Our centers have formed an international collaborative group composed of surgeons, pathologists, radiation oncologists, medical oncologists and immunologists working together with biotech and pharma sectors to evaluate biomarkers of immune status and develop effective combination immunotherapy for patients with NSCLC.Two phase I immunotherapies for NSCLC following surgical resection were begun at our institutions. One involved stage I-IIIA patients given an irradiated, autologous whole-tumour cell vaccine following induction of lymphopenia by chemotherapy and reinfusion of autologous peripheral blood mononuclear cells (PBMC). The other recruited stage IV patients given an autophagosome-enriched vaccine generated from irradiated autologous tumour cells. Histologic sections, enzymatically-digested tumour, pleural effusions and apheresis are available from a number of these patients. Current efforts are evaluating immunoscore and immune profiling by IHC and comparing results with flow cytometric analyses of the tumour.Preliminary studies have evaluated CD3+ CD8+ CD45RO+ cytotoxic memory T cells associated with tumour. We are continuing to examine myeloid to lymphoid infiltrate ratios. While preliminary, and with only 4 patients evaluated, preexisting autologous tumour-reactive T cells (IFN-γ) were only detected when T cells predominated in the tumour preparation analysed. Studies comparing this with IHC staining and analysis using Definiens software are underway.A consortium of institutions has come together to improve the outcome of patients with NSCLC. The progress made to date will be used to evaluate immune responses to next generation immunotherapy. Evaluation of gene expression profiling of NSCLC has identified common overexpressed antigens and an off the shelf vaccine of autophagosomes containing at least 9 NCI prioritised cancer antigens, 5 TLR agonists and a DC targeting molecule has been developed. A multi-center phase II trial of combination immunotherapy for NSCLC employing this vaccine is open in the USA and efforts are underway to open this trial in Munich with coordinated efforts to evaluate anti-cancer immunity in patients on this and other trials.


Cystic Fibrosis (CF) is the most common autosomal recessive disease affecting about 1 in 3200 in Caucasians with increased morbidity, chronic infections, disability and reduced life expectancy. The mutations causing CF are well characterized, but the gene-gene and gene-environment interactions which significantly modify CF disease severity are completely unknown.FAS gene on human chromosome 10q24.1, which includes the binding site of many transcription factors especially the NFκB complex, but no molecular alterations were detected by conventional approaches. Using a combination of functional in-silico gene expression analysis and computational transcription factor binding analysis together with electrophoretic mobility shift and Supershift assays, we have identified that an allele of the regulatory SNP disrupts the binding of the master transcription factor NFκB on FAS and which likely interferes with normal immune activation and programmed cell death.We report the pathogenetic mechanisms underlying how a regulatory SNP modifies Cystic Fibrosis (CF). Association studies of affected individuals with Cystic Fibrosis identified the causal variant, a regulatory SNP rs7910656 on the non-coding region of Thus, our work demonstrates for the first time how a regulatory SNP disrupts the binding of a master transcription factor NFκB and a key signaling pathway FAS in immune regulation and programmed cell death modifying Cystic Fibrosis.


It remains uncertain whether neuromonitoring reliably predicts outcome in adult post-cardiac arrest patients in the early stage treated with therapeutic hypothermia. Recent reports demonstrated a regional cerebral oxygen saturation of cardiac arrest patients on hospital arrival could predict their neurological outcome. There has been little discussion about the significance of regional cerebral oxygen saturation in patients with post-cardiac arrest syndrome. Amplitude-integrated electroencephalography monitoring may also provide early prognostic information for post-cardiac arrest syndrome. However, even when the initial electroencephalography is flat after the return of spontaneous circulation, good neurological outcome may still be obtainable if the electroencephalography shifts to a continuous pattern. The electroencephalography varied from flat to various patterns, such as flat, epileptic, or continuous during the first 24 h, while regional cerebral oxygen saturation levels varied even when the electroencephalography was flat. It is therefore difficult to estimate whether regional cerebral oxygen saturation accurately indicates the coupling of cerebral blood flow and metabolism in the early stage after cardiac arrest. Careful assessment of prognosis is necessary when relying solely on regional cerebral oxygen saturation as a single monitoring modality. Monitoring with electroencephalography (EEG) may be able to provide early prognostic information after ROSC in patients with therapeutic hypothermia [2 values tend to vary widely even when EEG patterns are flat in the early stage, which makes it difficult to estimate the neurological outcome using only a single modality for monitoring by rSO2.Recent reports demonstrate a relationship between regional cerebral oxygen saturation  and cerebral blood flow (CBF), which linearly correlates with cerebral venous oxygen saturation and with CBF [2, whereby CBF would be affected by these dysautoregulatory factors. Physicians therefore have to consider many factors when estimating rSO2 values after cardiac arrest. The rSO2 data of brain-dead patients also demonstrates that rSO2 values do not always indicate the cerebral oxygen metabolism [2 value. The rSO2 value may depend on the blood pressure, because CMRO2 is thought be extremely suppressed when the EEG pattern is flat , or hyperperfusion (lower CMRO2 and higher CBF). They can also reflect hyperemia caused by severe metabolic depression due to severe brain damage in PCAS. Cerebral oxygen extraction fraction, however, can be expected to decrease in comatose patients immediately after ROSC as a consequence of the primary cerebral metabolic suppression [2 levels are detected when the EEG is flat, given that the CMRO2 may be drastically suppressed. Figures 2 level that starts at around 80 % and remains constantly high thereafter. Finally, the aEEG indicated epileptic or suppression-burst EEG patterns of a type thought to portend poor outcome. It was difficult to determine the clinical significance of the high rSO2 values in the early post-resuscitation phase [2 values with epileptic or suppression-burst EEG patterns indicate more severe brain damage after cardiac arrest.Higher rSOpression . This apon phase –6. We th2 values in PCAS. The main causes of low rSO2 stem from too little oxygen supply to meet the cerebral oxygen demand, a sign of cerebral ischemia caused by unstable hemodynamics, hypoxia, or decreased PaCO2 rather than a cerebral metabolic suppression. Physicians will be able glean hints for the next steps in their treatment strategies for conditions of these types. Good neurological outcome may be obtainable after PCAS if two conditions are met: first, the patient shows no drastic elevation of rSO2 accompanying an extremely low voltage on the initial EEG; second, the patient shows and no sign of electrographic status epilepticus  in PCAS during therapeutic hypothermia was recently classified into four categories: extremely low voltage ; suppression-burst pattern; electrographic status epilepticus with recurrent epileptic form activity; and continuous EEG [2 values might be reflected by the influences from factors such as blood pressure, CBF, PaCO2 or no-reflow phenomenon. These result demonstrate that rSO2 alone is insufficient for predicting neurological outcome after PCAS and that rSO2 cannot be confirmed to reliably indicate whether CBF and metabolism are coupling or uncoupling in the early stage after ROSC.There has been little discussion about the significance of rSOuous EEG . Status uous EEG –6. Patteuous EEG , 5. Alth2 might also be initially depressed while the EEG is suppressed. Given the possible therapeutic implications of continuous rSO2 monitoring in patients with brain injury, the variations of rSO2 and potential influences of many factors at this stage made it difficult to determine the clinical significance of rSO2 in PCAS. Careful assessment of prognosis is necessary when relying solely on rSO2 as a single monitoring modality.The EEG is extremely suppressed after ROSC and gradually changes to various patterns. CMROInformed consent was obtained from all individual participants included in the study.This study was approved by the Clinical Research Institutional Review Board (IRB: RK-140613-3) of this hospital.


Soybean is an important food allergen and it is often incorporated in complex formulated foods. Thermal processing induces conformational changes of food allergens and accelerates its interaction with carbohydrates. This reaction is called Maillard reaction (MR) and occurs always during food processing. It has been shown to influence allergenic potential of several proteins.The aim of the study was to establish the effect of processing conditions on allergenic potential of soy protein extract containing the major soy allergens Gly m 5 and 6.oC) for 10 or 30 minutes with glucose and SPE heated (121oC) for 10 or 30 minutes without sugar as a control. The allergenic potential of tested extract was examined using the basophil activation test (BAT) and inhibition ELISA. Maillard reaction products (MRP) were identified by western blot.Clinically characterized soy allergic patients (n=15) with specific IgE against Gly m 5 and 6 were selected for the study. Here we show the complete data obtained for seven patients. Five chemically characterized soy protein extracts (SPE) were tested: raw SPE, SPE heated  or decrease  of allergenicity for all processed extracts was seen. For 2 patients miscellaneous changes for different processing conditions were observed. For 70% of the patients SPE heated for 30 minutes with glucose stimulated basophils stronger than control SPE. The neo-allergens formed during heating of SPE with glucose were characterized on blots as high-molecular weight agglomerates of proteins and sugars, which contain advanced MRP. Their inhibitory ability for specific IgE binding was established in ELISA.Maillard-type neoallergens formed during soy processing can trigger stronger basophil stimulation than raw soy proteins in soy allergic patients. The use of only raw soy extracts in diagnostic tests may provide false negative results.


