CHCHD4-TRIAP1 regulation of innate immune signaling mediates skeletal muscle adaptation to exercise

Exercise training can stimulate the formation of fatty-acid-oxidizing slow-twitch skeletal muscle fibers, which are inversely correlated with obesity, but the molecular mechanism underlying this transformation requires further elucidation. Here, we report that the downregulation of the mitochondrial disulfide relay carrier CHCHD4 by exercise training decreases the import of TP53-regulated inhibitor of apoptosis 1 (TRIAP1) into mitochondria, which can reduce cardiolipin levels and promote VDAC oligomerization in skeletal muscle. VDAC oligomerization, known to facilitate mtDNA release, can activate cGAS-STING/NFKB innate immune signaling and downregulate MyoD in skeletal muscle, thereby promoting the formation of oxidative slow-twitch fibers. In mice, CHCHD4 haploinsufficiency is sufficient to activate this pathway, leading to increased oxidative muscle fibers and decreased fat accumulation with aging. The identification of a specific mediator regulating muscle fiber transformation provides an opportunity to understand further the molecular underpinnings of complex metabolic conditions such as obesity and could have therapeutic implications.

WASF3 disrupts mitochondrial respiration and may mediate exercise intolerance in myalgic encephalomyelitis/chronic fatigue syndrome

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is characterized by various disabling symptoms including exercise intolerance and is diagnosed in the absence of a specific cause, making its clinical management challenging. A better understanding of the molecular mechanism underlying this apparent bioenergetic deficiency state may reveal insights for developing targeted treatment strategies. We report that overexpression of Wiskott-Aldrich Syndrome Protein Family Member 3 (WASF3), here identified in a 38-y-old woman suffering from long-standing fatigue and exercise intolerance, can disrupt mitochondrial respiratory supercomplex formation and is associated with endoplasmic reticulum (ER) stress. Increased expression of WASF3 in transgenic mice markedly decreased their treadmill running capacity with concomitantly impaired respiratory supercomplex assembly and reduced complex IV levels in skeletal muscle mitochondria. WASF3 induction by ER stress using endotoxin, well known to be associated with fatigue in humans, also decreased skeletal muscle complex IV levels in mice, while decreasing WASF3 levels by pharmacologic inhibition of ER stress improved mitochondrial function in the cells of the patient with chronic fatigue. Expanding on our findings, skeletal muscle biopsy samples obtained from a cohort of patients with ME/CFS showed increased WASF3 protein levels and aberrant ER stress activation. In addition to revealing a potential mechanism for the bioenergetic deficiency in ME/CFS, our study may also provide insights into other disorders associated with fatigue such as rheumatic diseases and long COVID.

Carvacrol preserves antioxidant status and attenuates kidney fibrosis via modulation of TGF-β1/Smad signaling and inflammation

Chronic kidney disease (CKD) with diverse aetiologies is emerging as a challenging kidney disorder associated with inflammation and interstitial fibrosis. Carvacrol (CVL) is a bioactive monoterpenoid found abundantly in oregano, thyme, and bergamot, having diverse pharmacological benefits. However, the effect of CVL against fibrotic changes in the kidneys is poorly defined. In the current study, a robust mouse model of renal fibrosis induced through unilateral ureteral obstruction (UUO) is used to investigate the anti-fibrotic activity of CVL. The mice were treated with two different oral doses of CVL (25 mg kg^-1 and 50 mg kg^-1 body weight) for 14 consecutive days. The UUO induction resulted in impaired renal function, severe histological damage, and collagen deposition in the obstructed kidney. Our findings revealed profound activation of transforming growth factor-β1 (TGF-β1) and NF-κB (p65) signaling along with the downregulation of antioxidant proteins, nuclear factor-erythroid factor 2-related factor 2 (Nrf2), NAD(P)H: quinone oxidoreductase 1 (NQO1), and superoxide dismutase (SOD) in the obstructed kidney. CVL administration markedly recovered antioxidant proteins and kidney histological changes. In addition, CVL blunted the NF-κB (p65) phosphorylation and reduced the levels of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, and cyclooxygenase 2 (COX-2) compared to the UUO control group. CVL also alleviated the increased fibrotic protein levels of TGF-β1, pSmad2/3, collagen I, collagen III, fibronectin, and myofibroblast activation and epithelial-mesenchymal transition (EMT) markers, including alpha-smooth muscle actin (α-SMA), E-cadherin, and vimentin in the kidneys. Findings from in vitro study also confirmed that CVL inhibits the EMT process in TGF-β1 stimulated renal tubular epithelial cells (NRK 52E cells). Collectively, our findings indicate that CVL administration attenuates kidney fibrosis by targeting oxidative stress and inflammation.

