Jeffrey A. Kant

Carrier Screening for Cystic Fibrosis Costs and Clinical Outcomes

Objectives. To evaluate the costs and clinical effects of 16 alternative strategies for cystic fibrosis (CF) carrier screening in the reproductive setting; and to test the sensitivity of the results to assumptions about cost and detection rate, stakeholder perspective, DNA test specificity, chance of nonpaternity, and couples reproductive plans. Method. Cost-effectiveness analysis. Results. A sequential screening strategy had the lowest cost per CF birth avoided. In this strategy, the first partner was screened with a standard test that identifies 85% of carriers. The second partner was screened with an expanded test if the first partners screen was positive. This strategy identified 75% of anticipated CF births at a cost of

Advantages of firefly luciferase as a reporter gene: application to the interleukin-2 gene promoter.

367,000 each. This figure does not include the lifetime medical costs of caring for a patient with CF, and it assumes that couples who identify a pregnancy at risk will choose to have prenatal diagnosis and termination of affected pregnancies. The cost per CF birth identified is approximately half this figure when couples plan two children. Conclusions. The cost-effectiveness of CF carrier screening depends greatly on couples reproductive plans. CF carrier screening is most cost-effective when it is performed sequentially, when the information is used for more than one pregnancy, and when the intention of the couple is to identify and terminate affected pregnancies. These conclusions are important for policy considerations regarding population-based screening for CF, and may also have important implications for screening for less common diseases.

Phase II Trial of Short-Course CHOP-R Followed by 90Y-ibritumomab Tiuxetan and Extended Rituximab in Previously Untreated Follicular Lymphoma

The chloramphenicol acetyltransferase (CAT) gene is widely used in recombinant constructs employed to study promoter and enhancer control of gene expression. However, CAT-based assays require a laborious, multi-step procedure for quantitation of promoter activity. We have applied the recently described firefly luciferase (LUC) reporter gene to the study of the interleukin-2 (IL2) promoter and have further defined the properties of this reporter gene system. We find that IL2-LUC constructs have multiple advantages over IL2-CAT constructs. The LUC assay is highly sensitive and requires 1/10 the cells used in the CAT system. A final quantitative measure of promoter activity can be obtained within 25 h following transfection with IL2-LUC, compared to 108-160 h with IL2-CAT. Light emission significantly (fourfold) above background is detectable 3 h after induction in a direct assay of extracts from transfected cells. We have described the variability of the assay, the minimum number of transfected cells required to detect light, the stability of luciferase in cell extracts, the effect of Triton X-100 on the assay, and a rapid cell lysis procedure. The luciferase system is a simple, rapid, and sensitive method for the study of promoter activity in transfected cells, particularly for weakly expressed genes such as IL2 which give low activity in the CAT assay.

Cutaneous marginal zone lymphomas have distinctive features and include 2 subsets.

Purpose: Radioimmunotherapy has been approved for relapsed follicular lymphoma (FL), including rituximab-refractory FL. This study was designed to determine the CR rate with short-course chemoimmunotherapy with cyclophosphamide, doxorubicin, vincristine, prednisone, and rituximab (CHOP-R) followed by 90-Y ibritumomab tiuxetan (RIT) with extended rituximab as first-line treatment. Experimental Design: Between March 2004 and February 2007, 60 patients with stage II to IV symptomatic or bulky FL from a single institution supported by a large community network entered this phase II trial. Patients received CHOP-R for three treatment cycles before RIT followed by four additional weekly treatments with rituximab. Response was determined using fusion [18 F] fluorodeoxyglucose-positron emission tomography (PET)-computed tomography (CT) imaging. Results: Of the 60 patients entering this trial, 55 patients completed all protocol therapy. The median follow up was 19.7 months (range, 0.26-35.9 months). For intent-to-treat analysis, the complete response (CR) rate after CHOP-R, as assessed by CT and PET imaging, was 40% and 46%, respectively. After RIT, the CR rate improved, as assessed by CT and PET imaging, to 82% and 89%, respectively. Ten patients have progressed, including eight from best response of CR. Seven of 18 patients who were PET positive after CHOP-R progressed compared with 3 of 37 patients who were PET negative (P = 0.010). Conclusions: In patients with previously untreated, symptomatic or bulky FL, short-course chemoimmunotherapy and consolidation RIT and extended rituximab resulted in a high CR rate. Failure to achieve an early PET CR after CHOP-R indicated high risk of relapse.

