New pharmacokinetic and pharmacodynamic tools for interferon-alpha (IFN-α) treatment of human cancer

Interferon (IFN-) has been widely used in the treatment of human solid and haematologic malignancies. Although the antitumour activity of IFN- is well recognised at present, no major advances have been achieved in the last few years. Recent findings have provided new information on the molecular mechanisms of the antitumour activity of the cytokine. In fact, IFN- appears to block cell proliferation, at least in part, through the induction of apoptotic effects. This cytokine can also regulate the progression of tumour cells through the different phases of the cell cycle inducing an increase of the expression of the cyclin-dependent kinase inhibitors p21 and p27. However, it must be considered that IFN- is a physiologic molecule with ubiquitously expressed receptors that is likely to activate survival mechanisms in the cell. We have recently identified an epidermal growth factor (EGF) Ras-dependent protective response to the apoptosis induced by IFN- in epidermoid cancer cells. The identification of tissue- and/or tumour-specific survival pathways and their selective targeting might provide a new approach to improve the efficacy of IFN-–based treatment of human cancer. Moreover, new pegylated species of IFN- are now available with a more favourable pharmacokinetic profile. We will review these achievements, and we will specifically address the topic of IFN-–based molecularly targeted combinatory antitumour approaches.     

A sandwich-type enzyme-linked immunosorbent assay for the analysis of recombinant human interferon α-2b

The ability of a previously developed sandwich-type enzyme-linked immunosorbent assay (ELISA) for discriminating incorrectly folded recombinant human interferon -2b (IFN-2b) molecular species from multi disulphide-bonded species was investigated. This ELISA was applied to evaluate and improve the effectiveness of the renaturation of IFN-2b, a step that is currently used in the large-scale production of IFN-2b produced in recombinant Escherichia coli strains.     

α-Tocopheryl succinate sensitizes established tumors to vaccination with nonmatured dendritic cells

Purpose: Dendritic cells (DCs) are considered potential candidates for cancer immunotherapy due to their ability to process and present antigens to T cells and stimulate immune responses. However, DC-based vaccines have exhibited minimal effectiveness against established tumors in mice and human cancer patients. The use of appropriate adjuvants can enhance the efficacy of DC-based cancer vaccines in treating established tumors. Methods: In this study we have employed -tocopheryl succinate (-TOS), a nontoxic esterified analogue of vitamin E, as an adjuvant to enhance the effectiveness of DC vaccines in treating established murine Lewis lung (3LL) carcinomas. Results: We demonstrate that locally or systemically administered -TOS in combination with nonmatured DCs injected intratumorally (i.t.) or subcutaneously (s.c.) significantly inhibits the growth of preestablished 10-day tumors (mean tumor volume of 77.5 ± 17.8 mm³ on day 30 post–tumor injection) as compared to -TOS alone (mean tumor volume of 471 ± 68 mm³ on day 30 post–tumor injection). Additionally, the adjuvant effect of -TOS was superior to that of cyclophosphamide (CTX). The mean tumor volume on day 28 post–tumor injection in mice treated with CTX+DCs was 611 ± 94 mm³ as compared to 105 ± 36 mm³ in mice treated with -TOS+DCs. Analysis of purified T lymphocytes from mice treated with -TOS+DC revealed significantly increased secretion of IFN- as compared to T cells from the various control groups. Conclusion: This study demonstrates the potential usefulness of -tocopheryl succinate, an agent nontoxic to normal cell types, as an adjuvant to augment the effectiveness of DC-based vaccines in treating established tumors.Abbreviations AO acridine orange - CTX cyclophosphamide - DC dendritic cell - dUTP deoxyuridine triphosphate - FACS fluorescence-activated cell sorter - FBS fetal bovine serum - FITC fluorescein isothiocyanate - GM-CSF granulocyte-macrophage colony-stimulating factor - IFN- interferon-gamma - IL-4 interleukin-4 - NaS sodium succinate - OCT optimal cutting temperature - PBS phosphate-buffered saline - PI propidium iodide - Tdt terminal deoxynucleotidyl transferase - TNF- tumor necrosis factor alpha - -TOS -tocopheryl succinateSupported by grants 1 RO1 CA94111-02 from the NIH and DAMD 17010126 from the DOD.     