Up-regulation of Nrf2/HO-1 and inhibition of TGF-β1/Smad2/3 signaling axis by daphnetin alleviates transverse aortic constriction-induced cardiac remodeling in mice

Oxidative damage and accumulation of extracellular matrix (ECM) components play a crucial role in the adverse outcome of cardiac hypertrophy. Evidence suggests that nuclear factor erythroid-derived factor 2 related factor 2 (Nrf2) can modulate oxidative damage and adverse myocardial remodeling. Daphnetin (Daph) is a coumarin obtained from the plant genus Daphne species that exerts anti-oxidative and anti-inflammatory properties. Herein, we investigated the roles of Daph in transverse aortic constriction (TAC)-induced cardiac hypertrophy and fibrosis in mice. TAC-induced alterations in cardiac hypertrophy markers, histopathological changes, and cardiac function were markedly ameliorated by oral administration of Daph in mice. We found that Daph significantly reduced the reactive oxygen species (ROS) generation, increased the nuclear translocation of Nrf2, and consequently, reinstated the protein levels of NAD(P)H quinone dehydrogenase1 (NQO1), heme oxygenase-1 (HO-1), and other antioxidants in the heart. Besides, Daph significantly inhibited the TAC-induced accumulation of ECM components, including α-smooth muscle actin (α-SMA), collagen I, collagen III, and fibronectin, and interfered with the TGF-β1/Smad2/3 signaling axis. Further studies revealed that TAC-induced terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) positive nuclei and the protein levels of Bax/Bcl2 ratio and cleaved caspase 3 were substantially decreased by Daph treatment. We further characterized the effect of Daph on angiotensin II (Ang-II)-stimulated H9c2 cardiomyoblast cells and observed that Daph markedly decreased the Ang-II induced increase in cell size, production of ROS, and proteins associated with apoptosis and fibrosis. Mechanistically, Daph alone treatment enhanced the protein levels of Nrf2, NQO1, and HO-1 in H9c2 cells. The inhibition of this axis by Si-Nrf2 transfection abolished the protective effect of Daph in H9c2 cells. Taken together, Daph effectively counteracted the TAC-induced cardiac hypertrophy and fibrosis by improving the Nrf2/HO-1 axis and inhibiting the TGF-β1/Smad2/3 signaling axis.

Biochanin A alleviates unilateral ureteral obstruction-induced renal interstitial fibrosis and inflammation by inhibiting the TGF-β1/Smad2/3 and NF-kB/NLRP3 signaling axis in mice

AIMS

Tubulointerstitial fibrosis, a frequent complication of chronic kidney disease (CKD) is a major public health issue. Biochanin A (BCA), an isoflavone, has numerous pharmacological activities. However, its effect on renal fibrosis and underlying molecular mechanism has not yet been clarified. This study explored the effect of BCA on renal tubulointerstitial fibrosis and inflammation in mice.

MAIN METHODS

The mouse model of unilateral ureteral obstruction (UUO) in vivo and transforming growth factor (TGF)-β1 activated renal fibroblast (NRK 49F) cells in vitro model were used to assess the antifibrotic effect of BCA. Biochemical analysis, histopathology, western blotting, and immunofluorescent staining methods were performed to elucidate the mechanism of BCA.

KEY FINDINGS

In vitro, BCA suppressed the expression of fibrogenic proteins in TGF-β1-activated renal fibroblasts. The treatment with BCA displayed less tubular injury, prevented the aberrant accumulation of extracellular matrix (ECM) components, and inhibited the TGF-β1/Smad2/3 signaling axis in the kidneys. Furthermore, BCA impeded the phosphorylation of NF-kB(p65) and blunted the expression of inflammatory genes in the obstructed kidneys. The UUO induced expressions of nod-like receptor protein 3 (NLRP3), active caspase 1, interleukin(IL)-18, and IL-1β proteins were decreased in the BCA treated groups. We also found the increased expression of redox-sensitive nuclear factor erythroid 2-related factor 2 (Nrf2) and heme oxygenase 1 (HO-1) proteins in BCA treated groups compared to the UUO control.

SIGNIFICANCE

These findings indicate that BCA has a therapeutic benefit against renal fibrosis, and the ameliorative effect is mediated via inhibiting the TGF-β1/Smad2/3 and NF-kB/NLRP3 signaling axis.

Biological Activities, Pharmacokinetics and Toxicity of Nootkatone: A Review

Abstract:

Plant-based drugs have a significant impact on modern therapeutics due to their vast array of pharmacological activities. The integration of herbal plants in the current healthcare system has emerged as a new field of research. It can be used for the identification of novel lead compound candidates for future drug development. Nootkatone is a sesquiterpene derivative and an isolate of grapefruit. Shreds of evidence illustrate that nootkatone targets few molecular mechanisms to exhibit its pharmacological activity and yet needs more exploration to be established. The current review is related to nootkatone, drafted through a literature search using research articles and books from different sources, including Science Direct, Google Scholar, Elsevier, PubMed, and Scopus. It has been reported to possess a wide range of pharmacological activities such as anti-inflammatory, anticancer, antibacterial, hepatoprotective, neuroprotective, and cardioprotective. Although preclinical studies in experimental animal models suggest that nootkatone has therapeutic potential, it is further warranted to evaluate its toxicity and pharmacokinetic parameters before being applied to humans. Hence in the present review, we have summarized the scientific knowledge on nootkatone with a particular emphasis on its pharmacological properties to encourage researchers for further exploration in preclinical and clinical settings.

Aloin alleviates pathological cardiac hypertrophy via modulation of the oxidative and fibrotic response

AIMS

Pathological cardiac hypertrophy is a characteristic feature in many cardiovascular diseases (CVDs). Aloin is an anthraquinone glycoside from Aloe species, and the effect of aloin on cardiac hypertrophy and associated fibrotic changes have not been elucidated. This study investigated the effect of aloin against the isoproterenol (ISO)-induced cardiac hypertrophy in rats.

MAIN METHODS

Cardiac hypertrophy experimental model was induced in rats by subcutaneous injection of ISO for 14 days. Meanwhile, the animals were administered orally with aloin at doses of 25 and 50 mg/kg/day. On the 15th day, cardiac echocardiography was performed, the heart was collected and subjected for histopathological, gene expression, and immunoblot studies. Additionally, the effect of aloin on ISO-induced hypertrophic changes in H9c2 cells was investigated.

