Hypofractionated Intensity Modulated Proton Therapy (IMPT) and Systemic Therapy for Unresectable Hepatobiliary Cancers

PURPOSE/OBJECTIVE(S)

Proton therapy offers significantly reduced normal liver dose compared to photon therapy for liver tumors, and therefore has the potential for dose escalation and hypofractionation. Employing IMPT, we have initiated a hypofractionated treatment regimen for unresectable liver cancer at a single academic institution. Here we report our initial results on dosimetry and clinical outcomes of hypofractionated IMPT for unresectable hepatocellular carcinoma (HCC) and cholangiocarcomas (CC).

MATERIALS/METHODS

We retrospectively reviewed records of consecutive patients treated with IMPT for CC and HCC from 2018 to 2021. Inverse treatment planning with robust optimization, daily image guidance, pencil beam scanning dose delivery were used for all patients. Motion management included 4D-CT and abdominal compression. Toxicity was graded using the Common Terminology Criteria for Adverse Events version 5.0 and survival was calculated using the Kaplan Meier method.

RESULTS

We identified 15 patients (3 HCC, 4 intrahepatic CC, 8 hilar CC) treated with IMPT to a median dose of 5805 cGy (range, 4500 - 6000 cGy) in 15 fractions. Two had metastatic and 13 had regional disease. Median tumor volume was 91.5 cc (range, 10.92 - 366.31 cc). Prior therapies included: 12 patients received upfront chemotherapy, (gemcitabine plus cisplatin most common), 4 received prior surgery on the liver, and 5 received prior liver directed treatment. With a median follow up of 10 months, the median overall survival (OS) and 1-year OS was 18.7 months and 76% respectively. One patient underwent resection and 1 patient received liver transplant; 7 (47%) patients had disease progression (3 local, 1 regional lymph node, 4 elsewhere liver, 5 distant metastatic). Five patients with CC developed grade 3 toxicity in the form of cholangitis (4) and hemobilia (1). Of these patients, 4 patients were of the hilar type.

CONCLUSION

Our early results using hypofractionated IMPT for unresectable HCC and CC resulted in encouraging local control rates with an acceptable toxicity profile. Further study is warranted to determine the optimal liver directed therapy for this challenging patient population.

A single infusion of intravenous lidocaine for primary headaches and trigeminal neuralgia: a retrospective analysis

Introduction

Intravenous (IV) lidocaine has been used as a transitional treatment in headache and facial pain conditions, typically as an inpatient infusion over several days, which is costly and may increase the risk of adverse effects. Here we report on our experience using a single one-hour IV lidocaine infusion in an outpatient day-case setting for the management of refractory primary headache disorders with facial pain and trigeminal neuralgia.

Methods

This is a retrospective, single-center analysis on patients with medically refractory headache with facial pain and trigeminal neuralgia who were treated with IV lidocaine between March 2018 and July 2022. Lidocaine 5 mg.kg-1 in 60 mL saline was administered over 1 h, followed by an observation period of 30 min. Patients were considered responders if they reported reduction in pain intensity and/or headache frequency of 50% or greater. Duration of response was defined as short-term (< 2 weeks), medium-term (2-4 weeks) and long-term (> 4 weeks).

Results

Forty infusions were administered to 15 patients with trigeminal autonomic cephalalgias (n = 9), chronic migraine (n = 3) and trigeminal neuralgia (n = 3). Twelve patients were considered responders (80%), eight of whom were complete responders (100% pain freedom). The average duration of the treatment effect for each participant was 9.5 weeks (range 1-22 weeks). Six out of 15 patients reported mild and self-limiting side effects (40%).

Conclusion

A single infusion of IV lidocaine might be an effective and safe transitional treatment in refractory headache conditions with facial pain and trigeminal neuralgia. The sustained effect of repeated treatment cycles in some patients may suggest a role as long-term preventive therapy in some patients.

Short-term risk prediction after major lower limb amputation: PERCEIVE study

BACKGROUND

The accuracy with which healthcare professionals (HCPs) and risk prediction tools predict outcomes after major lower limb amputation (MLLA) is uncertain. The aim of this study was to evaluate the accuracy of predicting short-term (30 days after MLLA) mortality, morbidity, and revisional surgery.

METHODS

The PERCEIVE (PrEdiction of Risk and Communication of outcomE following major lower limb amputation: a collaboratIVE) study was launched on 1 October 2020. It was an international multicentre study, including adults undergoing MLLA for complications of peripheral arterial disease and/or diabetes. Preoperative predictions of 30-day mortality, morbidity, and MLLA revision by surgeons and anaesthetists were recorded. Probabilities from relevant risk prediction tools were calculated. Evaluation of accuracy included measures of discrimination, calibration, and overall performance.

