Radiosurgery for the treatment of previously irradiated recurrent primary brain tumors and brain metastases: initial report of radiation therapy oncology group protocol (90-05)

PURPOSE

To determine the maximum acutely tolerable dose of single fraction radiosurgery in patients with recurrent previously irradiated primary brain tumors or brain metastases.

METHODS AND MATERIALS

Between August 1990 and September 1993, 102 analyzable patients were entered on Radiation Therapy Oncology Group (RTOG) protocol 90-05, 38 of whom had recurrent primary brain tumors (median prior dose 60 Gy), and 64 of whom had recurrent brain metastases (median prior dose 30 Gy) < or = 40 mm in maximum diameter. Unacceptable toxicity was defined as irreversible Grade 3, any Grade 4, or Grade 5 central nervous system (CNS) toxicity according to the RTOG CNS criteria, occurring in > 20% of patients per treatment arm within 3 months of radiosurgery.

RESULTS

Patients were initially entered onto one of three treatment arms according to the maximum diameter of the recurrent lesion. Twelve to 22 patients were entered on each arm. The dose levels were: arm 1, < or = 20 mm, 18 Gy; arm 2, 21-30 mm, 15 Gy; and arm 3, 31-40 mm, 12 Gy. Subsequently, doses were escalated as follows: arm 4, < or = 20mm, 21 Gy; arm 5, 21-30 mm 18 Gy; and arm 6, 31-40 mm, 15 Gy. Unacceptable acute toxicity secondary to cerebral edema occurred in 0, 7 and 5% of patients on Arms 1, 2 and 3, respectively, and in no patients on arms 4, 5, or 6. Multivariate analysis revealed that tumor volume > or = 8200 mm(3) and a ratio of maximum dose to prescription dose (MD/PD) > or = 2 were significantly associated unacceptable toxicity. Of 15 patients with both tumor volume > or = 8200 mm(3) and MD/PD > or = 2, unacceptable toxicity occurred in 2 of 4 treated with a single isocenter and 1 of 11 treated with multiple isocenters. Subsequently, operation for symptomatic radionecrosis was required in 6% of patients.

CONCLUSION

We found that the incidence of acute toxicity was acceptable at 0-7% in patients with recurrent, previously irradiated primary brain tumors or brain metastases < or = 40 mm in maximum diameter treated according to the protocol described.

Prevalence of and risk factors for Chlamydia in a rural pregnant population

BACKGROUND

Chlamydia trachomatis infection is the most common sexually transmitted bacterial disease in the United States. Perinatal infection with C trachomatis has been associated with preterm labor, preterm rupture of membranes, stillbirth, and both conjunctivitis and pneumonia in newborns. Little is known about the prevalence of C trachomatis infection in rural pregnant women.

METHODS

We completed a retrospective chart analysis of 347 obstetric patients in a rural family practice residency training program to determine the prevalence, associated risk factors, and screening criteria for cervical C trachomatis infection.

RESULTS

The prevalence of C trachomatis infection in our study was 9.0%. Factors predictive of a positive test for C trachomatis infection included single marital status, African-American race, history of sexually transmitted diseases, presence of gonorrhea during the current pregnancy, age less than 20 years, and late onset of prenatal care.

CONCLUSIONS

The prevalence of C trachomatis in this rural obstetric population emphasizes the importance of laboratory screening of rural pregnant women for this disease.

Factors associated with noncompliance of patients taking antihypertensive medications

Poor adherence to drug therapy decreases the effectiveness of antihypertensive treatment. Patients must take more than 80% of their antihypertensive drugs to maintain adequate blood pressure control. To understand the incidence of noncompliance and contributing factors, a pilot study was conducted in which a questionnaire was devised and administered to a random sample of 243 hypertensive patients of the adult ambulatory care clinic at Methodist Hospital of Indiana. Ninety-eight patients completed the telephone survey. Demographic data were obtained through chart reviews. The results indicated that 30-46% of the patients were noncompliant with their antihypertensive drug regimens. Factors found to be associated with noncompliance were; employment (P = .0077), use of home remedies (P = .0043), age (P = .0165), experience of side effects (P = .0051), level of concern with missed doses (P = .0043), and cost (P = .014). The incidence of noncompliance in this pilot sample is lower than the estimated 50% noncompliance rate of published data. More research is needed to understand the determinants of noncompliance in order to design interventions to improve compliance.

