Stephanie D. Reilly

Histological Characteristics of the Fetal Inflammatory Response Associated with Neurodevelopmental Impairment and Death in Extremely Preterm Infants

OBJECTIVE To test the hypothesis that increasing severity of the fetal inflammatory response (FIR) would have a dose-dependent relationship with severe neurodevelopmental impairment or death in extremely preterm infants. STUDY DESIGN We report 347 infants of 23-28 weeks gestational age admitted to a tertiary neonatal intensive care unit between 2006 and 2008. The primary outcome was death or neurodevelopmental impairment at the 18- to 22-month follow-up. Exposure status was defined by increasing stage of funisitis (stage 1, phlebitis; stage 2, arteritis with or without phlebitis; stage 3, subacute necrotizing funisitis) and severity of chorionic plate vasculitis (inflammation with or without thrombosis). RESULTS A FIR was detected in 110 placentas (32%). The rate of severe neurodevelopmental impairment/death was higher in infants with subacute necrotizing funisitis compared with infants without placental/umbilical cord inflammation (60% vs 35%; P < .05). Among infants with stage 1 or 2 funisitis, the presence of any chorionic vasculitis was associated with a higher rate of severe neurodevelopmental impairment/death (47% vs 23%; P < .05). After adjustment for confounding factors, only subacute necrotizing funisitis (risk ratio, 1.87; 95% CI, 1.04-3.35; P = .04) and chorionic plate vasculitis with thrombosis (risk ratio, 2.21; 95% CI, 1.10-4.46; P = .03) were associated with severe neurodevelopmental impairment/death. CONCLUSION Severe FIR, characterized by subacute necrotizing funisitis and severe chorionic plate vasculitis with thrombosis, is associated with severe neurodevelopmental impairment/death in preterm infants.

Incremental Value of Live/Real Time Three‐Dimensional Transesophageal Echocardiography over the Two‐Dimensional Technique in the Assessment of Sinus of Valsalva Aneurysm Rupture

We present an adult patient with rupture of the right sinus of Valsalva aneurysm in whom the two‐dimensional transesophageal echocardiogram failed to show the rupture. On the other hand, live/real time three‐dimensional transesophageal echocardiography clearly delineated the site of rupture into the pericardium and mediastinum. (Echocardiography 2011;28:918‐920)

Anterior Gradient Protein-2 Is a Regulator of Cellular Adhesion in Prostate Cancer

Anterior Gradient Protein (AGR-2) is reported to be over-expressed in many epithelial cancers and promotes metastasis. A clear-cut mechanism for its observed function(s) has not been previously identified. We found significant upregulation of AGR-2 expression in a bone metastatic prostate cancer cell line, PC3, following culturing in bone marrow-conditioned medium. Substantial AGR-2 expression was also confirmed in prostate cancer tissue specimens in patients with bone lesions. By developing stable clones of PC3 cells with varying levels of AGR-2 expression, we identified that abrogation of AGR-2 significantly reduced cellular attachment to fibronectin, collagen I, collagen IV, laminin I and fibrinogen. Loss of cellular adhesion was associated with sharp decrease in the expression of α4, α5, αV, β3 and β4 integrins. Failure to undergo apoptosis following detachment is a hallmark of epithelial cancer metastasis. The AGR-2-silenced PC3 cells showed higher resistance to Tumor necrosis factor-related apoptosis- inducing ligand (TRAIL) induced apoptosis in vitro. This observation was also supported by significantly reduced Caspase-3 expression in AGR-2-silenced PC3 cells, which is a key effector of both extrinsic and intrinsic death signaling pathways. These data suggest that AGR-2 influence prostate cancer metastasis by regulation of cellular adhesion and apoptosis.

A 51-Year-Old Man With Acute Dyspnea and Leg Swelling

1. What are the patient’s most striking clinical, laboratory, and histopathologic findings? 2. How do you explain these findings? 3. What is the patient’s most likely diagnosis? 4. What is the most common causal organism for this patient’s disease? 5. What is the pathogenesis of this patient’s disease? 6. What is the appropriate treatment for this disease? 7. What are the complications and prognosis of this disease?

A fatal case of systemic lupus erythematosus complicated by macrophage activation syndrome, portal vein thrombosis and acute colitis.

