Review article: Asia-Pacific consensus recommendations on endoscopic tissue acquisition for biliary strictures

BACKGROUND

Pre-operative tissue diagnosis for suspected malignant biliary strictures remains challenging.

AIM

To develop evidence-based consensus statements on endoscopic tissue acquisition for biliary strictures.

METHODS

The initial draft of statements was prepared following a systematic literature review. A committee of 20 experts from Asia-Pacific region then reviewed, discussed, and modified the statements. Two rounds of independent voting were conducted to reach a final version. Consensus was considered to be achieved when 80% or more of voting members voted "agree completely" or "agree with some reservation."

RESULTS

Eleven statements achieved consensus. The choice of tissue sampling modalities for biliary strictures depends on the clinical setting, the location of lesion, and availability of expertise. Detailed radiological and endoscopic evaluation is useful to guide the selection of appropriate tissue acquisition technique. Standard intraductal biliary brushing and/or forceps biopsy is the first option when endoscopic biliary drainage is required with an overall (range) sensitivity and specificity of 45% (26%-72%) and 99% (98%-100%), and 48% (15%-100%) and 99% (97%-100%), respectively, in diagnosing malignant biliary strictures. Probe-based confocal laser endomicroscopy and fluorescence in situ hybridisation using 4 fluorescent-labelled probes targeting chromosomes 3, 7, 17 and 9p21 locus may be added to improve the diagnostic yield. Cholangioscopy-guided biopsy and EUS-guided tissue acquisition can be considered after prior negative conventional tissue sampling with an overall (range) sensitivity and specificity of 60% (38%-88%) and 98% (83%-100%), and 80% (46%-100%) and 97% (92%-100%), respectively, in diagnosing malignant biliary strictures.

CONCLUSION

These consensus statements provide evidence-based recommendations for endoscopic tissue acquisition of biliary strictures.

[Stratified sampling survey of major human parasitic diseases in Henan province]

Objective: To understand the prevalence of major human parasitic diseases and related factors in Henan province. Methods: This stratified sampling survey was carried out according to the requirement of national survey protocol of major human parasitic diseases, 2014-2015. The prevalence of soil-transmitted helminths infection, taeniasis and intestinal protozoiasis were surveyed in 104 sites selected from 35 counties (districts) and the prevalence of clonorchiasis was surveyed in 62 sites selected from 37 townships. In each survey spot, 250 persons were surveyed. A total of 26 866 persons and 15 893 persons were surveyed. Modified Kato-Katz thick smear was used to detect the eggs of intestinal helminthes. Tube fecal culture was used to identify the species of hookworm. The Enterobius eggs were detected in children aged 3 to 6 years by using adhesive tape. The cyst and trophozoite of intestinal protozoa were examined with physiological saline direct smear method and iodine stain method. Results: The overall infestation rate of intestinal parasites was2.02% in Henan, and the worm infection rate was higher than protozoa infection rate. Fourteen kinds of intestinal parasites were found, including nematode (5 species), trematode (2 species), and protozoan (7 species). The infection rate of Enterobius vermicularis was highest, and Qinba Mountain ecological area had the highest infestation rate of intestinal parasites in 4 ecological areas of Henan. There was no significant difference in intestinal parasite infection rate between males and females (χ(2)=3.630, P=0.057), and the differences in intestinal parasite infection rate among different age groups had significance (χ(2)=124.783, P=0.000 1). The infection rate reached the peak in age group ≤9 years and the major parasite was Enterobius vermicularis. Furthermore the overall human infection rate of parasite showed a downward trend with the increase of educational level of the people (χ(2)=70.969, P=0.000 1), the differences had significance (χ(2)=120.118, P=0.000 1). For different populations, the infection rate of intestinal parasites was highest among preschool children. The infection of intestinal helminth was mainly mild, only 2 severe cases were detected. The infection rate of Clonorchis sinensis in urban residents was only 0.006%. Logistic regression analysis showed that being preschool children (χ(2)=15.765, P=0.000 1) and drinking well water (χ(2)=45.589, P=0.000 1) were the risk factors for intestinal parasite infection, and annual income per capita of farmers was the protective factor against intestinal parasite infection. The infection rates of protozoa and intestinal parasites decreased sharply compared with the results of previous two surveys, and the rate of intestinal helminth infection also dropped sharply compared with the second survey. The numbers of protozoa, helminth and intestinal parasites detected in this survey were all less than the numbers found in the previous two surveys. Conclusions: Compared the results of three surveys in Henan, the infection rate of protozoa and intestinal parasites showed a downward trend. The prevention and treatment of Enterobius vermicularis infection in children should be the key point of parasitic disease control in the future.

