Management of Nasopharyngeal Carcinoma: Is Adjuvant Therapy Needed?

Nasopharyngeal carcinoma of the undifferentiated histologic subtype is endemic and prevalent in southeast Asia. The dramatic improvement of treatment outcomes and overall prognosis during the past few decades has been attributed to advances in disease screening and diagnosis, diagnostic imaging, radiotherapy techniques, use of combination systemic therapy, and dedicated clinical and biomarker surveillance. The current practice of treating patients with advanced locoregional disease using cisplatin concurrent with conventional fractionated radiotherapy, followed by adjuvant cisplatin and fluorouracil, was established in 1998 when the landmark Intergroup-0099 Study demonstrated a survival benefit with the addition of systemic therapy.

There is little doubt regarding the need for concurrent chemotherapy, but there has been uncertainty about the magnitude of the benefit attributed to the adjuvant phase. Furthermore, instead of one-size-fits-all recommendations, it will be ideal if we can tailor adjuvant therapy to high-risk patients only to avoid unnecessary toxicities. In addition, recent evidence suggests that induction chemotherapy before concurrent chemoradiation can achieve better outcomes, especially in distant control, even in the modern era of intensity-modulated radiation therapy. This article provides a comprehensive review of key literature on the current management of locoregionally advanced nasopharyngeal carcinoma and highlights future research directions to unravel these controversies.

Global tidal variations, regional distribution of ventilation, and the regional onset of filling determined by electrical impedance tomography: reproducibility

The reproducibility of the regional distribution of ventilation and the timing of onset of regional filling as measured by electrical impedance tomography lacks evidence. This study investigated whether electrical impedance tomography measurements in healthy males were reproducible when electrodes were replaced between measurements. Part 1: Recordings of five volunteers lying supine were made using electrical impedance tomography and a pneumotachometer. Measurements were repeated at least three hours later. Skin marking ensured accurate replacement of electrodes. No stabilisation period was allowed. Part 2: Electrical impedance tomography recordings of ten volunteers; a 15 minute stabilisation period, extra skin markings, and time-averaging were incorporated to improve the reproducibility. Reproducibility was determined using the Bland-Altman method. To judge the transferability of the limits of agreement, a Pearson correlation was used for electrical impedance tomography tidal variation and tidal volume. Tidal variation was judged to be reproducible due to the significant correlation between tidal variation and tidal volume (r² = 0.93). The ventilation distribution was not reproducible. A stabilisation period, extra skin markings and time-averaging did not improve the outcome. The timing of regional onset of filling was reproducible and could prove clinically valuable. The reproducibility of the tidal variation indicates that non-reproducibility of the ventilation distribution was probably a biological difference and not measurement error. Other causes of variability such as electrode placement variability or lack of stabilisation when accounted for did not improve the reproducibility of the ventilation distribution.

Characterization of replication-competent adenovirus isolates from large-scale production of a recombinant adenoviral vector

Replication-deficient adenoviral vectors have been developed for the delivery of DNA sequences encoding a variety of proteins intended for the management of disease through gene therapy. One concern is the occurrence of replication-competent adenovirus (RCA) in the population of replication-deficient adenoviral vectors as a result of recombination or contamination. To address this concern, it is necessary to determine the frequency of occurrence and to fully characterize the molecular structure and biological infectivity of RCA. rAd/p53 is a pIX-deleted p53 gene therapy vector that is designed to lower the RCA occurrence and to deliver the tumor suppressor gene p53 for treatment of various cancers. Multiple preparations of the replication-deficient adenoviral vector rAd/p53 were tested for the presence of RCA, employing a sensitive biological assay. Single plaques from RCA-positive preparations of rAd/p53 were isolated for molecular characterization. All of the RCA isolates displayed a single unique structure that contains the complete E1 sequence of adenovirus type 5 but lacks the p53 sequence. The detailed sequence analysis of the RCA suggests that it is most likely generated as a result of recombination events between the rAd/p53 DNA and the 293 host adenoviral sequence. Results from viral infectivity analysis by flow cytometry demonstrate no substantial difference in infectivity of RCA, rAd/p53, and wild-type adenovirus type 5 in 293 cells.