JAK2 V617F mutation in patients with catastrophic intra-abdominal thromboses.

Cutaneous marginal zone lymphomas (CMZL) were segregated in the WHO/EORTC consensus classification but grouped with other MALT lymphomas in the subsequent WHO classification. It has been suggested, however, that CMZL have distinctive features and might include 2 subsets. To address these issues, the clinicopathologic, phenotypic and, when possible, genotypic features of 29 CMZL with plasmacytic differentiation were assessed. The monotypic plasma cells had class-switched heavy chain expression in 22 cases, technically inadequate staining in 1 case (included with class-switched cases for analysis) and 6 were IgM+. The class-switched cases had a predominance of T cells in 22 out of 23 cases with a CD4:CD8>1 in 15 out of 16 cases, usually showed nodules and scattered small B cells often with IgD+ apparently nonneoplastic follicles, lacked CXCR3 B-cell expression, never showed a totally diffuse growth pattern, often had prominent mast cells, and lacked known extracutaneous involvement. The IgM+ cases showed a predominance of B cells in 5 out of 6 (P=0.0003), a diffuse proliferation of CD20+ B cells in all (P<0.0001), CXCR3+ B cells in 2 out of 5 (P<0.04), and extracutaneous disease in 3 out of 6 (P<0.008). CD21+ usually disrupted follicular dendritic meshworks were seen in 9 out of 12 class-switched and 5 out of 5 IgM+ cases. CD123+ plasmacytoid dendritic cells, PD1+ T follicular helper cells, CD25+ or FOXP3+ regulatory T cells, and TIA1+/granzyme B− cytotoxic cells were never numerous. Only 1 out of 14 tested cases showed a low-level clonal/oligoclonal T cell receptor &ggr; gene rearrangement. These findings support the presence of 2 types of cutaneous MALT lymphomas with the class-switched cases being the most distinctive but still sharing significant features with MALT lymphomas from other sites, specifically an extranodal extramedullary CD5-, CD10- indolent small B cell lymphoma with plasmacytic differentiation, frequent benign follicular structures, and not fulfilling the criteria for any other well-defined lymphoma.

Non-radioactive detection of the most common mutations in the cystic fibrosis transmembrane conductance regulator gene by multiplex allele-specific polymerase chain reaction

Catastrophic intra-abdominal thrombosis can result from a variety of prothrombotic states, including polycythemia vera and essential thrombocythemia, both of which are frequently associated with an acquired mutation (V617F) in the JAK2 gene. To assess the prevalence and clinical implications of this mutation in the setting of intra-abdominal thrombosis, JAK2 V617F genotyping was performed in 42 patients who had catastrophic intra-abdominal thromboses resulting in visceral transplants. The prevalence of V617F was compared with that of other prothrombotic states for which molecular testing is routinely performed. V617F mutations were detected in 7 patients (17%), who were not distinguishable on the basis of their peripheral blood cell counts. The median posttransplantation survival of V617F+ patients was 17.5 months, compared with 116.4 months for the V617F- patients (ratio, 6.6; 95% confidence interval, 6.3-7.0). These results highlight the diagnostic usefulness of JAK2 V617F testing in this setting and underscore the clinical significance of a positive result.