RESULTS

Some 537 patients were included. HCPs had acceptable discrimination in predicting mortality (931 predictions; C-statistic 0.758) and MLLA revision (565 predictions; C-statistic 0.756), but were poor at predicting morbidity (980 predictions; C-statistic 0.616). They overpredicted the risk of all outcomes. All except three risk prediction tools had worse discrimination than HCPs for predicting mortality (C-statistics 0.789, 0.774, and 0.773); two of these significantly overestimated the risk compared with HCPs. SORT version 2 (the only tool incorporating HCP predictions) demonstrated better calibration and overall performance (Brier score 0.082) than HCPs. Tools predicting morbidity and MLLA revision had poor discrimination (C-statistics 0.520 and 0.679).

CONCLUSION

Clinicians predicted mortality and MLLA revision well, but predicted morbidity poorly. They overestimated the risk of mortality, morbidity, and MLLA revision. Most short-term risk prediction tools had poorer discrimination or calibration than HCPs. The best method of predicting mortality was a statistical tool that incorporated HCP estimation.

Overall survival in the OlympiA phase III trial of adjuvant olaparib in patients with germline pathogenic variants in BRCA1/2 and high risk, early breast cancer

BACKGROUND

The randomized, double-blind OlympiA trial compared 1 year of the oral poly(adenosine diphosphate-ribose) polymerase inhibitor, olaparib, to matching placebo as adjuvant therapy for patients with pathogenic or likely pathogenic variants in germline BRCA1 or BRCA2 (gBRCA1/2pv) and high-risk, human epidermal growth factor receptor 2-negative, early breast cancer (EBC). The first pre-specified interim analysis (IA) previously demonstrated statistically significant improvement in invasive disease-free survival (IDFS) and distant disease-free survival (DDFS). The olaparib group had fewer deaths than the placebo group, but the difference did not reach statistical significance for overall survival (OS). We now report the pre-specified second IA of OS with updates of IDFS, DDFS, and safety.

PATIENTS AND METHODS

One thousand eight hundred and thirty-six patients were randomly assigned to olaparib or placebo following (neo)adjuvant chemotherapy, surgery, and radiation therapy if indicated. Endocrine therapy was given concurrently with study medication for hormone receptor-positive cancers. Statistical significance for OS at this IA required P < 0.015.

RESULTS

With a median follow-up of 3.5 years, the second IA of OS demonstrated significant improvement in the olaparib group relative to the placebo group [hazard ratio 0.68; 98.5% confidence interval (CI) 0.47-0.97; P = 0.009]. Four-year OS was 89.8% in the olaparib group and 86.4% in the placebo group (Δ 3.4%, 95% CI -0.1% to 6.8%). Four-year IDFS for the olaparib group versus placebo group was 82.7% versus 75.4% (Δ 7.3%, 95% CI 3.0% to 11.5%) and 4-year DDFS was 86.5% versus 79.1% (Δ 7.4%, 95% CI 3.6% to 11.3%), respectively. Subset analyses for OS, IDFS, and DDFS demonstrated benefit across major subgroups. No new safety signals were identified including no new cases of acute myeloid leukemia or myelodysplastic syndrome.

CONCLUSION

With 3.5 years of median follow-up, OlympiA demonstrates statistically significant improvement in OS with adjuvant olaparib compared with placebo for gBRCA1/2pv-associated EBC and maintained improvements in the previously reported, statistically significant endpoints of IDFS and DDFS with no new safety signals.

Physical Activity Determinants in Older People: An Analysis of the UK Understanding Society Wave 2

Background

Ageing leads to inactivity and conditions like heart disease, type II diabetes, and risk of falls. Regular physical activity (PA) helps with a renewed feeling of ability, efficient blood circulation, balance, and coordination. In the UK, physical inactivity is the fourth largest killer of the elderly. This study examines some physical activity determinants in older people.

Methods

A cross-sectional analysis of the UKUS cohort study Wave 2 (2010-12) with participants aged 65 and above was done. The descriptive analyses involved crosstabulations and pictorials in SPSS and Microsoft Office. Data was dichotomised for 2x2 tables in OpenEpi for the univariate analyses. Multivariate analysis was via ordinal logistic regression in SPSS. As Wave 2 had no variable describing PA, a ‘total physical activity' (TPA) score was created. TPA is composed of the addition of the total walking score (TWS), total hobbies/sports score (THSS), ‘total physicality score' (TPS), and total sport frequency (TSF). All five variants were created by indexing available proxy variables unique to each category. Results were reported with odds ratios and 95% confidence intervals.