The evolution of the type I interferon gene family in mammals

A phylogenetic analysis of mammalian type I interferon (IFN) genes showed: (1) that the three main subfamilies of these genes in mammals (IFN-, IFN-, and IFN-) diverged after the divergence of birds and mammals but before radiation of the eutherian orders and (2) that IFN- diverged first. Although apparent cases of interlocus recombination among mouse IFN- genes were identified, the hypothesis that coding regions of IFN- genes have been homogenized within species by interlocus recombination was not supported. Flanking regions as well as coding regions of IFN- were more similar within human and mouse than between these species; and reconstruction of the pattern of nucleotide substitution in IFN- coding regions of four mammalian species by the maximum parsimony method suggested that parallel substitutions have occurred far more frequently between species than within species. Therefore, it seems likely that IFN- genes have duplicated independently within different eutherian orders. In general, type I IFN genes are subject to purifying selection, which in the case of IFN- and IFN- is strongest in the putative receptor-binding domains. However, analysis of the pattern of nucleotide substitution among IFN- genes suggested that positive Darwinian selection may have acted in some cases to diversify members of this subfamily at the amino acid level.     

Modulation of cytokine responses of murine CD8+ αβ intestinal intraepithelial lymphocytes by IL-4 and IL-12

The immune responses of the intestine mucosa feature the noninflammatory type, such as IgA production and oral tolerance. Th2 type cytokines have been implicated in the induction of these noninflammatory responses. In the present study, cytokine responses of CD8+ and CD4+ TCR+ intestinal intraepithelial lymphocyte ( iIEL) subsets to TCR stimulation under the influence of IL-12, IL-4, or CD28 costimulation were examined. IL-12 enhanced production of IL-10 and IFN- by the CD8+ iIEL significantly but only marginally affected the CD8+ subset, whereas IL-4 induced IL-4, IL-5, and IL-10 production and augmented TGF- production by both subsets. CD28 costimulation induced production of Th2 cytokines by CD4+ iIEL in the absence of exogenous IL-4. Unlike lymph node CD4+ cells, the CD28 costimulation-induced Th2 differentiation of CD4+ iIEL was not inhibited by IFN-. These results demonstrate active cytokine production by CD4+, CD8+, as well as CD8+ iIEL. The Th2-skewed cytokine profile of CD8+ iIEL and the IFN--resistance of Th2 differentiation of the CD4+ iIEL suggest that both iIEL subsets contribute to the induction of noninflammatory mucosal immune responses.     

Acute Multiple Sclerosis Characterized by Extensive Mononuclear Phagocyte Infiltration

In this study, we examine the clinical, neuroradiological, and immunohistochemical findings of a 51 year old white female who died 27 months after onset of acute multiple sclerosis despite treatment with interferon-, azathioprine, corticosteroids, and cyclophosphamide. Immunohistochemical studies revealed extensive gliosis and mononuclear phagocyte infiltration with corresponding upregulation of proinflammatory cytokines (eg. IFN-, TNF-). The significance of immunohistochemical findings with respect to clinical presentation is discussed.     

Expression of STAT1 and STAT2 in malignant melanoma does not correlate with response to interferon-alpha adjuvant therapy

Interferon-alpha (IFN-) is used as an adjuvant therapy in patients with malignant melanoma and who have undergone surgical resection of high-risk lesions. Defective expression or activation of STAT1 or STAT2 has been shown to correlate with IFN- or resistance in vitro; however, recent data from our laboratory suggest that the anti-tumor effects of IFN- are dependent on STAT1 signaling within host immune cells. We measured STAT1 and STAT2 expression in 28 melanoma biopsies (8 cutaneous lesions; 1 lung metastasis; 19 nodal metastases) obtained from patients prior to the initiation of adjuvant IFN- therapy. Disease recurrence following IFN- treatment did not correlate with the staining intensity of either STAT1 (P=0.61) or STAT2 (P=0.52). Tumors with minimal STAT1 or STAT2 expression (<20% positive) were present in four patients with tumor-positive lymph nodes, who exhibited prolonged relapse-free survival (>44 months) following adjuvant therapy. Conversely, high levels of STAT1 were present in a patient who recurred during the course of IFN- therapy. A case study of one patient who experienced recurrent disease during IFN- treatment revealed that STAT1 levels were greater in the recurrent tumor when compared to the original lesion. These studies provide direct evidence to suggest that levels of STAT1 and STAT2 within the tumor do not influence a patients response to adjuvant IFN-.     