KEY FINDINGS

Aloin markedly alleviated ISO-induced heart injury, reduced cardiac hypertrophy, improved cardiac function, and histological alterations in the heart. Mechanistically, aloin attenuated ISO-induced fibrosis via inhibition of the levels of collagen I, α-smooth muscle actin (α-SMA), fibronectin, transforming growth factor-β (TGF-β) and pSmad2/3 proteins in the heart. Aloin alleviated ISO-induced myocardial oxidative damage and up-regulated the levels of antioxidant transcription factor nuclear factor erythroid 2-related factor 2 (Nrf2) and heme oxygenase-1 (HO-1) proteins. Moreover, aloin treatment attenuated ISO-induced hypertrophic changes and the generation of reactive oxygen species (ROS) in H9c2 cells in vitro.

SIGNIFICANCE

Our findings demonstrated that aloin alleviated ISO-induced cardiac hypertrophy and fibrosis via inhibiting TGF-β/pSmad2/3 signaling and restoring myocardial antioxidants, and therefore has promising therapeutic potential against cardiac hypertrophy and fibrosis.

A review on herbal Nrf2 activators with preclinical evidence in cardiovascular diseases

Cardiovascular diseases (CVDs) are an ever-growing problem and are the most common cause of death worldwide. The uncontrolled production of reactive oxygen species (ROS) and the activation of ROS associated with various cell signaling pathways with oxidative cellular damage are the most common pathological conditions connected with CVDs including endothelial dysfunction, hypercontractility of vascular smooth muscle, cardiac hypertrophy and heart failure. The nuclear factor E2-related factor 2 (Nrf2) is a basic leucine zipper redox transcription factor, together with its negative regulator, kelch-like ECH-associated protein 1 (Keap1), which serves as a key regulator of cellular defense mechanisms to combat oxidative stress and associated diseases. Multiple lines of evidence described here support the cardiac protective property of Nrf2 in various experimental models of cardiac related disease conditions. In this review, we emphasized the molecular mechanisms of Nrf2 and described the detailed outline of current findings on the therapeutic possibilities of the Nrf2 activators specifically from herbal origin in various CVDs. Based on evidence from various preclinical experimental models, we have highlighted the activation of Nrf2 pathway as a budding therapeutic option for the prevention and treatment of CVDs, which needs further investigation and validation in the clinical settings.

Toll-like receptor 4: An attractive therapeutic target for acute kidney injury

Acute kidney injury (AKI) is a progressive renal complication which significantly affects the patient's life with huge economic burden. Untreated acute kidney injury eventually progresses to a chronic form and end-stage renal disease. Although significant breakthroughs have been made in recent years, there are still no effective pharmacological therapies for the treatment of acute kidney injury. Toll-like receptor 4 (TLR4) is a well-characterized pattern recognition receptor, and increasing evidence has shown that TLR4 mediated inflammatory response plays a pivotal role in the pathogenesis of acute kidney injury. The expression of TLR4 has been seen in resident renal cells, including podocytes, mesangial cells, tubular epithelial cells and endothelial cells. Activation of TLR4 signaling regulates the transcription of numerous pro-inflammatory cytokines and chemokines, resulting in renal inflammation. Therefore, targeting TLR4 and its downstream effectors could serve as an effective therapeutic intervention to prevent renal inflammation and subsequent kidney damage. For the first time, this review summarizes the literature on acute kidney injury from the perspective of TLR4 from year 2010 to 2020. In the current review, the role of TLR4 signaling pathway in AKI with preclinical evidence is discussed. Furthermore, we have highlighted several compounds of natural and synthetic origin, which have the potential to avert the renal TLR4 signaling in preclinical AKI models and have shown protection against AKI. This scientific review provides new ideas for targeting TLR4 in the treatment of AKI and provides strategies for the drug development against AKI.

Targeting NLRP3 inflammasome as a promising approach for treatment of diabetic nephropathy: Preclinical evidences with therapeutic approaches

Diabetes mellitus is an increasingly prevalent disease around the globe. The epidemic of diabetes mellitus and its complications pretenses the foremost health threat globally. Diabetic nephropathy is the notable complication in diabetes, leading to end-stage renal disease (ESRD) and premature death. Abundant experimental evidence indicates that oxidative stress and inflammation are the important mediators in diabetic kidney diseases and interlinked with various signal transduction molecular mechanisms. Inflammasomes are the critical components of innate immunity and are recognized as a critical mediator of inflammation and autoimmune disorders. NOD-like receptor protein 3 (NLRP3) inflammasome is the well-characterized protein and it exhibits the sterile inflammation through the regulation of pro-inflammatory cytokines interleukin (IL)-1β and IL-18 production in tissues. In recent years, the role of NLRP3 inflammasome in the pathophysiology of diabetic kidney diseases in both clinical and experimental studies has generated great interest. In the current review, we focused on and discussed the role of NLRP3 inflammasome in diabetic nephropathy. A literature review was performed using online databases namely, PubMed, Scopus, Google Scholar and Web of science to explore the possible pharmacological interventions that blunt the NLRP3 inflammasome-caspase-1-IL-1β/IL-18 axis and shown to have a beneficial effect in diabetic kidney diseases. This review describes the inhibition of NLRP3 inflammasome activation as a promising therapeutic target for drug discovery in future.

