Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Lunar soil hydration constrained by exospheric water liberated by meteoroid impacts

Analyses of samples from the Apollo missions suggest that the Moon formed devoid of native water. However, recent observations by Cassini, Deep Impact, Lunar Prospector and Chandrayaan-1 indicate the existence of an active water cycle on the Moon. Here we report observations of this water cycle, specifically detections of near-surface water released into the lunar exosphere by the Neutral Mass Spectrometer on the Lunar Atmosphere and Dust Environment Explorer. The timing of 29 water releases is associated with the Moon encountering known meteoroid streams. The intensities of these releases reflect the convoluted effects of the flux, velocity and impact location of the parent streams. We propose that four additional detected water releases represent the signature of previously undiscovered meteoroid streams. We show that water release from meteoroid impacts is indicative of a lunar surface that has a desiccated soil layer of several centimetres on top of uniformly hydrated soil. We infer that the Moon is currently in the process of losing water that was either delivered long ago or present at its formation.

High prevalence of osteoporosis in cardiac transplant recipients and discordance between biochemical turnover markers and bone histomorphometry

OBJECTIVE

All patients attending the cardiac transplantation clinic at the Royal Perth Hospital were investigated to determine the prevalence of osteoporosis and to assess changes in bone metabolism and histomorphometry in a cohort of cardiac transplant recipients.

DESIGN

Retrospective cross-sectional study.

PATIENTS

Thirty-two patients (27 male; 5 female) who had received a cardiac transplant during the past 10 years and who were receiving immunosuppressive therapy with cyclosporin, azathioprine and prednisolone were studied.

MEASUREMENTS

All patients had bone densitometry by DEXA of the lumbar spine and femoral neck and X-rays of the thoracolumbar spine. Fasting serum ionized calcium, intact PTH, creatinine, 25 hydroxy-vitamin D, alkaline phosphatase, osteocalcin, testosterone and free thyroxine and urine calcium, creatinine, hydroxyproline and deoxypyridinoline were measured. Six osteoporotic patients consented to transiliac bone biopsy following double tetracycline labelling.

RESULTS

Osteoporosis was present at the lumbar spine in eight patients, femoral neck in seven patients and was present at one or more sites in 13 patients (41%). Seven patients (22%) had vertebral fractures which were asymptomatic in five patients. Secondary hyperparathyroidism was present in 16 patients (53%) but significant renal failure (creatinine clearance < 70 ml/min) was only found in 8 (50%). Levels of biochemical markers of bone turnover were increased in 23 patients (72%). Serum osteocalcin (P = 0.02) and alkaline phosphatase (P = 0.04) were significantly higher in osteoporotic patients than in nonosteoporotic patients. Histomorphometric findings varied markedly between patients. Microscopic features of hyperparathyroidism were not observed.

CONCLUSIONS

Osteoporosis and asymptomatic vertebral fractures are common following cardiac transplantation. Biochemical markers of bone turnover were increased in the majority of patients. Many had biochemical evidence of secondary hyperparathyroidism but this could be attributable to significant renal failure in only 50% of cases. Osteocalcin and alkaline phosphatase correlated inversely with bone density. Histomorphometric findings did not correlate with these biochemical changes in most cases. These results suggest that multiple factors are responsible for osteoporosis in cardiac transplant recipients. Osteocalcin and alkaline phosphatase may be useful biochemical markers, predicting patients at highest risk of fracture.

Reduced expression and normal nucleotide sequence of androgen receptor gene coding and promoter regions in a family with partial androgen insensitivity syndrome

BACKGROUND AND OBJECTIVES

Androgen insensitivity syndrome (AIS) is an X-linked disorder of XY males characterized by varying degrees of impaired masculinization. In many AIS cases, mutations have been identified in the coding sequence of the human androgen receptor (AR) gene which impair receptor function. Cases have also been reported in which reduced AR mRNA expression may contribute to AIS in association with AR gene mutations. The purpose of this study was to define the molecular basis of AIS in members of a family with clinical and laboratory features of partial androgen insensitivity (PAIS).

DESIGN

Genital skin fibroblast (GSF) cultures were established from foreskin tissue for androgen receptor binding analysis. Genomic DNA was obtained from blood leucocytes for AR gene nucleotide sequence analysis. AR mRNA levels were determined in total RNA extracted from GSF cultures.

