Proteasome inhibition reduces donor-specific antibody levels.

BACKGROUND: Current antibody-mediated rejection (AMR) therapies (intravenous immunoglobulin, apheresis, rituximab, polyclonal antibodies) do not target the primary antibody producing B cells, that is, the plasma cell. We report the preliminary results from the first clinical experience with plasma cell targeted therapy with bortezomib. Bortezomib is approved by the US Food and Drug Administration for the treatment of plasma cell tumors (multiple myeloma). METHODS: Kidney transplant patients with mixed acute cellular rejection (ACR) and AMR episodes (by Banff '97 criteria, update 2005) were treated with bortezomib (1.3 mg/m(2) per dose x 4) at standard labeled doses. Patients were monitored by serial donor specific anti-HLA antibody (DSA) determinations [Luminex/Labscreen beads] and quantified by conversion to fluorescence intensity to molecules of equivalent soluble fluorescence (MESF). RESULTS: Five patients were treated with bortezomib. Each patient also had coexisting ACR. In each case, bortezomib treatment led to prompt ACR and AMR rejection reversal. DSA levels decreased significantly in all patients (except 1 patient who had short follow-up). Observed toxicities from bortezomib included a transient grade III thrombocytopenia (1 patient) and mild-to-moderate nausea, vomiting, and/or diarrhea (3/5 patients). Opportunistic infections were not observed. CONCLUSIONS: Bortezomib therapy provides effective reduction in DSA levels with long-term suppression. These preliminary results indicate that proteasome inhibition provides an effective means for reducing HLA antibody levels in transplant recipients.

Outcomes of patients with rejection post-polyomavirus nephropathy.

INTRODUCTION: We sought to determine the effects of rejection in renal transplant recipients with polyomavirus nephropathy (PVN). METHODS: SCr, biopsy findings, BKV serum and urine loads (Taqman PCR), and BKV antibody titers (HA inhibition assay) were analyzed by two-sample median tests and z tests in 11 patients with median follow-up of 7.3 (2.0 to 31.5) months post-PVN. All patients underwent immunosuppression reduction (ISR) as PVN treatment. RESULTS: Post-PVN, 3 (27%) patients had five rejection episodes, with 80% being mild. Median time to rejection was 18 (2 to 60) weeks. One hundred percent of patients who experienced post-PVN rejection also experienced rejection pre-PVN. Rejection episode treatments consisted of: none in one, increased tacrolimus in two, IVIG in one, IVIG and increased tacrolimus in one. Median viral loads in patients with post-PVN rejection versus those without rejection were not different in serum (2.01 x 10(4) vs 9.00 x 10(4) BKV copies/mL; P = .22) or urine (5.37 x 10(5) vs 8.93 x 10(6) BKV copies/mL; P = .28). Median BKV antibody titers were slightly lower (16384 vs 32768 HA units; P = .02) and median SCr values were significantly higher (2.7 vs 1.9 mg/dL, P = .0003) in patients who had experienced post-PVN rejection. Graft losses occurred in one rejection-free patient (chronic allograft nephropathy) and in one patient who experienced multiple acute rejection episodes, humoral rejection, and worsening PVN. CONCLUSIONS: Patients who experience rejection prior to PVN are at high risk of developing rejection post-ISR and post-PVN; however, low graft loss rates may still be achieved.

Thyroglossal duct carcinoma: a rational approach to management.

OBJECTIVE: To discuss the authors' experience with thyroglossal duct carcinoma and present a rational approach to the management of this entity. STUDY DESIGN AND METHODS: A retrospective review of the cytopathology and pathology records of all patients with the diagnosis of a thyroglossal duct remnant from 1965 to 1997 was performed. RESULTS: Three cases of papillary thyroglossal duct carcinoma were identified, with one suspected squamous cell carcinoma by needle aspiration. The papillary carcinomas are discussed in detail to illustrate the difficulty encountered in managing the thyroid gland in the setting of a thyroglossal duct carcinoma. Fine-needle aspiration proved effective in making the diagnosis preoperatively. CONCLUSIONS: The authors recommend that a thyroglossal duct cyst with a microscopic focus of papillary carcinoma, without cyst wall invasion, be managed with a Sistrunk procedure. Treatment of all other thyroglossal duct papillary carcinomas should include removal of all thyroid tissue followed by radioactive iodine treatment.

Fine needle aspiration cytology of renal and retroperitoneal angiomyolipoma. Report of two cases with cytologic findings and clinicopathologic pitfalls in diagnosis.

BACKGROUND: Angiomyolipoma is a benign soft tissue neoplasm that usually arises in the kidney, although rare extrarenal examples have been documented. CASES: Two cases of the neoplasm occurred in which fine needle aspiration (FNA) biopsies were performed. The first patient was a 73-year-old female with a history of breast carcinoma who presented with a large retroperitoneal mass. Transabdominal FNA biopsy revealed multiple fragments of spindle-shaped mesenchymal cells, a few of which showed marked cellular atypia with occasional cells containing fat vacuoles, producing a lipoblastlike appearance. However, the atypical spindle cells were immunohistochemically reactive for actin, raising the possibility of a smooth muscle tumor rather than a liposarcoma. The surgically resected specimen revealed an extrarenal, retroperitoneal angiomyolipoma. The second patient was a 71-year-old female who presented with a right renal mass and hepatomegaly. Computed tomography showed a mass in the upper pole of the kidney and multiple enhancing lesions in the liver. FNA biopsy was diagnostic of angiomyolipoma, which was confirmed histologically. CONCLUSION: Angiomyolipoma should be considered in aspirates of both renal and extrarenal masses when an admixture of blood vessels, fat and smooth muscle cells is encountered. Pitfalls leading to an incorrect diagnosis include aspiration at unusual sites for angiomyolipoma and/or the presence of atypical spindle cells and lipoblastlike cells, which can be mistaken for leiomyosarcoma or liposarcoma cells. Ancillary studies, such as immunocytochemistry for smooth muscle markers, may be helpful in making the correct diagnosis.