Non-lysosomal cycling pathway for atrial natriuretic peptide activated by protein kinase C in human NPE cells

Atrial natriuretic peptide (ANP) stimulates aqueous humor formation in primates, but the membrane-bound receptors which mediate this effect have not been well studied in the eye. Endocytosis of [125I]ANP bound to natriuretic peptide C receptors was characterized in fetal human nonpigmented ciliary epithelial (NPE) cells. [125I]ANP which bound to cells at 4 degreesC was detected in the cell interior after a temperature shift to 37 degreesC. Appearance of ligand within the cell peaked at 5 min, and then declined towards zero over 20 min. The endocytosis inhibitor phenylarsine oxide blocked the appearance of internalized ligand, whereas the lysosomotropic drug chloroquine had no effect on internalization but blocked subsequent loss of internalized ligand. Chloroquine also blocked the accumulation of degraded ligand in the extracellular medium. Treatment with phorbol 12-myristate, 13-acetate accelerated the loss of internalized ligand from cells and increased the accumulation of ligand in the extracellular medium. Ligand in the medium was also increased by dioctanoylglycerol but not by 4alpha phorbol didecanoate, an isomer which does not activate protein kinase C. The protein kinase inhibitors staurosporine and bisindolylymaleimide blocked the increase in ligand. Phorbol ester-stimulated loss of internalized ligand occurred in the presence of chloroquine. TCA precipitation of ligand in the extracellular medium showed that both degraded and undegraded [125I]ANP were present. However, in the presence of chloroquine only, undegraded ANP was detected in the medium, and phorbol esters stimulated its rate of appearance by approximately 2 fold. A similar stimulation occurred when cells containing internalized ligand, but stripped of membrane-bound ligand, were exposed to phorbol esters. The data suggest that ANP bound to natriuretic peptide C receptors on NPE cells is endocytosed, and that protein kinase C activates a non-lysosomal pathway for ANP retroendocytosis in these cells.

Differential regulation of natriuretic peptide receptors on ciliary body epithelial cells

Atrionatriuretic peptide (ANP) lowers intraocular pressure in the eyes of humans and rabbits. We examined the effects of natriuretic peptides on cGMP formation and 125I-labelled-ANP binding to cultured cells derived from ciliary body epithelium, the site of aqueous humour formation in the eye. ANP, brain natriuretic peptide (BNP) and C-natriuretic peptide (CNP) at 1 microM stimulated cGMP formation 8.2(+/-1.2)-fold, 4.8(+/-0.6)-fold and 87.3(+/-12.1)-fold respectively. 125I-ANP bound to intact cells at a single site, with a dissociation constant KD=0.30+/-0.01 nM. BNP was as effective as ANP in displacing 125I-ANP, whereas CNP displaced label with a slightly higher IC50. 125I-ANP binding was displaced >95% by c-ANP, a specific ligand for natriuretic peptide C receptors (NPR-C). Cross-linking of 125I-ANP to cells labelled predominantly a protein of Mr 62000. These data suggest that 125I-ANP binding was primarily to NPR-C, whereas cGMP stimulation occurred primarily via natriuretic peptide B receptors (NPR-B). Vasopressin and histamine, both activators of the inositol phosphate/diacylglycerol phosphate pathway in non-pigmented ciliary epithelial cells, inhibited CNP stimulation of guanylate cyclase (NPR-B) and 125I-ANP binding (NPR-C) by 30-38%. Inhibition was mimicked by PMA, dioctanoylglycerol and phorbol didecanoate, whereas 4alpha phorbol didecanoate had no effect. Staurosporine and bisindolylmaleimide both blocked inhibition of 125I-ANP binding and cGMP formation by PMA. These results suggest that protein kinase C (PKC) down-regulates both NPR-B and NPR-C. PKC down-regulation of NPR-B varied inversely with CNP concentration. Inhibition by 1 microM PMA was 30.6(+/-4.0)% with 500 nM CNP, but 83.4(+/-8.8)% with 10 nM CNP, indicating that increasing CNP could partially overcome inhibition by PMA. Since extracellular CNP levels were not affected by PKC activation, the effect of PKC on NPR-B is best explained as a reduction in NPR-B affinity for CNP. NPR-C measured as 125I-ANP binding was likewise reduced 36.4(+/-5.1)% by exposure to PMA. In contrast with NPR-B inhibition, however, inhibition of NPR-C was due largely to a reduction in the number of receptor binding sites per cell rather than a reduction in receptor affinity for ligand. The data therefore suggest that both NPR-B and NPR-C are down-regulated by PKC, but that the mechanisms of down-regulation of the two receptors are different.