Our data shows the regional coronary artery calcium scores (lesion CAC) on multidetector computed tomography (MDCT) and the cross-section imaging on MDCT angiography (CTA) in the target lesion of the patients with stable angina pectoris who were scheduled for percutaneous coronary intervention (PCI). CAC and CTA data were measured using a 128-slice scanner  before PCI. CAC was measured in a non-contrast-enhanced scan and was quantified using the Calcium Score module of SYNAPSE VINCENT software  and expressed in Agatston units. CTA were then continued with a contrast-enhanced ECG gating to measure the severity of the calcified plaque condition. We present that both CAC and CTA data are used as a benchmark to consider the addition of rotational atherectomy during PCI to severely calcified plaque lesions. Specifications TableValue of the data•Regional CAC obtained from a non-contrast-enhanced multidetector computed tomography (MDCT) imaging is useful for evaluating regional calcified plaque condition because of a simple marker when the percutaneous coronary intervention (PCI) was scheduled in patients with stenotic coronary artery.•Cross-section imaging of a contrast-enhanced ECG gating MDCT angiography (CTA) is also useful for evaluating the regional calcified plaque condition into the lumen of coronary artery because of a viewpoint from the inside practically when the PCI was scheduled in patients with stenotic coronary artery.•Both CAC and CTA cross-section imaging data are used as a benchmark to consider the addition of rotational atherectomy during PCI to severely calcified plaque lesions.1In this present data 22.1The data of CAC and CTA on MDCT were obtained in patients with stable angina pectoris who were scheduled for first PCI.2.2http://www.fujifilmusa.com/products/medical/radiology/3d/) CAC data were obtained using a non-contrast-enhanced 128-slice scanner  before PCI. CAC data was quantitatively analyzed using the Calcium Score module of SYNAPSE VINCENT software (Fujifilm Co. Tokyo, Japan, 2.3The software displayed the calcified plaque lesion of the coronary artery by color and calculated the quantitative value of the calcified plaque by using the Agatston score method . CAC dat2.4The software extracted the path of the target blood vessels  and visu


Woven coronary artery is relatively rare and can be complicated in both acute and chronic phases. A few case reports have been published until now. Herein we report a case with right woven coronary artery managed with drug-eluted stent implantation without complication. Woven coronary artery (WCA) disease is an extremely rare congenital anomaly with unexplained etiology . In this54-year-old male with tightening chest pain and palpitation on exertion for two months was admitted to cardiology outpatient clinic two years ago. Resting electrocardiogram showed q waves and extra systoles on D3 and aVF. Echocardiography showed akinesia at inferior and posterior walls, and ejection fraction was 44%. We performed coronary angiography by using the Judkins technique from right femoral artery. There were plaques at LAD and %50 stenosis at proximal Circumflex arteries, the lesions were considered to be insignificant , and theWoven coronary artery (WCA) is a very rare congenital anomaly which can affect both RCA and LAD and may lead to acute coronary syndromes in some circumstances . It was This anomaly may be accepted as a benign disease. Some reports showed no cardiovascular adverse events during 5-year follow-up –5. NeverIn conclusion, WCA may cause myocardial ischemia and damage. All interventional cardiologists might keep this anomaly in mind and should beware of the possible consequences of WCA in catheterisation laboratory. PCI or coronary artery bypass grafting may be treatment options for this anomaly.


Type II A aortic dissection after mechanic aortic valve replacementis a major complication and may be life threatening.We present a case of a 51 years-old male patient having an acute Type II A aortic dissection after mechanic aortic valve replacement.A 51-years-old male was hospitalized in our clinic on Mach 26, 2015. He had mild aortic insufficiency and mild mitral insufficiency. Ejection fraction was 60%. CT-Scan revealed type II A aortic dissection.He had Type II A aortic dissection with intimal tear at proximal region of the right coronary ostium. Mechanic aortic valve was normal function. Ascending aorta was replaced by using 26 mm Dacron tube graft between annulus of previous mechanic aortic valve and distal ascending aort by using hypothermic circulatory arrest and antegrade selective cerebral perfusion. An 8 mm dacron tube graft was anastomosed between right and left coronary annulus and this tube graft was anastomosed to neo-aorta (Cabrol technique). Postoperative period was event-free. The patient was discharged on 14 postoperative day with warfaine and methoprolol treatment.Although acute aortic dissection after mechanic aortic valve replacement is a rare complication, physicians should keep this potential life-threatening complication in mind.Written informed consent was obtained from the patient for publication of this abstract and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.


Idiopathic intracranial hypertension (IIH) is a condition of increased intracranial pressure (ICP) without identifiable cause. The majority of IIH patients are obese, which suggests a connection between CSF regulation and obesity. However, the pathophysiological mechanisms remain widely unresolved.To develop a long-term ICP monitoring method and investigate ICP in lean and obese rats. We also aimed to clarify if any ICP difference could be attributed to changes in some well-known ICP modulators; retinol and arterial partial pressure of CO2 (pCO2).ICP was measured in six obese and six lean Zucker rats with a newly developed epidural ICP monitoring method over a period of 31 days. Furthermore, arterial pCO2 and serum retinol were measured in blood samples from each animal.Obese rats had significantly elevated ICP-levels compared to lean controls on all recording days (p < 0.0001). Serum retinol  and arterial pCO2  did not differ between the two groups.Obesity-related intracranial hypertension in rats is not related to altered pCO2 levels or retinol metabolism. This indicates that the increase in ICP might be related to molecular changes in the brain caused by the adipose state. Although further studies are warranted, obese Zucker rats could potentially constitute a model for IIH.No conflict of interest.


Breast cancer is the main cancer type affecting women in the Kingdom of Saudi Arabia. The relatively young age of onset in this population could be explained by the interplay between common genetic susceptibility background substantiated by increased consanguinity and epigenetic aberrations caused by the shift in life style experienced in this region . GenomicMethyl binding domain-sequencing (MBD-Seq) was applied on DNA extracted from surgically-resected breast tumors using the MethylMiner™ kit from Invitrogen followed by fragment identification using next generation sequencing on the SOLiD platform (Applied Biosystems). Determination of methylation frequency and correlation with clinicopathological parameters was performed using the MethyLight assay on DNA extracted from FFPE tissues. Fisher’s exact test and univariant Kaplan-Meier survival analysis were applied where p<0.05 considered statistically significant.MTNR1B methylation frequency in breast cancer is 35% (n=157). MTNR1B methylation was largely limited to the IDC, ILC and DCIS subtypes. Furthermore, MTNR1B methylation is significantly associated with histological grade I of breast cancer . The association of MTNR1B methylation and disease-free or specific survival is investigated.Finding significant levels of methylation of a key circadian clock gene as the MTNR1B in a tumor-specific fashion may provide an intriguing evidence to the role of environmental factors (day-night cycles) and breast cancer development.This project is funded by KACST grant ARP-29-292.


However, data on the clinical relevance of right ventricular (RV) failure are limited.To establish the prognostic implications of RV failure in a large series of post cardiac surgery patients.®, Baxter), enabling continuous RV ejection fraction (RVEF) measurements. RVEF was categorized into three subgroups: RVEF < 20%, 20-30% and >30%. Demographic data and hemodynamic variables were recorded. Primary outcome was predefined as the correlation between the average RVEF over the first 24 hours in the ICU and markers of morbidity.We performed a single-centre retrospective analysis of all high risk cardiac surgery patients in a four year period. By protocol these patients were equipped with a pulmonary artery catheter (VigilanceA total of 1115 patients were included. Patient characteristics are summarized in table A RVEF < 20% is independently associated with increased ICU mortality and morbidity in high risk postoperative cardiac surgery patients.


Defects in lamin A maturation result in premature aging syndromes and severe atherosclerosis as observed in Hutchinson-Gilford Progeria Syndrome. In age-related atherosclerosis, several features of cells senescence have been characterized in endothelial cells lamin A alterations. We propose a cellular model to study lamin A-related senescence in primary endothelial cells. In this model, lamin A defects were induced by protease inhibitor (PI: Atazanavir) treatment during 48h on normal cells issued from placenta  or cord blood (ECFC)). We showed that PI treatment led to the accumulation of farnesylated prelamin A and induced nuclear shape abnormalities and premature senescence in both HUVEC and ECFC. ICAM-1-dependent activation was present and monocytes adhesion was increased in HUVEC whereas ability to generate microvascular network in matrigel was decreased for ECFC. The effects of PI treatment on nuclei shape were reversed when cells were PI-treated in combination with Pravastatin and Zoledronate in both mature and progenitor endothelial cells. Reversion also was demonstrated with 2 antisens-oligonucleotides targeted toward lamin A specific splice sites. This study confirms that PI treatment reproduces premature senescence due to lamin A maturation defects in primary endothelial cells after a 2 days exposure. The cells used were extracted from full term and healthy neonates i.e. from individuals of age 0. This allows us to consider that other senescence pathways were not activated and that the observed alterations were specific of prelamin A accumulation. This model constitutes a valuable tool to test different approaches aimed at reversing specifically lamin A-related cells senescence.


Theta-frequency oscillations 8-12 Hz) of large groups of synaptically coupled cells are commonly seen throughout the mammalian brain. The theta oscillations of entorhinal cortex grid cells and hippocampal place cells have received special attention recently due to their role they apparently play in the encoding of positional information. In a previous study 2 Hz of l.


Joint moments modeled from a musculoskeletal tool differ from those recorded by a dynamometer. In order to solve the problem, numerical methods to minimize the variance of the joint moments have been adopted . The exiNOF was designed to strengthen the linear relationship between: (1) the recorded and modeled joint moments, and (2) the muscle activations and the muscle forces. One male  participated in the study with the informed consent prior to commencing the experimental trials. Surface electrodes were attached to record EMG signals from elbow major muscles using an eight-channel surface EMG system . Dynamometer tasks were performed with Biodex System 3 Pro  to measure elbow joint moments. The participant was asked to perform three maximum isometric contractions at 90° (flexed). The subject then generated an elbow flexion moment, rested, and generated an elbow extension moment. To evaluate the effects of NOF compared to EOF briefly, we focused on the changes in biceps brachii long head (BIClong) muscle force and compared the relative root-mean-square error.Modeled joint moments with no parameter calibration (NOT Adjusted) showed undesirable negative offset during the 3-second-rest period, but this problem was solved by the parameter calibration with EOF or NOF Figure . Even thEven though NOF yielded relatively low performance in joint moment prediction, it estimated muscle forces better, providing more reasonable kinetic information about human movements such as walking and running.