Developing policy options for SARS and SARS-like diseases - a Delphi study

The objective of the SARSControl Delphi study was to develop options for national and international emerging infectious diseases policies. The aim of this paper is to present the results of the study, which gathered expert opinions on gaps and inconsistencies concerning preparedness and response planning for Severe Acute Respiratory Syndrome (SARS) and SARS-like diseases. The Delphi technique was employed, which comprised a pilot round, two written rounds and a face-to-face meeting. The Delphi panel consisted of 38 experts from 22 countries, who highlighted the necessity to test plans and stressed the importance of surveillance measures for the swift containment of communicable disease outbreaks and the inclusion of detailed triage plans in national pandemic plans. The experts also suggested a need to define criteria for testing pandemic preparedness plans at different regional levels. New policy alternatives were identified, such as the need for generic plans on pandemics and universal access to healthcare during an outbreak. The usefulness of some non-medical interventions, such as bans on travel, could not be established and need further research. Dissemination of the findings will help to bridge gaps and rectify inconsistencies in current pandemic planning and response strategies for SARS and SARS-like diseases, as well as add valuable knowledge towards the development of national and international emerging infectious disease policies.

Pattern of homicidal deaths autopsied at Penang Hospital, Malaysia, 2007-2009: a preliminary study

This article describes the homicide pattern in Penang Island, Malaysia over a three-year period (2007-2009). 65 homicide autopsies were performed at the Department of Forensic Medicine, Penang Hospital over the study period. The homicide rates ranged from 0.01 to 0.09/1000 population, the highest being in the Indian ethnic group. The majority (37%) of victims were in the 20-39 years age group. The male: female ratio was 3:1. The majority of deaths were caused by blunt instruments (46%), followed by stab/slash wounds (25%) and asphyxiation (12%). 63% of homicides occurred in areas served by the police stations at Jalan Patani (23.1%), Sg. Nibong (16.9%), Central (12.3%) and Bayan Lepas (10.9%). 56 (86%) victims were brought in dead to the hospital, while 9 (14%) died after admission. Most (39%) incidences occurred in the morning. The methods of homicide were different from Kuala Lumpur, another highly urbanised area of Malaysia.

Completed suicides in the district of timur laut, penang island - a preliminary investigation of 3 years (2007-2009) prospective data

This article describes the completed suicide patterns which occurred in the Timur Laut district of Penang Island, Malaysia. In a prospective cohort study over the three years period (2007-2009) there were 138 cases of suicide deaths. The number of suicide deaths for the year 2007, 2008 and 2009 were 45, 41 and 52 deaths, respectively. Majority of the suicide deaths were by jumping from height (47.1%), followed by hanging (34.1%) and by drowning (10.9%). The male victims outnumbered females in a 3 : 1 ratio.

Virtual colonoscopy vs conventional colonoscopy in patients at high risk of colorectal cancer--a prospective trial of 150 patients

OBJECTIVE

Virtual colonoscopy (VC)/CT colonography has advantages over the well-documented limitations of colonoscopy/barium enema. This prospective blinded investigative comparison trial aimed to evaluate the ability of VC to assess the large bowel, compared to conventional colonoscopy (CC), in patients at high risk of colorectal cancer (CRC).

METHOD

We studied 150 patients (73 males, mean age 60.9 years) at high risk of CRC. Following bowel preparation, VC was undertaken using colonic insufflation and 2D-spiral CT acquisition. Two radiologists reported the images and a consensual agreement reached. Direct comparison was made with CC (performed later the same day). Interobserver agreement was calculated using the Kappa method. Postal questionnaires sought patient preference.

RESULTS

Virtual colonoscopy visualized the caecum in all cases. Five (3.33%) VCs were classified as inadequate owing to poor distension/faecal residue. CC completion rate was 86%. Ultimately, 44 patients had normal findings, 44 had diverticular disease, 11 had inflammatory bowel disease, 18 had cancers, and 33 patients had 42 polyps. VC identified 19 cancers--a sensitivity and specificity of 100% and 99.2% respectively. For detecting polyps > 10 mm, VC had a sensitivity and specificity (per patient) of 91% and 99.2% respectively. VC identified four polyps proximal to stenosing carcinomas and extracolonic malignancies in nine patients (6%). No procedural complications occurred with either investigation. A Kappa score achieved for interobserver agreement was 0.777.

CONCLUSION

Virtual colonoscopy is an effective and safe method for evaluating the bowel and was the investigation of choice amongst patients surveyed. VC provided information additional to CC on both proximal and extracolonic pathology. VC may become the diagnostic procedure of choice for symptomatic patients at high risk of CRC, with CC being reserved for therapeutic intervention, or where a tissue diagnosis is required.

High-dose-rate brachytherapy in the treatment of carcinoma of the prostate

BACKGROUND

Although radical prostatectomy for localized disease is considered as a standard of care, external-beam radiotherapy and brachytherapy are equally effective. We report on the technique and preliminary results of high-dose-rate (HDR) brachytherapy using a temporary iridium-192 implant technique.

METHODS

The authors reviewed the literature on the techniques, treatment protocols, and results of HDR brachytherapy in the treatment of carcinoma of the prostate, and they report their own protocols, technique, and results.

RESULTS

The combination of HDR brachytherapy and external irradiation has been well tolerated by all 200 patients in our series, with less than 3% grade 3 late complications and with 95% PSA relapse-free survival with a median follow-up of 24 months.