Abstract P2-02-07: Predicting germline mutations in BRCA1/2 and beyond: A comparison of women with single and multiple breast primaries

Synchronous or metachronous breast primaries are a well-known indication of hereditary breast cancer, particularly within BRCA1/2 mutation carriers. However, the frequency of gene mutations within this patient group has not been well defined, especially in the setting of multi-gene panel testing (MGPT). We conducted a retrospective review of mutation carrier status in a population of females with breast cancer(s), but no other reported cancer diagnoses, and who had MGPT at a single diagnostic laboratory. Among 31,864 females tested, the following were excluded from analysis: 5389 (17%) had variants of unknown significance (VUS), 133 (0.4%) had moderate risk mutations and 316 (1.0%) had MUTYH monoallelic mutations. For the remaining 26,026 females, we evaluated whether mutation status is associated with risk of multiple breast primaries using Fisher's exact test and logistic regression analysis adjusting for age at testing, age at first breast cancer diagnosis, and mutations in other genes. The number of genes analyzed ranged from 5-49, depending on the panel ordered. Gene-specific analyses were limited to with 10 or more mutations in this cohort (ATM, BARD1, BRCA1, BRCA2, BRIP1, CDH1, CDKN2A, CHEK2, MRE11A, MUTYH, MSH6, NBN, NF1, PALB2, PMS2, PTEN, RAD50, RAD51C, RAD51D, and TP53).

In this cohort the average age of first breast cancer diagnosis was 47.7 (range 12-95) and the average age of second diagnosis was 56 years (range 17-89). A positive result (pathogenic mutation or variant, likely pathogenic) in any gene was more likely for women with three or more breast cancer primaries (p=0.007) and two or more primaries (p=1.2e-08) than those with one breast primary.

Overall, women with a mutation in any gene were more likely to have multiple primary breast cancers than those without mutations. Specifically, women with mutations in ATM, BRCA1, CDH1, PALB2, PTEN, and TP53 mutations were more likely to have multiple breast primaries than non-carriers of mutations in those genes (table 1).

Table 1: Risk of multiple breast primaries in mutation carriers versus non-carriers No. (%) with multiple primaries  GeneCarrierNon-CarrierOR (95% CI)p-valueATM55/262 (21%)2189/15057 (15%)1.6 (1.1, 2.2)0.006BRCA1100/526 (19%)3104/24117 (13%)1.9 (1.5, 2.4)3.2e-07CDH16/24 (25%)3338/25016 (13%)2.8 (1.0, 1.7)0.04PALB245/218 (21%)2199/15101 (15%)1.7 (1.2, 2.4).004PTEN7/28 (25%)3429/25788 (13%)3.8 (1.5, 8.9)0.003TP5319/96 (20%)3419/25787 (13%)2.4 (1.3, 4.0)0.002

Our results show that women with multiple breast primaries are more likely to have mutations in some genes than others. Interestingly, all genes with significant odds ratios are well-described and most are known to cause high risk for breast cancer, with the exception of ATM. Additional studies are needed to confirm these results and quantify risks for second primary breast cancers. With further work defining the risks of multiple primary breast cancers, this information could be implemented into clinical practice to aid women in risk management following a positive result.

Citation Format: Panos Smith L, Tian Y, Qian D, McFarland R, Espenschied CR. Predicting germline mutations in BRCA1/2 and beyond: A comparison of women with single and multiple breast primaries [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-02-07.