Due to the absence viral vectors and of cytotoxicity the Int based binary system offers advantages over previously described counterparts and may therefore be developed into a safer cancer cell killing system.Binary systems based on site-specific recombination have been used for tumor specific transcription targeting of suicide genes in animal models. In these binary systems a site specific recombinase or integrase that is expressed from a tumor specific promoter drives tumor specific expression of a cytotoxic gene. In the present study we developed a new cancer specific binary expression system activated by the Integrase (Int) of the lambdoid phage HK022. We demonstrate the validity of this system by the specific expression of a luciferase ( The recombinases of the former two systems belong to the tyrosine recombinase family and of the latter system to the serine recombinase familySite-specific recombinases are widely used for genome manipulations by catalysis of site-specific recombination reactions (SSR) between two defined DNA sequences of ~20–200 base pairs (bp) functioning as recombination sites (RSs)12345SSR systems are also used in binary systems for cell and gene specific expression that are based on two DNA modules. One module carries a recombinase substrate comprising a target gene silenced by a transcription terminator placed between two RSs. The second module carries the recombinase gene controlled by a cell type specific promoter. This promoter targets the expression of the SSR to the desired cells where it excises the terminator and thus activates the expression of the gene of interest910Escherichia coli chromosome as well as its excision from the E. coli chromosome. In these regards it acts very much like the well-documented coliphage λ IntegraseattB or BOB′ to indicate its composition of a central 7 bp overlap region (O) and the two flanking incomplete inverted repeats of 7 bp (B and B′). O is the site of DNA exchange while B and B′ are Int binding sites. The phage recombination site termed attP is ~200 bp long. It contains a 21 bp core (COC′) that is similar to attB and is flanked by two long arms (P and P′) that carry additional Int binding sites and others that bind accessory proteins required for the SSR reactions. The phage integration reaction occurs between attP and attB. It yields two hybrid recombination sites flanking the integrated prophage termed attL (BOP′) and attR (POB′). The reverse prophage excision reaction occurs between the attL and attR sites and restores the original attP and attBE. coli host are dispensable in the eukaryotic milieu14151617hTERT promoter. hTERT serves as the catalytic reverse transcriptase subunit of telomerase and is specifically expressed in immortal and cancer cells19hTERT-promoted Int specifically activates a luc reporter in immortalized human embryonic kidney 293 cells (HEK293T) and in mouse lung tumors originating from injected Lewis lung carcinoma line 1 (LLC1). This cancer specific expression system offers certain advantages over those previously described910Coliphage HK022 encodes an Integrase recombinase (Int) belonging to the tyrosine integrase family that catalyzes the integration of the phage genome into its RS on the int gene under the control of the cancer specific promoter hTERT19CMV) promoter as control. The other carries a luc gene separated from a CMV promoter by a transcription terminator (Stop) flanked by tandem attR and attL recombination sites  or under the constitutive CMV promoter (pNA979) that served as a positive control. The quantitative analysis of the Luc activity assay in HEK293T cells  is the most effective. This linear polyethylenimine reagent is used to deliver DNA, siRNA and oligonucleotides. It forms stable complexes with the nucleic acid cargo, protecting it from degradation thereby facilitating in vivo delivery. These complexes pass the capillary barrier in the lung, explaining the propensity of in vivo-jet PEI to deliver its cargo specifically into lungsluc), whose product emits characteristic yellow-green bioluminescence in the presence of its luciferin substrate is most suitable. BALB/c mice were intravenous (IV) tail-injected with a sample of the jet PEI delivery agent complexed with a reporter plasmid (pYM1600) that carries the luc gene under the control of CMV promoter. 24 hours later the mice were injected with the Luciferase substrate luciferin and underwent bioluminescence imaging. The treated mouse . As a positive control two mice were each similarly treated with two doses of a CMV-luc expressing plasmid . 24 hours later bioluminescence imaging of these mice Entacmaea quadricolor known as Katushka cells (LLC-Kat)25Having demonstrated that the jet PEI DNA delivery reagent has delivered the in vivo micro-CT scanning. No tumors were detected in the lungs of the non-injected control [ex-vivo fluorescence detection using the Maestro imaging system [Lung tumor metastases development was examined nine days following the injection of the LLC-Kat cells using  control  whereas  control . The preg system  as compag system  and by ig system  comparedg system . In bothin vivo-jet PEI carrier complexed with different combinations of plasmids [panels (b–e)] while groups (a) remained untreated. In groups (b) the jet PEI carrier was complexed with the CMV-luc reported as positive control; in groups (c) the carrier was complexed with the silent recombination substrate (CMV-RSL-luc) alone to validate the absence of luc leakage; in groups  the carrier was complexed with the silenced substrate and the CMV-promoted Int (d) or with the hTERT-promoted Int (e). 24 hours later all mice were injected with luciferin and underwent bioluminescence imaging. As expected, in both healthy and cancerous mice the negative controls (a) and the ones treated with the silent substrate (c) showed no bioluminescence while the positive controls (b) did. So did the two groups (d) treated with the silent substrate along with the constitutive CMV-Int. However, in groups (e) only the cancerous mice treated with the silent substrate along with the hTERT-Int showed bioluminescence  only the cancerous ones showed an immune response. These results unambiguously confirmed the cancer specificity of our binary system.Finally, to test the cancer specificity of the binary Int-activated cell expression system in mice we performed a comparative analysis of this system between healthy C57BL/6 mice  and LLC-nescence  while innescence  no biolupression . The expCre is one of the most widely SSRs used in mammalian gene manipulations, however, Cre-dependent cellular toxicity has been reported in eukaryotic cells and organisms some even under transient conditions. These include reduced cell growth, chromosome aberrations, brain development, cardiac fibrosis, heart failure, thymic atrophy and severe hematological toxicity28293031hTERT promoter showing that when the expression of coliphage HK022 Int is promoted by hTERT it activates, by a site-specific recombination reaction, the expression of the luc reporter gene exclusively in lung cancer cells without affecting normal tissues. In previous two reports that employed the Cre/lox system in such binary systems one used an adenovirus vector as the gene delivery carrierIn the present study a new cancer specific binary cell expression system was developed that is based on the cancer-specific hTERT promoted substrate, though being cancer specific, may be somewhat leaky on its voyage from its delivery spot to the cancer tissue thereby loosing specificity by damaging healthy tissues. Admittedly, a successful direct adenoviral carrier delivery of an hTERT promoted DTA toxin that cured ovary cancer in mice was reportedWhen using a toxin gene to be specifically expressed in cancer cells it is essential that in the binary system the recombinase, being an enzyme, be promoted by a weak and specific promoter and that the toxic gene of the substrate be completely blocked by a tight transcription terminator. Because more substrate than enzyme needs to be delivered  the direattB sites, such sites need to to carry a perfect wild type 7 bp overlap with two flanking palindromic sequencesattL and attR RS sites in the binary system are incomplete attPs. These and the fact that Int is weakly promoted by hTERT reduce the likelihood of off target Int-catalyzed integration events into human secondary attB sites.With regards to possible off-target chromosomal integration events catalyzed by Int, we have previously shown that for Int to promote integration into secondary attL and attR as recombination sites because they proved more efficient in mammalian recombination activity than does the attB + attP pair. Another reason is because their recombination leads to the short 21 bp attB site located between the promoter and the Luc gene  have already shown that with the DTA toxicity is clearly specific in the LLC-Kat as compared to normal human foreskin BJ cells and experiments with live mice using DTA and other toxins to eradicate the lung cancer are in progress. Success may render the system useful with other cancer cases using relevant cell specific promoters and cell specific DNA carries.E. coli K12 strain TAP114 (lacZ)M15The bacterial host used was Human embryonic kidney cells HEK293T (ATCC CRL-3216) were cultured in Dulbecco’s modified Eagle’s medium. Mouse Lewis lung carcinoma LLC1 (ATCC CRL-1642) cells labelled by Katushka fluorescent gene reporter5) were plated in a 6 well plate and 24 hours later treated with 2 μg circular plasmid DNA using Puro-Fection transfection reagent  or TransIT-XT2 reagent , respectively.For transient transfection of HEK293T and LLC-Kat, the cells  was constructed as follows. A BglII-HindIII hTERT PCR fragment, was generated using primers oEY638 + oEY639 . The pAE1855 plasmid, used as a substrate for the CMV-Luc assays, was constructed by ligation of a AgeI-NotI luc PCR fragment, obtained using pYM1600 as template and primers oEY807 + 808, into the same sites of the intermediate plasmid construct pAE1855inter carrying CMV- attR-Stop-attL cassette on pCDNA3. All plasmid constructs were verified by DNA sequencing.The pNA1263 plasmid  carrying+ oEY639  and an hluc plasmids were collected 48 hours later by trypsin treatment and centrifugation, resuspension in 100 μl of x1 Passive Lysis Buffer  followed by sonication and centrifugation. Quantitative Luc analysis of the supernatant was performed using Dual-luciferase reporter assay kit  and Synergy2 plate reader  according to the manufacturer’s instructions.HEK293T or LLC-Kat cells transfected by the appropriate in vivo-jet PEI delivery reagent  complexed with an appropriate luc reporter plasmid. 24 hours later the mice were injected with 250 μl of 3 mg/ml luciferin solution  and underwent bioluminescence imaging by Biospace Photon Imager .BALB/c or C57BL/6 mice were IV tail-injected with 250 μl of the 6 LLC-Kat cells were IV tail-injected into 8 week old (17–21 gr) female C57BL/6 mice. Lung tumor metastases development was examined nine and twelve days following the injection using in vivo micro-CT scanner . The Katushka fluorescent signal in the lung metastases was analyzed on day 12 by an in vivo fluorescence imaging system .0.8 × 10At the end of the experiments, biopsy specimens from lungs were collected, fixed in 4% paraformaldehyde (PFA), embedded in paraplast and 5 μm sections were prepared. Healthy and cancer lungs carrying metastases were treated in parallel with H&E stained and immune-stained anti-Luciferase antibody  at 1:100 dilution, with a PCNA kit  and with a TUNEL kit  according to manufacturer’s instructions. Donkey anti-Goat IgG (H + L) secondary antibodies conjugated with Alexa Fluor 488 dye  were used for Luciferase detection. Nuclei were detected with DAPI . At least 20 images of five tissue sections from 3 different mice per group were obtained for each analysis. Microscopic observation and image acquisition were performed using a Zeiss 510 Meta – NLO confocal laser-scanning microscope . TUNEL assay analysis was performed using Image J software.E. coli was prepared using a DNA Spin Plasmid DNA purification Kit  or a NucleoBondTM Xtra Maxi Plus EF kit . General genetic engineering experiments were performed as described by Sambrook and RussellPlasmid DNA from How to cite this article: Elias, A. et al. Cancer-specific binary expression system activated in mice by bacteriophage HK022 Integrase. Sci. Rep.6, 24971; doi: 10.1038/srep24971 (2016).


