Efficacy and safety of voriconazole in the treatment of chronic pulmonary aspergillosis: experience in Japan

BACKGROUND

Though various clinical conditions of aspergillosis can occur, depending essentially on the host's immunological status, the focus of research in North American and European countries has mainly been on invasive pulmonary aspergillosis in immunocompromised patients. There are, however, also many problems to overcome in chronic forms of aspergillosis. One of those problems is that there are no codified treatment guidelines for chronic pulmonary aspergillosis (CPA). Especially in Japan, this issue is more serious, because there are more cases with CPA due to the many aged people with past history of tuberculosis. Several clinical cases and case series have reported the usefulness of the various antifungal agents that are available. The new triazole, voriconazole, in particular, seems to be effective in the treatment of CPA. The aim of the present study is to evaluate the efficacy and safety of voriconazole in the treatment of CPA in non-immunocompromised patients.

PATIENTS AND METHODS

We conducted a prospective, open-label, non-comparative, multicenter study over a 2-year period. For inclusion in the study, patients with confirmed or probable CPA were recruited in 11 hospitals of the National Hospital Organization in Japan. Clinical, radiological, serological, and mycological data were collected at baseline and 12 weeks after treatment or at the end of treatment.

RESULTS

Among 77 patients enrolled in the study, 71 patients (mean age 65.9 years, 56 males and 15 females) were eligible for the study. All of the eligible patients presented with underlying lung diseases, including sequelae of tuberculosis (n = 35), non-tuberculous mycobacterial lung disease (n = 8), chronic obstructive pulmonary disease (COPD) (n = 8), interstitial pneumonia (n = 7), cystic lung disease (n = 4), pneumothorax (n = 3), bronchial cancer (n = 1), and others (n = 5). Voriconazole was indicated in 48 cases (68 %) as the first-line treatment for CPA and 23 patients previously received other antifungal therapies. Based on a composite of clinical, radiologic, serological, and mycologic criteria, good response was seen in 43 patients (60.6 %), no response was observed in 19 patients (26.8 %), and 4 cases (5.6 %) got worse. Five patients (7.0 %) were unassessable for efficacy. The common adverse events were visual disturbances (17 patients, 23.9 %), abnormal liver function test results (12 patients, 16.9 %), adverse psychological effects (3 patients, 4.2 %), and others (10 patients, 14.0 %). Treatment with voriconazole had to be stopped in 2 cases (2.8 %) because of serious adverse events (abnormal liver function test results). There was no association between adverse effects and trough voriconazole levels in serum.

CONCLUSIONS

In Japan, voriconazole provides effective therapy of CPA in non-immunocompromised patients with an acceptable level of toxicity.

Distribution of HLA-G 14-bp insertion/deletion polymorphism in six Chinese ethnic groups

Recently, a 14-bp insertion/deletion polymorphism (+14 bp/-14 bp) in exon 8 of the Human leucocyte antigen-G (HLA-G) gene has been studied extensively because this polymorphism has been associated with HLA-G mRNA stability and could influence HLA-G mRNA expression. We investigated the distribution of the 14-bp insertion/deletion polymorphism in six different Chinese ethnic groups (Bulang, Wa, Hani, Jinuo, Maonan and Zhuang), which originated from three major ancient tribes (Di-Qiang, Baipu and Baiyue) in China. Comparison of the 14-bp insertion frequency in the six groups with other Chinese groups showed marked variation among the three ancient tribes, Di-Qing (0.490-0.534), Baipu (0.470-0.609) and Baiyue (0.280-0.344). Furthermore, the frequencies of the 14-bp insertion were similar in groups that came from the same ancient tribe, which indicated that the individuals who share the 14-bp insertion have the most probably inherited the 14-bp element from a common ancestor. In addition, an intra-tribal comparison of the 14-bp insertion/deletion frequencies between the descendants of the ancient ancestral tribes suggests that population histories or some environmental effects, such as founder effect or isolation, might also influence the distribution.

