Erythropoietin level and hematologic parameters in healthy adults.

Since the major physiological control of erythropoiesis is related to the eryhtropoietin (EPO) level, correlating the EPO level with hematologic parameters in healthy adults, which constitutes an inexpensive and simple routine laboratory report, would be very useful. Two hundred healthy adult blood donors, 100 males and 100 females, aged between 17 and 60 years old were randomly chosen. The EPO reference range was determined by enzyme linked immunosorbent assay (ELISA) using a reagent kit from Research & Development Systems Inc. The hematologic values for reticulocyte and red blood cell parameters were assessed using the Technicon H*3 RTC, an automated blood cell analyzer. The EPO reference range in the studied population was 2.21-20.95 mU/ml. The correlations between the EPO level and hematologic parameters were between -0.302 (p < 0.01) and 0.294 (p < 0.01). The results suggested that there were none or low correlations between the EPO level and hematologic parameters in healthy adults. According to our results, these parameters could not be used to indicate the level of EPO in healthy adults.

Phase II trial of tropisetron and dexamethasone in the prevention of cisplatin-induced emesis.

Thirty-one patients treated with 58 cycles of cisplatin-based chemotherapy at a dose > 80 mg/m2 were enrolled into the study using tropisetron and dexamethasone in the prevention, of cisplatin-induced emesis. There was 87.9 per cent complete control, 10.3 per cent major control, and 1.7 per cent failure for nausea episode on the first day of cycle. For the vomiting control, there was 96.6 per cent complete control, 3.4 per cent major control, and no failure. After the second day, the percentage of complete control increased gradually for both nausea and vomiting. The complete control for acute nausea and vomiting was 85.7 per cent and 92.9 per cent, respectively. The efficacy for delayed emesis was lower. There was 76.4 per cent complete control for delayed nausea and 85.7 per cent for delayed vomiting. The treatment was well tolerated without any serious adverse events related to tropisetron. Only hiccups was reported in 4 patients and recovered spontaneously at the end of the cycle. Combination of tropisetron and dexamethasone is an effective and safe antiemetic regimen in the prevention of cisplatin-induced emesis.

Recombinant interferon-alpha 2b and megestrol acetate in patients with advanced renal cell carcinoma.

Fifteen patients with histologically proven metastatic or unresectable renal cell carcinoma were enrolled for a phase II trial of Interferon-alpha 2b (> or = 6 x 10(6) U/m2) plus megestrol acetate (160 mg/day). A response rate of 14.3 per cent was achieved in this study. We observed weight gain (median 3.2 kilogram; range 1.1 to 6.9) in 5 patients, and stable weight in 5 of the 14 patients who completed the protocol. Weight gain occurred regardless of extent of metastasis or response to interferon. Our data suggest a possible role for megestrol acetate in alleviating anorexia and weight loss in patients with renal cell carcinoma undergoing interferon treatment. Further clinical trials are clearly warranted.

P53 expression and polysomies of chromosome 9, 17 in head and neck cancer prognosis.

Sixty-nine cases of head and neck squamous cell carcinoma were examined by immunohistochemistry for p53 and chromosome in situ hybridization for chromosome 9 and 17 to determine the relationship between p53 expression and polysomies of chromosome 9 and 17 with the development of a second primary tumor as well as recurrence of primary tumor of head and neck squamous cell carcinoma. We found early expression of p53 in the normal and premaligant lesions adjacent to tumor which was associated with a gradual increase in the fraction of positive nuclei as well as numbers of cancer. We also found statistically significant increments of polysomies of chromosome 9 and 17 in terms of the polysomy index seen through the histologic changes occurring during multistep tumorigenesis. Our results could not demonstrate statistically significant correlation between p53 expression and PI 9 and 17 in tumorigenesis. Interestingly, however, there was a strong correlation between p53 expression and second primary tumor as well as recurrence of primary tumor. The p53 expressed group had a seven fold increased incidence in developing second primary tumor and a two and a half times increased incidence for recurrence of primary tumor, compared to the non-expressed group. We conclude that p53 expression and polysomies of chromosome 9 and 17 have an important role in multistep tumorigenesis in HNSCC. There was no significant correlation between p53 expression and polysomies of chromosome 9 and 17. However, the expression of p53 was statistically significant for association with second primary tumor and recurrence of primary tumor of head and neck squamous cell carcinoma.

Tumor angiogenesis.