Improving the functional avidity of effector T cells is critical in overcoming inhibitory factors within the tumor microenvironment and eliciting tumor regression.+ T cells and inhibits their functional avidity against tumor.We have found that Cish, a member of the Suppressor of Cytokine Signaling (SOCS) family, is induced by TCR stimulation in CD8Cish in CD8+ T cells enhances their expansion, functional avidity and cytokine polyfunctionality, resulting in pronounced and durable regression of established tumors. Although Cish is commonly thought to block STAT5 activation, we found that the primary molecular basis of Cish suppression is through inhibition of TCR signaling. Cish physically interacts with the TCR intermediate PLCg1, targeting it for proteasomal degradation following TCR stimulation. Furthermore we extend these findings to patients PBL retrovirally transduced with tumor-specific TCRs and shorthairpin microRNAs targeting CISH.Genetic deletion of + T cells and can be manipulated to improve adoptive cancer immunotherapy.These findings establish a novel targetable interaction that regulates the functional avidity of tumor-specific CD8


Respiratory motion in PET/MR imaging leads to reduced quantitative and qualitative image accuracy. Correction methodologies include the use of respiratory synchronized gated frames which lead to low signal to noise ratio (SNR) given that each frame contains only part of the count available throughout an average PET acquisition. In this work, 4D MRI extracted elastic transformations were applied to list-mode data either inside the image reconstruction or to the reconstructed respiratory synchronized images to obtain respiration corrected PET images.Five patient datasets acquired on the SIEMENS mMR PET/MR system were used. T1-weighted 4D MR images were registered to the end expiration MR image using an elastic B-spline registration algorithm to derive deformation matrices used to account for the respiratory motion. The derived matrices were subsequently applied during the List Mode OSEM PET image reconstruction of the original emission list-mode data. The corrected images were compared with those produced by applying the elastic transformation after reconstructing PET frames followed by summing the realigned gated frames, as well as with uncorrected motion averaged images.Significant improvement was obtained by using any of the two respiratory motion correction techniques compared to uncorrected motion average images (>30% differences in tumor position and size and 25% SNR increase). Both correction approaches lead to nearly equivalent improvements (differences of <8% and <6% for the lesion FWHM and the SNR respectively).A list-mode reconstruction based respiratory motion correction for PET has been implemented and its performance evaluated. This approach was based on the use of elastic transformations derived from 4D MRI during PET image reconstrucion. Our results show significant respiratory motion compensation when compared to the motion average PET images, with slightly better contrast and SNR compared to an equivalent 4D PET image space elastic motion correction method.


Glu89Gln transthyretin (TTR) variant is a well-known cause of systemic amyloidosis with a cardiologic, neurologic or mixed phenotype. Even though Glu89Gln transthyretin (TTR) variant has been described worldwide, it remains unknown whether geographical area influences the phenotypic expression of the disease . We hypothesized that significant phenotypic differences exist between patients with Glu89Gln-related amyloidosis according to the specific geographic origin.We retrospectively analysed and compared the clinical, electrocardiographic and echocardiographic findings of 64 patients with Glu89Gln TTR-related amyloidosis from Italy and Bulgaria.Despite a similar age at diagnosis of the disease (55 [52-60] years) patients in Bulgarian cohort have a mixed phenotype. A more severe left ventricular wall thickening was present in Bulgarian cohort compared to Italian one  with a normal ejection fraction in all cases.This is the largest series so far of patients with Glu89Gln TTR-related amyloidosis systematically analysed. Overall, disease onset is late with a mixed phenotypic expression. Despite a similar age at onset and a predominance of neurological routes, Bulgarian patients showed a more pronounced cardiomyopathy.


Systemic light chain amyloidosis (AL) is associated with a high cardiovascular morbidity and mortality. Cardiovascular involvement and determination of prognosis is underestimated by standard imaging parameters. Recently, cardiac deformation analysis of global circumferential and longitudinal strain has been shown to have great clinical impact on the assessment of prognosis and survival in this rare disease. For further analysis we applied the novel non-invasive post-processing feature tracking imaging (FTI) algorithm on pre-acquired regular CMR SSFP images in healthy volunteers and in patients with AL and sought to investigate different strain patterns.87 patients (mean age 60 ± 11 years) with biopsy proven systemic AL were scanned on a clinical 1.5 T CMR scanner (Philips Achieva). Short axis slices covering entirely both ventricles as well as 2-, 3- and 4-chamber views were acquired using standard SSFP-sequences before initiation of any specific pharmaceutical AL therapies. The control group consisted of 47 healthy subjects (mean age 59 ± 5 years). Besides the standard CMR parameters for volumes, ejection fraction, myocardial mass and wall thickness we measured the circumferential and the longitudinal strain on cine SSFP images by the application of the post-processing FTI algorithm.In patients with AL mean longitudinal strain from the four chamber view  as well as midventricular mean circumferential strain  were significantly reduced compared to healthy subjects. Global circumferential strain and global longitudinal strain correlated with left ventricular ejection fraction . In the subgroup analysis of AL patients with a mean wall thickness less than 12 mm global longitudinal strain showed significantly reduced values in comparison to healthy control subjects , whereas global circumferential strain did not show a significant difference. Patients with an ejection fraction ≥55% already had reduced global longitudinal strains , again global circumferential strain did not show a significant difference.FTI strain analysis derived from regular cine SSFP sequences offers the possibility for a fast quantitative assessment of myocardial strain imaging patterns without additional and time-consuming strain imaging sequences. FTI strain analysis provides important insight into the disturbed contraction in AL. Further investigations are necessary to analyze the impact of this new method on the prediction of clinical outcome in AL patients.None.


Mycobacterium tuberculosis (Mtb) is one of the most successful human pathogens, and a key mechanism in its virulence arsenal is its ability to influence host immune responses to its advantage. In recent years it has become clear that one such mechanism pivots on bacterial-derived, secreted small molecules that are released from the intracellular phagosome of macrophages into the host cell cytosol where they interfere with host cell signaling and downstream cytokine responses. Using small molecules such as cyclic nucleotides, Mtb subverts the host's innate bactericidal responses to remodel the intracellular niche to an environment favorable for mycobacterial survival or growth . Upon infection Mtb produces a burst of cAMP within macrophages. Through a microbial adenylate cyclase gene, bacterial-derived cAMP is delivered to the macrophage cytoplasm increasing cytosolic cAMP levels 3–5-fold above baseline and triggering the PKA-CREB pathway to upregulate NFκB transcription. One consequence of bacterial subversion of host cAMP signaling is the elevated TNF-α secretion at the early stages of infection promoting necrosis and granuloma formation—outcomes that foster bacterial survival .Mtb also interferes with immune signaling by secreting another bacterial-derived second messenger, cyclic-di-adenosine monophosphate (c-di-AMP) . This paThe failure to control the global TB epidemic despite the availability of curative drug regimens is partly driven by the inherent difficulties of maintaining continuous chemotherapy over at least six months . MoreoveSmall molecule phosphodiesterase (PDE) inhibitors – which raise levels of certain cytosolic cyclic nucleotides – have become important drugs in human medicine with the introduction of PDE3 inhibitors for intermittent claudication, PDE5 inhibitors for erectile dysfunction and pulmonary hypertension, and PDE4 inhibitors for chronic obstructive pulmonary disease. PDE4 inhibitors have been of particular interest for lung infections since they reduce pulmonary inflammation. Not surprisingly, the evaluation of FDA-approved human PDE inhibitors as well as those in the pipeline for FDA approval has emerged as an attractive strategy for adjunctive HDTs against TB.PDE inhibitors are isoenzyme-specific compounds of different binding affinities and potencies that also act according to the tissue distribution of the isozyme . SeveralIn this issue, Subbian et al. assess the adjunctive value of the PDE inhibitor CC-11050 when used in combination with isoniazid to treat TB . CC-1105The authors have no relevant conflicts of interest to disclose.


