Survival after neoadjuvant chemotherapy with or without bevacizumab or everolimus for HER2-negative primary breast cancer (GBG 44-GeparQuinto)†

BACKGROUND

The GeparQuinto study showed that adding bevacizumab to 24 weeks of anthracycline-taxane-based neoadjuvant chemotherapy increases pathological complete response (pCR) rates overall and specifically in patients with triple-negative breast cancer (TNBC). No difference in pCR rate was observed for adding everolimus to paclitaxel in nonearly responding patients. Here, we present disease-free (DFS) and overall survival (OS) analyses.

PATIENTS AND METHODS

Patients (n = 1948) with HER2-negative tumors of a median tumor size of 4 cm were randomly assigned to neoadjuvant treatment with epirubicin/cyclophosphamide followed by docetaxel (EC-T) with or without eight infusions of bevacizumab every 3 weeks before surgery. Patients without clinical response to EC ± Bevacizumab were randomized to 12 weekly cycles paclitaxel with or without everolimus 5 mg/day. To detect a hazard ratio (HR) of 0.75 (α = 0.05, β = 0.8) 379 events had to be observed in the bevacizumab arms.

RESULTS

With a median follow-up of 3.8 years, 3-year DFS was 80.8% and 3-year OS was 89.7%. Outcome was not different for patients receiving bevacizumab (HR 1.03; P = 0.784 for DFS and HR 0.974; P = 0.842 for OS) compared with patients receiving chemotherapy alone. Patients with TNBC similarly showed no improvement in DFS (HR = 0.99; P = 0.941) and OS (HR = 1.02; P = 0.891) when treated with bevacizumab. No other predefined subgroup (HR+/HER2-; locally advanced (cT4 or cN3) or not; cT1-3 or cT4; pCR or not) showed a significant benefit. No difference in DFS (HR 0.997; P = 0.987) and OS (HR 1.11; P = 0.658) was observed for nonearly responding patients receiving paclitaxel with or without everolimus overall as well as in subgroups.

CONCLUSIONS

Long-term results, in opposite to the results of pCR, do not support the neoadjuvant use of bevacizumab in addition to an anthracycline-taxane-based chemotherapy or everolimus in addition to paclitaxel for nonearly responding patients.

CLINICAL TRIAL NUMBER

NCT 00567554, www.clinicaltrials.gov.

Abstract P1-14-05: Phase I/II Trial of primary chemotherapy with non-pegylated liposomal doxorubicin, paclitaxel and lapatinib in patients with HER2-positive, early stage breast cancer

Background: Several studies showed that pathologic complete response (pCR) is a surrogate for disease free survival (DFS) and overall survival (OS). Combinations of trastuzumab and anthracyclines in HER2-positive breast cancer are highly active but associated with a high incidence of cardiotoxicity. The risk of cardiac damage can be significantly reduced through liposomal encapsulation of anthracyclines. This phase I/II study was initiated to evaluate the combination of non-pegylated liposomal doxorubicin (NPLD), paclitaxel and lapatinib as primary treatment for patients with early stage, HER2-positive primary breast cancer.

Patients and Methods: Patients with newly diagnosed HER2-positive (IHC 3+ or FISH+) early stage (T1c N1-2 or T2 N0-2) breast cancer were treated with NPLD (60mg/m2; day 1), paclitaxel (175mg/m2, day 1) and lapatinib (750–1500 mg orally daily) in 3-week intervals for up to 6 cycles. The primary endpoints were dose-limiting toxicities (DLT) and pathological complete response (pCR). Secondary endpoints include safety, incidence of cardiac events, and clinical response. Exploratory endpoints include molecular markers for sensitivity or resistance to chemotherapy and/or lapatinib evaluated.

Results: A total of 84 patients have been included. No dose-limiting toxicity were observed and the maximum tolerated doses were NPLD 60mg/m2, paclitaxel 175mg/m2 and lapatinib 1500mg. Recommended phase 2 doses (P2D) were NPLD 60mg/m2, paclitaxel 175mg/m2 and lapatinib 1250mg. The treatment was generally well tolerated and associated with toxicities that were consistent with the known side-effects of the individual agents. No cardiac event has been observed to date. Preliminary efficacy data confirm a pCR breast rate of 41.7% and pCR rate in breast and lymph nodes of 37.5%, in 32 evaluable patients treated at ≥P2D.

Conclusions: The combination of NPLD, paclitaxel and lapatinib is well tolerated and has high antitumor activity in patients with HER2-positive primary breast cancer. Updated results of all 84 patients will be presented.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-14-05.

The Clinical Value of Preoperative Wire Localization of Breast Lesions by Magnetic Resonance Imaging – A Multicenter Study

To evaluate the clinical value of MRI guided preoperative wire localization of clinically and mammographically occult lesions of the breast. In a multicenter study, we evaluated 132 preoperative MRI guided localizations. Median lesion size evaluated by MRI prior to wire localization was 9mm. MRI guided localization was successfully performed in 96.2% of cases. Median wire deviation from the lesion was 0 (0-10) mm. Moderate bleeding with no further treatment required occurred in three patients. We conclude that MRI guided preoperative wire localization is a safe and accurate procedure in cases of clinically and mammographically occult lesions of the breast.

Prognostic significance of local recurrence in breast cancer after postmastectomy radiotherapy

PURPOSE

We have retrospectively analyzed the impact of local recurrence in patients with adjuvant radiation therapy after mastectomy for breast cancer.

PATIENTS AND METHODS

From January 1985 through December 1993, 959 patients were irradiated after mastectomy for breast cancer. The age ranged from 34 to 79 years, the median follow-up was 3.1 years (range: 0.3-12.2 years). 368 (38%) were pre- and 591 (62%) postmenopausal. 35% had T3-4 tumors, 62% had axillary lymph node involvement, and 66% received additional systemic hormonal and/or cytotoxic therapy. Postmastectomy radiotherapy was administered in case of positive axillary nodes and in high-risk pN0-patients. The chest wall and lymphatics (axilla, parasternal and supraclavicular nodes) were irradiated with an anterior photon field with 50 Gy and the chest wall with an electron field with 44 Gy in 2-Gy fractions.