Tumor angiogenesis is the growth of new blood vessels which is required for tumor growth and progression. Vascularization of the tumor occurs through a series of sequential steps before or during the multistep progression to neoplasia. Several events occur during the formation of new vessels including production of protease enzymes, unregulation of positive regulators of angiogenesis, and down regulation of negative regulators. In addition, tumor associated macrophage also influence angiogenesis by secreting enzymes, enzymes inhibitors and cytokines. Recent knowledge in tumor angiogenesis may have clinical implications in diagnosis and treatment. Quantification of microvessel density in tumor specimen correlates either metastasis or recurrence in many malignancies such as breast cancer and lung cancer. Therefore, assessment of tumor angiogenesis may serve as prognostic factors. Therapeutic applications include the development of new agents with antiangiogenic properties, vascular targeting drugs, antibody-based therapy, and gene therapy. Combination of antiangiogenic therapy with cytotoxic drugs may enhance antitumor activity. Moreover, the role of antiangiogenic therapy in adjuvant setting may provide and alternative approach to better cancer treatment in the near future.

Reference ranges of reticulocytes in adults.

According to the International Committee for Standardization in Haematology (ICSH), we determined the reference values for reticulocytes using an automated blood cell analyzer Technicon H*3 RTC in 200 healthy adult blood donors, aged between 17 and 60 years, 100 of whom were male and 100 female. The parameters included reticulocyte count, and its corpuscular indices; mean reticulocyte corpuscular volume (MCVr), mean reticulocyte corpuscular hemoglobin concentration (CHCMr), mean reticulocyte hemoglobin content (CHr), reticulocyte distribution width (RDWr), reticulocyte hemoglobin distribution width (HDWr) and reticulocyte corpuscular hemoglobin concentration distribution width (CHDWr). The reference ranges were established by setting the reference limits at two standard deviations from the arithmetic reference mean.

Ruptured primary hepatocellular carcinoma at Chulalongkorn University Hospital: a retrospective study of 32 cases.

Rupture of Primary hepatocellular carcinoma (HCC) is relatively common in high incidence areas including Thailand. There have been attempts to establish a standard treatment to manage this phenomenon. We retrospectively reviewed the records of patients with HCC from January 1989 to June 1997, and ten per cent (32/306) had tumor rupture during the course of the disease. Overall median survival of the patients with tumor rupture was 2.7 months [95% confidence interval (CI), 0-5.9 months] that was not significantly different from that of the patients without rupture (median 6.6 months; 95% CI, 4.0-9.1 months) (P = 0.4605). Among the ruptured group, the patients treated with surgical intervention survived longer than those receiving supportive care alone (median = 15.5 months; 95% CI, 8.7-22.2 months and median = 0.4 months; 95% CI, 0.2-0.5 months, P = 0.0027). The resectional and non-resectional surgical subgroups also had better survival than the supportive group (P = 0.0300 and P = 0.0209, respectively). In conclusion, surgical intervention, if applicable, should be performed in managing ruptured HCC.

Squamous cell carcinoma of head and neck.

Head and neck cancers are a major heath problem and common malignancies in Thailand. Up to 80 per cent of cases are caused by smoking and alcohol consumption. Epithelial mucosa of the aerodigestive tract exposed to carcinogens results in cellular mutations at different areas by a process called field cancerization and causes multistep carcinogenesis. Over 90 per cent of cases are squamous cell carcinoma. Prognostic factors depend on the patients, diseases and treatment. Currently, several molecular pathogenesis have been discovered such as abnormalities of c-myc, c-ras, c-erbB-1, bcl, int-2, hst1 oncogenes, p53 and p16 tumor suppressor genes. Common chromosomal abnormalities are 3p, 9p, 11q, 13q, 17p. Diagnosis requires symptoms and signs, radioimaging, and pathology. Stage I and II can be treated by surgery or radiotherapy. However, stage II requires and combination of surgery and radiotherapy, and studies of chemotherapy and local treatment to increase therapeutic efficacy by several approaches such as combination chemotherapy, new drugs, and biologic therapy.

Genetic instabilities of chromosome 9, 17 and accumulation of p53 overexpression during multistage tumorigesis in head and neck cancer.