Fine-needle aspiration cytology of the adrenal gland. Fifty biopsies in 48 patients.

Fine-needle aspiration biopsy of 50 adrenal masses from 48 patients was performed between 1984 and 1991. The series consisted of 28 males and 20 females, with an age range of 12 months to 79 years (mean age, 55 years). Clinical and/or pathologic follow-up was available in 37 patients. Fine-needle aspiration was diagnostic in all 29 malignant cases having follow-up, with no false-positive diagnoses. There were six primary malignancies (three neuroblastomas, two pheochromocytomas, and one adrenal cortical carcinoma) and 23 metastatic lesions. Of these, the lung was the most frequent primary malignancy (60%), followed by melanoma and renal cell carcinoma (8.6% each). The remaining nonmalignant fine-needle aspiration diagnoses were adrenal cortical neoplasms (most likely adenoma), adrenal cortical hyperplasia, myelolipoma, benign adrenal tissue, and abscess. Based on clinical follow-up, three other adrenal adenomas were not diagnosed by fine-needle aspiration. Six biopsy specimens (12%) were insufficient for diagnosis. Ancillary studies including electron microscopy and/or immunocytochemistry were performed on 13 malignant aspirates and provided additional confirmation of the cytology diagnosis in 12 cases. This study confirms that fine-needle aspiration is a sensitive and highly specific procedure for the evaluation of primary and metastatic malignancies involving the adrenal gland. The technique is less useful in the workup of benign processes but, in some instances, can provide specific diagnostic information.

A comparison of the clinical utility of the radioimmunoassay, high-performance liquid chromatography, and TDx cyclosporine assays in outpatient renal transplant recipients.

Rapid and precise cyclosporine measurements are necessary to maximize immunosuppression and minimize toxicity. The new cyclosporine and metabolites TDx fluorescent polarization immunoassay was studied to determine its precision, sensitivity, and stability. Further, it was compared with the existing radioimmunoassay and high-performance liquid chromatography assays for clinical utility. The TDx procedure utilizes 50 microliter of serum or blood. The range of the assay is 0-1000 ng/ml for serum and 0-2000 ng/ml for whole blood. Precision studies of three control levels provided coefficients of variation of 2.1-5.8% for both assays. The sensitivities of the assays were less than 25 ng/ml for serum and less than 50 ng/ml for whole blood. In order to compare the TDx with the currently used RIA and HPLC methods, 362 simultaneous whole blood and serum samples were obtained from 122 renal transplant recipients over a 4-month period. The serum and whole blood TDx assays excluded fewer patients than either the RIA or HPLC assays with regard to sensitivity. The mean serum cyclosporine concentration for samples above the sensitivity was as follows: TDx 120 +/- 5 ng/ml, RIA 116 +/- 4 ng/ml, and HPLC 100 +/- 5 ng/ml. The mean whole-blood cyclosporine concentration for samples above the sensitivity was as follows: TDx 585 +/- 19 ng/ml, RIA 543 +/- 14 ng/ml, and HPLC 178 +/- 5 ng/ml. Serum and blood TDx levels correlated well with RIA levels, with regression coefficients of r = 0.813 and r = 0.897, respectively. Serum and blood TDx levels did not correlate strongly with HPLC levels, with regression coefficients of 0.332 and 0.781, respectively. Seventeen patients were diagnosed as having acute cyclosporine nephrotoxicity. The serum and whole-blood cyclosporine concentrations in these patients were at the upper end of the therapeutic range for all analytical methods. Five patients had acute cellular rejection; serum and whole-blood cyclosporine levels in these patients did not differ significantly from the stable patients when measured by each of the analytical methods. In conclusion, the TDx cyclosporine and metabolites assay provides reliable blood and serum concentrations that correlate well with RIA measurements in renal transplant recipients. This assay offers rapid sample turn-around times making possible same-day results for all patients without putting great demands upon the laboratory.

An evaluation of the cyclosporine and metabolites whole blood TDx assay.

The new Abbott TDx cyclosporine and metabolites fluorescent polarization immunoassay procedure provides a 20-min sample turn-around time, using 50 microliters of sample for the analysis of cyclosporine in whole blood. A precipitation agent and a lysing agent are utilized as a pretreatment step. The range of the whole blood assay is from 0 to 2,000 ng/ml, with a sensitivity of 50 ng/ml. Precision studies at 3 control levels provided coefficients of variation of 2.1-4.8% for both assays. In order to compare this assay with the currently used Sandoz polyclonal radioimmunoassay (RIA) method. 200 whole blood samples were obtained from 20 renal, cardiac, and hepatic transplant recipients. The mean whole blood cyclosporine concentrations for samples above the sensitivity level were as follows: TDx 754 ng/ml (+/- 31) and RIA 619 ng/ml (+/- 22). Blood TDx levels correlated strongly with RIA levels, with a regression coefficient of r = 0.915. This new assay provides reliable blood cyclosporine concentrations that correlate well with RIA measurements. This assay offers rapid sample turn-around times, making same-day results for outpatient drug monitoring possible.