RESULTS

The overall survival was 70.5% after 5 and 59.8% after 10 years. 53 patients (5.5%) developed a locoregional recurrence 2-96 months after treatment (median 26 months). The local control rate was 92.7% after 5 and 86.4% after 10 years. Axillary lymph node involvement was the most important and (in a multivariate analysis the only) risk factor for local recurrence (p = 0.0001). Patients with local control had a significantly better 10-year distant-disease-free survival and overall survival as compared to patients with local recurrence (44.5% vs 15.4%, p = 0.002 and 62.1% vs 34.8%, p = 0.004). Local recurrence increased the risk of death by a factor of 1.7 and in a Cox regression model, axillary lymph node status, T-category and local recurrence were significant prognostic factors for overall survival. In patients with local recurrence, the initial axillary lymph node status was the most important prognostic factor for survival after local recurrence. The 3-year survival after local relapse was 86% for patients with pN0 status vs 27% in with positive axillary nodes (p = 0.025).

CONCLUSIONS

Local recurrence after treatment of breast cancer with mastectomy + radiotherapy +/- systemic therapy is associated with a significantly higher risk of distant metastases and death. In this analysis, local recurrence was a strong and, besides lymph node status and T category, an independent risk factor for survival. Minimizing the risk of local recurrence is therefore an essential goal of a curative treatment concept.

[Preoperative chemotherapy in primary operable breast cancer with a dose-dense combination of doxorubicin and docetaxel (ADoc) - Experience of the GEPARDO-GABG study group]

OBJECTIVE

The German Adjuvant Breast Cancer Study Group (GABG) conducts trials of preoperative chemotherapy in patients with primary breast cancer using a combination of doxorubicin and docetaxel (ADoc). -

PATIENTS AND METHODS

We conducted a parallel-grouped phase IIa-study with 42 patients with a conventionally dosed and a dose-dense ADoc-schedule (4 cycles of Doxorubicin 50 mg/m(2), Docetaxel 75 mg/m(2) i. v. day 1, q day 15 or 22; G-CSF day 3-15 only for the dose-dense schedule) and a randomized phase IIb-study (GEPARDO-Study) with 250 patients with ADoc +/- Tamoxifen. Biological factors were determined immunohistochemically on 197 core biopsies before treatment. A comparison to a sequential AC-Doc regimen including 913 patients has been completed recently. -

RESULTS

ADoc can be applicated on schedule in 93 % of all patients. The dose-dense regimen shows a tendency to more toxicity but also to more efficacy. The rate of complete pathological remissions (pCR) was 9.7 %. No difference was found between chemo- and chemoendocrine treatment. Clinically negative lymphnodes and a negative estrogen receptor status is predictive for a higher pCR-rate. To date no differences in toxicity could be found between ADoc and AC-Doc. -

CONCLUSIONS

The dose-dense ADoc regimen is well tolerated and highly effective as preoperative therapy of breast cancer.

[New knowledge regarding tumor cell inactivation and histological evaluation after radiofrequency therapy. Single case observation and in vitro proof of a new hypothesis]

In a study, a radiofrequency (RF) treatment was performed on a patient with a small breast cancer after vacuum biopsy. As usual in cases with a malignant diagnosis, surgical excision and axillary dissection followed. Histopathology revealed some residual tumor in the margin of the cavity. It could not be distinguished from vital tumor on the hematotoxylin eosin (HE) stain. Based on the correlation of MRI and histopathology after subsequent surgical excision, we did, however, presume that the residual was contained within the zone of inactivation. Thus the hypothesis arose that, if too high temperatures can be avoided, it might be possible to inactivate tumor cells without significantly impairing histopathologic assessment. This hypothesis was supported by the following in vitro experiment performed on a fresh specimen: An RF treatment was performed using temperatures up to 70 degrees C only. Half of the specimen underwent HE-staining, the other half vitality testing. The results indicate that if a given temperature range is strictly observed it appears possible to inactivate tissue before tissue sampling, since histopathologic diagnosis will not be impaired. Further technologic improvements may eventually allow to develop a pre-treatment method which might permit to avoid potential hematogenous tumor spread during subsequent biopsy.

In situ and minimally invasive breast cancer: morphologic and kinetic features on contrast-enhanced MR imaging

PURPOSE

This retrospective study was undertaken to investigate the morphologic and dynamic features of in situ and minimally invasive breast cancer on contrast-enhanced (c.-e.) MR imaging and to examine possible associations to pathology features.

MATERIAL AND METHODS

A total of 71 patients underwent MR imaging. T1-weighted FLASH-3D images were obtained before and after intravenous administration of Gd-DTPA. Histopathologic analysis of 78 lesions revealed ductal carcinoma in situ (DCIS) n = 50 and DCIS with microinvasion n = 28. MR features were correlated with histopathologic findings.

RESULTS

Enhancement in DCIS was focal (73%), diffuse (10%) or ductal (17%). No enhancement occurred in two cases (4%). In 65% enhancement speed was classified as delayed. There was a tendency toward a more ill-defined (83 vs. 43%) enhancement pattern in high grade DCIS and a more ductal (29 vs. 12%) and faster (50 vs. 29%) enhancement in comedo type DCIS. However, significant differences in the enhancement behaviour could neither be demonstrated between high grade and non high grade DCIS nor between comedo and non comedo type DCIS. No significant differences were noted between pure and microinvasive DCIS.