CONCLUSIONS

HDR brachytherapy may be the most conformal type of irradiation in the treatment of carcinoma of the prostate regardless of tumor size, anatomical distortion, and organ mobility.

Long-term results of treatment for prostate carcinoma by staging pelvic lymph node dissection and definitive irradiation using low-dose rate temporary iridium-192 interstitial implant and external beam radiotherapy

BACKGROUND

The objective of this study was to evaluate long-term treatment outcome of definitive irradiation by using temporary interstitial implant and limited dose of external beam radiotherapy in treatment of localized prostate carcinoma.

METHODS

In total, 536 patients with biopsy-proven adenocarcinoma of the prostate, classification T1-T3, underwent staging pelvic lymph node dissection and brachytherapy delivering an average tumor dose of 30 grays (Gy), supplemented by external beam radiation therapy for an additional dose of 36 Gy delivered over 4 weeks. One hundred of 536 (18%) patients had pathologic D1 disease. A total of 181 patients had undergone transurethral prostatectomy before the treatment. Repeat prostate biopsy was performed on 132 patients 18 or more months after treatment. None of the patients received neoadjuvant or adjuvant hormone therapy.

RESULTS

Cumulative disease free survival (DFS) including biochemical DFS at 10 and 15 years for classification T1B,C was 78% and 72%; for T2A, 78% and 78%; for T2B,C, 68% and 66%; and for T3A-C, 45% and 45%, respectively. Cause specific survival for the entire group at 10 and 15 years was 89% and 87%, respectively. Severe complications occurred only in the early developmental phase of the study.

CONCLUSIONS

In univariate analysis, the clinical stage, histologic grade, pretreatment PSA level, lymph node status, and results of repeat posttreatment biopsy were all independently significant prognostic factors. However, the authors' study indicates that in multivariate analysis, only two factors emerged with statistical significance-the status of pelvic lymph nodes and the results of posttreatment biopsy. This signifies the importance of local tumor control to achieve ultimate cure and the importance of assessment of pelvic lymph nodes before definitive local therapy other than radical prostatectomy, especially in the high-risk group.

Brachytherapy for primary and recurrent nasopharyngeal carcinoma: 20 years' experience at Long Beach Memorial

PURPOSE

We evaluated treatment outcomes of patients with mostly locally advanced primary and recurrent cancer of the nasopharynx managed with interstitial and intraluminal brachytherapy.

METHODS AND MATERIALS

This is a retrospective analysis of 56 patients with cancer arising from the nasopharynx treated with interstitial and intracavitary afterloading brachytherapy from 1978 to 1997. Patients were divided into three treatment groups: 15 patients with primary cancer (Group 1), 34 patients with recurrent or persistent disease (Group 2), and 7 patients with cancer in the nasopharynx who had history of previous definitive radiation therapy to the nasopharynx for head and neck cancer (Group 3). Fifty-three percent of patients in Group 1 had 1992 AJCC Stage IV disease, and 49% of patients in Groups 2 and 3 had extensive disease (defined as T3, T4, or parapharyngeal extension). Group 1 received megavoltage radiation to 50-60 Gy followed by a boost to the primary site and neck (in cases of persistent neck disease) with a combination of interstitial and intracavitary brachytherapy (mean dose 33-37 Gy). Five patients received chemotherapy, and 6 patients received hyperthermia. Groups 2 and 3 patients were treated with brachytherapy implants (mean dose 50-58 Gy) without external beam radiation. Twenty-five patients received chemotherapy either before or during radiation, and 21 patients received hyperthermia.

RESULTS

The overall survival at 2, 5, and 10 years for patients in Group 1 was 79%, 61%, and 61%, respectively, and for patients in Groups 2 and 3 combined was 48%, 30%, and 20%, respectively. Cause-specific survival at 2, 5, and 10 years was 87%, 74%, and 74%, respectively, for patients in Group 1; and 82%, 60%, and 60%, respectively, for patients in Groups 2 and 3. Local control at 2, 5, and 10 years was 93%, 93%, and 77%, respectively, for patients in Group 1; and 81%, 59%, and 49%, respectively, for patients in Groups 2 and 3. Control in the neck at 2, 5, and 10 years was achieved in 93%, 93%, and 93% of patients, respectively, in Group 1; and 88%, 81%, and 81%, respectively, for patients in Groups 2 and 3. Disease-free survival was 87%, 74%, and 62%, respectively, for patients in Group 1, and 56%, 41%, and 34%, respectively, for patients in Groups 2 and 3. There were 4 peri-operative deaths. One death (2%) was attributable to the development of late complications. Forty-five percent of patients experienced some form of late complications.

CONCLUSION

Interstitial afterloading brachytherapy can provide effective treatment for nasopharyngeal cancers, especially for locally persistent/recurrent and locally extensive lesions.

Needle displacement during HDR brachytherapy in the treatment of prostate cancer

PURPOSE

We used clinical patient data to examine implant displacement between high dose rate (HDR) brachytherapy fractions for prostate cancer to determine its impact on treatment delivery.

MATERIALS AND METHODS

We analyzed the verification films taken prior to each fraction for 96 consecutive patients treated with HDR brachytherapy boosts as part of their radiation therapy for definitive treatment of organ-confined prostate cancer at our institution. Patients were treated with 18-24 Gy in 4 fractions of HDR delivered in 40 hours followed by 36-39.6 Gy external beam radiation to the prostate. We determined the mean and maximum displacement distances of marker seeds placed in the prostate and of the implanted needles between HDR fractions.