The incidence of ocular surface squamous neoplasia (OSSN) is strongly associated with solar ultraviolet (UV) radiation, HIV and human papilloma virus (HPV). Africa has the highest incidence rates in the world. Most lesions occur at the limbus within the interpalpebral fissure particularly the nasal sector. The nasal limbus receives the highest intensity of sunlight. Limbal epithelial crypts are concentrated nasally and contain niches of limbal epithelial stem cells in the basal layer. It is possible that these are the progenitor cells in OSSN. OSSN arises in the basal epithelial cells spreading towards the surface which resembles the movement of corneo-limbal stem cell progeny before it later invades through the basement membrane below. UV radiation damages DNA producing pyrimidine dimers in the DNA chain. Specific CC → TT base pair dimer transformations of the p53 tumour-suppressor gene occur in OSSN allowing cells with damaged DNA past the G1-S cell cycle checkpoint. UV radiation also causes local and systemic photoimmunosuppression and reactivates latent viruses such as HPV. The E7 proteins of HPV promote proliferation of infected epithelial cells via the retinoblastoma gene while E6 proteins prevent the p53 tumour suppressor gene from effecting cell-cycle arrest of DNA-damaged and infected cells. Immunosuppression from UV radiation, HIV and vitamin A deficiency impairs tumour immune surveillance allowing survival of aberrant cells. Tumour growth and metastases are enhanced by; telomerase reactivation which increases the number of cell divisions a cell can undergo; vascular endothelial growth factor for angiogenesis and matrix metalloproteinases (MMPs) that destroy the intercellular matrix between cells. Despite these potential triggers, the disease is usually unilateral. It is unclear how HPV reaches the conjunctiva. •Limbal epithelial stem cells are the likely progenitor cells of OSSN.•UV radiation causes DNA damage via dimers, photoimmunosuppression and reactivates latent HPV.•HPV E6 inhibits p53 tumour suppressor gene allowing DNA-damaged cells past the G1-S checkpoint of the cell cycle.•HPV E7 inhibits pRB gene antitranscription at G1 so infected cells keep replicating.•HIV, photoimmunosuppression and vitamin A deficiency impair tumour surveillance. Early lOSSN occurs worldwide but the peak incidence is found at a latitude of 16° South . The mea2The ocular surface consists of the cornea, limbus and conjunctiva but in a wider anatomical and embryological sense the mucosa of the ocular adnexa  is included. The epithelia of the cornea, conjunctiva and eyelid are formed from differentiation of the surface ectoderm during embryonic development. The corneal endothelium and the corneal stroma, conjunctiva and eyelids are formed when periocular mesenchymal cells of neural crest origin migrate and differentiate .The cornea has a stratified squamous non-keratinizing epithelium with five to seven cell layers. It is immunologically privileged due to its lack of blood vessels and lymphatics, with dendritic cells present usually only in the peripheral cornea .The limbal epithelium is 8–10 cells thick and is constantly being replenished from stem cells in the basal layer . The limThe conjunctiva consists of an epithelium on a basement membrane and underlying loose connective tissue called the lamina propria. The lamina propria is loosely anchored to the episclera and sclera making the conjunctiva easily mobile. The epithelium varies between 2–3 and 10–12 cell layers, depending on whether it is the bulbar, fornix or tarsal portion. Lymphocytes and plasma cells are abundant in the conjunctiva . They fo3Stem cell biology is a rapidly progressing field. A stem cell is a special undifferentiated progenitor cell capable of giving rise to many more cells of the same type, and from which other kinds of cells arise by differentiation. There are three types of stem cells. Embryonic stem cells originate from pre-implantation embryos and can develop into tissues that belong to one of the three germ layers . Non-embCorneo-limbal lineage is distinct from conjunctival lineage . EvidencLimbal stem cells are found in special niches in the basal region called limbal epithelial crypts which are cords of epithelial cells extending from the palisades of Vogt into the underlying stroma . The cryThe ocular surface is self-renewing. Superficial cells are constantly lost and are replaced by basal cells entering the differentiation pathway. To replenish the corneal epithelium, corneal epithelial stem cells undergo mitosis producing a progeny of fast-dividing transient amplifying cells (TAC) that make up the majority of the proliferating cell population in the epithelium . TAC mig4The term cancer stem cell is a relatively new one in cancer biology, though this is a concept known for many years . In maliCancer stem cells comprise less than 5% of the cell population in most tumours . They arTheir existence could help to explain the clinical observation of the inaction of conventional cancer chemotherapy and radiotherapy in some instances since these treatments target rapidly dividing cells yet stem cells by nature are slow-cycling. For example, treatment with fluorouracil (5-FU) selects and enriches the cancer stem cell population since the rapidly dividing cells would be killed while slow-cycling ones incorporate the drug at a lower rate . Potenti5The clinical presentation of ocular surface dysplastic and neoplastic diseases provides clues to the pathophysiology of OSSN. Firstly, OSSN, pterygium, pingueculae, climatic droplet keratopathy and actinic keratosis are usually located within the interpalpebral fissure, the space between the open upper and lower eyelid that is exposed to UV radiation . Secondl6θ) and the corneal central radius of curvature (r0), is intensely focused onto the nasal limbus, lid margin or lens with up to a 20-fold increase in peak intensity  or epigenetic (variations in gene expression that do not involve changing the nucleotide sequence). DNA damage affects genome stability and stem cell function leading to cancer . Mutatio7.1.17.1.1.1Ambient UVR can be broadly divided into UVA  and UVB  wavebands . UVC (20UVB radiation causes direct DNA damage by crosslinking adjacent bases to form cyclobutane pyrimidine dimers (CPDs) and 6-4 photoproducts (6-4 PPs) . The mos−OH , O2−  or H2O2 (hydrogen peroxide) leading to DNA strand breaks (UVA causes indirect DNA damage via reactive oxygen species (ROS), like d breaks . No studd breaks .7.1.1.2Exposure to UVB reactivates latent HPV, HIVBre, varicelMuch of what is known about the pathophysiology of HPV in cancer is derived from cervical studies. HPV invades the basement membrane through micro abrasions where it initially binds to heparin sulphate proteoglycan (HSPG) . It doesHow HPV initially reaches the conjunctiva is not clear. The prevalence of HPV in OSSN tissue is heterogeneous, varying widely from zero to 100% .HPV infection is associated with an increased incidence of HIV acquisition  .7.2Several mechanisms prevent UV-induced DNA mutations from being incorporated into the genome and UV-damaged cells from establishing themselves. Cells can correct carcinogen-induced DNA damage; severely damaged cells are eliminated from healthy tissues by processes that trigger apoptosis; and abnormal cells are recognized, targeted and destroyed by immune surveillance .The cell-division cycle involves duplication of the genome and intracellular organelles . The staDNA damage activates checkpoint pathways that regulate specific DNA repair mechanisms in the different phases of the cell cycle . There aThe molecular mechanisms that repair UVR-induced DNA damage include excision repair, mismatch repair, strand break repair, and cross-link repair . During Base excision repair (BER) is the predominant pathway against lesions caused by ROS, ionizing radiation and strong alkylating agents . It proc7.2.1The p53 tumour-suppressor gene is found on the short arm of chromosome 17 (17p13.1) . P53 is 7.3Tumour immunology presumes that tumour cells express antigens such as mutp53 and HPV proteins that distinguish them from non-transformed cells. The immune system prevents tumour formation in 3 ways (i) elimination or suppression of viral infection (ii) preventing establishment of a pro-inflammatory environment and (iii) specifically identifying and eliminating cells that express tumour-specific antigens or molecular signals of cellular stress before they cause harm . The lat7.3.1Ambient UV radiation suppresses cell-mediated immunity . UVB is 7.3.2HIV preferentially infects helper T cells (CD4+), inducing their apoptosis . The virHIV potentiates the oncogenic action of other viruses such as HPV, Kaposi sarcoma-associated herpes virus (KSHV) and Epstein–Barr virus (EBV) by enhancing their transmission to target cells . A reporLastly, HIV induces a state of persistent inflammation . Markers7.3.3Vitamin A helps to maintain the integrity of the ocular surface . Its defp < 0.001)  than HIV-negative women  .We hypothesize that vitamin A deficiency has three effects; it compromises the integrity of the surface epithelium creating micro-abrasions for HPV entry, it leads to cell-mediated immunodeficiency, and dysregulation of stem cell differentiation.88.1Human somatic cells can only undergo a limited number of cell divisions (50–70) then arrest, an event related to shortening of telomeres . In comp8.2Neovascularization occurs to meet the increased tumour metabolic demand. Tumours overproduce vascular growth factors such as vascular endothelial growth factor (VEGF) . In conj8.3Metastasis is considered a hallmark of malignancy. Cells loose adherence with each other and secrete proteolytic enzymes such as matrix metalloproteinases (MMPs) that degrade the extracellular matrix . UVB rad9The short lifespan of ocular surface cells means that epithelial cells with DNA mutations do not last long enough to have an effect, as they are constantly being shed from the surface. The longevity of stem cells however gives them enough time to accumulate mutagenic insults. Why tumours are heterogeneous yet originating from the same stem cells could partly be explained by ongoing mutagenesis .The location of stem cells on the ocular surface coincides with the position of OSSN tumours while the growth pattern of lesions (from base upwards) is consistent with the stem cell theory. A study in Australia described concurrent existence of features of OSSN and primary acquired melanosis and stem cells arranged in micro-clusters in the basal epithelium in 12% of pterygiums . Focus w10The known risk factors of OSSN – solar UV radiation, HIV and HPV are implicated in the aetiology. The pattern of distribution of OSSN lesions within the interpalpebral fissure of the ocular surface at the limbus, particularly the nasal side provides further clues. The site is highly vulnerable to solar UVR and has a high concentration of stem cells in the basal epithelium. Stem cells in the limbal epithelial crypts are the likely originators of this disease, and may take on cancer stem cell properties.Neoplasia is probably initiated when background solar UV radiation causes various forms of genetic and epigenetic DNA damage. UVB mainly creates pyrimidine dimers. Specific dimer CC → TT transformation, a signature UV mutation, occurs at the p53 gene, a tumour suppressor that maintains cell-cycle arrest at the G1-S checkpoint. UV radiation also reactivates latent viruses such as HPV. HPV's E7 protein keeps infected cells in a proliferative state while E6 inhibits cell cycle arrest of DNA-damaged cells. Immunosuppression caused by UV radiation, HIV and vitamin A deficiency weakens the tumour surveillance system and allows DNA-damaged cells to proliferate into tumours. Vitamin A deficiency interferes with ocular surface integrity creating micro-abrasions through which HPV may invade the conjunctival basement membrane and epithelial cells. Cancer cells reactivate telomerase which maintains long telomeres increasing the number of cell divisions a cell can undergo. Further tumour expansion and metastasis is enhanced by angiogenesis and increased matrix metalloproteinases (MMPs) which destroy the intercellular matrix.Despite these advances in our understanding there remain gaps, which are areas for further research. For example, there is no explanation why the disease is mostly unilateral despite both eyes receiving equal sunlight exposure. Equally the route of transmission of HPV to the conjunctiva is unknown. The drivers on a molecular level which convert intraepithelial neoplasia to squamous cell cancer are also out with our current understanding of the disease.


At UHCW Hospitals NHS Trust  the MRI guided breast biopsy service has been running since June 2011. Initially, the service was offered to patients imaged at UHCW NHS Trust. With increased experience and confidence the service is now offered to all the eight NHSBSP screening sites in the West Midlands. Here we present our experience regarding the outcomes.Since June 2011, 50 cases were referred for MRI guided breast biopsy of which 10 cases were referred from outside the UHCW NHS Trust diagnostic imaging cohort. There were three high-risk screening cases whilst the remaining cases already had diagnosis of cancer but MRI identified further lesions. All cases were graded B3 or above on diagnostic imaging. All images were reviewed (obtained via IEP) and biopsy performed within 10 days of the initial request. Biopsy samples were sent to local hospitals for pathological analysis.Forty-eight out of 50 cases were considered for biopsy. Two cases were deemed benign (one on review of diagnostic MRI and one case on second-look US). There were 24 malignancies . A follow-up MRI or surgical excision recommendation was made as necessary for non-malignant cases in the biopsy report.MRI guided breast biopsy has been successfully established at UHCW NHS Trust which currently serves as the regional referral centre in the West Midlands.