CONCLUSION

In this retrospective analysis the majority (96%) of DCIS lesions show contrast enhancement. However, in only about 50% of DCIS the criteria of a so-called 'typical' enhancement behaviour was fulfilled, that means strong, early, focal ill-circumscribed or ductal. Enhancement that follows a duct is often associated with malignancy, however this feature was only present in 17% of the cases. c.-e. MR imaging allowed the detection of 25 additional foci of DCIS. Therefore malignant in situ lesions can be present with atypical enhancement, and should be taken into consideration in high-risk patients in particular.

Direct measurement of sound velocity in various specimens of breast tissue

RATIONALE AND OBJECTIVES

Previous studies using ultrasound CT or clinical amplitude/velocity reconstruction imaging ultrasound may indicate that cancers differ from normal breast tissue by increased sound velocity. However, only limited experience with direct measurements of sound velocity exists. This study aimed to investigate sound velocity measured directly in a variety of breast specimens.

METHODS

Sound velocity was measured directly by forceps in fresh breast specimens chosen to contain one type of tissue only. Eighty specimens (31 cancers, 18 benign changes of glandular/fibrous tissue, 22 fatty tissues, 5 fibroadenomas, 2 compound tissues, 1 phylloides tumor, and 1 inflammation) were analyzed.

RESULTS

Ultrasound velocities in carcinoma, benign changes, fibroadenoma, inflammation, and the phylloides tumor were very similar, with almost complete overlap. In contrary, the ultrasound velocity of fatty tissue was significantly lower. Compound tissues containing fat had an intermediate sound velocity.

CONCLUSIONS

Sound velocity may add complementary information to echogenicity (B-scan). Because fat lobules exhibit low ultrasound velocity and carcinomas do not, a locally exact combination of ultrasound velocity information and reflexivity information should allow improved breast cancer detection by ultrasound.

Mutagenesis of Neisseria meningitidis by in vitro transposition of Himar1 mariner

Now that the meningococcal genome sequence has been completed, the lack of a suitable method for saturation mutagenesis remains a major obstacle to the unraveling of the pathogenic propensity of Neisseria meningitidis. Here, we demonstrate that in vitro Himar1 mariner transposition on chromosomal or PCR-amplified meningococcal DNA, which is subsequently reintroduced into N. meningitidis by natural transformation, is an extremely efficient mutagenesis method. Southern blot analysis, sequencing the Himar1 insertion point in numerous transposition mutants, and a limited screening of the mutant libraries for clones impaired in maltose catabolism confirmed that Himar1 transposed randomly in N. meningitidis. Taken together, these data demonstrate that Himar1 in vitro transposition can lead to the exhaustive mutagenesis of N. meningitidis, allowing for the first time a genomic-scale mutational analysis of this important human pathogen.

[Direct in-vitro measurement of ultrasound velocity in carcinomas, mastopathic tissue, fatty tissue and fibroadenomas of the female breast]

PURPOSE

The study aimed to investigate ultrasound velocity (SV) in carcinomas, fibrocystic changes, fibroadenomas and fatty tissue of the female breast by means of direct in-vitro measurements. We intended to test whether or not differences in SV exist between the various types of tissue and whether the SV is a useful criterion to differentiate the different tissues.

METHOD

SV was measured by comparing transmission time of the ultrasound beam through the specimen and through water. Altogether 40 specimens (12 cancer, 14 fibrocystic changes = FCD, 10 fatty tissues, 3 fibroadenomas, and 1 mixed tissue) were analysed.

RESULTS

Velocity differed significantly between fat (1478.5 +/- 6.5 m/s) and tumor (1523.1 +/- 5.9 m/s) (p approximately 10(-11)) and between fat and FCD (1526.0 +/- 9.0 m/s) (p approximately 10(-12)). No significant differences and much overlap were seen between the ultrasound velocities of tumors and FCD. Ultrasound velocity in fibroadenomas (1533.2 +/- 3.8 m/s) was comparable with that in carcinomas and FCD.

CONCLUSIONS

We conclude that ultrasound velocity may add complementary information to echogenicity (B-scan). Thus, a locally exact correlation of echogenicity and sound velocity might allow for an improved tissue characterization.

MR-guided percutaneous excisional and incisional biopsy of breast lesions

The aim of this study was the realisation and clinical application of MR-guided vacuum biopsy for percutaneous excisional and incisional biopsy of enhancing breast lesions. A breast biopsy system and procedure have been developed which allow precise and safe access to breast lesions in any location and use of vacuum biopsy (VB) under MR guidance. Fifty-one patients with 55 MR-detected lesions were examined. Verification of these diagnoses included re-excision histology of all 14 malignancies and for benign lesions retrospective correlation of histology and imaging, assessment of complete or partial removal of the enhancing area directly after VB (40 of 40 lesions) and follow-up MRI (33 of 40 lesions), which in contrast to conventional needle biopsy can be used as proof of representative removal. Fifty-four of 55 procedures (including 15 lesions </= 5 mm and another 26 lesions of 5-10 mm size) were successful. One failure was caused by incorrect use of the VB gun. Vacuum biopsy yielded 14 malignancies and 40 benign lesions. With the available verification techniques all diagnoses proved correct. Percutaneous VB became possible under MR guidance. With minimal invasion it allowed increased certainty and accuracy even for very small lesions.

[New methods for minimal invasive assessment of uncertain mammography and MRI tomography findings]

Results of 3 minimal invasive techniques for breast biopsy of clinically occult lesion are presented. 1. Mammographically guided Site-Select biopsies allow removal of tissue in one piece using a large diameter core biopsy instrument (similar to the ABBI-principle). However the overlying subcutaneous tissue is saved. No technical problems occurred in 13/13 diagnostic biopsies. Complete removal was, however, only possible in 2/4 tumors < 1 cm due to tissue shift during insertion of the instrument. 2. Mammographically guided vacuum biopsy also allows contiguous removal of areas of 1.2-1.8 cm diameter, while blood is suctioned out, as well. 3 stereotaxic miscalculations were immediately recognized. Diagnostic accuracy in 405 biopsies so far is 100%. The examination was very well tolerated by the patients. 3. By means of a specially developed biopsy coil and vacuum biopsy percutaneous in- or excisional biopsy of enhancing lesions visible by MRI alone has been realized by us for the first time. 24/25 diagnoses are definitely representative--as proven by lack of enhancement after biopsy. One diagnosis, which was uncertain due to overlying blood, is being followed. Minimal invasive methods may open up new perspectives.