Effect of Recombinant Interferon-α2b (Laferon) on Transport of Sodium Ions in Human Neuroblastoma Cells

To elucidate molecular mechanisms of neurotropic action of a recombinant interferon, IFN-2b (laferon), its effect on transport of ²²Na⁺ through the membrane of cultured human neuroblastoma cells (line IMR 32) was investigated. Within the first minutes after treatment with IFN-2b, the influx of ²²Na⁺ ions was reduced by 20%, as compared with the control. Depolarization of the plasma membrane by a mixture of veratrine and scorpion (Leiurus quinquestriatus) toxin (200 and 10 g/ml, respectively) increased this flux by 50% in the control and by 70% in the IFN-2b-treated cells. A blocker of voltage-operated sodium channels, tetrodotoxin (TTX, 4 · 10^-7 M), suppressed the inward flux of ²²Na⁺ ions (completely in the control cells and by 75% in the IFN-2b-treated cells). The influx of ²²Na⁺ ions into neuroblastoma cells depended on the concentration of IFN-2b in the incubation medium, reaching a maximum at concentrations of 600-1000 IU/ml. This allows us to suggest that entry of Na⁺ ions into neuroblastoma cells caused by IFN-2b is basically performed through voltage-operated TTX-sensitive sodium channels.     

Combined effects of interferon α and interleukin 2 on the induction of a vascular leak syndrome in mice

Summary Immunotherapy with interleukin 2 (IL-2) alone or in combination with lymphokine-activated killer cells can mediate tumor regression in mice and in man. Further dose escalation of IL-2 along with lymphokine-activated killer cells has been prevented by the development of a vascular leak syndrome produced by IL-2. Because we have found that interferon (IFN-) or tumor necrosis factor (TNF-) has synergistic antitumor effects when administered together with IL-2, we have tested the vascular leakage induced by these lymphokine combinations. We used a murine model to quantify vascular leakage by measuring the extravasation of ¹²⁵I-albumin from the intravascular space as well as the wet and dry lung weights after treatment with different cytokines. Cytokines (or Hanks balanced salt solution) were administered to C57BL/6 mice and 4 h after the last injection the vascular leak was quantified. IFN- alone did not cause extravasation of radiolabel or increase in wet lung weights, though when given in combination with IL-2, significantly greater extravasation (P<0.01) as well as increase in lung water weights (P<0.05) was observed compared to the response in mice treated with IL-2 alone. IFN- in combination with IL-2 induced significant vascular leakage earlier than the response induced by IL-2 alone. For example treatment with IFN- and IL-2 induced accumulation of 14674±605 cpm in the lungs at day 1 while IL-2 alone induced 12340±251 cpm. The degree of vascular leakage was highly related to the dose of IFN- administered along with IL-2 and increased vascular leak syndrome was evident even at low doses (5000 units) of IFN-. Immunosuppression of mice by pretreatment irradiation (500 rad) markedly decreased the development of vascular leak syndrome induced by IL-2 and IFN-. Interestingly IFN- and TNF- did not induce vascular leakage in the lungs when given alone, and did not add or synergize with IL-2 in causing the syndrome. Thus the administration of IFN- in combination with IL-2 produces a dose-limiting vascular leakage that is more severe than that caused by IL-2 alone, and may be mediated, directly or indirectly by host radiosensitive cells. Abbreviations used: LAK, lymphokine-activated killer; IFN, interferon; TNF, tumor necrosis factor; IL-2, interleukin-2     

Antiproliferative effects of bacillus Calmette-Guérin and interferon α2b on human bladder cancer cells in vitro

Direct inhibitory effects of bacillus Calmette-Guérin (BCG) and interferon 2b (IFN2b) on six human bladder carcinoma cell lines, UCRU-BL-13, UCRU-BL-17, UCRU-BL-28, 5637, T24 and J82, were studied using an in vitro proliferation assay. Effects on proliferation following exposure to BCG or IFN2b were analysed by [³H]thymidine incorporation over 7 days. BCG had an antiproliferative effect on all bladder lines, while sensitivity to IFN2b varied greatly, being as remarkably low as 1 U/ml for some lines. The antiproliferative effect was greatest when cells were exposed continuously to either agent, but was still evident with a limited exposure. When clinical concentrations were simulated in vitro, BCG+IFN2b was more effective than BCG alone and as effective as a double BCG concentration. We conclude that, in addition to their immunomodulatory effects, BCG and IFN2b directly inhibit the proliferation of human bladder cancer cells, and often at extremely low concentrations.     