Prevalence, awareness, treatment and control of diabetes mellitus in rural China: results from Shandong Province

AIMS

To estimate the prevalence, awareness, treatment and control of diabetes in rural areas in Shandong Province, China.

METHODS

The Luxemburg-WHO-Shandong Project on Rural Health Personnel Training and Chronic Disease Control, a cross-sectional study, examined 16 375 rural residents aged 25 years and over using multistage cluster sampling in April 2007. An overnight fasting blood specimen was collected to measure plasma glucose and a 2-h 75-g oral glucose tolerance test was conducted among people with a fasting blood glucose of ≥ 6.1 mmol/l. Information on the history of diabetes and hypoglycaemic medication was obtained using a standard questionnaire. Diabetes and prediabetes were defined according to the 1999 World Health Organization diagnostic criteria.

RESULTS

Overall, the prevalence rates for diabetes, prediabetes and previously diagnosed diabetes in the rural population were estimated to be 3.5%, 6.0% and 1.2%, respectively. Among those with diabetes, only 34.8% were aware of their condition, 30.6% were currently undergoing medication treatment, and 11.5% achieved glycaemic control.

CONCLUSIONS

These results indicate that diabetes has become a public health problem in poor rural areas of China and the rates of awareness, treatment and control of diabetes were relatively low. There is an urgent need for strategies aimed at the prevention and treatment of diabetes in the rural population in Shandong Province, China.

Does Low Body Mass Index Matter? Relationship between Body Mass Index and Subjective Well-Being among Long-Lived Women over 95 Years of Age

OBJECTIVES

To examine the relationship between body mass index (BMI) and subjective well-being (SWB) among long-lived women over 95 years of age and evaluate whether this relationship is mediated by functional ability.

DESIGN

Retrospective cohort study.

SETTING

Data from the Rugao longevity cohort, a population-based study in Rugao, China.

PARTICIPANTS

A sample of 342 long-lived women (mean age 97.4 ± 2.1, range 95-107) whose SWB and other covariates were available were included in this study.

MEASUREMENTS

BMI was calculated as weight in kilograms divided by height in meters-squared (kg/m(2)). SWB was measured by life satisfaction (LS), positive affect (PA), negative affect (NA) and affect balance (AB). Functional ability was assessed by the Katz Index of Activities of Daily Living (ADL).

RESULTS

According to BMI classification standards for China, the underweight group had lower levels of LS than the normal and overweight groups (28.62 vs. 30.51 and 31.57, respectively; p<.05). Correlation analysis showed that BMI was significantly related to LS (r = 0.166, p<.01). The strength of the BMI and LS association was diminished when ADL was included in the general linear regression models. Mediation analysis revealed that ADL mediated this relationship (effect size = 22.6%). We did not observe significant associations of BMI with other SWB components (PA, NA, and AB).

CONCLUSION

For long-lived women, low BMI, rather than elevated BMI, is an indicator of poor psychological well-being. The findings call for public health awareness about low body weight in long-lived women, especially in those with physical disabilities when focusing on quality of life.

Inhibition of human positive cofactor 4 radiosensitizes human esophageal squmaous cell carcinoma cells by suppressing XLF-mediated nonhomologous end joining

Radiotherapy has the widest application to esophageal squamous cell carcinoma (ESCC) patients. Factors associated with DNA damage repair have been shown to function in cell radiosensitivity. Human positive cofactor 4 (PC4) has a role in nonhomologous end joining (NHEJ) and is involved in DNA damage repair. However, the clinical significance and biological role of PC4 in cancer progression and cancer cellular responses to chemoradiotherapy (CRT) remain largely unknown. The aim of the present study was to investigate the potential roles of PC4 in the radiosensitivity of ESCC. In this study, we showed that knockdown of PC4 substantially increased ESCC cell sensitivity to ionizing radiation (IR) both in vitro and in vivo and enhanced radiation-induced apoptosis and mitotic catastrophe (MC). Importantly, we demonstrated that silencing of PC4 suppressed NHEJ by downregulating the expression of XLF in ESCC cells, whereas reconstituting the expression of XLF protein in the PC4-knockdown ESCC cells restored NHEJ activity and radioresistance. Moreover, high expression of PC4 positively correlated with ESCC resistance to CRT and was an independent predictor for short disease-specific survival of ESCC patients in both of our cohorts. These findings suggest that PC4 protects ESCC cells from IR-induced death by enhancing the NHEJ-promoting activity of XLF and could be used as a novel radiosensitivity predictor and a promising therapeutic target for ESCCs.