Rituximab is an anti-CD20 monoclonal antibody that has proven to be effective in the treatment of ANCA-associated vasculitis (AAV) in adults. Standard treatments rely on corticosteroids and cyclophosphamide. Only isolated case reports of pediatric AAV treated by rituximab have been reported so far.Our objective was to collect clinical data and outcomes of children with AAV treated with rituximab in a multicenter retrospective study.We conducted a retrospective study within the French paediatric rheumatology society (SOFREMIP) in 2011-2012.2; one patient received only 3 infusions. Mean duration of follow-up was 2.65 yrs. All patients achieved clinical remission after 12 months. One patient presented several relapses associated with B cell increase and was dependent on rituximab infusions. No severe adverse event had been reported.We identified 6 children with AAV treated with rituximab . The age at onset ranged from 4 to 16 yrs. Treatment with rituximab consisted in 4 infusions of 375 mg/mFrom this multicenter retrospective series, short-term safety and efficicacy of rituximab in pediatric AAV is promising so that B cell depleting agents may represent an alternative to conventional treatment with cyclophosphamide but larger prospective studies are mandatory.None declared.


Acute kidney injury (AKI) is a significant complication following cardiac surgery associated with an increase in morbidity, hospital stay and mortality. Although the estimated incidence of AKI following cardiac surgery is 30%, few studies have identified the incidence of AKI following cardiac surgery as defined by the Kidney Disease: Improving Global Outcomes (KDIGO) group . We condA prospective analysis was performed on 103 adult patients admitted to ICU post-cardiac surgery from September to October 2013. Data for perioperative risk factors and renal biochemical markers were collected up to the sixth postoperative day and are expressed as mean (SD).P = 0.03, P = 0.04 and P < 0.01 respectively) for developing postoperative AKI following cardiac surgery. See Table Ordered logistic regression was used to analyse the data. Thirty- three per cent of cardiac surgery patients at our institution developed AKI. Factors such as poor left ventricular (LV) function, low preoperative haematocrit and low preoperative glomerular filtration rate (GFR) were significant risk factors (Our results suggest that we should focus on LV function and GFR as predictors for developing AKI following cardiac surgery. Strategies to increase preoperative haematocrit should be investigated to reduce in the incidence and severity of postoperative AKI.


Quadricuspid aortic valves are rare congenital anomalies which can bediagnosed by various imaging modalities. Described is the case of a 77year old female with a quadricuspid aortic valve diagnosed by cardiacCT.  A 77-year-old woman was referred for the investigation of atypical chest pain and exertional dyspnea. Cardiac CT demonstrated the following: (1) a quadricuspid aortic valve (QAV) with four equally sized cusps, mildly thickened leaflets and incomplete coaptation  . As wellThe authors declared that there is no conflict of interests.Movie 1: Gated images of the short-axis view of a quadricuspid aortic valve demonstrating motion of four equally sized cusps with incomplete coaptation.Movie 2: Axial images of the heart demonstrating a persistent left-sided superior vena cava and a left atrial appendage which is juxtaposed to the aorta.Click here for additional data file.Click here for additional data file.


Toe deformities are highly prevalent in older people with up to 74% of older men and women having some degree of hallux valgus . DespiteForty-four older adults (60+ years) were recruited to participate in the study. Each participant had their feet assessed by the Chief Investigator (KJM), with hallux valgus severity rated using the Manchester Scale . The abdThe older women with moderate-severe hallux valgus were found to have a significantly reduced cross-sectional area of the abductor hallucis muscle (p < 0.05; Figure


A previously fit and well 37-year-old woman collapsed on her doorstep. Her next door neighbour started cardiopulmonary resuscitation (CPR). A police car arrived at the scene as first responder. An automated external defibrillator was connected and administered two shocks in between which CPR was continued by the police officers. When the ambulance arrived she had a return of spontaneous circulation. Due to massive aspiration she was not intubated. Upon arrival at the Accident and Emergencies Department, we saw this ECG Fig. . After sWhat do you see?AnswerYou will find the answer elsewhere in this issue.


Double strand break (DSB) repair is suppressed during mitosis because RNF8 and downstream DNA damage response (DDR) factors, including 53BP1, do not localize to mitotic chromatin. Discovery of the mitotic kinase-dependent mechanism that inhibits DSB repair during cell division was recently reported. It was shown that restoring mitotic DSB repair was detrimental, resulting in repair dependent genome instability and covalent telomere fusions. The telomere DDR that occurs naturally during cellular aging and in cancer is known to be refractory to G2/M checkpoint activation. Such DDR-positive telomeres, and those that occur as part of the telomere-dependent prolonged mitotic arrest checkpoint, normally pass through mitosis without covalent ligation, but result in cell growth arrest in G1 phase. The discovery that suppressing DSB repair during mitosis may function primarily to protect DDR-positive telomeres from fusing during cell division reinforces the unique cooperation between telomeres and the DDR to mediate tumor suppression. Genome integrity is constantly threatened by DNA lesions resulting from both endogenous stress and exogenous insult. Of the many types of genomic damage, double strand breaks (DSBs) present the greatest threat to genomic health. Left unrepaired, a DSB can result in the loss of substantial genetic material. Alternatively, if DSBs are repaired incorrectly this may result in chromosomal structural abnormalities; including dicentric chromosomes that drive further genome instability through a breakage-fusion-bridge cycle. Eukaryotic cells have thus evolved a sophisticated DNA damage response (DDR) that controls DNA repair and cell cycle arrest to cope with the dangers presented by genotoxic stress While it is critical that cells engage in efficient DSB repair, it is just as important that DSB repair is silenced under certain conditions. One such condition is at the naturally occurring chromosome ends where DSB repair is prevented by specialized nucleoprotein structures called telomeres Spatiotemporal localization of DDR factors during DSB repair is routinely analyzed through observation of cytological ionizing radiation induced foci IRIF, . In brieIn addition to regulating DSB repair, the DDR also controls interphase cell cycle arrest in response to genotoxic stress While there were indications that the DDR differed in mitotic and interphase cells Orthwein et al. Like RNF8 pT198, 53BP1 pT1609 and pS1618 are residues phosphorylated specifically during mitosis Both studies found that generating a double phosphomimetic allele (53BP1 T1609E S1618E or “53BP1 TESE”) resulted in the exclusion of 53BP1 TESE from mitotic and interphase IRIF Mitotic cells are sensitive to DSBs, presumably because DSB repair is silenced Discussed below is the current understanding of how the telomeres cooperate normally with the DDR to mediate cell cycle arrest and the implications of the findings by Orthwein et al. on telomere-dependent tumor suppression.DDR activity is modulated at chromosome ends by the telomere-specific “shelterin” protein complex However, an emerging theme in telomere biology is that telomere deprotection under physiological or pathological conditions is different from telomere dysfunction induced by genetically deleting shelterin subunits We now understand that human telomeres adopt three distinct protective states in relation to DDR activation and DSB repair Observation of spontaneous intermediate-state telomeres in immortalized or cancer cells indicated that TRF2 possessed independent protective functions which (1) inhibited DDR activation and (2) suppressed NHEJ Also reminiscent of the mitotic DDR, intermediate-state telomeres in asynchronous cultures induce muted ATM checkpoint signaling where ATM is activated but CHK2 and NBS1 are not phosphorylated In the recent study using TRF2 knockdown to induce intermediate- and uncapped-state telomeres it was observed that the telomere DDR is refractory to G2/M checkpoint activation The initial static observations of spontaneous telomere deprotection revealed that γ-H2AX, MRE11 and MDC1, but not 53BP1, localized to metaphase-TIF  . For DSBWhy intermediate-state telomeres fuse when mitotic DSB repair is activated is not immediately clear, as some TRF2 remains bound at metaphase-TIF in aged cells and during prolonged mitotic arrest The passage of intermediate-state telomeres through mitosis is likely a critical feature of telomere-dependent tumor suppression Intermediate-state telomeres routinely pass through mitosis in increasing abundance during cellular aging, until sufficient numbers accumulate to induce senescence When DSB repair competent mitotic cells were irradiated to induce non-specific genome wide damage, this resulted in telomere-fusion-dependent genomic instability A potential answer is that Aurora B activation of the telomere DDR during prolonged mitosis is a general response to accumulating stress in mitotic cells. This is supported by the observation that increasing duration of mitotic arrest corresponds with increasing numbers of metaphase-TIF The recent discoveries described here highlight our emerging understanding of the complex relationship between telomeres, mitosis, and the DDR. Suppressing DSB repair during mitosis appears to ensure that intermediate-state telomeres pass through cell division to facilitate telomere-dependent growth arrest in stable diploid G1 phase cells without inducing genomic instability. However, much about the connectivity between mitosis, DSB repair and telomeres remains to be understood. For example, what is the molecular mechanism that facilitates telomere fusion in DSB repair competent mitotic cells? Also, what is the mechanism linking genomic breaks induced during mitosis to the Aurora B dependent mitotic telomere DDR, and how does this impact cells with silenced mitotic DSB repair? It is also unclear if 53BP1 dissociation from TIF at the G2/M boundary is controlled by the same mechanism that prevents 53BP1 from associating with mitotic IRIF or if there is another independent level of control regulating mitotic DSB repair that remains to be discovered.An appealing prospect raised by the discovery of the mechanism inhibiting mitotic DSB repair is that the spontaneous occurrence of abundant intermediate-state telomeres in many cancer cells may present a vulnerability to be exploited for therapeutic means. A combinatorial approach that arrests cancer cells in mitosis while simultaneously targeting mitotic kinases and/or the DDR may hold promise to induce telomere fusions that kill tumor cells. It will be exciting to unravel this surprising and complex relationship between telomeres, mitosis, and DSB repair and to identify the implications of this relationship on human aging and oncogenesis.