Inhibition of growth of human TE2 and C-33A cells by the cell-permeant calpain inhibitor benzyloxycarbonyl-Leu-Leu-Tyr diazomethyl ketone

Calpains are Ca(2+)-requiring, nonlysosomal proteases which are thought to participate in some aspects of intracellular Ca(2+)-signal transduction. However, their exact physiologic function has not yet been established. Addition of the cell-permeant, irreversible calpain inhibitor, ZLLY-CHN2, to human TE2 or C-33A cells inhibited growth, as assessed either by mitochondrial MTT reductase activity or by direct cell counting. Inhibition of growth produced by a 24-h exposure to 50 microM ZLLY-CHN2 was reversed upon substituting growth medium without inhibitor. Homogenates produced from cells cultured in the presence of ZLLY-CHN2 displayed decreased calpain and Ca(2+)-independent proteolytic activities. Protein immunoblot analysis showed that cell cultures which had lost 80% of their calpain activity still retained full calpain immunoreactivity. Therefore, inhibition by ZLLY-CHN2 appeared to result in accumulation of irreversibly inactivated calpain within the cells. Homogenates from cells cultured in the presence of 20 or 50 microM ZLVG-CHN2, a cell-permeant inhibitor with little activity against calpains, had decreased Ca(2+)-independent proteolytic activity, but demonstrated no decrease in calpain activity. ZLVG-CHN2 did not inhibit cell growth under these conditions. Growth of Saccharomyces cerevisiae cells, which do not appear to express calpain-like proteases, was not inhibited by including 50 microM ZLLY-CHN2 in the culture medium. These results indicate that calpains participate in the social regulation of cell growth in multicellular organisms.

Sequence and structure similarities of cathepsin B from the parasite Schistosoma mansoni and human liver

A three-dimensional structure of Schistosoma mansoni cathepsin B was modelled using the coordinates of the crystal structure of the human liver enzyme. Both enzymes appear to share remarkable structural similarity. However, an examination of the models complexed with two synthetic inhibitors revealed differences in inhibitor binding, as confirmed by differences in the 50% inhibitory concentration of the same inhibitor.

Screening for abdominal aortic aneurysm: a single scan is enough

A group of 223 men who were found to have a normal abdominal aortic diameter (less than 2.6 cm) at the age of 65 or 66 years when first examined by ultrasonography in 1988 was studied again 5 years later. Twenty-seven patients had died, none from confirmed aneurysm rupture, and repeat scans were obtained in 189 of the 196 survivors. A further patient was reassessed at laparotomy. Mean aortic diameter was unchanged during the intervening 5 years and 166 of 189 repeat scan measurements were within 3 mm of the original value. Only two patients were found to have an aortic diameter of 3 cm or more on rescanning. These results suggest that a single ultrasonographic examination at the age of 65 years can safely be used to exclude over 90 per cent of those examined from future risk of significant aneurysmal dilatation of the aorta, with important cost and organizational benefits for a population screening programme.

Proteolytic cleavage of wild type and mutants of the F protein of human parainfluenza virus type 3 by two subtilisin-like endoproteases, furin and Kex2

The fusion (F) protein of human parainfluenza virus type 3 contains the tribasic cleavage site R-T-K-R, which was altered by site-directed mutagenesis. Wild-type F protein and various mutants were expressed by recombinant vaccinia viruses. The endogenous endoprotease present in CV-1 cells cleaves F variants containing the furin recognition motif R-X-K/R-R but not variants containing the dibasic site K-R or a single R at the cleavage site. A similar cleavage pattern was obtained when the subtilisin-like endoproteases Kex2 and furin were coexpressed with the wild type and mutants of the F protein. Peptidylchloromethylketone inhibitors mimicking basic cleavage sites prevent cleavage of the precursor Fo by the endogenous protease only when the furin-specific motif is present in the peptidyl portion. The data support the concept that furin is a cellular protease responsible for the activation of the F protein of human parainfluenza virus type 3.