PATIENTS

Three related subjects with perineo-scrotal hypospadias, bifid scrotum and microphallus were studied. The family pedigree of these subjects suggested an X-linked pattern of inheritance. Hormone assay results were consistent with AIS.

MEASUREMENTS

AR binding capacity and affinity were determined in three subjects and compared with unaffected male controls. The coding sequence and 1.4 kb of promoter region of the AR gene were amplified in overlapping fragments by polymerase chain reaction from genomic DNA and sequenced. GSF AR mRNA was measured by a competitive PCR technique.

RESULTS

In the PAIS subjects, AR affinity in cultured GSF was normal (Kd = 0.24, 0.30, 0.48 vs 0.27 +/- 0.07 (SD) nmol/l) but binding capacity was reduced (Bmax = 0.31, 0.36, 0.27 vs 1.26 +/- 0.37 (SD) fmol/microgram DNA). Sequence analysis of the CAG repeat polymorphism within exon 1 of the AR gene showed that both mothers were heterozygous at this locus, and that the three subjects had inherited the same allele. GSF AR mRNA levels were reduced in all three patients compared with controls (0.25, 0.74 and 0.74 vs 3.8 +/- 0.9 (SEM), range 1.8-7.3 amol/microgram total RNA). The nucleotide sequences of the entire AR coding region and of a 1.4 kb segment containing the promoter region were normal.

CONCLUSION

Members of this family with clinical and biochemical evidence of X-linked partial androgen insensitivity syndrome demonstrated normal androgen receptor binding affinity and androgen receptor gene nucleotide sequence but reduced androgen receptor binding capacity and reduced androgen receptor mRNA. These results suggest that partial androgen insensitivity syndrome in this family may be caused by reduced expression of a normal androgen receptor gene.

Partial androgen insensitivity caused by an androgen receptor mutation at amino acid 907 (Gly-->Arg) that results in decreased ligand binding affinity and reduced androgen receptor messenger ribonucleic acid levels

Androgen insensitivity is an X-linked disorder of sexual differentiation resulting from mutations in the androgen receptor (AR) gene. In this paper, we report the clinical phenotype and molecular analysis of two siblings with severe partial androgen insensitivity due to a novel mutation in the ligand-binding domain of the AR gene. Binding studies using cultured genital skin fibroblasts demonstrated reduced AR affinity and binding capacity. Nucleotide sequence analysis of the AR gene of both siblings revealed a point mutation causing a glycine to arginine amino acid substitution at position 907 within a conserved region of the ligand-binding domain. A silent guanine to adenine substitution was also identified in the protein-coding region of exon 1. Using an expression vector in which the identified mutation was recreated by site-directed mutagenesis, the mutant receptor was found to have a reduced binding affinity (Kd = 3.06 nmol/L) for mibolerone compared with that of normal AR (Kd = 1.71 nmol/L) when expressed in COS-7 cells. In cotransfection experiments using CV-1 cells and a mouse mammary tumor virus-chloramphenicol acetyltransferase reporter system, the concentration of dihydrotestosterone required to induce half-maximal chloramphenicol acetyltransferase gene expression was 50-fold higher in cells transfected with the mutant AR complementary DNA than in cells transfected with normal AR complementary DNA. AR messenger ribonucleic acid levels in genital skin fibroblasts determined by both competitive PCR amplification and ribonuclease protection assay were decreased compared with normal values. Our studies demonstrate the importance of this region of the AR gene in normal AR function and AR gene expression.

An evaluation of competitor type and size for use in the determination of mRNA by competitive PCR

The technique of competitive PCR for measuring mRNA is used widely. Several variations of the method have been reported. We have evaluated some of the commonly used competitor types as part of our study into expression of the androgen receptor (AR). These included mutant, intron, deletion construct, and nonhomologous competitors, which were assessed with an emphasis on their ability to amplify the target with the same efficiency, as well as their capacity to form heteroduplexes with it. The effect of competitor size on amplification efficiency was also investigated. We found that the use of a common primer set did not guarantee equal amplification efficiencies among DNAs sharing the same primer sequences. For the competitors evaluated in this study, sequence length was the major determinant of amplification efficiency. The longest competitors were amplified with the least efficiency. Differences in amplification efficiencies were corrected for by standardizing the competitor against the target. Constructing competitors of different sizes to the target may not eliminate heteroduplex formation when they share common sequence with the target as with the intron and deletion type competitors. Such heteroduplexes may interfere with the analysis if they cannot be resolved from both the target and competitor. Use of a mutant competitor constructed by the conversion of one enzyme restriction site to another produced determinations that were independent of both heteroduplex formation and cycle number. A method is described for generating a mutant competitor with a single PCR.(ABSTRACT TRUNCATED AT 250 WORDS)