Retrospective analysis for evaluation of the value of contrast-enhanced MRI in patients treated with breast conservative therapy

PURPOSE

The aim of this study was to assess the value of contrast-enhanced (c.-e.) MRI in the follow-up of patients with conservatively treated breast cancer since detection and exclusion of malignancy may interfere significantly with posttherapeutic changes within the treated breast.

MATERIAL AND METHODS

A total of 207 patients with a history of limited surgery and radiation therapy underwent MR imaging, 40 patients were examined 0-12 months and 167 patients were examined later than 12 months after radiotherapy. Suspicious or indeterminate findings were suggested by clinical examination or conventional imaging in 80 studies. In 127 women, MRI was performed within breast tissue that was difficult to assess due to scarring or dense breast tissue.

RESULTS

Recurrent carcinoma was confirmed in 27 patients by surgical biopsy. All 27 carcinomas, except for one with a slow signal increase, demonstrated early rise of signal intensity on dynamic T1-weighted contrast enhanced images. During the first year after therapy, the diagnostic accuracy could not be improved by additional use of c.-e. MRI. Differentiation between posttherapeutic changes and recurrent carcinoma was frequently not possible because of strong and sometimes early and ill-circumscribed enhancement. Later than 12 months after therapy enhancement decreased significantly, thus the false positive calls could be reduced from 49 (conventional imaging) to 12 (conventional imaging plus MRI). A total of 12 of 26 recurrences and multifocality in 4/5 cases were diagnosed by MR imaging alone at this time interval.

CONCLUSION

In the first year after therapy, c.-e. MRI is only indicated in selected cases. The results later than 12 months emphasize that c.-e. MRI may contribute significant additional information. It allows better distinction of posttherapeutic fibrosis from recurrent carcinoma and proved to be able to detect recurrent disease more sensitive and at an earlier stage.

Dosing of MMF in combination with tacrolimus for steroid-resistant vascular rejection in pediatric renal allografts

Steroid-resistant vascular rejection was treated in seven adolescent renal allograft recipients using the combination of mycophenolate mofetil (MMF) and tacrolimus (FK506). Since there are no published pediatric dose recommendations for MMF using this combination, trough concentrations and pharmacokinetic profiles were used for therapeutic drug monitoring. In order to keep the mycophenolic acid (MPA) concentrations between 2-5 micrograms/ml, mean MMF doses were reduced from 600 to 250 mg/m2 b.i.d. Apparent clearance of MPA decreased from 5 to 1 ml/min per kg within 2 weeks. Pharmacokinetic monitoring revealed substantial variability among patients of both MMF and FK506. The MPA dose ranged from 178 to 1008 mg/m2 per day to achieve an area under the curve (AUC) of 59.9 micrograms x h/ml +/- 10.5 SD (range 49-65 micrograms). FK506 dose ranged from 1.3 to 8.8 mg/m2 per day to achieve an AUC of 116 ng x h/ml +/- 27 SD (range 83-145). We recommend adjusting MMF doses using therapeutic drug monitoring.

Minimally invasive stereotaxic vacuum core breast biopsy

The purpose of our study was the assessment of the diagnostic value of vacuum core biopsy, which promises high accuracy by minimally invasive percutaneous excision of 1-2 cm3 of tissue. The materials used were a digital stereotaxic biopsy table (Fischer Imaging) and a Mammotome-gun (Biopsys). A total of 236 patients with 261 predominantly indeterminate lesions (indeterminate: 230; suspicious: 26; malignant: 5) underwent vacuum core biopsy (VCB). Verification was as follows: (a) demonstration of complete or partial removal of the lesion or replacement of the lesion by a small hematoma by comparison of the pre- and post-VCB mammogram; (b) reexcision of 45 malignant and 6 borderline lesions; (c) radiologic-histologic correlation; and (d) 6-month-follow-up mammograms in 129 cases. Two VCBs were not possible because very fine microcalcifications could not be visualized. Two puncture errors occurred which, however, were immediately recognized and VCB was repeated. Based on the above verification a 100 % accuracy was achieved. No relevant side effects occurred. Except for 2 cases mammographically hardly any scarring was visible. Based on the excellent accuracy and excellent tolerance of the procedure VCB appears to be the future method of choice for the workup of those indeterminate mammographically detected lesions that up to now have still required surgical biopsy.

[Preoperative axilla sonography in breast tumor suspected of malignancy--a diagnostic advantage?]

PURPOSE

To assess the value of preoperative axillary sonography possibly malignant for breast tumours.

METHOD

We performed preoperative axillary sonography on 89 patients with suspicious breast tumours. In 78 cases, among which there were 74 invasive carcinomas, the surgery that followed included an axillary lymph node dissection and a comparison with the histology was possible.

RESULTS

The sonographic detection of axillary lymph node metastases has a sensitivity of 90% and a specificity of 91.7% in relation to all tumour stages and a sensitivity of 100% and specificity of 89.6% in relation to T1 tumours. In our analysis, therefore, it is vastly superior to a clinical examination of the axilla.

CONCLUSION

Ultrasonography is an accurate imaging method for the diagnosis of axillary lymph node metastases. Broadening this analysis to include more patients will validate this conclusion. The results of our preliminary study suggest that this diagnostic method could help reduce unnecessary radical surgery in the treatment of breast cancer.