Regulatory circuits involved with pH-regulated gene expression in Salmonella typhimurium

Salmonella typhimurium encounters a variety of acid conditions during both its natural and pathogenic existence. The ability of this organism to respond transcriptionally to low pH is an area of active interest but little knowledge. As part of an ongoing investigation of low-pH adaptation, 18 pH-controlled lacZ operon fusions in Salmonella typhimurium have been identified (15 in this study) and categorized into at least 11 different loci. They include iroA (at 57 min), aciA (99 min), aciB (90-93 min), aciD (ompC, 45 min), aciJ, aciK (33-36 min), aniC (93 min), anil (33-36 min), hyd (59 min), cadA (54 min) and aniG (63 min). All but two were induced by low pH. One of the exceptions, the iron-regulated iroA locus, was induced at high pH. The unusual aciA locus was induced by low pH under semiaerobic conditions but high pH under aerobic conditions. Most of the other aci genes were expressed best under anaerobic conditions. Many of these genes exhibited strict co-inducer requirements for small molecules to be expressed in minimal medium. These included iron for iroA, tyrosine for aniC, I and aciK, mannose for aniG, formate for hyd, lysine for cadA, and unknown components of complex medium for aciA, aciB and aciD. Six regulatory circuits were revealed involving at least five regulatory loci (fur, oxrG, earAB, earC and ompR). As part of the adaptive response to low pH, S. typhimurium will induce an acid protection system called the acid tolerance response (ATR). As has been shown for fur mutations, the oxrG regulatory mutation interfered with the normal induction of this system.

Processing of viral glycoproteins by the subtilisin-like endoprotease furin and its inhibition by specific peptidylchloroalkylketones

The spike glycoproteins of many enveloped viruses are proteolytically cleaved at the carboxytermini of sequences containing the basic motif R-X-K/R-R. Cleavage is often necessary for the fusion capacity of the glycoproteins and, thus, for virus infectivity. Among these viruses are pathogenic avian influenza viruses, human parainfluenza virus, human cytomegalovirus, and human immunodeficiency virus; it has been demonstrated that these viruses can be activated by furin. Indigenous furin has been identified in T-lymphocytes, which are host cells for HIV. Furin has been localized in the TGN and on the surface of cells after vectorial expression. Peptidylchloroalkylketones have been designed that inhibit with high specificity cleavage and fusion activity of viral glycoproteins, as well as virus replication.

Reaction of proteasomes with peptidylchloromethanes and peptidyldiazomethanes

The multicatalytic endopeptidase complex (proteasome) has multiple distinct peptidase activities. These activities have often been referred to as 'chymotrypsin-like', 'trypsin-like' and 'peptidylglutamyl-peptide hydrolase' activities according to the type of residue in the P1 position, although it is now clear that mammalian proteasomes have at least five distinct catalytic sites. In the present study, potential affinity-labelling reagents (peptidylchloromethanes, peptidyldiazomethanes, a peptidylfluoromethane and peptidylsulphonium salts) containing hydrophobic, basic or acidic amino acid residues in the P1 position have been tested for inhibition of the different activities of the rat liver proteinase complex. The results show that individual peptidase activities of proteasomes can be inhibited by a variety of peptidylchloromethanes and peptidyldiazomethanes. Although the rate of inactivation of proteasomes by even the most effective peptidylchloromethanes and peptidyldiazomethanes are often quite slow (k(obs)/[I] in the range 0.1-10 M-1 x s-1) compared with the reaction of similar compounds with some other proteinases, the results provide useful information concerning the specificity of the distinct catalytic centres of proteasomes, and some selective affinity-labelling reagents have been identified. Tyr-Gly-Arg-chloromethane was found to be a useful inhibitor of trypsin-like activity. Inhibition of the other peptidase activities was often incomplete, even after repeated addition of inhibitor, and it proved to be difficult to predict the effect of different reagents. For example, Cbz-Tyr-Ala-Glu-chloromethane was found to inhibit 'chymotrypsin-like' activity (assayed with Ala-Ala-Phe-7-amino-4-methylcoumarin or succinyl-Leu-Leu-Val-Tyr-7-amino-4-methylcoumarin), while the best inhibitors of 'peptidylglutamyl-peptide hydrolase' activities (assayed with benzyloxycarbonyl-Leu-Leu-Glu beta-naphthylamide) were peptidyldiazomethanes containing hydrophobic amino acid residues. These results suggest that the original nomenclature of proteasome activities is misleading, because the residue in the P1 position is not the only determinant of specificity.