Familial glucocorticoid resistance caused by a splice site deletion in the human glucocorticoid receptor gene

The clinical syndrome of generalized, compensated glucocorticoid resistance is characterized by increased cortisol secretion without clinical evidence of hyper- or hypocortisolism, and manifestations of androgen and/or mineralocorticoid excess. This condition results from partial failure of the glucocorticoid receptor (GR) to modulate transcription of its target genes. We studied the molecular mechanisms of this syndrome in a Dutch kindred, whose affected members had hypercortisolism and approximately half of normal GRs, and whose proband was a young woman with manifestations of hyperandrogenism. Using the polymerase chain reaction to amplify and sequence each of the nine exons of the GR gene alpha, along with their 5'- and 3'-flanking regions, we identified a 4-base deletion at the 3'-boundary of exon 6 in one GR allele (delta 4), which removed a donor splice site in all three affected members studied. In contrast, the sequence of exon 6 in the two unaffected siblings was normal. A single nucleotide substitution causing an amino acid substitution in the amino terminal domain of the GR (asparagine to serine, codon 363) was also discovered in exon 2 of the other allele (G1220) in the proband, in one of her affected brothers and in her unaffected sister. The functional importance of this mutation was tested in a cotransfection study using the recombinant expression vector pRShGR-Ser363 and the glucocorticoid responsive vector mouse mammary tumor virus-chloramphenicol transferase. This amino acid substitution did not alter the function of the glucocorticoid receptor. Using reverse transcription-polymerase chain reaction we could only identify messenger RNA transcripts of the G1220-allele but not of the delta 4-allele in the affected members of this family who were heterozygous for the G1220 mutation. This deletion in the glucocorticoid receptor gene was, thus, associated with the expression of only one allele and a decrease of GR protein by 50% in affected members of this glucocorticoid resistant family. The mutation identified in exon 2 did not segregate with the disease and appears to be of no functional significance. The presence of the null allele was apparently compensated for by increased cortisol production at the expense of concurrent hyperandrogenism.

Point mutation causing a single amino acid substitution in the hormone binding domain of the glucocorticoid receptor in familial glucocorticoid resistance

Familial glucocorticoid resistance is a hypertensive, hyperandrogenic disorder characterized by increased serum cortisol concentrations in the absence of stigmata of Cushing's syndrome. Our previous studies of the first reported kindred showed a two- to threefold reduction in glucocorticoid receptor-ligand binding affinity in the propositus, and a lesser reduction in affinity in his mildly affected son and nephew. Glucocorticoid receptor cDNA from these three patients was amplified by polymerase chain reaction and sequenced. The cDNA nucleotide sequence was normal, except for nucleotide 2054, which substituted valine for aspartic acid at amino acid residue 641. The propositus was homozygous while the other relatives were heterozygous for the mutation. COS-7 monkey kidney cells were cotransfected with expression vectors for either wild type or Val 641-mutant receptors, together with the reporter plasmid pMMTV-CAT. Dexamethasone increased chloramphenicol acetyltransferase activity in cells expressing wild type receptor, but had no effect in cells expressing Val 641-mutant receptors, despite similar receptor concentrations, as indicated by Western blotting. The binding affinity for dexamethasone of the Val 641-mutant receptor was threefold lower than that of the wild type receptor. These results suggest that glucocorticoid resistance in this family is due to a point mutation in the steroid-binding domain of the glucocorticoid receptor.