Abstract P4-15-08: Discovery of a potent inhibitor of CREB-mediated gene transcription that completely suppresses the growth of triple-negative breast cancer cells

Background: Breast cancers are a heterogeneous group of diseases with distinct and complex mechanisms of pathogenesis. Triple-negative breast cancers (TNBC) form a subgroup of breast cancers with poor prognosis. TNBCs lack the expression of estrogen receptor (ER), progesterone receptor (PR) or HER2 and no targeted therapies exist. The cyclic-AMP (cAMP) response element binding protein (CREB) is a stimulus-induced transcription factor activated by multiple extracellular signals through phosphorylation. The transcription activity of CREB depends on its phosphorylation at Ser133 by mitogen- and stress-activated protein serine/threonine kinases, which are often dysregulated in TNBCs. The phosphorylated CREB (p-CREB) can then bind the mammalian transcription co-activator, CREB-binding protein (CBP), via the kinase-inducible domain (KID) in CREB and KID-interacting (KIX) domain in CBP. This binding event will further recruit other transcriptional machinery to the gene promoter to initiate CREB-dependent gene transcription. CREB is overexpressed in breast cancer tissues compared to normal mammary tissues and the level of expression inversely correlates with disease-free survival. Genetic studies have shown that inhibition of CREB's activity leads to decreased breast cancer cell proliferation. We describe here the discovery of a potent small molecule inhibitor of CREB-mediated gene transcription with in vitro and in vivo activity in TNBCs.

Methods: The small molecule inhibitor (compound 1) was reporter earlier by us (Li and Xiao ChemBioChem 2009). Starting from this lead compound, we designed and synthesized a more potent compound 2. The in vitro antiproliferative activity and apoptosis induction were evaluated in MDA-MB-231 and MDA-MB-468 cells with MTT assays and flow cytometry, respectively. In vivo activity was investigated in a human xenograft model of MDA-MB-468. The CREB target gene expression was investigated by Western blot and qRT-PCR analysis.

Results: Starting from compound 1, which is a low micromolar and cell-permeable inhibitor of CREB-mediated gene transcription, we designed and synthesized compound 2. Compound 2 potently inhibited CREB-mediated gene transcription with IC50 ∼80 nM. In vitro, this compound inhibited proliferation of MDA-MB-231 and MDA-MB-468 cells with concomitant activation of apoptosis and necrosis. In contrast, compound 2 was not toxic to normal human mammary epithelial cells. In vivo, compound 2 completely suppressed the growth of MDA-MB-468 cells at a dose not toxic to the mice.

Conclusion: Compound 2 potently inhibited CREB-mediated gene transcription and TNBC cell growth in vitro and in vivo. These results suggest that CREB is a promising druggable target for TNBCs.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-15-08.

Phase I study of the histone deacetylase inhibitor entinostat in combination with 13-cis retinoic acid in patients with solid tumours

BACKGROUND

Preclinical studies suggest that histone deacetylase (HDAC) inhibitors may restore tumour sensitivity to retinoids. The objective of this study was to determine the safety, tolerability, and the pharmacokinetic (PK)/pharmacodynamic (PD) profiles of the HDAC inhibitor entinostat in combination with 13-cis retinoic acid (CRA) in patients with solid tumours.

METHODS

Patients with advanced solid tumours were treated with entinostat orally once weekly and with CRA orally twice daily × 3 weeks every 4 weeks. The starting dose for entinostat was 4 mg m(-2) with a fixed dose of CRA at 1 mg kg(-1) per day. Entinostat dose was escalated by 1 mg m(-2) increments. Pharmacokinetic concentrations of entinostat and CRA were determined by LC/MS/MS. Western blot analysis of peripheral blood mononuclear cells and tumour samples were performed to evaluate target inhibition.