Malignant transformation and tumor progression are currently thought to be the result of the accumulation of genetic alterations in critical genes, the proto-oncogenes and the tumor suppressor genes. Among the tumor suppressor genes, the p53 tumor suppressor gene mutations are the most prevalent. In order to determine genetic instability and p53 expression, we analyzed the genetic changes of chromosome 9 and 17 by non-isotopic in situ hybridization in formalin-fixed, paraffin embedded tissues and calculated for normalized chromosome index (NCI) and polysomy index (PI), and the expression of p53 by using immunohistochemistry (IHC). The means of chromosome 9 and 17 NCI were found to increase gradually as the tissues progressed from normal to squamous cell carcinoma; 1.02 and 1.03, respectively, in normal adjacent tissue (ANL), 1.19 and 1.20 in hyperplasia (HYP), 1.28 and 1.31 in mild dysplasia (MD), 1.38 and 1.43 in moderate dysplasia (ModD), 1.39 and 1.66 in severe dysplasia/carcinoma in situ (SD/CIS), and 1.65 and 1.83 in squamous cell carcinoma (SCC). Moreover, the PI 9 and 17 means also increased as the tissues passed from histologically normal epithelium to HYP to dysplasia (DYP) to cancer. In ANL, PI 9 and 17 means were 0.90 and 1.53 percent, compared to 3.78 and 3.38 percent in HYP, 3.73 and 5.12 percent in MD, 5.66 and 8.47 percent in ModD, 13.56 and 20.99 percent in SD/CIS, and 17.74 and 22.50 percent in SCC. Interestingly, p53 expression also increased continuously, not only in amount but also in the incidence of its expression, as the tissues progressed from normal to cancer, 2.29 percent in ANL, 4.65 percent in HYP, 9.09 per cent in MD, 9.58 per cent in ModD, 29 percent in SD/CIS, and 38.67 per cent in SCC in the amount; and 3 of 33 (9%) in ANL, 6 of 37 (16%) in HYP, 5 of 21 (24%) in MD, 3 of 12 (25%) in ModD, 8 of 18 (44%) in SD/CIS, and 24 of 49 (49%) in SCC in the incidence. Our studies demonstrated that genetic instability and p35 expression occurred very early from ANL to SCC and increased gradually through HYP, DYP, to SCC in head and neck cancer. The genetic instability and the loss of normal p53 function play the potential role in multistep tumorigenesis in head and neck cancer and might be the useful biomarkers in assessing the risk of tumor development.

Microsatellite instability in Epstein-Barr virus associated with nasopharyngeal carcinoma.

The result reported here represents the first human genomic screen for MSI in Epstein-Barr-Virus associated NPC. The analysis revealed the incidence of MSI only 1 of 23 cases (4%) which indicates that MSI is less common in NPC development.

Leukocyte alkaline phosphatase activity and peripheral changes of granulocyte following administration of granulocyte colony-stimulating factor.

The rhG-CSF had specificity of stimulation proliferation and differentiation of the neutrophil lineage in which there was an increase of younger stages, the earliest was myelocyte, of granulocyte in circulation. The effect of it was demonstrated within 24 hours of administration and reduced immediately after withdrawal. LAP activity in this condition was normal. The pattern of hematologic change in this condition may mimic CML and leukemoid reaction. It differed clearly from CML, since LAP activity in CML was lower than normal, but LAP activity could not define it from leukemoid reaction. The detection of young cells in peripheral blood through automated measurement of nuclear density by TechniconH*1 was observed for the high sensitivity (100%) and low specificity (54.8%). Furthermore, the study of cell kinetic in bone marrow should be evaluated to complete the cell kinetic effect of rhG-CSF and give a better evaluation for the H*1 blast flag.

Genetic instability and the development of recurrence of primary tumor and second primary tumor during head and neck tumorigenesis.

To determine whether the degree of genetic instability is associated with the development of recurrence of primary tumor (RPT) and second primary tumor (SPT), we examined 46 cases of head and neck squamous cell carcinomas (HNSCC) by nonisotopic in situ hybridization using chromosome specific DNA probes for chromosome 9 and 17. Forty-six cases were classified into three groups; group I, 15 cases without developing RPT and SPT; group II, 21 cases with RPT, and group III, 10 cases with SPT. We demonstrated the statistical significant increment of genetic instability in terms of normalized chromosome index (NCI) and polysomy index (PI) of chromosome 9 and 17 from normal adjacent to malignant lesions (ANL), to hyperplasia (HYP), to dysplasia (DYP), to squamous cell carcinomas (SCC). Our results demonstrated the trend of increased chromosome indices as the tissue progressed from ANL to SCC in group II over group I. However, when we compared the genetic instability between group I and the specimens from the patients who developed RPT within 6 months (group III), we found the significant increment of PI of both chromosome 9 (0.84 +/- 0.54 vs 1.25 +/- 0.46, p = 0.10) and 17 (1.02 +/- 0.62 vs 1.89 +/- 0.87, p = 0.06) on ANL in the later group. Our results also demonstrated the higher trend of genetic instability on ANL in group III over group I as shown by the statistical significance of NCI of both chromosome 9 (0.98 +/- 0.12 vs 1.06 +/- 0.02, p = 0.05) and 17 (1.02 +/- 0.09 vs 1.10 +/- 0.05, p = 0.05). These results suggested that the degree of genetic instability might be used as a potential molecular marker for the risk assessment of early RPT and SPT development during head and neck tumorigenesis.