Mycophenolate mofetil pharmacokinetics in renal transplant recipients on peritoneal dialysis

We prospectively studied the impact of peritoneal dialysis (PD) on the pharmacokinetics of mycophenolic acid (MPA) in five patients following renal transplantation. Three patients had a glomerular filtration rate (GFR) of less than 10 ml/min and two had a GFR of more than 40 ml/min. Pharmacokinetics of MPA and of its main metabolite, mycophenolic acid glucuronide (MPAG), were studied during two consecutive 12-h periods (with and without PD). After initiation of PD in patients with severe renal impairment (GFR < 10 ml/ min), MPA-area-under-the-concentration-curve (AUC) decreased up to 59% and MPAG-AUC decreased up to 26%. We did not observe any substantial changes in the MPA-AUC or MPAG-AUC of either patient with a GFR above 40 ml/min. Patients with a reduced GFR had much higher MPAG values than patients with a GFR above 40 ml/l; yet, we did not observe any differences in the MPA values. We found a significant inverse correlation between GFR and MPA-AUC (r = 0.81, P < 0.05) and between GFR and MPAG-AUC (r = 0.94, P < 0.01). While MPA was found only in traces in the peritoneal ultrafiltrate, the cumulative amount of MPAG removed by PD reached up to 2 g/ 12 h, representing 1.2 g of MPA. This is the first report describing a reduction in MPA-AUC and MPAG-AUC during PD. Further studies are needed to completely understand the pharmacokinetics of mycophenolate mofetil during PD.

Pharmacokinetics of mycophenolate mofetil in renal transplant recipients on peritoneal dialysis

Little is known about the pharmacokinetics of mycophenolatic acid (MPA) in the early posttransplant period after renal transplantation. We studied the impact of peritoneal dialysis on the pharmacokinetics of MPA in 5 patients following renal transplantation (3-6 weeks after transplantation). Three patients had a glomerular filtration rate (GFR) of less than 10 ml/min, 1 patient had a GFR of 32, and 1 of 58 ml/min. Pharmacokinetics of MPA and its main metabolite mycophenolic acid glucuronide (MPAG) were studied on 2 consecutive days (12-hour intervals: with and without peritoneal dialysis). Dosing of MPA was 2 x 1 g/day. MPA and MPAG concentrations were determined by HPLC methods. After initiation of peritoneal dialysis in patients with severe renal impairment (GFR < 10 ml/min) MPA area under the concentration curve (AUC) decreased substantially (15-59%). The calculated clearance of MPA was higher (14.6 vs 8.1 ml/min/kg) on the day of peritoneal dialysis than during the dwell-free day. MPAG-AUC decreased up to 26% in these patients. In both patients with a GFR > 30 ml/min we observed an increase of MPA-AUC on the day of peritoneal dialysis and a decreased MPA clearance. MPAG-AUCs remained stable. Patients with a reduced GFR had much higher MPAG values than patients with a GFR 30 ml/l, however, we did not observe any differences for the MPA levels. We found a significant inverse correlation between GFR and MPAG-AUC (r = 0.91, p < 0.05). While MPA was found only in traces in the peritoneal ultrafiltrate, the cumulative amount of MPAG removed by peritoneal dialysis reached up to 2 g per 12 hours, representing up to 1.2 g of MPA. This is the first report describing a reduction of MPA- and MPAG-AUC during peritoneal dialysis. Further studies are needed to better understand the pharmacokinetics of mycophenolat mofetil during peritoneal dialysis.

Prophylactic oral ganciclovir after renal transplantation-dosing and pharmacokinetics

Ganciclovir alone or in combination with hyperimmunoglobulin is replacing other treatment modalities for the prophylactic treatment of cytomegalovirus (CMV) infections. No dose recommendations are available for oral ganciclovir therapy in children with impaired renal function after renal transplantation of a kidney from a CMV IgG-positive donor. We undertook a pharmacokinetic study in 14 pediatric renal transplant recipients who were CMV IgG negative and had received a graft from a CMV IgG-positive donor. We estimated the daily dosage of oral ganciclovir in relation to the glomerular filtration rate (GFR). Oral ganciclovir was administered at a starting dose of 3 x 1 g for children with a weight above 50 kg, 3 x 750 mg for children between 50 and 37.5 kg, and 3 x 500 mg for children between 37.5 and 24 kg. The starting dose was reduced by 50% for GFR values < or = 50 ml/min per 1.73 m2 and by 75% for GFR values < or = 25 ml/min per 1.73 m2. The daily dose was divided into three daily doses unless GFR was < 40 ml/ min per 1.73 m2, when only two daily doses were given. Doses were adjusted according to the measured plasma trough concentrations (c) using the simple formula: c(ganciclovir)(measured)/c(ganciclovir)(desired) = dosage rate(used)/dosage rate(adjusted). Mean stable plasma trough concentration was 0.91 +/- 0.68 microg/ml. The dosage rate, adjusted to a trough concentration of 1.0 microg/ml, correlated with the GFR. The dose per day could be calculated according to a simple equation for a GFR < 100 ml/min per 1.73 m2: dosage per day (mg/kg per day) = GFR. No CMV disease developed in any of the patients during oral ganciclovir, but 1 patient developed an acute rejection episode and a positive pp65 antigen 5 weeks after discontinuation of ganciclovir. The drug was well tolerated and without side effects.

[Vacuum punch biopsy under digital stereotaxic control, a new procedure in percutaneous diagnostic incision and excision biopsy of mammographic findings: initial experience]

PURPOSE

To evaluate a digital, stereotactically controlled vacuum punch biopsy method.

MATERIAL AND METHOD

In 60/61 female patients a vacuum punch biopsy (14 G) was performed under digital stereotactic control; by means of a single biopsy 1-2 cm3 of tissue was obtained. In one patient the examination could not be carried out because of insufficient microcalcification. Excision biopsies were performed because of doubtful microcalcification (24), focal lesions (35) or abnormal tissue architecture (1).