The impact of prior radiotherapy on fatal complications after self-expandable metallic stents (SEMS) for malignant dysphagia due to esophageal carcinoma

The esophageal stent has been demonstrated to serve as a safe and effective palliative treatment for advanced inoperable esophageal carcinoma. However, the safety of esophageal stents in patients with prior radiotherapy (RT) remains debated. This article aims to investigate the impact of prior RT on the incidence of fatal complications after self-expandable metallic stents for palliation of malignant dysphagia because of esophageal carcinoma. Between January 2007 and July 2010, 93 patients with malignant dysphagia because of esophageal carcinoma underwent placement of self-expandable metallic stents in our hospital. Patients were retrospectively separated into two groups: patients with RT before stent placement (RT group, n=57) and patients with no treatment before stent placement (no RT group, n=35).The median survival after stent placement was 77 days (7-842 days) in the RT group and 246 days (15-878 days) in the no RT group. Improvement in dysphagia score was similar in both groups. The fatal complications included fatal gastrointestinal hemorrhage and uncontrolled pneumonia. The incidence of fatal gastrointestinal hemorrhage and uncontrolled pneumonia were 28.1% and 5.7% (P=0.009), 28.1% and 5.7% (P=0.009), respectively. Logistic regression analysis showed a significant interaction between prior RT and fatal gastrointestinal hemorrhage (relative risk 7.82, 95% confidence interval 1.54-39.61; P=0.013). Mortality of massive hemorrhage was 5.7% (2/35), 0% (0/4), 12.5% (3/24), and 44.8% (13/29), respectively, in patients who received 0, 1Gy∼49Gy, 50Gy∼60Gy, and >60Gy (χ(2) =17.761; P=0.000). Logistic regression analysis disclosed prior RT did not significantly increase the risk of uncontrolled pneumonia (relative risk 1.47, 95% confidence interval 0.21-10.12; P=0.697).

Surgery is an Effective and Reasonable Treatment for Degenerative Scoliosis: A Systematic Review

OBJECTIVE: A systematic review to evaluate the role of surgery for treating degenerative scoliosis (DS) in terms of improved function (Oswestry Disability Index [ODI]) and correction of deformity (Cobb angle); safety outcomes included complication and repeat surgery rates. METHODS: A search of the MEDLINE, ISI Web of Knowledge and Cochrane Library databases was performed. The methodological quality of each study was assessed according to standardized criteria and data were extracted. RESULTS: A total of 16 studies including 553 patients with DS met the eligibility criteria for inclusion. The mean ODI score at final follow-up was 36.0 ± 7.8 (304 patients) and the mean decrease in ODI was 23.3 ± 11.3 (302 patients). Mean reduction in curve angle (as a percentage of the original curve) was 48.5 ± 21.0% (527 patients). The overall incidence of complications was 49.0% (171 in 349 patients) and the rate of repeat surgery was 15.3% (61 in 398 patients). CONCLUSIONS: Despite a high incidence of complications and reoperations, surgery was an effective and reasonable treatment for DS, providing significant functional improvement and deformity correction.

Genetic polymorphisms of the sortase A gene and early childhood caries in two-year-old children

OBJECTIVE

To explore and compare the genetic polymorphisms of the sortase A (srtA) gene found in Streptococcus mutans (S. mutans) infecting two-year-old children suffering early childhood caries to those found in caries-free children through molecular identification methods.

METHODS

Clinical S. mutans strains were isolated from the dental plaques of two-year-old children. Fifteen strains of S. mutans from the caries-active group and 15 strains of S. mutans from the caries-free group were collected. Genomic DNA was extracted from the S. mutans isolates. DNA fragments, including the srtA gene, were amplified by PCR. The PCR products were purified, sequenced and analyzed. A chi-square test and BioEdit software were used to analyze the sequencing results.

RESULTS

All 30 clinically isolated S. mutans strains had a 741 base pair (bp) srtA gene. There were no nucleotide sequence insertions or deletions observed in the srtA genes. Twenty mutations were identified in the srtA genes that taken from the 30 clinical strains. There were 10 silent point mutations at the 78, 99, 150, 165, 186, 222, 249, 261, 312, and 636bp positions. The other 10 mutations were point mutations resulting in a missense mutation at the 23, 34, 36, 47, 112, 114, 168, 176, 470, and 671bp positions. None of the positions were enzyme-activity sites of srt A. The missense mutation rates of the two groups did not exhibit statistically significant differences.

CONCLUSION

There were no genetic polymorphisms of the sortase A gene associated with early childhood caries in two-year-old children.