Dear Editor, Systemic lupus erythematosus (SLE) may be associated with a wide variety of complications. Macrophage activation syndrome (MAS) is a severe, potentially lifethreatening systemic condition. It has been described in association with systemic juvenile idiopathic arthritis (sJIA), SLE and Kawasaki disease. The mechanism is excessive proliferation and activation of T lymphocytes and macrophages leading to secretion of toxic levels of proinflammatory cytokines. Diagnosis is based on the following criteria: persistent fever, splenomegaly, cytopenias involving at least two cell lines, hypertriglyceridemia and/or hypofibrinogenemia, hyperferritinemia and hemophagocytosis in the bone marrow. Thrombosis in SLE is attributed to a number of thrombophilic defects, including lupus anticoagulant and anticardiolipin antibodies. Lupus enteritis in SLE patients is mostly caused by small vessel vasculitis of the bowel wall, although severe infectious colitis in SLE patients has also been reported. We describe a fatal case of SLE, complicated by MAS, portal vein thrombosis (PVT) and acute colitis. The patient was a 60-year-old white female with long-standing SLE, Sj€ ogren’s syndrome, hypertension and chronic kidney disease. She presented to our emergency department with diarrhea, nausea and vomiting. At the time of presentation, her SLE therapy was low-dose prednisone (10 mg daily) and hydroxychloroquine (200 mg daily). Abdominal computed tomography (CT) scan showed colitis involving the transverse colon/splenic flexure extending into the descending colon. She was admitted with sepsis from infectious versus ischemic colitis and was treated with intravenous fluids, hydrocortisone, vancomycin, ciprofloxacin, metronidazole and meropenem. Admission blood cultures as well as post-treatment blood cultures were negative. Colon biopsy demonstrated necrotic debris and fibrinopurulent exudate; special stains showed no fungi or cytomegalovirus (CMV). Polymerase chain reaction on plasma for CMV DNA was also negative. No test for Epstein–Barr virus (EBV) was done. She developed altered mental status, hemodynamic instability and lactic acidosis. Continuous renal replacement therapy (CRRT) was begun. There was a concern for MAS. Her ferritin levels were significantly increased, along with positive disseminated intravascular coagulation (DIC) lab results, extremely abnormal hepatic function panel, high lactate dehydrogenase, and low red blood cell count (Table 1). Her white cell counts were high (40–50 9 10/mm) which was attributed to sepsis, masking the expected low white cell counts in MAS. Despite therapy, she expired on hospital day 8. Autopsy confirmed acute colitis involving a 60-cm segment. Acute PVT with extensive associated hepatic necrosis was revealed and the bone marrow showed increased numbers of macrophages with hemophagocytosis consistent with MAS. The immediate cause of

Abstract B52: Loss of anterior gradient protein in high-grade prostate cancer is associated with loss of tumor cell adhesion and epithelial cell polarity

Prostate cancer has the highest rate of incidence among all cancers in men in the United States and the second leading cause of death behind lung cancer. The human homologue of the frog (Xenopus) anterior gradient protein (AGR-2) has gained considerable attention in recent years for its putative role in neoplastic growth, metastasis and poor survival of patients with breast and prostate cancers. AGR-2 is reported to be androgen dependent and expressed only during the early stages of prostate cancer progression, whereas significant decline in AGR-2 levels in higher grades tumors coincided with metastatic disease. Human primary prostate cancer tissues and regional metastasis were immunostained for AGR-2 expression. Results indicated that AGR-2 was localized in the glandular epithelium of the prostate gland. No significant difference in AGR-2 staining was observed between normal, BPH and well-differentiated prostate cancers, except in normal prostate, where AGR-2 was mostly concentrated in the nuclei. Similar results were observed in a spontaneously developing transgenic adenocarcinoma of mouse prostate (TRAMP) model. AGR-2 expressions was reduced significantly in moderately and poorly-differentiated tumors in both human and TRAMP mice. Higher AGR-2 levels were found in the metastatic tissue albeit lower expressions in the highest grades prostate tumors within the same individual, suggesting further requirement of AGR-2 for growth at the metastatic sites. Targeted silencing of AGR-2 in a bone metastatic prostate cancer cell line, PC3, resulted in significantly reduced cellular adhesion to various extracellular matrix proteins and a failure to form acinar structures following 3-dimensional growth on matrigel. We also determined that AGR-2 silencing led to down-regulation of crucial integrins in PC3 cells, which possibly explains mechanism by which AGR-2 maintains polarized morphology of epithelial cells through promotion of cell adhesion. Based on our findings, we hypothesize that loss of AGR-2 in prostate cancer cells allows detachment from the basement membrane of the primary site and initiates metastasis. AGR-2 as well as integrin levels are restored during passage through circulation and at the metastatic site(s), helping them re-attach to the new microenvironment. Citation Format: Diptiman Chanda, Anandi Sawant, Jonathan Adam Hensel, Tatyana Isayeva, Stephanie D. Reilly, Gene P. Siegal, Claire Smith, Selvarangan Ponnazhagan. Loss of anterior gradient protein in high-grade prostate cancer is associated with loss of tumor cell adhesion and epithelial cell polarity [abstract]. In: Proceedings of the AACR Special Conference on Advances in Prostate Cancer Research; 2012 Feb 6-9; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2012;72(4 Suppl):Abstract nr B52.