Radiation Therapy Oncology Group: radiosurgery quality assurance guidelines

A multidisciplinary Radiation Therapy Oncology Group (RTOG) task force has developed quality assurance guidelines for radiosurgery. The purpose of the guidelines are fourfold: (1) To ensure that participating institutions have the proper equipment and appropriate technique(s) to administer radiosurgery; (2) to outline a standard data set for each treated patient to assess protocol compliance; (3) to define minor and major deviations in protocol treatment; and (4) to set forth clinical data necessary to determine treatment efficacy, including failure patterns, and treatment toxicity. These guidelines are being implemented into active and developing radiosurgery protocols.

The affinity-labelling of cathepsin S with peptidyl diazomethyl ketones. Comparison with the inhibition of cathepsin L and calpain

Since peptidyl diazomethyl ketones are useful irreversible inhibitors for inactivating cysteinyl proteinases in vitro and in vivo and in order to reveal their role, we set out to obtain selective and effective reagents for cathepsin S. A number of such derivatives with hydrophobic amino acid residues, such as valine, leucine and tryptophane in positions adjacent to the primary specificity site were synthesized and these provided inhibitors rapidly acting at high dilution. For example, 1 nM Z-Leu-Leu-Nle-CHN2 inactivates cathepsin S with k2nd = 4.6 x 10(6) M-1 x s-1 at pH 6.5, 25 degrees C. Similarities to the specificities of cathepsin L and calpain were evident. However, Z-Val-Val-NleCHN2 is over 300 times more effective in inactivating S than L. On the other hand, Z-Phe-Tyr(t-Bu)CHN2 is about 10(4) more effective against L than S. Reagents are thus now available for a clear discrimination between these proteases.

Familial abdominal aortic aneurysm: prevalence and implications for screening

The high prevalence of abdominal aortic aneurysm (AAA) in men over the age of 65 has led to the establishment of ultrasound screening programmes for this group. The apparent familial tendency towards AAA formation suggests that relatives of aneurysm patients may form another subpopulation in whom screening is appropriate. The first degree relatives of 100 consecutive aneurysm patients were identified. Of 110 relatives over 50 years of age, two were known to have had AAA and ultrasound scans were performed on 74, providing information on aortic size for 76 relatives (69%). No further aortic aneurysms (antero-posterior diameter > or = 4.0 cm) were found on scanning. However, nine relatives were demonstrated to have aortic dilatation (2.5-3.9 cm). Aortic dilatation was observed in 21% of male first degree relatives over 50 years of age, affecting 27% of sons and 17% of brothers. Only 4% of the sisters and none of the daughters were found to have aortic dilatation. The prevalence of aortic enlargement seems to be sufficiently high amongst male first degree relatives of AAA patients over 50 years of age to justify aortic screening.

The Gloucestershire Aneurysm Screening Programme: the first 2 years' experience

5337 men aged 65 were invited for ultrasound examination of the abdominal aorta between September 1990 and October 1992 as part of a General Practice based aneurysm screening programme covering the County of Gloucestershire. 4232 (79%) attended. 3877 (91.6%) had aortic diameters equal to or less than 2.5 cm. 302 (7.1%) had aortic diameters in the range 2.6-3.9 cm and 53 (1.3%) had a diameter of 4.0 cm or greater. Mean aortic diameter was 2.04 cm (S.D. 0.50 cm). The practicalities, costs and benefits of a community based aneurysm screening programme are discussed.