Biochemical and hormonal changes during a 1000 km ultramarathon

1. To examine individual hormonal responses to extreme physical stress, blood samples were taken from eight highly trained athletes 1 day before and within 15 min of finishing the 1986 1000 km Sydney to Melbourne Ultramarathon foot race. 2. The baseline hormonal state of these highly trained athletes was quite different from normal. Resting serum conjugated catecholamines--epinephrine (E), norepinephrine (NE), dopamine (D), free E and free D--were significantly elevated above the normal mean (P less than 0.01). ACTH levels were significantly elevated above the normal range. Immunoreactive beta-endorphin (IR-beta EP), growth hormone (GH), prolactin (PRL), testosterone, cortisol and cortisol-binding globulin (CBG) were within the normal range. 3. The effect of the race on serum catecholamine levels was to elevate further free and conjugated NE (P less than 0.01). Other catecholamines, free and conjugated, remained significantly elevated above the normal mean (P less than 0.01). Adrenocorticotrophic hormone (ACTH) remained elevated, and IR-beta EP within the normal range, without significant change. A significant increase in GH (P less than 0.05), PRL (P less than 0.01), and cortisol (P less than 0.01) was seen, with no change in CBG. 4. As a model of chronic physical stress, the ultramarathon runner demonstrates a significantly altered baseline hormonal state as reflected in the primary mediators of the stress response, the catecholamines and the hypothalamic-pituitary-adrenal axis. Their response to severe exercise is distinct from that of untrained individuals in whom conjugated catecholamines decrease and ACTH increase. This may represent hormonal adaptation to prolonged stress.

Subcutaneous administration of gonadotropin-releasing hormone: absorption kinetics and gonadotropin responses

To evaluate the suitability of the sc route for the pulsatile delivery of GnRH, plasma GnRH, LH, and FSH levels were measured by RIA in five women with hypothalamic amenorrhea after sc injection of single doses of 2.5, 5, and 10 micrograms GnRH. The results were compared with those obtained after bolus iv injection of 10 micrograms GnRH. After sc injection, plasma GnRH levels rose to a dose-related maximum after 5-10 min and fell to less than 10% of the peak value by 90 min. The mean plasma disappearance half-time was 24 min (range, 18-30 min). After bolus iv injection, an initial rapid phase of disappearance (t1/2, 2.8 min) was followed by a slower phase (t1/2, 33 min), falling within the 95% confidence intervals for the disappearance half-time after sc administration (12-36 min). The patterns of LH response to sc and iv GnRH were similar, with maximum levels reached between 20 and 30 min after injection, then declining to 50-69% of the peak value by 90 min after sc injection and 61% of the peak value 90 min after iv injection. There was no significant difference between peak LH responses to 10 micrograms iv and sc doses of GnRH [15.2 +/- 2.5 (+/- SEM) vs. 13.2 +/- 2.2 IU/L]. Subcutaneous administration of three consecutive GnRH pulses at 90-min intervals to four women resulted in gonadotropin responses to each GnRH pulse. We conclude that sc GnRH administration results in pulsatile plasma GnRH and gonadotropin responses, the latter resembling those seen after iv GnRH. These results confirm the suitability of the sc route for pulsatile GnRH delivery.

Induction of ovulation and fertility in amenorrheic women by pulsatile low-dose gonadotropin-releasing hormone

In functional hypothalamic amenorrhea, failure of ovulation probably results from deficient hypothalamic secretion of gonadotropin-releasing hormone (GnRH). We treated 14 infertile women in whom this condition was resistant to clomiphene with pulses of 5 to 15 micrograms of GnRH administered subcutaneously by portable pumps at 90-minute intervals in 36 cycles of treatment. Ovulation occurred in 30 cycles (83 per cent) and was followed by normal luteal function in 24. Singleton pregnancy occurred after 13 (54 per cent) of these cycles. Ovarian ultrasound consistently showed a single dominant follicle, and follicular-phase levels of gonadotropins and urinary estrone glucuronide were in the normal range in all cycles of treatment except two in which mild ovarian overstimulation occurred. Plasma profiles of GnRH and luteinizing hormone were highly pulsatile after subcutaneous administration of GnRH, and mean peak plasma levels of GnRH were comparable to those in pituitary portal blood. We conclude that treatment with low-dose subcutaneous pulses of GnRH is a safe, effective, and physiologic method of restoring reproductive function in hypothalamic amenorrhea and that it has advantages over gonadotropin therapy.