Somatic cell mapping of the bovine interferon-α receptor

The bovine interferon- receptor (BoIFN-R) mediates the activity of bovine IFN-s and IFN-. In addition, human IFN-s have uniformly high biological activity on bovine cells. A ³²P-labeled derivative of human recombinant IFN-A (HuIFN-A-P1) binds well and can form a characteristic 130-kDa complex on bovine cells, but not on hamster cells. We have, therefore, analyzed the binding and covalent crosslinking of [³²P]HuIFN-A-P1 to a panel of bovine-hamster somatic cell hybrids. Binding to several bovine-hamster hybrid cell lines was strong (about 30–50% of that seen with bovine MDBK cells) and specific. The binding correlated uniquely with bovine syntenic group U10. In several of the hybrid lines, the ability of human IFN-B to enhance the expression of endogenous MHC class I molecules correlated with the binding results. We thus conclude that the bovine IFN-R structural gene (locus designation IFNAR) localizes to syntenic group U10. This group includes a number of other genes whose homologs map to human Chromosome (Chr) 21.A summary of this work was presented at the annual meeting of the International Society for Interferon Research (November 1991, Nice, France) and appeared as an abstract for that meeting (Langer et al., J Interferon Res 11 (Suppl): S203, 1991).     

Evaluation of hydrophobicity versus chaperonelike activity of bovine alphaA- and alphaB-crystallin

Calf lens A-crystallin isolated by reversed-phase HPLC demonstrates a slightly more hydrophobic profile than B-crystallin. Fluorescent probes in addition to bis-ANS, like cis-parinaric acid (PA) and pyrene, show higher quantum yields or Ham ratios when bound to A-crystallin than to B-crystallin at room temperature. Bis-ANS binding to both A- and B-crystallin decreases with increase in temperature. At room temperature, the chaperone-like activity of A-crystallin is lower than that of B-crystallin whereas at higher temperatures, A-crystallin shows significantly higher protection against aggregation of substrate proteins compared to B-crystallin. Therefore, calf lens A-crystallin is more hydrophobic than B-crystallin and chaperone-like activity of -crystallin subunits is not quantitatively related to their hydrophobicity.     

The Immune Response to Artificial Proteins Containing Biologically Active Fragments of Human IFN-α2 and Insulin

A study was made of the humoral immune response of BALB/c mice to various doses of artificial proteins that contained biologically active fragments of human interferon 2 (IFN-2) and insulin. The insulin fragment had no effect on the response to any protein construct. The IFN-2 fragment increased the titer of antibodies against the construct. Mapping of continuous B epitopes with immune sera revealed several antigenic determinants, the C end of the IFN-2 fragment with the adjacent de novo protein region being immunodominant. The more effective binding of serum antibodies with the constructs containing the IFN-2 fragment was attributed to antibody interaction with the fragment and to better recognition of the entire protein construct by the immune system.     

The sialyl-α2,6-lactosaminyl-structure: Biosynthesis and functional role

Sialylation represents one of the most frequently occurring terminations of the oligosaccharide chains of glycoproteins and glycolipids. Sialic acid is commonly found ,3- or ,6-linked to galactose (Gal), ,6-linked to N-acetylgalactosamine (GalNAc) or ,8-linked to another sialic acid. The biosynthesis of the various linkages is mediated by the different members of the sialyltransferase family. The addition of sialic acid in ,6-linkage to the galactose residue of lactosamine (type 2 chains) is catalyzed by -galactoside ,6-sialyltransferase (ST6Gal.I). Although expressed by a single gene, this enzyme shows a complex pattern of regulation which allows its tissue- and stage-specific modulation. The cognate oligosaccharide structure, NeuAc,6Gal1,4GIcNAc, is widely distributed among tissues and is involved in biological processes such as the regulation of the immune response and the progression of colon cancer. This review summarizes the current knowledge on the biochemistry of ST6Gal.I and on the functional role of the sialyl-,6-lactosaminyl structure.     