RESULTS

A total of 19 patients were enroled. The maximum tolerated dose (MTD) was exceeded at the entinostat 5 mg m(-2) dose level (G3 hyponatremia, neutropenia, and anaemia). Fatigue (G1 or G2) was a common side effect. Entinostat exhibited substantial variability in clearance (147%) and exposure. CRA trough concentrations were consistent with prior reports. No objective responses were observed, however, prolonged stable disease occurred in patients with prostate, pancreatic, and kidney cancer. Data further showed increased tumour histone acetylation and decreased phosphorylated ERK protein expression.

CONCLUSION

The combination of entinostat with CRA was reasonably well tolerated. The recommended phase II doses are entinostat 4 mg m(-2) once weekly and CRA 1 mg kg(-1) per day. Although no tumour responses were seen, further evaluation of this combination is warranted.

Anthracyclines disrupt telomere maintenance by telomerase through inducing PinX1 ubiquitination and degradation

Telomere maintenance is essential for cancer growth. Induction of telomere dysfunction, for example, by inhibition of telomeric proteins or telomerase, has been shown to strongly enhance cancer cells' sensitivity to chemotherapies. However, it is not clear whether modulations of telomere maintenance constitute cancer cellular responses to chemotherapies. Furthermore, the manner in which anti-cancer drugs affect telomere function remains unknown. In this study, we show that anthracyclines, a class of anti-cancer drugs widely used in clinical cancer treatments, have an active role in triggering telomere dysfunction specifically in telomerase-positive cancer cells. Anthracyclines interrupt telomere maintenance by telomerase through the downregulation of PinX1, a protein factor responsible for targeting telomerase onto telomeres, thereby inhibiting telomerase association with telomeres. We further demonstrate that anthracyclines downregulate PinX1 by inducing this protein degradation through the ubiquitin-proteasome-dependent pathway. Our data not only reveal a novel action for anthracyclines as telomerase functional inhibitors but also provide a clue for the development of novel anti-cancer drugs based on telomerase/telomere targeting, which is actively investigated by many current studies.

Studies on pathogenicity and prevalence of white spot syndrome virus in mud crab, Scylla serrata (Forskal), in Zhejiang Province, China

Mud crab, Scylla serrata (Forskal), is the most commercially important marine crab species in China. In recent years, serious diseases have occurred in major mud crab culture regions in SE China. PCR detection of white spot syndrome virus (WSSV) in diseased mud crabs collected from Zhejiang Province during 2006-2008 showed a prevalence of 34.82%. To study the pathogenicity of WSSV to mud crab, healthy mud crabs were injected intramuscularly with serial 10-fold dilutions of a WSSV inoculum. The cumulative mortalities in groups challenged with 10⁻¹, 10⁻², 10⁻³ and 10⁻⁴ dilutions were 100%, 100%, 66.7% and 38.9% at 10 days post-injection, respectively. All moribund and dead mud crabs except the control group were positive for WSSV by PCR. Based on the viral load of the WSSV inoculum by quantitative real-time PCR, the median lethal dose (LD50) of WSSV in S. serrata was calculated as 1.10 × 10⁶ virus copies/crab, or 7.34 × 10³ virus copies g⁻¹ crab weight. The phenoloxidase, peroxidase and superoxide dismutase activities in haemolymph of WSSV-infected moribund crabs, were significantly lower than the control group, whereas alkaline phosphatase, glutamate-pyruvate transaminase and glutamic-oxaloacetic transaminase were higher than in the control group. WSSV was mainly distributed in gills, subcuticular epithelia, heart, intestine and stomach as shown by immunohistochemical analysis with Mabs against WSSV. The epithelial cells of infected gill showed hypertrophied nuclei with basophilic inclusions. Numerous bacilliform virus particles were observed in nuclei of infected gill cells by transmission electron microscopy. It is concluded that WSSV is a major pathogen of mud crab with high pathogenicity.