Tranilast prevents the progression of chronic cyclosporine nephrotoxicity through regulation of transforming growth factor β/Smad pathways

PURPOSE

Our aim was to investigate the role of tranilast in transforming growth factor (TGF) β/Smad pathways using a rat model of chronic cyclosporine (CsA) nephrotoxicity.

METHODS

Thirty Sprague-Dawley (SD) rats were equally randomized in to 5 groups for gavage treatments daily for 4 weeks: normal control (N), olive oil; CsA (25 mg/kg), (M) CsA plus low-dose tranilast group (T1; CsA 25 mg/kg and tranilast 100 mg/kg); CsA plus medium-dose tranilast group (T2; CsA 25 mg/kg and tranilast 200 mg/kg); and CsA plus high-dose tranilast group (T4; CsA 25 mg/kg and tranilast 400 mg/kg). Kidneys were harvested at the end of the fourth week. TGF-β1 as well as Smad3 and Smad7 were detected by reverse-transcription polymerase chain reaction and immunohistochemistry.

RESULTS

The administration of tranilast decreased the expression of TGF-β1 and Smad3 by CsA-treated rats, whereas it increased both mRNA and protein levels of Smad7. Semiquantitative analysis of mRNA production revealed these treatments to markedly reduce the amount of TGF-β1: T1: 0.8452 ± 0.0825 vs 0.8529 ± 0.0606 (P < .05); T2: 0.8414 ± 0.0696 vs 0.8529 ± 0.0606 (P < .05); T4: 0.8336 ± 0.0592 vs 0.8529 ± 0.0606 (P < .05). For Smad3: T1: 0.8581 ± 0.0328 vs 0.8613 ± 0.0542 (P < .05); T2: 0.8528 ± 0.0599 vs 0.8613 ± 0.0542 (P < .05); T4: 0.8436 ± 0.0185 vs 0.8613 ± 0.0542 (P < .05). The significantly elevated dose-dependent amounts of Smad7 were: T1: 0.9026 ± 0.0522 vs 0.8678 ± 0.0246, (P < .05); T2: 0.9087 ± 0.0506 vs 0.8678 ± 0.0246 (P < .05); T4: 0.9151 ± 0.0793 vs 0.8678 ± 0.0246 (P < .05).

CONCLUSION

Regulation of TGF-β/Smad pathways is one of the mechanisims by which tranilast mitigates the progression of chronic CsA nephrotoxicity in rats.

Simultaneous determination of lincomycin and spectinomycin residues in animal tissues by gas chromatography-nitrogen phosphorus detection and gas chromatography-mass spectrometry with accelerated solvent extraction

A new multi-dimensional analytical method using gas chromatography-nitrogen phosphorus detection (GC-NPD) and gas chromatography-mass spectrometry (GC-MS) was developed for qualitative and quantitative measurement of lincomycin and spectinomycin residues in food animal tissues. This method is based on a new extraction procedure using accelerated solvent extraction (ASE). The analytes were extracted by phosphate buffer with trichloroacetic acid deproteinization and clean-up by C₁₈ solid-phase extraction (SPE) adding dodecanesulfonic acid sodium salt as an ion-pair reagent. The eluted fraction was evaporated and derivatised with N,O-bis(trimethylsilyl) trifluoroacetamide (BSTFA) for GC-NPD analysis and GC-MS confirmation. Parameters for extraction pressure, temperature and cycle of ASE, clean-up, derivatisation and analysis procedure were optimised. The method was validated in muscle, kidney and liver of swine, bovine with a low concentration (limit of quantification) of 16.4 and 21.4 µg kg⁻¹ for these two analytes using GC-NPD. For GC-MS, the limits of quantification were 4.1 and 5.6 µg kg⁻¹, respectively. Spiked recoveries from levels of 20 to 200 µg kg⁻¹ were found to be between 73% and 99% with a relative standard deviation (RSD) of less than 17% in GC-NPD. For GC-MS, levels from 5 to 20 µg kg⁻¹ had between 70% and 93% with an RSD of less than 21%. This rapid and reliable method can be used for the characterisation and quantification of residues of lincomycin and spectinomycin in animal tissues.