Natriuretic peptide receptors on human trabecular meshwork cells

The effects of natriuretic peptides on cGMP formation and [125I]ANP binding in human trabecular meshwork cells were investigated. CNP at 1 microM stimulated cGMP formation approximately 18-25 fold, with a half maximal effective concentration approximately 20-30nM. BNP at 1 microM stimulated approximately 7 fold, while ANP stimulated cGMP formation 2-fold at 1 microM but had little or no effect at concentrations below 1 microM. Displacement binding of [125I]ANP to intact TM cells in the presence of unlabeled ANP indicated a single binding site with a dissociation constant approximately 0.15nM.c-ANP, which binds specifically to natriuretic peptide C receptors, displaced > 95% [125I]ANP binding to surface receptor sites with a half-maximal effective concentration comparable to that of ANP or BNP. c-ANP had no inhibitory effect on CNP stimulation of cGMP formation. The data suggest that human TM cells possess natriuretic peptide B receptors as the primary guanylyl cyclase-containing subtype and C receptors as the numerically predominant subtype of natriuretic peptide receptors.

Control of keratin gene expression by vitamin A in tracheobronchial epithelial cells

Vitamin A (retinol) treatment induces (and/or enhances) mucous cell differentiation and alters keratin gene expression in cultured airway epithelial cells of human and nonhuman primate origin. We observed that retinol greatly reduced the synthesis of keratins 5, 6, 14, 16, and 17, but slightly enhanced keratins 7, 8, 10, 13, 15, 18, and 19. These changes were also reflected at the mRNA level as demonstrated by cell-free translation and by cDNA cloning of human keratin genes based on differential hybridization. One of these cDNA clones, HT27, isolated from the cDNA library of human tracheobronchial epithelial cells and whose expression in cultured cells was greatly suppressed by retinol, had a nucleotide sequence identical to the C-terminus of keratin 16. The identity of this clone was further confirmed by Western blot analysis using an antibody specific to the 15-amino acid synthetic peptide and the C-terminal sequence. Using this cDNA clone and two known keratin clones, pKA1 (keratins 5 and 6) and pKB2 (keratin 14), we found the levels of these corresponding mRNAs in cultured cells to be reduced 10- to 25-fold after treatment of cells with vitamin A. The inhibition was time- and dose-dependent with respect to retinol and was sensitive to prior treatment with cycloheximide. However, nuclear run-on transcriptional assays revealed no significant reduction of the synthesis of these messages in retinol-treated cultures. Furthermore, no change in the half-life of these mRNAs was observed in cells after the retinol treatment. Based on these results, we conclude that vitamin A indirectly controls the synthesis of these keratins at the post-transcriptional level.

Half-life and vitreous clearance of trifluorothymidine after intravitreal injection in the rabbit eye

To determine the half-life and vitreous clearance of trifluorothymidine, a drug that demonstrates good toxicity against cytomegalovirus (CMV), we injected 200 micrograms of the drug intravitreally in the eyes of nine New Zealand white rabbits. None of the rabbits showed any adverse reactions to the injection or the drug. The rabbits were killed at 3, 6, 12, 24 or 72 hours. High-performance liquid chromatography was used to measure the vitreous trifluorothymidine concentration. The half-life of the drug was found to be 3.15 hours, and the vitreous concentration remained above the ID50 (concentration required to inhibit cytopathic effects by 50% compared with control cultures) for CMV for about 30 hours. We conclude that trifluorothymidine may be of future benefit in the management of CMV retinitis.