Additionally, we have shown tumor suppression and a 30% decrease of PD-1 expression in tumor infiltrating lymphocytes in an in vivo B16 mouse melanoma model. This approach may not only reprogram local signaling within the tumor microenvironment, but also promote polyclonal cytotoxic T cell responses in the absence of defining the antigenic specificity of the infiltrating T cells.One of the largest obstacles in cancer immunotherapy involves overcoming the immunosuppressive tumor microenvironment . While m


P<0.001) and longer white matter path length (P<0.05) compared to healthy individuals. Higher HbA1c was associated with lower network efficiency  and longer network path length . A disruption in local microstructural integrity was found in the multiple white matter regions and associated with higher HbA1c and fasting plasma glucose levels (corrected P<0.05). Poorer glycemic control is associated with lower efficiency and longer connection paths of the global brain network in individuals with diabetes. Chronic hyperglycemia in people with diabetes may disrupt the brain’s topological integration, and lead to mental slowing and cognitive impairment.Previous research has shown that the brain is an important target of diabetic complications. Since brain regions are interconnected to form a large-scale neural network, we investigated whether severe hyperglycemia affects the topology of the brain network in people with type 2 diabetes. Twenty middle-aged (average age: 54 years) individuals with poorly controlled diabetes  and 20 age-, sex-, and education-matched healthy volunteers were recruited. Graph theoretic network analysis was performed with axonal fiber tractography and tract-based spatial statistics (TBSS) using diffusion tensor imaging. Associations between the blood glucose level and white matter network characteristics were investigated. Individuals with diabetes had lower white matter network efficiency ( Furthermore, we did not examine cognitive/behavioral characteristics in our participants of the study.Some limitations of this study should be taken into account. The sample size for each group was relatively small (In summary, using DTI and graph theory, we found that poorly controlled hyperglycemia disrupts the topology of the brain network in T2DM. The measures of network integration showed decreased global efficiency and increased path length in patients with T2DM compared to those in healthy subjects and the measures had a correlation with the level of hyperglycemia. We suggest that disrupted network integration with widespread disruption of WM fiber integrity represent a manifestation of central neuropathy in diabetes, possibly contributing to mental slowing and cognitive impairments in individuals with diabetes.


Wellens' syndrome, also known as LAD coronary T-wave inversion syndrome, is a characteristic ECG pattern that highly suggests critical stenosis of the proximal left anterior descending (LAD) coronary artery. 75% of patients with this finding go on to develop acute anterior wall myocardial infarction within one week unless prevented by early intervention on the culprit lesion. Most instances of ST-elevation occurring during cardiac stress testing have been observed with exercise, with only seven cases reported in the literature with pharmacologic stress. We present a case of a patient with no known cardiac disease who presented with chest pain and an ECG consistent with Wellens' syndrome that developed an acute anterior wall ST-elevation myocardial infarction after pharmacologic stress test. Wellens' syndrome typically presents with the characteristic ECG findings of biphasic T-waves or deep symmetrical T-wave inversions in the precordial leads (leads V1–V4). This ECG finding usually occurs during a pain-free period and is highly suggestive of critical proximal LAD coronary artery stenosis. Given the significant number of patients that will go on to develop acute anterior wall myocardial infarctions, it is critical that all physicians recognize this classic ECG pattern and institute measures for the patient to undergo urgent coronary angiography and revascularization. If left untreated, managed medically, or further risk-stratified by cardiac stress testing, the patient may develop an extensive myocardial infarction or sudden death.A 72-year-old Hispanic male with a past medical history of hypertension, hyperlipidemia, end-stage kidney disease on hemodialysis, and cerebrovascular accident 5 years before presented to the emergency department with midsternal crushing chest pain that awoke him up from sleep at 7 am in the morning. The pain radiated to his jaws bilaterally and was associated with diaphoresis. The pain continued for 30 minutes until EMS arrived and improved after sublingual nitroglycerin and chewable aspirin 325 mg. Significant social history included a history of cigarette smoking. No additional pertinent history was appreciated including review of systems, family history, and social history. The patient's blood pressure on presentation was 137/70 mmHg, heart rate was 102 bpm, and physical exam was documented as essentially within normal limits.The patient's electrocardiogram upon presentation  showed aThroughout the hospitalization the patient remained chest-pain-free and subsequent cardiac markers remained normal. The patient was scheduled to undergo pharmacologic dipyridamole (Persantine) stress testing with nuclear imaging for further risk stratification. A repeat ECG taken before the test is displayed in Roughly sixty minutes after completion of the stress test the patient experienced severe retrosternal chest pain and diaphoresis. A subsequent electrocardiogram revealed sinus tachycardia at 102 bpm  and ST-eA subgroup of unstable angina with high risk of progression to anterior wall myocardial infarction has been described early in the literature as “left anterior descending coronary T-wave syndrome” . In earlECG patterns of Wellens' syndrome can be divided into variants. The larger group of patients (including our patient) demonstrate deep symmetrical T-wave inversion that can extend from V1 to V5. The other variant (24% of cases)  consistsOur case highlights several concerning features of Wellens' syndrome. At first the ECG changes developed during pain-free period. In Wellens' study, the characteristic pattern was seen in the first 24 hours in 60% of cases only (108 patients out of 180) .Despite the ominous ECG changes, our patient had limited myocardial injury as reflected by normal troponin levels. Baseline echocardiography and gated rest images were also normal. In the original series of patients, Wellens reported myocardial damage in 12% of cases only . We cameWellens' syndrome can progress to myocardial infarction over a course of days to weeks. STEMI has been precipitated in cases of Wellens' syndrome after regular exercise stress . Here, tRecognition of Wellens' syndrome and appropriate intervention prevent a potentially devastating myocardial infarction. It is prudent to recommend coronary angiography as the initial diagnostic modality in patients with ECG suspicious of Wellens' syndrome as stress tests including pharmacologic ones carry a risk of progression to myocardial infarction.


Immunostaining data in IgA nephropathy patients needs more test to investigate its potential clinical significance, especially with regards to Oxford classification.Journal of Renal Injury Prevention. In this study on 114 biopsies of IgA nephropathy (IgAN) patients they found no significant association of IgG deposits with age. There was no correlation of IgG deposit with four morphologic variables of Oxford classification  group and IgA deposition alone (IgA) group. They found, proteinuria was greater in the IgA-IgG group than the IgA group. Capillary wall IgA deposits were noted more frequently in the IgA-IgG group than the IgA group. They concluded that mesangial IgG deposition is associated with more severe clinical features in patients with IgAN  have been completely observed by the authors.None.


Tuberculosis (TB) remains a major killer amongst infectious diseases. Current treatment involves a four-drug regimen for at least six months. New drugs and regimens are required to shorten treatment duration, reduce toxicity and combat drug resistance however the optimal methodology to define the critical path for these regimens is not well-defined.We undertook a literature review to summarise outcomes reported in phase II trials of patients with newly-diagnosed pulmonary TB to determine the necessity for a core outcome set in TB.Relevant studies were identified by searching MEDLINE, EMBASE, LILACs and reference lists of included studies. All reported outcomes were considered.10 colony forming units (CFU) per ml sputum over various time points. Related outcomes such as CFU count were sometimes reported in preference (12 studies). Other popular outcomes included number of positive (20 studies) or negative cultures (4 studies) at selected time points while in others time to culture negativity was favoured (3 studies). In all cases there was disagreement as to which time points should be chosen with options ranging from two days to eight weeks. Results for novel drug combinations are currently being analysed and will be presented.49 included phase II studies presented data on 24 historic drug combinations. The most commonly reported outcome (35 studies) was early bactericidal activity (EBA) although there was disagreement regarding a definition. The majority of studies defined EBA as the fall (sometimes mean rate of change) in logThere is large variation in the outcomes reported across phase II studies in TB. To utilise results of multiple studies, and thus identify the best treatment regimens for TB, a core outcome set needs to be developed. This would enable trial results to be more easily compared and combined, potentially leading to improved treatment strategies for patients with TB.


Sudden cardiac arrest has a significant global health burden with an estimated incidence of 95.9 per 100 000 person-years. The causal malignant ventricular arrhythmia may arise secondary to myocardial ischaemia, infarct, oedema, fibrosis or infiltration and survivors are at significant risk for recurrent events. Coronary revascularization procedures have a significant associated morbidity/mortaility in this patient popuation and hence identifying those patients who are most likely to benefit from therapeutic intervention is vital. The aim of this study was to evaluate the role and safety of cardiac MR (CMR) in the investigation of patients successfully resuscitated from out of hospital sudden cardiac arrest.A retrospective study was performed of all patients referred to our institution between July 2006 and July 2011 for CMR evaluation following successfully resuscitated out of hospital sudden cardiac arrest. Patients were defined as having a likely coronary disease aetiology vs non-coronary disease aetiology based on cardiac risk factors, echocardiography, post-resuscitation and admission ECG findings prior to CMR. CMR imaging was blindly interpreted to assign each patient to either a coronary disease aetiology or non-coronary disease aetiology groups based on CMR evaluation. The results were subsequently compared with the post event coronary angiogram.A total of 79 patients underwent CMR evaluation following successfully resuscitated cardiac arrest. In total 55.7% of patients had a coronary disease aetiology and 44.3% had a non-coronary disease aetiology. CMR changed the diagnosis in 20% of patients with a pre-CMR likely diagnosis of coronary disease and 13.3% of patients with a pre-CMR likely diagnosis of non-coronary disease. All our patients tolerated the entire CMR study with no adverse events.CMR is a safe technique in the investigation of patients successfully resuscitated following out of hospital sudden cardiac arrest and identifies a non-coronary cause in a significant number of cases.No external funding.