RESULTS

48 of the biopsies proved benign, 2 showed dysplasias, 5 in situ and 5 invasive carcinomas. In all cases the histological and radiological diagnoses were in agreement. The possibility of a non-presentative biopsy could be excluded with a high degree of certainty because of the accurate localisation and the coherent tissue samples; this produced significant increase in diagnostic certainty. Subsequent haematomas seen mammographically (58/60) are smaller (1-1.5 cm) than for conventional percutaneous punch biopsies because of the effect of suction. The examination was well tolerated (there were no significant haematomas and no infection). Problems consisted of one case of bleeding (due to little experience) and one incorrect localisation which was immediately recognised.

DISCUSSION

If the high degree of accuracy, which is expected, can be confirmed, the procedure would appear suitable for replacing diagnostic operative biopsies of non-characteristic mammographic finding.

[Value of contrast medium magnetic resonance tomography of the breast in breast reconstruction with implant]

Early recognition of recurrence and work-up of clinically indeterminate lesions may be impaired after reconstruction with silicone implants due to superimposition of the implant or to scarring. This study was undertaken to evaluate the use of contrast-enhanced MRI in patients with silicone implant after breast cancer. Contrast-enhanced MRI was offered to 169 patients. Comparative two- to three-view mammography was also performed in 169 patients, as well as comparative sonography in 144 patients. Conventional imaging and clinical examination detected only 8/13 recurrences, whereas 12/13 were detected by MRI. One recurrence had been visible as a strongly enhancing 2-mm dot in a previous examination (2 years before), but was not called. It was therefore counted as false negative. In addition, multicentricity was detected by MRI alone in two of three cases. MRI correctly diagnosed scar tissue in all cases with indeterminate findings. However, due to false-positive calls caused by enhancing granulomas specificity could not be improved. Contrast-enhanced MRI allowed decisive additional information in our study group and improved the sensitivity significantly (concerning all diagnoses). Contrast-enhanced MRI is recommended in patients with diagnostic problems or high risk of recurrence after silicone implants.

[Vacuum punch biopsy of the breast with a stereotaxic guide. A new procedure for percutaneous diagnostic biopsy based on 120 cases]

PURPOSE

To test the capabilities of vacuum core biopsy (VCB) in the diagnosis of mammographically indeterminate lesions.

MATERIALS AND METHODS

120 patients (131 lesions) were examined using VCB with 14G or 11G vacuum core.

RESULTS

VCB was mostly performed because of indeterminate microcalcifications (67 cases) or soft tissue densities/architectural distortion (64 cases). 112 benign changes, 14 DCIS and 5 invasive carcinomas were found. Excellent accuracy was achieved (presently 100%), since complete excision of small lesions/areas (< or = 1 cm) or partial excision of larger lesions was possible. No relevant hematomas or infections occurred. Patients tolerated the painless procedure very well.

DISCUSSION

This report confirms our previous experiences. This method promises to replace diagnostic open biopsy of indeterminate or suspicious nonpalpable lesions.

Design of potent and selective inhibitors of myo-inositol 1,4,5-trisphosphate 5-phosphatase

The interactions of synthetic analogues of D-myo-inositol 1,4,5-trisphosphate [Ins(1,4,5)P3] with the Ins(1,4,5)P3 receptor in permeabilized SH-SY5Y cells and with two key metabolic enzymes, Ins(1,4,5)P(3)3-kinase from a supernatant preparation of rat brain homogenates and Ins(1,4,5)P(3)5-phosphatase from human erythrocyte ghosts, have been examined. L-chiro-Inositol 2,3,5-trisphosphorothioate [L-chiro-Ins(2,3,5)PS3], which we have previously identified as a partial agonist at the Ins(1,4,5)P3 receptor [Safrany, S. T., Wilcox, R. A., Liu, C., Dubreuil, D., Potter, B. V. L., & Nahorski S. R. (1993) Mol. Pharmacol. 43, 499-503], is identified as the most potent 5-phosphatase inhibitor yet described (inhibiting dephosphorylation of [3H]Ins(1,4,5)P3 with Ki = 230nM). L-chiro-Ins(2,3,5)PS3 was also found to be the most potent small-molecule inhibitor of 3-kinase (Ki = 820 nM). The properties of three novel, potent, and selective inhibitors of 5-phosphatase are described. L-myo-Inositol 1,4,5-trisphosphorothioate inhibited 5-phosphatase with Ki = 430 nM, showing 250-fold selectivity over 3-kinase (Ki = 108 microM); myo-inositol 1,3,5-trisphosphorothioate inhibited 5-phosphatase with 475-fold selectivity over 3-kinase (Ki = 520 nM and 247 microM, respectively). The most potent, selective inhibitor of 5-phosphatase was L-chiro-inositol 1,4,6-trisphosphorothioate [L-chiro-Ins(1,4,6)PS3]. L-chiro-Ins(1,4,6)PS3 inhibited 5-phosphatase with Ki = 300 nM and did not interact with the Ins(1,4,5)P3 receptor or 3-kinase at doses tested. These studies, therefore, identify a highly potent and selective inhibitor of 5-phosphatase, which should be considered the tool of choice when inhibiting this enzyme in a broken cell or cell-free system.