Abstract 5173: The human homologue of frog (Xenopus laevis) anterior gradient protein promotes metastasis via regulation of cellular adhesion

Proceedings: AACR 103rd Annual Meeting 2012‐‐ Mar 31‐Apr 4, 2012; Chicago, IL Our recent studies indicated a significant up-regulation of anterior gradient protein-2 (AGR-2) in bone metastatic human prostate cancer cells, PC3, following growth in bone marrow conditioned medium. Evidence indicates that AGR2 belongs to the family of protein disulfide isomerases and has been linked to intestinal mucus production, tumor growth and metastasis of various adenocarcinomas and poor survival of patients with breast and prostate cancers. Few recent reports have also reported the regulatory elements of AGR2 function, but its specific role(s) in tumorigenesis and metastasis is still unclear. In the present study, we have analyzed the role of AGR2 in cancer progression and metastasis using prostate cancer as a model. Human prostate cancer tissue microarrays and autopsy tissues, obtained from University of Alabama at Birmingham consortiums were immunostained for AGR-2 expression. Results were also confirmed in a spontaneously developing transgenic adenocarcinoma of mouse prostate (TRAMP) model. Further characterization of AGR-2 function was determined in PC3 cells with targeted silencing of AGR-2 expressions for tumor growth and metastases in vitro and in vivo. Results of our study found AGR-2 expression mainly in the prostate luminar epithelial cells, but no difference was observed between normal prostate gland, BPH and early stages of prostate cancer in both human and TRAMP mouse. Significant reduction in AGR-2 expression was observed in grade IV & V prostate cancers. Interestingly, although declining AGR-2 was evident in higher grade prostate tumors, significantly elevated AGR-2 expressions were observed in the metastatic sites of the same individuals. AGR-2-silenced PC3 cells formed tumors in SCID mice similar to control cells whereas their ability to remain attached to various ECM proteins were greatly compromised. Several key integrins, which mediates ECM binding, were also found to be down-regulated in the AGR-2 silenced PC3 cells, suggesting loss of AGR-2 may be associated with their detachment from the primary tumor and initiation of metastasis. AGR-2 is further up-regulated in metastatic sites indicating its necessity for restoration of integrins for attachment in a new microenvironment. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 5173. doi:1538-7445.AM2012-5173

A Fatal Case of High Fever in a 42-Year-Old Woman

1. What are this patient’s most striking clinical, laboratory, and histopathologic findings? 2. How do you explain these findings? 3. What is the patient’s most likely diagnosis? 4. What is the pathogenesis of this patient’s disease? 5. What is the genetic basis of this patient’s condition? 6. What are the diagnostic modalities for susceptible individuals? 7. What is the appropriate treatment for this disease? 8. What are the complications and prognosis for this disease?

A 34-Year-Old-Male with Progressive Neurologic Decline

Questions:1. What are the most common causes of aneurysms?2. What is the most likely cause of this patient’s aneurysm? 3. Name and describe the most likely underlying histologicdiagnosis. 4. What are the clinical features of this patient’s disease?5. Are there any laboratory tests to help in the diagnosis of thispatient’s disease? 6. How is this patient’s disease managed, and what is theexpected clinical outcome?Possible Answers:1. Common causes of aneurysms include atherosclerosis,Marfan syndrome, Ehlers-Danlos syndrome, bacterial and fun-gal infections, syphilis, arteritis, and trauma. A rare cause iscopper deficiency, which inhibits lysyl oxidase leading to non-crosslinked elastic muscle fibers.