RESULTS

Mean and maximum displacement distances between fractions were documented up to 7.6 mm and 28.5 mm, respectively, for the implant needles and 3.6 mm and 11.4 mm, respectively, for the gold marker seeds. All displacement of implant needles occurred in the caudal direction. At least 1 cm caudal displacement of needles occurred prior to 15.5% all fractions. Manual adjustment of needles was required prior to 15% of fractions, and adjustment of the CLP only was required in 24%. Most of the displacement for both the marker seeds and needles occurred between the first and second fractions.

CONCLUSIONS

There is significant caudal displacement of interstitial implant needles between HDR fractions in our prostate cancer patients. Obtaining verification films and making adjustments in the treatment volume prior to each fraction is necessary to avoid significant inaccuracies in treatment delivery.

Interstitial brachytherapy in the treatment of advanced and recurrent vulvar cancer

OBJECTIVE

Our purpose was to evaluate the role of interstitial brachytherapy in vulvar cancer management.

STUDY DESIGN

From 1985-1992 we performed a retrospective study of patients treated at the University of California, Irvine Medical Center, and Long Beach Memorial Medical Center.

RESULTS

Eleven patients received interstitial brachytherapy, with (n = 5) or without (n = 6) external beam radiotherapy, for locally advanced (n = 5) or recurrent (n = 6) vulvar cancer. Local control was achieved in all patients. Ten patients have died of disease at a mean interval of 33 months from the time of treatment, with 9 patients having maintenance of local control at death. One patient is alive without disease after 77 months of follow-up. There were 2 cases of local necrosis (18%) and 1 case of rectovaginal fistula (9%).

CONCLUSION

Local control of advanced vulvar cancer can be achieved with interstitial brachytherapy, with or without external beam radiotherapy. With improved systemic therapy this treatment modality may be used to salvage women with bulky, symptomatic tumors.

Temporary iridium-192 implant in the management of carcinoma of the prostate

The controversy about the treatment of carcinoma of the prostate has increased in the last decade, with most urologists favoring radical prostatectomy rather than primary irradiation. Several reports of persistent tumors in 50% to 90% of patients after external irradiation and permanent iodine-125 implantation of the prostate have been disturbing. From July 1977 to December 1985, 200 patients with adenocarcinoma of the prostate were treated by combining bilateral pelvic lymphadenectomy and temporary interstitial iridium-192 implantation of the prostate, followed by external irradiation. Seventy-four (36%) patients underwent biopsies of the prostate 4 months to 2 years after completion of the irradiation. Only 12 (16%) patients had persistent tumors. Complications were minimized subsequently by dose modifications.

Endocurietherapy in pediatric oncology

Endocurietherapy (brachytherapy) is the placing of radioactive sources directly into or near a solid tumor. This technique delivers a concentrated dose of radiation to a restricted volume while minimizing radiation effects on normal tissue. We have treated 11 patients (nine sarcomas, one carcinoma, and one Wilms') with endocurietherapy procedures as part of their multimodality treatment program. Six were treated as part of the primary management, and the other five were treated for recurrent or metastatic disease. Temporary afterloaded implants using ribbons embedded with radioactive iridium192 (Ir192) seeds delivered typical tumor doses of 4,000 cGy. Six patients, including four primary cases and two recurrent cases, are currently classified as no evidence of disease (NED) without further local regional treatment (follow-up of 11-62 months; median, 38 months), and one patient treated for metastasis also remains locally controlled. Two patients are classified as alive with disease (AWD), two died of disease (DOD), and one is now NED after surgical salvage. Special considerations were given to gonadal shielding, radioprotection techniques, and psychosocial issues in this pediatric population.

Limited external beam and interstitial 192iridium irradiation in the treatment of carcinoma of the base of the tongue: a ten year experience

A total of 70 patients with histologically proven diagnosis of carcinoma of the base of the tongue were treated with primary irradiation between May 1974 through April 1984. Fifty-eight (83%) of these patients had locally advanced tumors (Stage T3, T4, N2, N3). Fifty-one of the 70 (73%) patients had clinically palpable neck nodes at first presentation. All patients received a combination of external and interstitial irradiation. The dose of external irradiation was limited to 45-50 Gy over 4 1/2-5 1/2 weeks. Interstitial volume implants were performed 2-3 weeks after completion of external irradiation. The primary site as well as the vallecula, epsilateral pharyngeal wall, glossopalatine sulcus, tonsillar bed, and pillars were routinely implanted to encompass contiguous spread of the disease. The doses of implant varied according to the stage of disease, that is, 2000-2500 cGy for T1 and T2 lesions, 3000-4000 cGy for T3 and T4 lesions, with typical dose rates of 50-60 cGy per hour. The neck nodes were also separately implanted to deliver additional doses of 2000-4000 cGy in 50-80 hours. Overall, local tumor control was observed in 58 of 70 (83%) patients at minimum follow-up of 2 years. An absolute 3-year disease-free survival of the entire group was 67.0%. Treatment related complications such as soft tissue necrosis and/or osteoradionecrosis occurred in 8 of the 70 (11.4%) patients. The salvage of neck failures and the local failures was feasible in 74% and 46% of the patients, respectively either by surgery or by re-irradiation using interstitial 192iridium implant alone. This treatment region is well tolerated and it preserves the functional and asthetic integrity in most patients.