Modification at C2 of myo-inositol 1,4,5-trisphosphate produces inositol trisphosphates and tetrakisphosphates with potent biological activities

Novel 2-position-modified D-myo-inositol 1,4,5-trisphosphate [Ins(1,4,5)P3] analogues, DL-2-deoxy-2-fluoro-myo-inositol 1,4,5-trisphosphate [DL-2F-Ins(1,4,5)P3], DL-myo-inositol 1,2,4,5-tetrakisphosphate [DL-Ins(1,2,4,5)P4], DL-scyllo-inositol 1,2,4-trisphosphate [DL-sc-Ins(1,2,4)P3], scyllo-inositol 1,2,4,5-tetrakisphosphate [sc-Ins(1,2,4,5)P4] and scyllo-inositol 1,2,4,5-tetrakisphosphorothioate [sc-Ins(1,2,4,5)PS4] were investigated for their ability to bind to the Ins(1,4,5)P3 receptor, mobilise intracellular Ca2+ stores and interact with metabolic enzymes. With the exception of sc-Ins(1,2,4,5)PS4, all the Ins(1,4,5)P3 analogues potently displaced [3H]Ins(1,4,5)P3 from its receptor in bovine adrenal cortex and were apparently potent full agonists at the Ca2+ mobilising Ins(1,4,5)P3 receptor of SH-SY5Y cells, giving respective IC50 and EC50 values of: sc-Ins(1,2,4,5)P4 (IC50 14 nM, EC50 77 nM), DL-2F-Ins(1,4,5)P3 (IC50 25 nM, EC50 105 nM), DL-Ins(1,2,4,5)P4 (IC50 26 nM, EC50 163 nM), DL-sc-Ins(1,2,4)P3 (IC50 52 nM, EC50 171 nM), compared to Ins(1,4,5)P3 (IC50 4 nM, EC50 52 nM). sc-Ins(1,2,4,5)P4 was equipotent to Ins(1,4,5)P3 for Ca2+ release making it the most potent inositol tetrakisphosphate and indeed Ins(1,4,5)P3 analogue yet characterised. In contrast, although sc-Ins(1,2,4,5)P4 (IC50 425 nM, EC50 1603 nM) was a significantly weaker ligand and agonist than Ins(1,4,5)P3, it was a partial agonist of high intrinsic activity with maximally effective concentrations releasing only about 80% of Ins(1,4,5)P3-sensitive Ca2+ stores of SH-SY5Y cells. Ins(1,4,5)P3 and sc-Ins(1,2,4,5)P4 were readily metabolised by Ins(1,4,5)P3 3-kinase and 5-phosphatase activities, DL-2F-Ins(1,4,5)P3 and DL-sc-Ins(1,2,4)P3 were resistant to 5-phosphatase, while sc-Ins(1,2,4,5)PS4 and DL-Ins(1,2,4,5)P4 were resistant to both 3-kinase and 5-phosphatase activity and were potent inhibitors of the 5-phosphatase enzyme (Ki = 300 nM and 2.9 microM, respectively). These results demonstrate that modification of the 2-position of Ins(1,4,5)P3, even with an anionic group, does not critically affect Ins(1,4,5)P3 binding interaction or Ca2+ release, suggesting that the 2-OH of Ins(1,4,5)P3 fails to interact significantly with the binding site of its receptor. However, modification remote from the crucial vicinal 4,5-bisphosphate can affect analogue efficacy in Ca2+ release.

Calcium release activity and metabolism of inositol 1,4,5-trisphosphate in T cells. Modulation by novel inositol 1,4,5-trisphosphate 5-phosphatase inhibitors

Stimulation of the T cell antigen receptor/CD3 complex is followed by phospholipase C activation, phosphoinositol lipid metabolism and ultimately by a rapid rise in both myo-inositol 1,4,5-trisphosphate [Ins(1,4,5)P3] and myo-inositol 1,3,4,5-tetrakisphosphate [Ins(1,3,4,5)P4] as well as cytosolic free calcium concentration. A 5-phosphatase plays a pivotal role in the subsequent metabolism of Ins(1,4,5)P3 and Ins(1,3,4,5)P4. Synthetic routes have been developed which have enabled the synthesis of both natural and unnatural inositol phosphates and this approach has yielded several compounds which have been shown to act as inhibitors of Ins(1,4,5)P3 5-phosphatase. These compounds offer considerable potential for investigation of the complex metabolism and function of Ins(1,4,5)P3 and Ins(1,3,4,5)P4 in T cell activation and proliferation. We now report the time course and temperature sensitivity of Ins(1,4,5)P3-induced 45Ca2+ release in the permeabilised leukaemic T cell line Jurkat. Furthermore, we demonstrate that the metabolism of Ins(1,4,5)P3 in the presence of two novel 5-phosphatase inhibitors, namely L-myo-inositol 1,4,5-trisphosphorothioate [L-Ins(1,4,5)PS3] and myo-inositol 1,3,5-trisphosphorothioate [Ins(1,3,5)PS3], can be inhibited with concomitant elevation of the heparin-sensitive Ins(1,4,5)P3-induced release of 45Ca2+. These novel 5-phosphatase inhibitors provide a starting point for development of cell-permeable analogues which may be able to modulate cell function in intact cells and may be used as manipulative tools with which to elucidate the function of Ins(1,4,5)P3 and Ins(1,3,4,5)P4 with respect to T cell activation.

Synthesis of selective non-Ca(2+)-mobilizing inhibitors of D-myo-inositol 1,4,5-trisphosphate 5-phosphatase

Syntheses of novel phosphorothioate-based non-Ca(2+)-releasing inhibitors of myo-inositol 1,4,5-trisphosphate 5-phosphatase are described. 1L-myo-Inositol 1,4,5-trisphosphorothioate, myo-inositol 1,3,5-trisphosphorothioate, and 1L-chiro-inositol 1,4,6-trisphosphorothioate have been synthesized from 1L-2,3,6-tri-O-benzyl-1-O-(cis-prop-1-enyl)-myo-inositol, 2,4,6-tris-O-(p-methoxybenzyl)-myo-inositol orthoformate and 1L-2,3,5-tri-O-benzyl-chiro-inositol, respectively. 1L-2,3,5-Tri-O-benzyl-chiro-inositol was also used to prepare 1L-chiro-inositol 1,4,6-trisphosphate. The phosphorothioates did not mobilize intracellular Ca2+ but were highly potent inhibitors of Ins(1,4,5)P3 5-phosphatase, and myo-inositol 1,3,5-trisphosphorothioate and 1L-chiro-inositol 1,4,6-trisphosphorothioate were selective for this enzyme.