The synthesis of inhibitors for processing proteinases and their action on the Kex2 proteinase of yeast

Peptidyl chloromethane and sulphonium salts containing multiple Arg and Lys residues were synthesized as potential inhibitors of prohormone and pro-protein processing proteinases. The potencies of these compounds were assayed by measuring the kinetics of inactivation of the yeast Kex2 proteinase, the prototype of a growing family of eukaryotic precursor processing proteinases. The most potent inhibitor, Pro-Nvl-Tyr-Lys-Arg-chloromethane, was based on cleavage sites in the natural Kex2 substrate pro-alpha-factor. This inhibitor exhibited a Ki of 3.7 nM and a second-order inactivation rate constant (k2/Ki) of 1.3 x 10(7) M-1.s-1 comparable with the value of kcat./Km obtained with Kex2 for the corresponding peptidyl methylcoumarinylamide substrate. The enzyme exhibited sensitivity to the other peptidyl chloromethanes over a range of concentrations, depending on peptide sequence and alpha-amino decanoylation, but was completely resistant to peptidyl sulphonium salts. Kinetics of inactivation by these new inhibitors of a set of 'control' proteinases, including members of both the trypsin and subtilisin families, underscored the apparent specificity of the compounds most active against Kex2 proteinase.

Cross-reactivity between B. burgdorferi and other spirochetes affects specificity of serotests for detection of antibodies to the Lyme disease agent in dogs

Western immunoblots, the kinetics-based enzyme-linked immunosorbent assay (KELA), and the microagglutination test were used to evaluate cross-reactivity among antibodies to serovars of Leptospira interrogans (leptospiral serovars), and B. burgdorferi from naturally infected dogs, and to Serpulina (Treponema) hyodysenteriae from vaccinated rabbits. Whole-cell lysates from Borrelia spp., leptospiral serovars, and Serpulina spp. were used for SDS-PAGE, western blots, and KELA. Crossreactivity occurred between the antibodies to B. burgdorferi and leptospiral serovars when tested on the heterologous antigens. Antibodies to leptospiral serovars tended to cross-react more strongly with antigens of B. burgdorferi spp. than did antibodies to B. burgdorferi when tested against antigens of leptospiral serovars. The antibodies against B. burgdorferi showed a lesser degree of cross-reactivity to the antigens of S. hyodysenteriae and S. innocens than they did to leptospiral serovars. We conclude that cross-reactivity occurs between B. burgdorferi and leptospiral serovars. Validation and interpretation of ELISA tests for detection of antibody activity to whole cell lysates of the Lyme agent must take this cross-reactivity into consideration. Conversely, dogs infected with the Lyme agent do not show significant cross-reactivity in the microagglutination test for antibody to the leptospiral serovars.

Synthesis of oligopeptide chloromethanes to investigate extended binding regions of proteinases: application to the interaction of fibrinogen with thrombin

A method was established for the synthesis of oligopeptide chloromethanes which should be useful in the study of serine and cysteine proteinases with extended binding sites. The method involved condensation of an N-terminal peptide fragment obtained by solid-phase synthesis with a C-terminal peptide chloromethane synthesized by solution-phase chemistry. By using this procedure, oligopeptide chloromethanes of up to 16 residues were synthesized. These chloromethanes were based on the sequence of fibrinopeptide A. By using oligopeptide chloromethanes of different length, it was possible to show that the residues Asp7-Phe8-Leu9 play a crucial role in the recognition of fibrinopeptide A by thrombin. In contrast, the residues Ala1-Asp2-Ser3-Gly4-Glu5-Gly6 seem to play a minor role. Substitution of valine for Gly12, which occurs in a dysfibrinogenaemia, markedly decreased the rate of inactivation of thrombin by the oligopeptide chloromethane. The results are discussed in terms of the recently published structure of the complex between human thrombin and a chloromethane inhibitor based on fibrinopeptide A.