Enhancement of epidermal growth factor receptor expression on glioma cells by recombinant tumor necrosis factor α

Summary Recombinant tumor necrosis factor (rTNF; optimal dose 1000 U/ml) significantly increased the density of epidermal growth factor receptor (EGF-R) in three of four glioma cell lines in culture as determined by binding analysis of anti-EGF-R monoclonal antibody (mAb) 425. Since enhancement of EGF-R expression by rTNF- was inhibited when cells were treated with the protein synthesis inhibitor cycloheximide, the effects of rTNF may be protein-synthesis-dependent. The dose of rTNF that was optimal for up-regulation of EGF-R on glioma cells did not inhibit the growth of these cells.¹²⁵I-labeled mAb 425 lysed glioma cells in culture following its internalization into the cells. After glioma cells had been treated with rTNF, the growth-inhibitory effects of the mAb were significantly enhanced, probably a reflection of the increase in EGF-R density on the tumor cell surfaces. The rTNF effects were specific to the EGF-R and did not affect unrelated glioma-associated antigens. In our previous clinical trials,¹²⁵I-labeled mAb 425 showed immunotherapeutic effects in glioma patients. The present study provides the basis for considerations of combined immunotherapy of glioma patients with¹²⁵I-labeled mAb 425 and rTNF.     

Complete protection against melanoma in absence of autoimmune depigmentation after rejection of melanoma cells expressing α(1,3)galactosyl epitopes

The major barrier for xenotransplantation in humans is the presence of (1–3) Galactosyl epitopes (Gal) in xenogeneic tissue and the vast quantities of natural antibodies (Ab) produced by humans against this epitope. The binding of anti-Gal Ab to cells expressing Gal triggers a complement-mediated hyperacute rejection of target cells. The hyperacute rejection of whole cancer cells, modified to express Gal epitopes, could be exploited as a new cancer vaccine to treat human cancers. We tested this hypothesis in Galactosyltransferase knockout (GT KO) mice which, like humans, do not express Gal on their cell surfaces and can produce anti-Gal Ab. Forty-five percent of mice with preexisting anti-Gal Ab rejected Gal positive melanoma cells (B16Gal). These mice remained tumor-free for more than 90 days. The majority of control mice injected with B16Null, Gal negative cells succumbed to melanoma. The rejection of B16Gal induced strong long-lasting antitumor immunity against B16Null measured by the expansion of cytotoxic T lymphocytes. In addition, mice rejecting B16Gal were protected against melanoma since they survived a second rechallenge with B16Null. Protected mice developed antitumor immunity in the absence of autoimmune depigmentation (vitiligo). These results show that rejection of Gal positive melanoma cells can efficiently boost the immune response to other tumor associated antigens present in Gal negative melanoma cells. This study supports the concept of a novel anticancer vaccine to treat human malignancies.     

Ala99ser mutation in RIα Regulatory Subunit of protein kinase A causes reduced kinase activation by cAMP and arrest of hormone-dependent breast cancer cell growth

Expression of the RI regulatory subunit of protein kinase A type I is increased in human cancer cell lines, in primary tumors, in cells after transformation, and in cells upon stimulation of growth. Ala99 (the pseudophosphorylation site) of human RI was replaced with Ser (RI-p) for the structure-function analysis of RI. MCF-7 hormone- dependent breast cancer cells were transfected with an expression vector for the wild-type RI or mutant RI-p. Overexpression of RI-P resulted in suppression of protein kinase A type II, the isozyme of type I kinase, production of kinase exhibiting reduced cAMP activation, and inhibition of cell growth showing an increase in G0/G1 phase of the cell cycle and apoptosis. The wild-type RI overexpression had no effect on protein kinase A isozyme distribution or cell growth. Overexpression of protein kinase A type II regulatory subunit, RII, suppressed RI and protein kinase A type I and inhibited cell growth. These results show that the growth of hormone-dependent breast cancer cells is dependent on the functional protein kinase A type I.     