Role of renal arterial pressure in the regulation of extracellular volume in conscious dogs

1. This study in conscious dogs examined the quantitative effects of a reduction in the renal arterial pressure on the renal homeostatic responses to an acute extracellular fluid volume expansion. 2. Seven female beagle dogs were chronically instrumented with two aortic catheters, one central venous catheter and a suprarenal aortic cuff, and were kept under standardized conditions on a constant high dietary sodium intake (14.5 mmol of Na+ day-1 kg-1 body weight). 3. After a 60 min control period, 0.9% (w/v) NaCl was infused at a rate of 1 ml min-1 kg-1 body weight for 60 min (infusion period). Two different protocols were applied during the infusion period: renal arterial pressure was maintained at 102 +/- 1 mmHg by means of a servo-feedback control circuit (RAP-sc, 14 experiments) or was left free (RAP-f, 14 experiments). 4. During the infusion period, in the RAP-sc protocol as well as in the RAP-f protocol, the mean arterial pressure increased by 10 mmHg, the heart rate increased by 20 beats/min, the central venous pressure increased by 4 cmH2O and the glomerular filtration rate (control 5.1 +/- 0.3 ml min-1 kg-1 body weight, mean +/- SEM) increased by 1 ml min-1 kg-1. 5. Plasma renin activity [control 0.85 +/- 0.15 (RAP-f) and 1.08 +/- 0.23 (RAP-sc) pmol of angiotensin I h-1 ml-1] decreased similarly in both protocols.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diagnosis of angiologic function in unilateral leg edema following combined treatment of cervix cancer]

For the clarification of the genesis of a unilateral dropsy of the legs which had appeared in 16 women after operative and radiologic therapy of a carcinoma of the cervix apparative angiological functional investigations were carried out. A slightly diminished plethysmographic drainage volume in a Doppler-sonographically unhandicapped deep venous flow off corresponded to the clinical picture of the secondary lymphatic oedema. The findings were compared with the behaviour of the parameters in thrombosis of the iliofemoral vein and test persons with healthy vessels. Only in two cases a venous component in form of a stenosis of the pelvic veins and a postthrombotic syndrome, respectively, could be objectified. Since the methodology renders possible a differentiation of lymphatic oedema and phleboedema, it is suitable for non-invasive controls of the course and has practical significance in the after-care of female patients with carcinoma of the cervix.

Capillary blood, dried on filter paper, as sample for monitoring cyclosporin A concentrations

For monitoring the immunosuppressive drug cyclosporin A by radioimmunoassay (Sandoz Ltd.) we propose a simple method of sampling in which 20 microL of capillary blood is dried on filter paper. Patients can collect their own samples and mail or bring them to the laboratory. Results for such samples, and their variability, correspond to those for conventional methods of sampling (collection of venous or capillary blood into buffer). Capillary blood can be stored on paper at room temperature for more than four weeks with no effect on assay results.

Capillary blood, dried on filter paper, as sample for monitoring cyclosporin A concentrations

For monitoring the immunosuppressive drug cyclosporin A by radioimmunoassay (Sandoz Ltd.) we propose a simple method of sampling in which 20 microL of capillary blood is dried on filter paper. Patients can collect their own samples and mail or bring them to the laboratory. Results for such samples, and their variability, correspond to those for conventional methods of sampling (collection of venous or capillary blood into buffer). Capillary blood can be stored on paper at room temperature for more than four weeks with no effect on assay results.

[Effect of portasystemic anastomoses in childhood on propranolol pharmacokinetics]

Kinetics of propranolol after oral administration were investigated in 9 children aged 5--11 years with intact liver function who had undergone porto-systemic anastomosis surgery for pylethrombosis and in a 16-year-old boy with a Warren shunt. Bioavailability of the drug had increased by twice the values measured in physiologic liver blood flow; elimination half-life had doubled. These alterations must be taken into consideration in medication, e.g. extreme care must be exercised in the oral administration of "first pass" drugs in porto-systemic shunt patients and it is recommended that the initial dose should be at the level of intravenous administration. The reduced rate of elimination should be taken into account in the case of drugs whose elimination depends on liver blood flow.

On the problem of optimum digitlaization in man

The low therapeutic index of cardiac glycoside requires an optimum individual digitalization. This is also a difficulty in the case of known serum glycoside concentrations because individual differences of biochemical and physiological factors (which influence both therapeutic and side effects) are important. As a rule the physician's criterion for an optimum digitalization is that side effects are avoided. This investigation attempted to find a measure for the effect of glycosides by noninvasive recording of parameters of myocardial contractility (systolic time intervals, STI). The measurements were made under oral digitalization with digoxin (Dilanacin). The serum glycoside concentration was determined by the radioimmunoassay method. The changes in STI were investigated in the rage of 1 to 3 ng digoxin per ml serum. In this concentration a significant correlation was demonstrated between STI shortening and glycoside level. It was found that the shortening of STI was maximum at the lowest concentration (1 ng/ml). It appears that the control of STI is for the physician a useful aid for an optimum digitalization in man.

[Over-additive increase of the toxicity of lidocaine by pethidine]

The influence of LD50 of lidocain by preliminary treatment with pethidin, aminophenazone or diazepam, respectively, is examined at the mouse. When pethidine is given within 1/100 to 1/10 of its LD50 develops a dose-dependent increase of toxicity for lidocaine. In 10 mg pethidin/kg the LD50 for lidocain decreases about the half. Under the conditions chosen amino phenazone and diazepam had no influence on the toxicity of lidocaine. It is referred to clinical aspects when pethidine and lidocain are simultaneously applied.