A human myeloma immunoglobulin G binding four moles of calcium associated with asymptomatic hypercalcemia

A calcium-binding immunoglobulin G (IgG_I^RUP) was identified in the serum of a patient with multiple myeloma, asymptomatic hypercalcemia, and a normal ionized serum calcium. Calcium binding by IgG^RUP was confirmed by two-dimensional electrophoresis with calcium-45 and equilibrium dialysis. Amino acid analyses indicated an unusually high number of glutamic (or glutamine) residues in the L chain and Fab fragment but no detectable -carboxyglutamic acid. As determined by equilibrium dialysis with⁴⁵Ca, the intact IgG^RUP and its Fab fragments bound calcium at an optimum pH of 7.4. There was minimal binding of calcium to H chains and no binding by L chains or the Fc fragment. Recombination of H and L chains partially restored the binding activity. By Scatchard analysis, the binding affinity (K _d) of IgG^RUP was 1.7×10^–3 M and the binding capacity was 4 mol of calcium/mol of IgG. The binding of 4 mol of calcium/mol of IgG is twice that reported previously for two other calcium-binding myeloma proteins and suggests unique properties of IgG^RUP.     

Specific measurement of o-linked core 2 sugar-containing isoforms of hyperglycosylated human chorionic gonadotropin by antibody b152.

There have been a significant number of reports on the clinical utility of measurement of 'hyperglycosylated' isoforms of the pregnancy hormone, human chorionic gonadotropin (hCG). Although there are a variety of hCG isoforms which can be termed 'hyperglycosylated', the measurements were all made using a unique antibody designated B152. This antibody was raised using a choriocarcinoma-derived form of hCG, which was hyperglycosylated with N- and O-glycans and was also 100% 'nicked' hCG. Antibody B152 was recently mapped to a linear epitope around a single O-glycan on the beta-subunit of hCG at residue number 132. Thus, the antibody can only measure isoforms of hCG that possess a core 2 type of branched O-glycan on this portion of the hCG beta-subunit. Isoforms that are hyperglycosylated in the hCG alpha-subunit or only on the N-glycans of hCGbeta will not be recognized by antibody B152. Apparently, measurements of these core 2 hCG isoforms have important clinical application in early pregnancy during which they are the predominant isoform of hCG until the 6th week of gestation. The secretory pattern of these isoforms can be used to predict the health status of the pregnancy in fertility clinics. Moreover, the measurements of these core 2 hCG isoforms are more useful than standard hCG for the prediction of Down syndrome pregnancies. The core 2 isoforms are also of important use in cancer diagnosis and monitoring since their concentration appears to correlate with malignancy.     

Peripheral blood progenitor cells mobilized by chemotherapy plus granulocyte-colony stimulating factor accelerate both neutrophil and platelet recovery after high-dose VP16, ifosfamide and cisplatin