Summary: Correlating disease mutations with clinical and phenotypic information such as drug response or patient survival is an important goal of personalized cancer genomics and a first step in biomarker discovery. HyperModules is a network search algorithm that finds frequently mutated gene modules with significant clinical or phenotypic signatures from biomolecular interaction networks.Availability and implementation: HyperModules is available in Cytoscape App Store and as a command line tool at www.baderlab.org/Sofware/HyperModules.Contact:Juri.Reimand@utoronto.ca or Gary.Bader@utoronto.caSupplementary information:Supplementary data are available at Bioinformatics online Establishing functional links between genetic variation and human disease is a key goal of cancer genome sequencing . ComplexDiscovery of modules (subnetworks) in biological networks helps isolate systems with disease-related properties and reduces interactome complexity. A growing number of methods are available for this purpose. A landmark paper combines gene expression signatures with protein–protein interactions (PPI) to find predictive modules of cancer outcome . Net-CoxBecause clinical profiles of patients are increasingly available in cancer genomics efforts such as the The Cancer Genome Atlas (TCGA) pan-cancer project  based onP-value reflecting the fraction of seed-specific modules from shuffled networks exceeding the significance of the true module. This removes artifacts of the greedy strategy and corrects for topological features such as highly connected nodes.HyperModules assumes that clinically informative mutations of complex disease occur in systems of closely interacting genes. The greedy network search algorithm focuses on a local network area, defined by a central seed node (a mutated gene) and its surrounding subnetwork. All mutated genes are sequentially considered as seeds in module discovery. Search starts from the seed and grows the module toward increased benefit by adding connected genes that best improve clinical significance. This objective is driven by statistical tests where patients defined by the module are compared with other patients. Categorical clinical variables are studied with Fisher’s exact test and survival times with log-rank test. Cox regression is currently not supported; however, we plan to add this feature in the future. To establish statistical significance of detected modules, we build a null distribution by searching networks with permuted gene names. Each module of the true network is quantified with an empirical Supplementary Fig. S1). For example, network analysis of 30 000 interactions with 121 liver cancer patients, 686 mutated genes and 10 000 permutations takes 10 min on an 8-core computer with 16 GB RAM. HyperModules is thus applicable to a range of networks and mutation datasets.The analysis pipeline is outlined in Supplementary File S1. It comprises 183 ovarian cancer patients from the TCGA study . Second, the categorical variable search with Fisher’s exact test revealed fivemodules with significant enrichment of alive patients . The modules are also summarized in Supplementary Table S1.An example dataset is provided in GA study  and the GA study . The ovaHyperModules is a biological network-mining algorithm that reveals modules of interacting genes with clinically informative disease mutations. Diverse biomolecular interaction networks can be analyzed, including PPI networks, gene regulatory networks and curated biological pathways. Disease mutations are also broadly defined. Although we initially studied cancer point mutations, other types of alterations such as copy number and gene expression changes can be used. HyperModules finds correlations with groups of genes where mutations may be infrequent but the signature strengthens through network integration. Such modules are not often directly usable as biomarkers because of small sample size; however, we believe that our approach helps discover genes and pathways as potential multivariate biomarkers for further experiments.


Genetic cystic kidney diseases, including autosomal recessive polycystic kidney disease (ARPKD), are among the most common causes of end stage renal disease in children and in adolescents. While the detailed biological events resulting in cyst formation remain incompletely understood, nowadays there is wide agreement that dysfunction of a specialized cellular organelle, the primary cilium, underlies genetic cystic kidney disease. In addition to cystic kidney disease, phenotypes resulting from impaired ciliary function can affect nearly every organ of the human body and are nowadays termed ciliopathies.Ruvbl1 in the renal tubule leads to a severe ARPKD-like cystic kidney phenotype in mice. RUVBL1 has previously been linked to regulation of cilia-associated signaling pathways.We recently identified the AAA ATPase RUVBL1 as part of various ciliopathy-associated renal protein complexes and could show that loss of in vivo data strongly supports this concept.To obtain novel insights into the cellular function of RUVBL1 and its partner protein RUVBL2, we generated stable murine cell lines with single genomic integration of coding sequences for fluorescence-tagged Ruvbl1 and Ruvbl2. Out of these cell lines we performed protein interaction screens by repetitive and independent immunoprecipitations followed by quantitative mass spectrometry. Along with multiple known interaction partners we identified novel candidates including proteins that had already been linked to ciliary function. In addition to the important role of RUVBL1 in the renal tubule our data point to a more general function of the RUVBL proteins and the RUVBLs-containing chaperone-like R2TP protein complex for ciliary function. Novel murine In summary, we obtained novel functional insights into the cell biological link of the AAA ATPases RUVBL1 and RUVBL2 to primary cilia. Our data suggest a role of the RUVBL proteins in the cytosolic pre-assembly of ciliary protein complexes.


Ewing’s sarcoma (ES) or primitive neuro-ectodermal tumor (PNET) typically occurs in long or flat bones, the chest wall, extra-skeletal soft tissue, and rarely in solid organs. Incidence of adrenal Ewing’s sarcoma is very rare. Here we report a case of Ewing’s sarcoma of the right adrenal gland in an 8-year-old girl who presented with an abdominal mass. The huge tumor was managed by preoperative neo-adjuvant chemotherapy followed by surgical resection. She died due to metastasis after five months of surgery. An 8-year-old girl presented with progressive pain and palpable lump in right flank for the last one month. Ultrasonography (USG) showed right retroperitoneal tumor, suprarenal in location. Contrast enhanced computed tomography (CECT) demonstrated 12.7 cm x 11.8 cm large variegated mass in right adrenal gland with retroperitoneal lymphadenopathy . A 24-hour urinary catecholamines, plasma metanephrine, aldosterone, and plasma renin levels were within normal range. CT-guided core biopsy revealed malignant small round cell tumor. Bone-marrow aspiration was unremarkable. Tumor was large and appeared unresectable thus neoadjuvant chemotherapy was planned and given for seven cycles using vincristine, doxorubicin and cyclophosphamide alternating with ifosfamide/etoposide with granulocyte colony stimulating factor (GCSF). Tumor regressed to one-fourth of its original size and lymph nodes appeared insignificant size . Patient also improved symptomatically. At operation the tumor was found densely adherent to surrounding tissues especially the upper pole of right kidney and inferior vena cava . The tumor was ultimately resected. Grossly the specimen was 8 cm x 6 cm with tan-yellow cut surface and areas of hemorrhage and necrosis. Histopathology showed adrenal medulla and cortex completely replaced by a small round blue cell tumor . Immunohistochemical (IHC) studies showed that tumor cells were positive for CD99 (membranous), synaptophysin and chromogranin . Postoperatively the patient was lost to follow up and admitted after five months with metastasis in lungs and liver and died within few days.Ewing’s sarcoma/PNET of the adrenal gland is extremely rare.[1-3] Usually the patients present with flank pain and rapidly growing mass. USG should be done as an initial screening tool but CECT is essential to find out the relation with the surrounding structures. CECT imaging helps in distinguishing between benign and malignant adrenal tumors but exact nature.[4] Hormonal studies should be done to differentiate it from the functional adrenal tumors. It is difficult to make a definitive diagnosis of ES/PNET even on histopathology without IHC.[5] Our patient had very large tumor and considered non-resectable, so needle biopsy was done to find out the nature of the tumor. Final diagnosis was made after IHC. CD 99 is a highly sensitive marker for PNET/ES. Patients of ES/PNET show reciprocal translocation of t  involving the EWSR1 gene on chromosome 22 and the FLI1 gene on chromosome 11 in more than 90% of cases but this is not routinely assessed.[2] As per available literature these tumors are very rapidly growing with aggressive nature. As this is a rare tumor, there is no definite guideline for management but surgical resection is considered to be the mainstay for local disease control.[5-7] This tumor is considered as radio and chemo sensitive so adjuvant chemotherapy and radiotherapy are advocated for better disease control but there is no consensus on standard chemo-radiation regimen.[8] We initially tried chemotherapy which worked well in our patient. The outcome seems good in case of complete excision but the prognosis was poor in our case. Proper postoperative surveillance with imaging modalities and adjuvant chemotherapy might alter the outcome in index case.Source of Support: NilConflict of Interest: None declared


The case reported is a young “light” ex-smoker who initially had a localized adenosquamous carcinoma bearing an epidermal growth factor receptor (EGFR) sensitizing mutation. He first recurred six months after initial treatment within the brain with a pure squamous histology and the same EGFR mutation. Surgical resection and radiation rendered him disease-free. Subsequent isolated recurrence within the lung eighteen months later was a pure adenocarcinoma, again with the same identified EGFR mutation. These histologic changes (from adenosquamous to pure squamous to pure adenocarcinoma) have been described but not before in the absence of any selection pressure with EGFR tyrosine kinase inhibitors. This case points out the histologic “flexibility” of EGFR mutant lung cancers and the importance for appropriate molecular testing in nonsmokers with lung cancer of any histologic type. The identification of mutations within the epidermal growth factor receptor (EGFR), and the finding that these mutations make tumors exquisitely sensitive to EGFR tyrosine kinase inhibitors (TKIs), has revolutionized treatment of non-small-cell lung cancer (NSCLC). EGFR mutations are more common in never-smokers, in patients with Asian ethnicity, and in patients with adenocarcinoma histology . We presThe patient was a 43-year-old male who felt well until the onset of intermittent hemoptysis. A chest X-ray demonstrated a left upper lobe (LUL) mass. A Computed Tomography (CT) scan of the chest demonstrated a large LUL mass with satellite lesions and a 1 cm left lower lobe (LLL) nodule . No mediSix months after completion of adjuvant chemotherapy, the patient experienced headaches and altered mental status. A brain MRI showed an irregular frontal lobe lesion measuring 7 by 5 cm Figures . CraniotApproximately eighteen months following resection of the brain metastatic disease, surveillance imaging demonstrated new left lung and hilar nodules Figures . The patAdenosquamous carcinomas are uncommon primary lung tumors. A report in 25 Korean patients with adenosquamous tumors showed that if an EGFR mutation is present (in 44% of their patients), it is present in both components. This finding supports a monoclonal derivation of this tumor  .This report also helps inform the strategy for mutational analysis. While the incidence of “actionable” EGFR or other mutations is infrequent in heavy smokers or squamous histology, the exclusion of these patients from testing would exclude a large proportion of patients with actionable mutations . The NatThis case points out that all nonsmoking lung cancer patients should have molecular testing for “actionable” mutations, regardless of histologic type.