Iridium-192 implants in the treatment of tonsillar region malignancies

A total of 127 patients with histologically proved diagnosis of carcinoma of the tonsillar region and soft palate were treated over the past ten years utilizing interstitial iridium-192 implants. Eighty patients were treated for primary tumors and 47 patients for either recurrent or persistent tumors after definitive irradiation and/or surgery. All patients with primary tumors were treated by a combination of external megavoltage irradiation and interstitial iridium-192 implants, whereas patients with recurrent tumors were treated by interstitial implants alone. In the primary group, 95% of patients with T1 and T2 lesions and 79% with T3 and T4 lesions achieved complete local tumor control. The three-year absolute disease-free survival rate was 72%. Seventy-five percent local tumor control was obtained in patients with recurrent disease, with two-year absolute disease-free survival of 42%. Treatment-related complications such as soft-tissue necrosis or osteoradionecrosis occurred in 6% of patients in the primary group and 23% in recurrent group. This treatment regimen offers an excellent locoregional control with no significant functional or esthetic impairment. Most patients with primary lesions who fail this regimen can be salvaged by surgery or reirradiation using interstitial implants. Reirradiation with interstitial implants is feasible and offers a good chance of long-term local tumor control in the selected group of patients with recurrent disease for whom external irradiation and/or surgery had not been successful.

Limited external irradiation and interstitial 192iridium implant in the treatment of squamous cell carcinoma of the tonsillar region

Between January 1976 and March 1982, 80 patients with histologically proven diagnosis of squamous cell carcinoma of the tonsillar region were treated with definitive radiotherapy. Sixty-five (81%) of these patients had locally advanced tumors (Stage III and IV); 49% of patients had clinically palpable cervical lymphadenopathy. All patients received a combined external megavoltage and interstitial irradiation. The dose of external irradiation was limited to 4500-5000 cGy over 41/2 to 51/2 weeks. This was followed by interstitial 192iridium implants to doses of 2000-2500 cGy in 50-60 hours for T1, T2 lesions and 3000-4000 cGy in 60-100 hours for T3 , T4 lesions. The neck masses were also separately implanted to deliver additional doses of 2000-4000 cGy in 50-80 hours. Overall local tumor control was observed in 84% of patients with a minimum follow-up period of 2 years. An absolute 3-year disease free survival of the entire group was 72%. Treatment related complications such as soft tissue necrosis or osteoradionecrosis occurred in 6% (5/80) of patients. The salvage of neck failures and local failures was possible in 78 and 38% of patients, respectively, either by surgery or by re-irradiation employing interstitial 192iridium implants. Functional and esthetic integrity was well preserved in most cases.

Combined external and interstitial irradiation in the treatment of stage III breast cancer

One hundred six patients with locally advanced carcinoma of the breast underwent definitive radiation therapy for loco-regional control following incisional and/or needle biopsy. Doses of external and interstitial irradiation were 5000 rad (50 Gy) in 5 to 6 weeks, and 3000 to 4000 rad (30-40 Gy) in 60 to 80 hours, respectively. Forty-eight of 106 patients (45%) also received adjuvant systemic chemotherapy. Loco-regional control was observed in 93 of the 106 patients (88%), with five-year disease-free survival of 47%. Distant metastases developed in 59 of the 106 patients (56%). Good to satisfactory cosmetic results were obtained in the majority of these patients; morbidity was at an acceptable level. Locally advanced breast cancer can be treated adequately and satisfactorily without mastectomy by a combination of external and interstitial irradiation.

Primary irradiation in the management of early and locally advanced carcinoma of the breast

Between September 1, 1974, and July 31, 1979, we have treated 142 patients with a diagnosis of carcinoma of the breast by a combination of megavoltage external irradiation and interstitial iridium-192 implant. Sixty-four patients had T1 and T2 lesions and 78 patients had T3 and T4 lesions of the breast. Since June 1977, pre- and perimenopausal patients with T1 and T2 lesions have undergone axillary node dissection in addition to excisional biopsies of the breasts. All patients received external irradiation to the breast and regional lymph nodes and an interstitial implant boost to the primary site and residual axillary nodes. Most of the patients with positive axillary nodes, and those with locally advanced disease, received systemic chemotherapy. Sixty-two of 64 patients (97%) with T1 and T2 lesions and 72 of 78 (92%) patients w ith T3 and T4 lesions achieved ultimate loco-regional control. The minimum follow-up period was 48 months.

Management of prostate carcinoma. Combination of pelvic lymphadenectomy, temporary Ir-192 implantation, and external irradiation

Forty patients with prostate adenocarcinoma had bilateral pelvic lymphadenectomy, temporary Ir-192 implantation, and external irradiation. With the implant, the prostate received less than or equal to 3,000 rad (30 Gy) for A2 and B1 and 3,500 rad (35 Gy) for B2 and C lesions in 40-45 hours. Ten days to 2 weeks later, 4,000 rad (40 Gy) external irradiation was given in 4-5 weeks using AP and PA parallel opposed fields, a "box," or rotation. Patients with positive nodes were given 5,000 rad (50 Gy) to the pelvis with a midline block at 4,000 rad (40 Gy) so that the prostate received 7,000-7,500 rad (70-75 Gy). All patients were free of local recurrence. Treatment was tolerated well, with rapid regression and few complications.