Secondary Ph-positive CML with a minority monosomy 7 clone

SummaryA rapid, simple, nonradioactive method for detection of four common mutations causing cystic fibrosis (CF) has been developed combining multiplexing with allele-specific polymerase chain reaction amplification. This approach (MASPCR) provides an easy assay for direct genotyping of normal and mutant CF alleles in homozygotes and heterozygotes. The strategy involves multiplex PCR of exons 10, 11, and 21 within the cystic fibrosis transmembrane conductance regulator (CFTR) gene in a single reaction containing three common oligoprimers and either the four normal or four mutant oligos corresponding to the ΔF508, G551D, G542X, and N1303K mutations. Primers are chosen so that the size of the four PCR products differ, thereby facilitating detection on agarose gels following amplification in the same reaction. Patient samples are primed with either four normal or four mutant oligo mixtures, and PCR products run in parallel on gels to detect band presence or absence. This approach provides a simple and potentially automated method for cost-effective population screening.

Comparative biochemical and genetic characterization of clonally related human B-cell lines secreting pathogenic anti-Pr2 cold agglutinins

We report a case of Ph-positive chronic myelogenous leukemia (CML) secondary to previous treatment for a lymphoma. At the time of original diagnosis of lymphoblastic lymphoma, chromosome studies of blood and bone marrow were normal. Following therapy and a clinical remission complicated by CNS relapse, the patient presented 16 months after treatment was discontinued with a WBC of 110,000 mm-3, consistent with CML. Blood and marrow cytogenetic studies at this time showed a Ph chromosome, t(9;22)(q34;q11) translocation, without other karyotypic alteration. A separate small clone with the karyotype 45,XY, -7 was found in the blood. His disease followed an aggressive course and he died 3 months later. The autopsy findings indicated CML in blast crisis. Molecular studies performed on cells replacing a lymph node revealed a rearrangement of the breakpoint cluster region (bcr) of chromosome #22 and of the immunoglobulin heavy chain locus. Taken together, it seems most likely that the patients CML developed as a second neoplasm following successful elimination of his lymphoblastic lymphoma by therapy.

Richter's syndrome associated with loss of response to transforming growth factor-beta☆

To study the biology of cold autoimmune hemolytic anemia, Epstein-Barr virus (EBV)-transformed B-cell clones were established from a patient with splenic lymphoma associated with immune hemolysis due to an anti-Pr2 cold autoantibody. Studies were performed comparing the cold autoantibody present in culture supernatants of these cell lines to the pathogenic cold autoantibodies present in the patients plasma. Cytogenetic studies of splenic lymphocytes demonstrated an abnormal karyotype (51XX, +3, +9, +12, +13, +18). After EBV transformation, eight clones secreting IgM, kappa anti-Pr were isolated; each clone had the same abnormal karyotype as above. DNA isolated from the clones and spleen was analyzed by Southern blot hybridization with JH, C mu, and C kappa probes; identical gene rearrangements were seen in each case. Anti-Pr antibodies, isolated from culture supernatant and serum were compared by isoelectric focusing (IEF) and demonstrated similar banding patterns. Distinctive binding patterns, however, were observed in 2/8 clones, suggesting structural differences. Adsorption studies with red blood cells further showed that the observed IEF banding patterns were solely due to anti-Pr cold autoantibody. With a thin-layer chromatography method, the biochemical determinants recognized by the cold autoantibodies were defined as glycolipids containing Neu Ac alpha 2-3Gal beta 1-4Glc sequences. The data demonstrate that the autoantibodies of the EBV-transformed B-cell lines were similar to the pathogenic monoclonal serum autoantibody in both structure and specificity. These clonal cell lines may thus serve to further study the biology of human B-cell lymphomas with defined autoantibody specificity.

Marrow fibrosis associated with a Philadelphia chromosome

A patient with chronic lymphocytic leukemia developed a large cell lymphoma apparently derived from the same neoplastic B-cell clone (Richters syndrome). At the same time, mitogen-stimulated proliferation of the patients circulating leukemic B-cells was no longer inhibited by the regulatory cytokine transforming growth factor-beta (TGF-beta), suggesting that such loss of inhibition might be contributing to the clinical and biological progression of the disease.