Ovulation induction with subcutaneous pulsatile gonadotropin-releasing hormone: singleton pregnancies in patients with previous multiple pregnancies after gonadotropin therapy

Three patients with hypothalamic amenorrhea who had previously had multiple pregnancies following gonadotropin therapy were treated with subcutaneous pulsatile gonadotropin-releasing hormone (GnRH), administered by a portable pump. After treatment with lower doses in some cases, pulses of 5 to 10 micrograms were given at 90-minute intervals, resulting in ovulation on six occasions. Ovarian steroid profiles closely resembled those of normal ovulatory cycles, and spontaneous ovulation of a single ovarian follicle was consistently demonstrated by ultrasound. Singleton pregnancy was confirmed in each patient. The results imply normal operation of the ovarian-pituitary feedback loop and suggest that subcutaneous pulsatile GnRH therapy is a safe and effective means of ovulation induction in clomiphene-resistant cases of hypothalamic amenorrhea and may possibly become the preferred method of treatment.

Limitations of a new free thyroxine assay (Amerlex free T4)

We have assessed a new method of free T4 measurement (Amerlex) which uses a novel unidentified T4-labelled analogue, said to be unreactive with T4 binding proteins in serum, together with an antibody that binds both analogue and T4. Free T4 is assessed by competition with analogue for antibody binding-sites. The test method has been compared with free T4 measured by equilibrium dialysis and with a technique using an immobilized T4 antibody. All methods gave the expected free T4 levels in normal, hyperthyroid and hypothyroid subjects and normal free T4 levels with high or low levels of T4 binding globulin. However, in autosomal dominant familial euthyroid T4-excess, where T4 is abnormally bound to albumin, the test method gave apparent high free T4 levels suggestive of hyperthyroidism. In a selected group of severely-ill euthyroid patients the new method gave apparent low free T4 levels. In view of these discrepancies, binding of labelled analogue was evaluated by dextran-charcoal separation of 4 degraees C. Familial euthyroid T4-excess sera showed greater analogue binding and samples with low prealbumin concentration showed less binding than did normal sera. Despite its validity with variations in TBG, it appears that Amerlex Free T4 is influenced by lower-affinity, high-capacity T4 binding sites in serum, so that apparent free T4 concentration may vary with changes in the concentration of such sites.

Familial euthyroid thyroxine excess: an appropriate response to abnormal thyroxine binding associated with albumin

Responses of the pituitary-thyroid axis and T4 binding to plasma proteins were studied in three kindreds with familial euthyroid T4 excess, an autosomal dominant condition in which affected subjects have high concentrations of plasma T4 with a high free T4 index, but normal free T4 by equilibrium dialysis. Treatment of affected subjects with exogenous T4 or T3 led to gradual suppression of TSH secretion when the free level of T4 or T3 increased above normal. When total T4 was reduced toward normal by potassium iodide treatment or previous subtotal thyroidectomy, the findings suggested mild hormone deficiency. In affected subjects from all three families, equilibrium dialysis showed increased [125I]T4 binding, with evidence of abnormal high capacity binding when an excess of unlabeled T4 was added. In contrast, T3 binding showed no major abnormality. Serum concentrations of T4-binding globulin, prealbumin, and albumin were normal, but gel electrophoresis and immunoprecipitation of binding proteins indicated that 25-30% of tracer [125I]T4 was albumin bound (normal, 10-12%). Abnormal binding, studied by an adsorption separation system in the presence of T4 excess, was inhibited by increments of barbitone. These findings suggest that T4 excess is an appropriate response to abnormal T4 binding so as to maintain normal free T4. The excess bound T4 is associated with a normal quantity of albumin. The basis for increased T4-albumin binding remains to be determined.

Atrial fibrillation and arterial embolism in hyperthyroidism

Atrial fibrillation or flutter was present in 70 of 381 patients with uncontrolled hyperthyroidism; return to stable sinus rhythm occurred in 39 with antithyroid and antiarrhythmic treatment. One third of the patients who reverted did so in the first week of treatment while still hyperthyroid. As expected, reversion was more likely in younger patients, and in those with arrhythmia of recent onset, without evidence of other heart disease. Eight patients with arrhythmia had proven (five) or probable (three) major arterial embolic episodes. Four of these eight patients died. Embolism tended to occur at an early stage, during uncontrolled hyperthyroidism, in patients with both atrial fibrillation and cardiac failure. These findings suggest that prophylactic anticoagulation may be appropriate in this high risk group, although more extensive studies are necessary before effective prevention of embolism can be claimed.