132 EFFECTS OF OXYGEN TENSION, MEDIUM, AND WELL OF THE WELL ON IN VITRO DEVELOPMENT OF THE MOUSE EMBRYO

The objectives of the present research were to investigate whether embryo culture media have preferences for oxygen tension, to explore the feasibility of using physical lung air to support the in vitro development of mouse embryos, and to evaluate the effect of well of the well (WOW) culture on in vitro preimplantational development of mouse embryos. The results are as follows. First, cleavage rate and blastocyst rate were not significantly different between medium CZB and mKSOM regardless of using 3 gas phases: 4% CO2 + 16% O2 + 78% N2 + 2% H2O (lung air), 5% CO2 + 5% O2 + 90% N2 (5% O2, low oxygen), and 5% CO2 + 95% air (20% O2, high oxygen; P > 0.05), but mean total cell numbers per blastocyst cultured in CZB medium were higher than those in mKSOM when the lung air was used (P < 0.05). Second, when mKSOM was used as the basic medium, the blastocyst rate (22.6%) in the 5% O2 gas phase was notably higher than that in other 2 gas phases (P < 0.05). Third, for the CZB medium, the blastocyst rate was not different significantly among 3 gas environments (P > 0.05). Fourth, both the blastocyst rate (74.6 ± 5.1%) and the mean total cell numbers per blastocyst (76 ± 2) cultured in the WOW system were obviously higher than those in the group culture system (38.2 ± 6.6% and 58 ± 4). Taken together, our results indicate that mKSOM and CZB have preferences for oxygen tension during in vitro culture of mouse embryos, the lung air was reaffirmed to be able to effectively support in vitro preimplantation development of mouse embryos, and the WOW culture system can apparently enhance in vitro developmental competence and blastocyst quality of mouse embryos. L. YS, C. ZB: equal contribution; supported by NSFC (30700574), 863 (2008AA101003).

250 HUMAN EXHALED AIR CAN EFFECTIVELY SUPPORT IN VITRO MATURATION OF PORCINE OOCYTES AND SUBSEQUENT IN VITRO DEVELOPMENT

The objective of the present study was to examine the feasibility of culturing porcine oocytes and embryos in vitro using the human exhaled lung air atmosphere. In Experiment 1, the effects of lung air atmosphere on nuclear maturation of prepubertal gilt oocytes and subsequent development in vitro of parthenogenetic-activated and somatic-cell-cloned embryos were explored. Abattoir-derived prepubertal gilt cumulus–oocyte complexes (COC) were matured in TCM-199 supplemented with 10 IU mL–1 of eCG, 10 IU mL–1 of hCG, 10 ng mL–1 of epidermal growth factor, and 10% porcine follicular fluid (pFF) for 40 to 44 h at 38.5°C, 100% humidity, and 5% CO2+20% O2 (high oxygen tension) or human exhaled air encapsulated in plastic, airtight bags (lung air) or 5% CO2+7% O2 (low oxygen tension) in the incubator. Nuclear maturation was evaluated by the presence of the 1st polar body. For parthenogenetic activation, denuded oocytes with the 1st polar body were selected and stimulated with a single 1.6-kV/cm, 100-μs direct current pulse followed by culture in porcine zygote medium-3. For NT, denuded metaphase II oocytes were enucleated, and then the donor cell was directly injected into the perivitelline space. After NT, reconstructed couplets were fused and activated electrically followed by treatment in 7.5 μg mL–1 of cytochalasin B and 10 μg mL–1 of cycloheximide for 4 to 6 h before culture in porcine zygote medium-3. We found no significant difference among groups in terms of nuclear maturation rate (66.5% v. 60.2%, 63.2%), cleavage rate (94.8% v. 94.2%, 85.2%), blastocyst formation rate (39.5% v. 40.3%, 32.5%), and total cell number (37 v. 38, 32). Moreover, as for porcine cloned embryo, no significant difference between the lung-air and high-oxygen (20% O2) groups was observed in the cleavage rate (88.3% v. 80.3%), blastocyst formation rate (7.3% v. 10.7%), and total cell number (34 v. 36). The above results indicated that porcine oocytes can be matured in vitro safely and efficiently using the human exhaled lung air atmosphere. In Experiment 2, in vitro developmental competence of porcine zona-free parthenogenetically activated embryos cultured in a lung air, low oxygen (5% O2), or high oxygen (20% O2) tension gas environment was studied. We found no obvious difference among the 3 groups regarding the rates of cleavage (83.0%, 83.6%, 82.8%), but blastocyst formation rate (26.8% v. 48.6%, 48.2%) and total cell number (23 v. 34, 29) in lung air were lower than those in the rest of the groups (P < 0.05). The results show that lung air could be an alternative for preparing a gas environment for in vitro culture of porcine zona-free parthenotes, although not an ideal alternative. Taken together, porcine oocytes and embryos can be cultured in vitro safely and efficiently using the human exhaled lung air atmosphere. Z. B. Cao and L. C. Sui contributed equally to this work. X. R. Zhang and Y. H. Zhang are the corresponding authors. This work was supported by NSFC (30700574), 863 (2008AA101003).