Results

Univariate analysis with TPA showed an association with some variables like income, OR = 15.25 (8.57-27.12), social interaction, OR = 2.11 (1.46-3.05), family interaction, OR = 2.69(1.45-4.98), wellbeing, OR = 312(157.5-617.9), physical health, OR = 2.84(1.39-5.81) and emotional health, OR = 2.42(1.21-5.07). Multivariable analysis after adjusting for age and sex yielded no significant associations between most PA and predictors. Some significant associations include TWS and social class, AOR= 2.59 (P = 0.013), green food consumption, and TPS, AOR= 1.47 (P &lt; 0.05).

Conclusions

In general, higher income, gross personal income, social class, wellbeing, and green food consumption seemed to produce greater odds of participating in all physical activities.

Key messages

These findings suggest the need for other social determinants to be thoroughly investigated. There is also a need for older adults to be well provided for so these determinants of health can improve their quality of life.

Is Preexisting Cervical Degeneration a Risk Factor for Poor Prognosis in Whiplash-Associated Disorder?

BACKGROUND

The term whiplash describes the acceleration-deceleration mechanism of injury to the cervical spine. Whiplash injuries present with a variety of clinical and psychological manifestations, collectively termed as whiplash-associated disorders (WADs). Although largely self-limiting, some patients may experience long-lasting symptoms. This review aimed to summarize the current literature regarding the predictive value of cervical degeneration in the prognosis of patients with WAD.

METHODS

A comprehensive search of the literature was performed. Nine studies were identified, including 894 patients, with an age range between 16 and 76 years.

RESULTS

A statistically significant association was found between moderate facet joint degeneration and nonrecovery. Although no association was established between isolated disc degeneration and nonrecovery, total cervical degeneration (facet joint + disc degeneration) was shown to correlate with nonrecovery.All included studies demonstrated the lack of correlation between preexisting disc degeneration and clinical outcomes. Four studies showed a significant correlation between cervical degeneration and poor prognosis following whiplash injury. A significantly higher proportion of patients who remained symptomatic at 2 years following a whiplash injury had preexisting degenerative changes.

CONCLUSIONS

This review highlights the presence of significant variability in the existing literature concerning WAD in terms of study methodology, definitions of cervical degeneration, and outcome measures. Degenerative changes of the facet joint lead to alterations in its biomechanics. Several cadaveric, biomechanical, and clinical studies have demonstrated facet joints as a source of pain in patients with chronic WAD. We present moderate evidence to suggest that preexisting facet joint degeneration is a negative prognostic indicator for long-lasting symptoms in WAD. Conversely, preexisting disc degeneration is not associated with chronicity of WAD symptoms. We propose facet joint instability due to facet joint capsule rupture as a potential mechanism for nonrecovery. Further studies are needed to inform our knowledge of the long-term sequelae of WAD among patients with preexisting cervicalspine degeneration.

[Effect of enhanced recovery after surgery for elderly patients with hemiarthroplasty for the treatment of femoral neck fracture]

Objective: To explore the clinical effect of enhanced recovery after surgery (ERAS) for the elderly patients with femoral neck fracture. Methods: A total of 92 elderly patients with femoral neck fracture who received hemiarthroplasty from July 2018 to December 2018 in Beijing Jishuitan Hospital were enrolled in this study. The average age of the participants was (75±6) years, including 31 males and 61 females, and 72(78.3%) of the patients complicated with comorbidity. According to the perioperative management method, the patients were divided into the observational group (47 cases with ERAS) and the control group (45 cases with normal management). The data related to operation, hospitalization, complication and nursing satisfaction were compared between the 2 groups. The visual analogue scale (VAS) was used for pain evaluation. The Harris scores for hip joint and EQ-5D index scores were applied to evaluate the clinical outcomes. The follow-up were performed periodically for 3 months. The measurement data in accordance with normal distribution and homogeneity of variance were compared with t test. Results: All the surgeries completed successfully and no patient died during perioperative period. Compared with the control group, the operation rate in 48 hours (χ(2)=17.781, P<0.01), bed days (Z=-4.987, P<0.01), and medical costs (Z=-4.315, P<0.01) favored that in the observational group. The incidence of complication and nursing satisfaction showed no significant difference between the two groups (31.1% vs 14.9%, 86.7% vs 95.7%, χ(2)=3.432, 1.380, both P>0.05). The perioperative VAS score was lower in the observational group. The Harris scores were higher in the observational group after 1 months (t=4.458, P<0.01), however the quality of life for 2 groups was similar at all time points (t=1.293, 1.227, both P>0.05). Conclusion: ERAS can improve hip function and reduce the hospital stays and medical costs for patients underwent HA operation.

Commissioning and beam characterization of the first gantry-mounted accelerator pencil beam scanning proton system

PURPOSE

To present and discuss beam characteristics and commissioning process of the first gantry-mounted accelerator single room pencil beam scanning (PBS) proton system.