Loss of heterozygosity for chromosome 11 in Epstein-Barr-virus associated nasopharyngeal carcinoma.

In order to demonstrate and define possible tumor suppressor gene loci on chromosome 11 associated with NPC, we used 7 STR to test for LOH on 25 NPC samples. LOH was detected in 46 per cent of cases. Most LOH loci were clustered on the long arm. Further study demonstrated 22 per cent and 45.5 per cent of cases with LOH on 11q13 and 11q23 respectively.

Molecular biology of head and neck tumorigenesis: the role of p53 expression and genetic instability.

Head and neck cancers progress as multistep tumorigenesis through accumulation of genetic instability. The p53 tumor-suppressor gene encodes a cell-cycle checkpoint protein that functions in the G1 phase of the cell cycle. When DNA damage is incurred, p53 transactivates a number of downstream genes whose products, with diverse biologic activities, contribute to the cellular response to DNA damage. One major p53-mediated function in response to DNA damage is to induce the G1 cell-cycle arrest, or delay, which probably allows time for the cell to repair DNA damage prior to S-phase entry. In cell lacking of p53 function, a condition of genetic instability results from checkpoint loss (Fig. 4.). These events occur early from ANL to SCC and increase gradually through multistep tumorigenesis. Due to the potential role of p53 expression and genetic instability, both might be useful biomarkers in assessing the risk of head and neck tumorigenesis.

In situ hybridization: a new tool in molecular medicine.

In situ hybridization (ISH) is a molecular technique that been used over three decades to detect specific nucleic acid sequences of gene expression at the cellular level. It is a morphologic method of localizing specific DNA or RNA sequences in the individual cell. The technique can be applied to cells frozen or fixed tissues or whole organisms and cytologic preparations; various types of probes can be utilized and the reaction can be visualized by autoradiography using isotopic markers or by colorimetric methods using fluorochromes or enzymes. It has been used primarily for localization of DNA sequences and applied recently to the localization of viral DNA sequences which provides insight into the pathology of viral infection and is enabling the diagnosis of viral infection. Analysis of gene expression by in situ hybridization messenger RNA (mRNA) is a crucial step towards understanding gene function and biology at molecular level. Nowadays, ISH is applied in three major categories: 1) infectious disease 2.) cytogenetics and 3.) gene expression. This technique has undoubtedly become a powerful new tool for molecular diagnostic techniques and is increasingly important in several areas of molecular medicine.

Chemoprevention of head and neck cancer.

Tobacco-related upper aerodigestive tract cancer is a worldwide health problem. Clinical advances in surgery, radiation, and chemotherapy have shown only marginal improvement on the survival rate of these malignancies in the past two decades. The concept of multistage carcinogenesis and field cancerization, the high incidence of SPTs, and the promising results of chemopreventive agents especially 13 cRA to effectively reverse oral premalignancy and prevent SPTs indicate a new avenue to improve the outcome of these newplastic diseases. The study of second primary tumor prevention is too early to show any survival benefit in the treatment arm and toxicity of high dose 13 cRA is significant. The current prospective large scale phase III SPT prevention trial of low-dose 3 cRA may establish a new standard approach for the control of head and neck neoplasms. Identification of potentially useful panels of biomarkers as intermediate endpoints will undoubtedly reduce time and cost currently required to conduct chemoprevention trials.

Antineoplastic-associated colitis in Chulalongkorn University Hospital.