Variation of seed α-amylase inhibitors in the common bean

Variation of seed -amylase inhibitors was investigated in 1 154 cultivated and 726 non-cultivated (wild and weedy) accessions of the common bean, Phaseolus vulgaris L. Four -amylase inhibitor types were recognized based on the inhibtion by seed extracts of the activities of porcine pancreatic -amylase and larval -amylase and larval -amylase of the Mexican bean weevil, Zabrotes subfasciatus Boheman. Of the 1 880 accessions examined most (1 734) were able to inhibit porcine pancreatic -amylase activity, but were inactive against the Z. subfasciatus larval -amylase; 41 inhibited only the larval -amylase activity, 52 inhibited the activities of the two -amylases, and 53 did not inhibit the activity of either of the -amylases. The four different inhibitor types were designated as AI-1, AI2, AI-3, and AI-0, respectively. These four inhibitor types were identified by the banding patterns of seed glycoproteins in the range of 14–20 kDa by using SDSpolyacrylamide gel electrophoresis. Additionally, four different banding patterns were recognized in accessions with AI-1, and were designated as AI-1a, 1b, 1c, and 1d. Two different patterns of the accessions lacking an -amylase inhibitory activity were identified and designated as AI-0a and AI-0b. The largest diversity for seed -amylase inhibitors was observed in non-cultivated accessions collected from Mexico where all eight inhibitor types were detected. The possible relationships between the variation of seed -amylase inhibitors and bruchid resistance are discussed.     

Autologous tumor vaccines processed to express α-gal epitopes: a practical approach to immunotherapy in cancer

This review describes a method by which the human natural anti-Gal antibody can be exploited as an endogenous adjuvant for targeting autologous tumor vaccines to antigen-presenting cells (APCs). Tumor cells remaining in the patient after completion of surgery, radiation, and chemotherapy are the cause of tumor relapse. These residual tumor cells can not be detected by imaging, but their destruction may be feasible by active immunotherapy. Since specific tumor-associated antigens (TAAs) have not been identified for the majority of cancers, irradiated autologous tumor vaccines have been considered as an immunotherapy treatment that may elicit an immune response against the residual tumor cells expressing TAAs. However, tumor cells evolve in cancer patients in a stealthy way, i.e., they are not detected by APCs, even in the form of vaccine. Effective targeting of tumor vaccines for uptake by APCs is a prerequisite for eliciting an effective immune response which requires transport of the vaccine by APCs from the vaccination site to the draining lymph nodes. In the lymph nodes, the APCs transporting the vaccine process and present peptides, including the autologous TAA peptides for activation of the tumor-specific T cells. The required targeting of vaccines to APCs is feasible in humans by the use of anti-Gal. This antibody interacts specifically with the -gal epitope (Gal1-3Gal1-4GlcNAc-R) and is the only known natural IgG antibody to be present in large amounts in all humans who are not severely immunocompromised. The -gal epitope can be synthesized on any type of human tumor cell by the use of recombinant 1,3galactosyltransferase (1,3GT). Solid tumors obtained from surgery are homogenized and their membranes subjected to -gal epitope synthesis. Similarly, -gal epitopes can be synthesized on intact tumor cells from hematological malignancies. Administration of irradiated autologous tumor vaccines processed to express -gal epitopes results in in situ opsonization of the vaccinating cells or cell membranes due to anti-Gal binding to these epitopes. The bound antibody serves to target the autologous tumor vaccine to APCs because the Fc portion of the antibody interacts with Fc receptors on APCs. Since patients receive their own TAAs, the vaccine is customized for autologous TAAs in the individual patient. The repeated vaccination with such autologous tumor vaccines provides the immune system of each patient with an additional opportunity to be effectively activated by the autologous TAAs. In some of the immunized patients this activation may be potent enough to induce an immune-mediated eradication of the residual tumor cells expressing these TAAs.Abbreviations Ab Antibody - Ag Antigen - APC Antigen-presenting cell - DC Dendritic cell - FcR Fc receptor - -gal epitope Gal1-3Gal1-4GlcNAc-R - 1,3GT -1,3-Galactosyltransferase - KO mice Knockout mice for 1,3GT - OVA Ovalbumin - SA Sialic acid - TAA Tumor-associated antigen     

α-Thalassemia in Saudi Arabia: deletion pattern

Summary -Thalassemia exists at a high prevalence in several regions of Saudi Arabia. The restriction endonucleases Bam HI and BglII were used to investigate the molecular basis of deletion type of -thalassemia in 226 subjects from the eastern and 61 subjects from the northwestern regions of the country. The arrangements-/ and-/- were common. BglII digestion revealed the existence of rightward deletion in a majority of the cases. Leftward deletions, both homozygous and heterozygous, were also identified. Triple -gene arrangements -/ and -/- were observed at a low frequency in both regions.