316 INDUCTION OF PIG INDUCED PLURIPOTENT STEM CELLS BY RECOMBINANT PROTEINS ENCODED BY DEFINED FACTORS

Pluripotent cells derived from any differentiated cell type through ectopic expression of transcription factors were designated as induced pluripotent stem (iPS) cells, exhibiting similar morphology and growth properties to embryonic stem (ES) cells besides expressing ES cell marker. Because iPS have the ability to differentiate into all types of cells, iPS cell technology is thought to have enormous potential for generating disease models, drug screening, toxicology, and regenerative medicine. However, for virus-mediated transfection of defined factors, the exogenous genes generally would be randomly inserted into the target cell’s genome, possibly bringing the potential hazard of insertional mutagenesis. Therefore, it is necessary to seek some new methods to induce somatic cell reprogramming without viruses. With instruction from the work of Zhou et al. (2009 Cell Stem Cell 4, 381–384), in the present study we attempted to use defined factors recombinant proteins-carried cell-penetrating peptide for the generation of porcine iPS cells, which would be a benefit for safe applications of iPS cells. Defined factors genes were amplified by PCR with specific primers of 9 arginines (R9) from recombinant plasmid pLL-hOCT4/pSox2/pMyc/pKlf4-EGFP (Yin et al. 2010 Prog. Biochem. Biophys. 37, 607–612) and inserted into prokaryotic expression vector pET-28a-EGFP. After DNA sequencing confirmation, the 4 recombinant plasmids were then transformed into BL21 strains, respectively. After IPTG induction, hOCT4/pSox2/pMyc/pKlf4-R9-EGFP fusion proteins were purified using Novagen His-Bind kit and confirmed by sodium dodecyl sulfate–polyacrylamide gel electrophoresis, respectively. Then, defined factors recombinant proteins were added into pig fetal fibroblasts (PFF) medium every 48 h to establish pig iPS cells. The results showed that purified hOCT4/pSox2/pMyc/pKlf4-R9-EGFP fusion proteins could enter into PFF efficiently, and most of them were located in nuclei. The PPF were subcultured in stem cell medium condition and treated with defined factors recombinant proteins for 6 cycles simultaneously; the clear-cut cell colonies were gradually derived. These cells had large translucent nuclei and a high nucleo:cytoplasmic ratio and were positive for AP, Oct4, and Nanog. Detailed characterisation of such induced cells is ongoing. This research would provide new ideas for the induction of porcine somatic cell reprogramming. Y. H. Zhang and H. G. Cao contributed equally. This work was supported by NSFC (30700574 30800784/c120103) and 973 (2009CB941004).