Clostridium difficile is well known for causing pseudomembranous colitis. Most cases are associated with the use of antimicrobial agents. Non-antibiotic associated colitis has rarely been reported. The causes of colitis are related to dietary changes, anesthesia, uremia, and various non-antibiotics medications, especially antineoplastic agents. Most responsible antineoplastics in previous reports are methotrexate and 5FU. From July 1993 to August 1994, 34 cancer patients developed acute diarrhea after chemotherapy. Six cases hd chemotherapy-associated colitis. All patients presented with moderate to severe diarrhea and demonstrable C.difficile toxin in fecal specimens and did not receive any antibiotics before the onset of diarrhea. Premier enzyme immunoassay (EIA) was used for toxin A assay because it is easy to perform and needs no special tissue culture laboratory facility. Data from multicenters studies have shown good sensitivity and specificity of the test. We found documented antineoplastics associated colitis, 7 episodes from 35 episodes of diarrhea (20.0%) that had been tested with EIA for toxin A. Five of 6 episodes were 5FU related. One patient had 2 episodes of antineoplastic associated colitis with the same chemotherapy regimen. The underlying malignancies were GI malignancies in 3 of 6 patients. In conclusion, moderate to severe diarrhea in cancer patients after chemotherapy should alert the physician to be aware of a potential fatal complication caused by C.difficile infection. True incidence has been undoubtedly masked by concomitant antimicrobial treatment and physician unawareness. Early recognition, discontinuation of chemotherapy and prompt treatment should be done to reduce morbidity and mortality of this disease.

CA 50: a tumor marker for gastrointestinal malignancies.

Efforts to find the ideal tumor marker, together with the advanced knowledge of the carbohydrate expression by cancer and the development of monoclonal antibody technology have facilitated the generation of many new tests used in clinical oncology. CA 50, a novel cancer-associated carbohydrate marker, is detected by the C 50 antibody that has been obtained by immunization of mice with a human colorectal adenocarcinoma cell line. This antibody that defines CA 50 reacts with both the afucosyl form of sialylated Lewis(a) carbohydrate moiety and sialylated Lewis(a) moiety which is also the antigenic epitope in the CA 19-9 assay. CA 50 is not organ-specific and its elevated levels in serum can be observed in a variety of malignancies, especially gastrointestinal cancers. In contrast to CA 19-9, high CA 50 levels can also be seen in malignant tumors outside the digestive tract. The expectation, that CA 50 might be positive in the Lewis negative patients who cannot synthesize CA 19-9, is supported by the histoimmunologic study. However, in serum determination close correlation between CA 50 and CA 19-9 has been observed even in patients who have Lewis negative phenotype. In clinical application, CA 50 is marginally beneficial for the diagnosis, but very useful for the follow-up of patients with pancreatic cancers. It gives results rather similar to CA 19-9. Moderately high serum levels of CA 50 can also be seen in benign hepatobiliary diseases, especially in jaundice cases. Therefore, this should be considered in order to obtain the most advantage of the marker. For other gastrointestinal cancers, CA 50 in combination with other previously defined markers may give additional information for the evaluation of some patients with colorectal, biliary, or gastric cancers. At present, there are many new emerging tumor markers used in clinical oncology. Increasing our knowledge about these markers, their capabilities and limitations will enable us to use them effectively in the evaluation of cancer patients.

Changes in white blood cells and myeloperoxidase activity in rhG-CSF prophylactic patients receiving cytotoxic chemotherapy.

The patterns of white blood cell parameters and mean peroxidase index (MPXI) changes in recombinant human granulocyte colony-stimulating factor (rhG-CSF) prophylactic patients, receiving myelosuppressive chemotherapy, have been studied in 8 cases, using flow cytochemistry blood autoanalyser (Technicon R H*1). No severe neutropenia (absolute neutrophil count, ANC < 0.50 x 10(9)/L) appeared in 6 rhG-CSF primary prophylactic patients, but severe neutropenia was noticed in 2 rhG-CSF secondary prophylactic patients for a period less than 1 week. In most of the cases the significant increase of neutrophil during leukocytosis occurred within 24 hours after starting rhG-CSF prophylaxis, and decreased within 24 hours after the end of rhG-CSF prophylaxis. There was a small degree of lymphocytosis, monocytosis, and basophilia in some cases. From this study, there were no significant changes of MPXI during rhG-CSF prophylaxis, the neutrophils produced during proliferative response to rhG-CSF possessed normal myeloperoxidase (MPO) activity. We concluded that the information obtained from automated blood cell analyser Technicon R H*1 especially MPXI and ANC, could be very useful for monitoring rhG-CSF prophylactic patients receiving myelosuppressive chemotherapy. The advantages of the MPXI over other methods is its simplification when performed as part of a routine complete blood count (CBC) on an automated hematology instrument, and its ability to measure even severe neutropenic samples.