Summary. We report on the chemotherapy plus granulocyte colony-stimulating factor (G-CSF) induced mobilization of peripheral blood progenitor cells (PBPCs) and their impact on haematopoietic recovery following high-dose chemotherapy. Twenty-four patients with advanced solid tumours or lymphomas received standard-dose chemotherapy with VP16, ifosfamide and cisplatin (VIP) followed by filgrastim (G-CSF; 5 μg/kg s.c. daily for 14 d) for the prevention of chemotherapy induced neutropenia and for the simultaneous mobilization of PBPCs. Maximal numbers of progenitors of different lineages were reached at day 11 (range 9–14) after VIP chemotherapy. A median of 0·415 × 10⁹/1 CD34⁺ cells (range 0·11–1·98), 9000 CFU-GM/ml (range 2800–17700). 3500 BFU-E/ml (range 400–10800) and 200 CFU-GEMM/ml (range 0–4400) were recruited. One single apheresis yielded a median of 1·6 × 10⁸ mononuclear cells/kg (range 0·2–5·4) or 5·4 × 10⁶ CD34⁺ cells/kg body weight (range 0·2–24·2). Fourteen patients who showed at least a partial remission after two cycles of the standard-dose chemotherapy regimen were subjected to high-dose VIP chemotherapy (cumulative doses of 1500 mg/m² VP16, 12 g/m² ifosfamide and 150 mg/m² cisplatin) with or without PBPC support. The first six patients were treated with growth factors only (IL-3/GM-CSF) and did not receive PBPCs, whereas the following eight patients were supported with PBPCs in addition to IL-3 and GM-CSF. Neutrophil recovery as well as platelet recovery were significantly faster in patients receiving PBPCs with a median of 6·5 d below 0·1 × 10⁹ neutrophils/1 and 3 d below 20 × 10⁹ platelets/1 as compared to 10·5 d and 8 d in control patients receiving growth factors only. The accelerated platelet recovery in patients supported with PBPCs might be explained—in the absence of detectable colony-forming units megakaryocyte—by the presence of glycoprotein IIb/IIIa⁺, non-proliferating endomitotic megakaryocytic precursor cells within G-CSF mobilized PBPCs. Our data demonstrate that chemotherapy plus G-CSF mobilized PBPCs accelerate both neutrophil and platelet recovery after high-dose VIP chemotherapy in patients with solid tumours or lymphomas.     

Detection of desialylated forms of human chorionic gonadotropin

Urinary forms of human chorionic gonadotropin (hCG) with oligosaccharides deficient in sialic acid content (ashCG) have been reported to be excreted by patients with choriocarcinoma in greater amounts than by healthy, pregnant women. Although ashCG potentially could be a useful marker for the diagnosis and management of gestational trophoblastic neoplasia, the methods previously used for its detection were not suitable for routine clinical application. Therefore, we have devised a simpler method which can provide specific and sensitive measurements of ashCG in urine. This method, which is designated as a lectin-immunoradiometric assay (LIRMA), employs an agarose-coupled lectin to selectively extract the ashCG, which is then quantified directly with a purified and radiolabelled rabbit antibody. The LIRMA has been applied to demonstrate that there is an increased excretion of ashCG by choriocarcinoma patients. It is also applicable, in principle, for the study of any glycoprotein which has a reduced content of sialic acid in its carbohydrate side chains.     

High dosage pre-operative radiation and surgery for carcinoma of the larynx and laryngopharynx. A 14-year program

A carefully planned clinical program of combined pre-operative radiation and surgery has been conducted by the Department of Otolaryngology at The Mount Sinai Hospital for the past 14 years in an effort to improve the survival rates for advanced cancer of the larynx and laryngopharynx. The Combined Therapy Program, introduced in 1958, encompassed three separate but interdependent phases. The first stage consisted of a strict protocol of 5,500 rads of Cobalt 60 teletherapy administered over a five to six-week period. The second stage involved a rest period of three to six weeks to allow for proper healing of radiation reactions. The third stage comprised the radical procedure which included a wide field laryn-gectomy, ipsilateral hemithyroidectomy and radical neck dissection. Whenever indicated, a contralateral neck dissection was performed as soon as feasible. The protocol described above was applied only to those patients who fit all the criteria that categorized them as having advanced cancer of the larynx and laryngopharynx. In this study all patients had a biopsy proven diagnosis of squamous cell carcinoma. A very careful statistical analysis has been made of the survival experience of this series of cases. The three and five-year survival rates have been computed by the actuarial method,¹ which when compared to the direct method, adds more reliability to the results. The direct method removes those cases not treated at least three and five years ago in computing three and five-year survival rates, while the actuarial procedure includes all cases in the computation of survival rates. Between November, 1958, and March 1, 1972, 64 patients had been treated by combined therapy. According to the American Classification² the 64 cases are composed of 20 Stage II (T₂N₀ excluded), 12 Stage III and 32 Stage IV cases. According to the actuarial method the absolute survival rates for all cases were 77 percent and 59 percent for three and five years respectively. The corresponding determinate rates were 88 percent and 86 percent. Analyzing the results according to stages, the three-year determinate rates ranged from 100 percent for Stage II to 79 percent for Stage IV. The corresponding absolute rates ranged from 89 percent to 70 percent. The five-year determinate rates ranged from 100 percent to 74 percent, while the absolute five-year survival rates ranged from 50 percent for Stage II to 66 percent for Stage IV. This apparent reversal is far from being statistically significant because of considerable sampling error. The complications seen in patients treated with combined therapy have been essentially the same as those patients who undergo radical surgery without pre-operative radiation. Several preventive measures have been utilized during surgery, and it is to be emphasized that there have been no deaths related to complications, and all patients ultimately healed completely. The important controversy which exists in the- combined method of therapy concerns the question of using low dosage pre-operative radiation in the order of 1,000 to 3,000 rads or high dosages of radiation. It is our contention that serial section studies of biopsied laryngeal specimens labelled with tritiated thymidine tend to disprove the claims made favoring the value of low dosage radiation. The in vitro tritiated thymidine studies demonstrated that active DNA synthesis was observed in cancer cells in an appreciable number following dosages of 3,500 and also 5,500 rads.³ A further significant factor to be considered, we believe, is the effect of high dose pre-operative radiation on the incidence of cervical recurrence. In this series, 44 patients had clinically palpable nodes pre-operatively. There were six patients who developed local cervical recurrence, a rate of 14 percent. In conclusion, our statistics seem to indicate that our combined method of therapy has improved the survival rates of patients with advanced cancer of the larynx and laryngopharynx.     