290 GENERATION OF INDUCED PLURIPOTENT STEM CELLS FROM BOVINE FETAL FIBROBLAST CELLS BY DEFINED FACTORS

Induced pluripotent stem cells (iPS) have broad potential applications in drug screening, regenerative medicine, and basic biology, and using iPS as starting materials that have identical properties to embryonic stem cell would probably revolutionize the production of gene-targeted livestock. However, iPS in livestock is still lacking except for in pigs. Instructed by Yamanaka’s idea, in the current study we attempted to generate bovine iPS from fetal fibroblast cells (bFF; from a fetus 2.5 months old after gestation) by using 4 defined transcriptional factors: Oct-4, Sox2, Klf4, and c-Myc. A lentivirus haboring the 4 factors acted as a vehicle to transfect the bFF. One bFF cell line was infected for at least 3 replicates. After transfection, the treated bFF were then cultured in DMEM supplemented with 4 ng mL–1 of basic fibroblast growth factor and 1000 IU mL–1 of leukemia inhibitory factor at 37.5°C, 5% CO2, on the mouse embryonic feeder cells pretreatd with mitomycin C. From Day 16 after the onset of induction, morphology of a few typical spindle-like bFF gradually changed into round, ball-like cells and grew into colonies. Afterward, when these colonies were harvested and subcultured in stem cell medium supplemented with 1000 IU mL–1 of leukemia inhibitory factor and 4 ng mL–1 of basic fibroblast growth factor, new colonies with clear-cut, round edge emerged, and the cells in the colonies had increased nuclear:cytoplasm ratio, kept normal karyotype up to 10 passages, and were alkaline phosphatase staining positive. We also found that the cells exhibited part of the stem cell markers, as evidenced by being Nanog, SSEA1 positive but SSEA3 and TRA-60 negative. Moreover, embryoid bodies could be formed in vitro, and terotoma formation after injection into nude mice also displayed 3 layers. Taken together, we found that 4 lentivirus-mediated, defined transcriptional factors could successfully induce bFF into iPS-like cells. H. G. Cao and Y. Liu contributed equally to this work. The corresponding authors are Y. H. Zhang and X. R. Zhang. This work was supported by NSFC (30800784/c120103, 30700574), 973 (2009CB941004).

The association and differentiation of MHC class I polymorphic Alu insertions and HLA-B/Cw alleles in seven Chinese populations

We investigated polymorphic Alu insertion (POALIN) frequencies at five loci in the major histocompatibility complex (MHC) class I genomic region to determine their allele and haplotype frequencies and associations with the human leukocyte antigen (HLA)-B and -Cw genes in seven different Chinese ethnic populations, the Han, Bulang, Wa, Dai, Maonan, Hani and Jinuo. The POALINs varied in frequency between 0% and 42.3% with significant differences between populations at all of the loci. Each POALIN was in significant linkage disequilibrium with a variety of HLA-B or -Cw four-digit alleles. The percentage association between Alu insertions and the HLA-B or -Cw alleles was calculated in pairwise analyses of haplotypes to show possible crossing over events between loci. The POALIN insertions also helped to further stratify the HLA-B:-Cw haplotypes into different POALIN:HLA-B:HLA-Cw haplotype frequencies. Of the two-locus, five-locus and seven-locus haplotype analyses, the seven-locus haplotypes showed the largest number of differences between the populations. The most common multilocus haplotype in Han was MICB*1:B*4601:Cw*0102:TF*1:HJ*1:HG*2:HF*1 (15.6%) associated with the AluHG insertion, whereas the second most common multilocus haplotype in Han was MICB*1:B*1502:Cw*0801:TF*1:HJ*2:HG*1:HF*1 (11.8%) associated with the AluHJ insertion. This comparative study of multilocus POALINs in the HLA class I region of seven Chinese ethnic populations shows that POALINs alone or together with the HLA class I alleles are informative genetic markers for the identification of HLA class I allele and haplotype lineages and variations such as crossing over events within the same and/or different populations.

Vitamin D receptor genetic polymorphisms and tuberculosis: updated systematic review and meta-analysis

BACKGROUND

Host genetic susceptibility has been suggested as one of the most important explanations for inter-individual differences in tuberculosis (TB) risk. The vitamin D receptor (VDR) gene has been studied as a candidate locus due to genetic polymorphisms that affects the activity of the receptor and subsequent downstream vitamin D-mediated effects.

METHODS

We reviewed published studies on VDR polymorphisms and TB susceptibility up to 15 April 2009 and quantitatively summarised associations of the most widely studied polymorphisms (FokI, TaqI, ApaI and BsmI) using meta-analysis.

RESULTS

A total of 23 eligible studies were included in this review. Heterogeneous results were observed, which may be partly explained by the differences between populations. Among Asians, the FokI ff genotype showed a pronounced positive association (OR 2.0, 95%CI 1.3-3.2), a significant inverse association was observed for the BsmI bb genotype (OR 0.5, 95%CI 0.4-0.8), and marginal significant associations were found for TaqI and ApaI polymorphisms. However, none of the polymorphisms was significantly related to TB among Africans or South Americans.

CONCLUSIONS

The association of VDR polymorphisms with risk of TB observed in our analyses supports the hypothesis that vitamin D deficiency might play a role as risk factor during the development of TB.