Interstitial iodine-125 implant in the management of unresectable pancreatic carcinoma

Eighteen patients with locally advanced adenocarcinoma of the head, body and tail of the pancreas were treated by a combination of biliary bypass, external and interstitial irradiation at Southern California Cancer Center of California Hospital Medical Center, Los Angeles, and Memorial Hospital Medical Center of Long Beach, Long Beach, CA, from July 31, 1975 to December 31, 1980. A dose of 3000 to 5000 rad was delivered to the pancreas and regional lymph nodes by external irradiation utilizing megavoltage units and 10,000 to 15,000 rad to the pancreas and metastatic lymph nodes by permanent Iodine-125 implants. In this group of 18 patients with unresectable carcinoma of the pancreas, excellent palliation of pain, jaundice and vomiting was achieved, with a median survival of 14 months.

Integrated external and interstitial radiation therapy for primary carcinoma of the vagina

Twenty-seven patients with the diagnosis of primary carcinoma of the vagina were treated by definitive radiotherapy. Twenty-three patients received a combination of external and interstitial iridium-192 implant irradiation and four patients received only interstitial irradiation. Twenty-one patients had squamous cell carcinoma and six had adenocarcinoma. All patients were staged according to the FIGO classification. More than 70% of patients had relatively advanced local disease and conventional intracavitary irradiation was unsuitable. Local tumor control was observed in 85% (23 of 27 patients), and 56% of the patients remain alive and free of disease for a median follow-up period of 50 months to a maximum follow-up period of 84 months. Fifteen percent of the patients suffered from treatment-related complications.

Re-irradiation with interstitial implant for recurrent pelvic malignancies

Forty patients with a diagnosis of recurrent pelvic malignancy from various primary sites with no clinical evidence of distant metastasis were re-irradiated with interstitial implant. Removable after-loading 192Ir sources or permanent 125I seeds or a combination of both were used. Twenty-six of these patients received interstitial implant at the time of exploratory laparotomy. A complete local control of implanted pelvic tumors was achieved in 27 of the 40 patients (67%). Thirteen of the 40 patients (33%) remained alive and disease-free to a minimum follow-up period of two years. Serious complications such as soft tissue necrosis and fistulae occurred in 15% of the patients.

Definitive treatment of extensive anorectal carcinoma by external and interstitial irradiation

Forty-patients with locally extensive carcinoma of the anorectum were treated by a combination of external and interstitial irradiation from April 1, 1974 to January 30, 1979. Twenty-eight patients (70%) achieved complete local tumor control and two more patients with residual tumor were salvaged by surgery. Twenty-four patients remain alive with local control for an average follow up period of three years. The overall complication rate has been 20%.

Combination of external and interstitial irradiation in the primary management of breast carcinoma

The authors treated 83 patients with carcinoma of the breast using a combination of external and interstitial irradiation at Los Angeles County--University of Southern California Medical Center and Southern California Cancer Center between February 1, 1974, and May 31, 1977. All 30 patients who had T1 and T2 lesions, and who were followed for a minimum period of 24 months (24-50 months) are clinically still free of disease. Thirty-nine of 53 patients with T3 and T4 lesions, who were followed for a minimum of 30 months (30-56 months) are still alive with local control. Details of treatment techniques, dosimetry, results and complications are presented.

Interstitial-implant radiotherapy in upper-aerodigestive-tract malignancy

In the treatment of upper-aerodigestive-tract malignancy, interstitial-implant radiotherapy differs in several physical and biologic respects from conventional external-beam therapy: unlike external-beam therapy, it can deliver a high central dose with a rapid fall-off, which overcomes the central hypoxic resistance effect and yet greatly improves normal tissue tolerance. External-beam and interstitial-implant therapy can also be combined to the patient's benefit; in many cases, this combination offers advantages over external-beam therapy alone, preoperative external-beam therapy, or aggressive surgery. The recent upsurge of interest in this modality has come about because of three developments: more suitable radioactive sources, after-loading, and computerized dosimetry. The early results in upper-aerodigestive-tract malignancy, both as primary and as salvage therapy, are promising; but the precise role of this treatment in our therapeutic armamentarium remains to be established.

Primary treatment of carcinoma of the lower rectum and anal canal by a combination of external irradiation and interstitial implant

Ten patients with carcinoma of the anorectum were treated with a combination of external irradiation and after-loading interstitial 192Ir implant, which seems to be effective in controlling relatively small cancers of the anorectum and providing effective palliation of extensive lesions. Five of the 10 patients remain free of tumor after a minimum follow-up of 15 months. Four of the 10 were treated with one interstitial implant and 4,000--5,000 rads of external irradiation and 6 were treated with the same amount of irradiation and two implants. When two implants were used, complications were minimal.

Persistent carcinoma of the oropharynx and oral cavity re-treated by after-loading interstitial 192Ir implant

After-loading implantation techniques apparently offer an effective alternative in the management of persistent (or recurrent) oropharynx and oral cavity carcinoma postirradiation. A total of 29 patients with such lesions was treated from February 1974, to July 1975, in the LAC/USC Radiation Medicine Section, using after-loading 192Ir implantation techniques. These patients all had extensive persistent cancer after "full tolerance" irradiation (with or without previous surgery) and were referred for palliation or for possible salvage. Additional doses administered ranged from 5000 to 7000 rads in three to five days. Eighteen of the 29 patients (63%) have had complete local control for 18 to 36 months. These patients have maintained a relatively satisfactory palliative status. Ten of the 29 are dead. Follow-up periods are short, but early indications are that problem patients with persistent cancer after "full tolerance irradiation" can be salvaged, or at least satisfactorily palliated, with after-loading interstitial implant techniques. Clinical details, sites of involvement, implantation techniques, dosimetry methodology, reactions and complications will be described.