Recurrent meningitis secondary to idiopathic oval window csf leak

Bacterial meningitis remains a life-threatening infection even in the present antibiotic era; thus, any abnormality which predisposes a patient to a recurrence of this serious disease, must be identified and corrected. This report describes the history of a 12-year-old boy with a profound neurosensory hearing loss, a related absence of vestibular function and a Monclini-type of temporal bone dysplasia who developed recurrent episodes of meningitis which were due to an idiopathic cerebrospinal fluid otorrhea. Even though the meningitis was labyrinthogenic in origin, the patient did not experience the associated symptoms of hearing loss and/or vertigo since the affected inner ear was clinically unreactive. By surgically exploring the middle ear, the presence of a cerebrospinal fluid otorrhea was confirmed. The leak was observed to be coming from a defect in the stapes footplate, and it was controlled by firmly packing the inner ear vestibule with muscle. A remarkable similarity exists between the patient described above and the 15 previously reported cases of meningitis due to a spontaneous cerebrospinal fluid otorrhea. Generally, the problem occurred in young children, the average age being 6.4 years; male and female were equally afflicted. All 15 previously reported cases had a severe neurosensory hearing loss which was unilateral in 10 individuals and bilateral in the other five. In 11 of the case reports, the vestibular function was evaluated, and the labyrinth was noted to be unreactive in the affected ear. An associated congenital abnormality of the inner ear was described in 11 of the patients reviewed. Anatomically, in 13 cases, the leak was observed to be coming from the oval window area. Other affected sites included one report of a fissure of the promontory and one report of a defect in the roof of the eustachian tube. Multiple surgical procedures were required in 11 of the 15 patients in order to identify the exact source of the otorrhea and to seal it permanently. In three cases, the successful procedure was a middle ear exploration with stapedectomy and packing of the inner ear vestibule. Overall, a total of 36 operations was performed in the 15 patients reviewed. In conclusion, when the physician is confronted by a case of meningitis in a patient with a unilateral or bilateral total loss of hearing and vestibular function, the possible presence of an idiopathic cerebrospinal fluid leak should be considered, especially if radiographic studies demonstrate a temporal bone dysplasia. In these selected cases, if the etiology of the meningitis is obscure, a middle ear exploration should be performed both for diagnostic purposes as a means to ascertain definitely the presence of a leak and for therapeutic purposes to seal it effectively.