Tumor Ki67 Proliferation Index within 4 Weeks of Initiating Neoadjuvant Endocrine Therapy for Early Identification of Non-Responders

Background: The Preoperative Endocrine Prognostic Index (PEPI) scores the independent prognostic effects of tumor pathologic staging and expression levels of ER and the “proliferation” marker Ki67 in the surgical sample to predict long term outcomes after completion of neoadjuvant endocrine treatment (Ellis et al JNCI 100:1380, 2008). A limitation of the PEPI is that the prognostic information becomes available only after 4 months of treatment. We therefore evaluated the value of an early assessment of the Ki67 level in a tumor biopsy sample taken two to four weeks after initiating treatment in two neoadjuvant endocrine therapy trials for the purposes of the early identification of non- respondersMethods: A Ki67 cut point of greater than 10% for poor outcome in ER+ breast cancer was derived by comparing the PAM50 intrinsic subtype profile using a qRT-PCR assay with Ki67 data in a 700+ sample data set. A baseline level of 10% or less correlated most closely with a PAM50-based definition of LumA breast cancer and above 10% LumB breast cancer. We subsequently applied the 10% cut point to the baseline and early on-treatment Ki67 data in two trials, POL (Olson et al JACS 208:906, 2009) and IMPACT (Smith et al JCO: 23, 5108, 2005).Results: At baseline the dichotomized Ki67 definition was not significantly predictive for surgical Ki67 level, PEPI score or RFS in this modest size sample set. In contrast, in a result that emphasizes the enhaced prognostic properties of the on-treatment Ki67 approach, the one month POL sample Ki67 values (62 patients) predicted a higher level of Ki67 in the surgical samples at four months after treatment initiation (P=.01), a poorer PEPI score (P=0.01), a smaller number of patients in the PEPI risk point zero group (P=0.08) and worse relapse free survival (P=0.003). The IMPACT data (153 patients) confirmed that a two week Ki67 &gt;10% predicted higher Ki67 in the surgical specimen (P=0.001), a poorer PEPI score (P=0.001), smaller numbers of patients in the PEPI 0 risk point group (P= 0.004) and worse relapse free survival (P=0.008).Ki67 and OutcomePOL 4W Ki67% PEPI 0RFS (events)10%&gt;1/19 (5%)5/21 (23%)10%≤10/36 (28%)1/41 (2.4%)P ValueP=0.08 (Fisher)P=0.003 (log rank)IMPACT 2W Ki67% PEPI 0RFS (events)10%&gt;0/32 (0%)9/35 (26%)10%≤21/101 (21%)13/118 (11%)P ValueP=0.004 (Fisher)P=0.008 (log rank) Conclusions: A tumor Ki67 assessment taken a short time (2 to 4 week window) after the initiation of neoadjuvant AI identifies patients with poor outcome ER+ disease. Amendment 6 of the neoadjuvant endocrine therapy protocol ACOSOG Z1031 will triage patients with an “on treatment” Ki67 value above 10% to chemotherapy in order to assess the pathological response rate to cytotoxic therapy in this important tumor subset.Supported by R01 CA095614, Avon PFP award 3P50 CA68438-07S2, U01 CA114722, ACOSOG U10 CA 76001, Breakthrough Cancer UK and AstraZenica (IMPACT trial).

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 78.

Flexible CO2 laser system for fundamental research related to an extreme ultraviolet lithography source

A CO(2) laser system with flexible parameters was developed for fundamental research related to an extreme ultraviolet (EUV) lithography source. The laser is a master oscillator and power amplifier (MOPA) system, consisting of a master oscillator, an externally triggered plasma switch, a preamplifier, a main amplifier, and electronic synchronization units. The laser pulse duration can be varied easily from 10 to 110 ns, with a constant peak power for pulse durations from 25 to 110 ns. The MOPA laser system can also be operated in dual-oscillator mode to produce laser pulse with pulse duration as long as 200 ns and a train of laser pulses with flexible interval. The divergence of the laser beam is 1.3 times the diffraction limit. The laser intensity on the target surface can be up to 8x10(10) W/cm(2). Utilizing this CO(2) MOPA laser system, high conversion efficiency from laser to in-band (2% bandwidth) 13.5 nm EUV emission has been demonstrated over a wide range of laser pulse durations.