block local venous reaction. Subsequent doses of esorubicin were modified according to granulocyte and platelet nadirs and the drug was not administered until recovery of platelets (> 100,000/ul) and wbc (> 3000/ul). Three partial responses, 20 stable, and 31 with increased disease were observed. Forty-seven had severe granulocytopenia (< 250), and two patients had severe thrombocytopenia (< 25,000). One patient experienced a decrease in left ventricular ejection fraction with a total dose of 180 mg/m². The dose of esorubicin in this study demonstrated that the drug has minimal activity in adenocarcinoma of the pancreas but the toxicity is tolerable. Search should continue for single agents with activity in this disease.