METHODS

The Mevion HYPERSCAN employs a design configuration with a synchrocyclotron mounted on the gantry to eliminate the traditional beamline and a nozzle that contains the dosimetry monitoring chambers, the energy modulator (Energy Selector (ES)), and an Adaptive Aperture (AA). To characterize the beam, we measured the integrated depth dose (IDDs) for 12 energies, from highest energy of 227 MeV down to 28 MeV with a range difference ~ 2 cm between the adjacent energies, using a large radius Bragg peak chamber; single-spot profiles in air at five locations along the beam central axis using radiochromic EBT3 film and cross compared with a scintillation detector; and determined the output using a densely packed spot map. To access the performance of AA, we measured interleaf leakage and the penumbra reduction effect. Monte Carlo simulation using TOPAS was performed to study spot size variation along the beam path, beam divergence, and energy spectrum.

RESULTS

This proton system is calibrated to deliver 1 Gy dose at 5 cm depth in water using the highest beam energy by delivering 1 MU/spot to a 10 × 10 cm² map with a 2.5 mm spot spacing. The spot size in air varies from 4 mm to 26 mm from 227 MeV to 28 MeV at the isocenter plane with the nozzle retracted 23.6 cm from isocenter. The beam divergence of 28 MeV beam is ~ 52.7 mrad, which is nearly 22 times that of 227 MeV proton beam. The binary design of the ES has resulted in shifts of the effective SSD toward the isocenter as the energy is modulated lower. The peaks of IDD curves have a constant 80%-80% width of 8.4 mm at all energies. The interleaf leakage of the AA is less than 1.5% at the highest energy; and the AA can reduce the penumbra by 2 mm to 13 mm for the 227 and 28 MeV energies at isocenter plane in air.

CONCLUSIONS

The unique design of the HYPERSCAN proton system has yielded beam characteristics significantly different from that of other proton systems in terms of the Bragg peak shapes, spot sizes, and the penumbra sharpening effect of the AA. The combination of the ES and AA has made PBS implementation possible without using beam transport line and range shifter devices. Different considerations may be required in treatment planning optimization to account for different design and beam characteristics.

Multifocal and multicentric breast cancer, is it time to think again?

Multifocal multicentric breast cancer has traditionally been considered a contraindication to breast conserving surgery because of concerns regarding locoregional control and risk of disease recurrence. However, the evidence supporting this practice is limited. Increasingly, many breast surgeons are advocating breast conservation in selected cases. This short narrative review summarises current evidence on the role of surgery in multifocal multicentric breast cancer and shows that when technically feasible the option of breast conservation is oncologically safe.

Abstract P6-17-17: Pertuzumab, trastuzumab, and docetaxel for HER2-positive early or locally advanced breast cancer in the neoadjuvant setting: Efficacy and safety analysis of a randomized phase III study in Asian patients (PEONY)

Background

Pertuzumab and trastuzumab (P and H; F. Hoffmann-La Roche Ltd, Basel, CH) bind to distinct HER2 subdomains and have complementary modes of anticancer activity in HER2-positive breast cancer (BC). A global Phase II study (NeoSphere) reported that neoadjuvant treatment with P+H+docetaxel (D) significantly increased breast pathologic complete response (bpCR) vs H+D in patients (pts) with early/locally advanced/inflammatory HER2-positive BC (Gianni et al. Lancet Oncol 2012). PEONY (NCT02586025), a randomized, multicenter, double-blind, placebo-controlled, Phase III trial conducted in an Asian population (mainland China, Taiwan, Korea, Thailand), primarily compared the efficacy, safety, and tolerability of P+H+D vs placebo (Pla)+H+D in the neoadjuvant setting. We present data from the primary analysis.

Methods

Pts with centrally confirmed HER2-positive early (T2–3, N0–1)/locally advanced (T2–3, N2 or N3; T4, any N) BC were randomized 2:1 to 4 cycles of P+H+D or Pla+H+D every 3 weeks, before surgery: P, 840 mg loading/420 mg maintenance doses (or Pla); H, 8 mg/kg loading/6 mg/kg maintenance; D, 75 mg/m2. Post-surgery, pts received 3 cycles of fluorouracil, epirubicin, and cyclophosphamide followed by 13 cycles of P+H or Pla+H for up to 1 year (total of 17 HER2-targeted therapy cycles). The primary endpoint was total pCR rate (tpCR; absence of any residual invasive cancer in the breast and lymph nodes [ypT0/is, ypN0]) assessed by independent review committee (IRC) when pts completed surgery with a tpCR assessment. Missing/invalid assessments were considered residual disease.

Results

A total of 329 pts were randomized: 219 to P, 110 to Pla. Baseline characteristics were well balanced. Most pts had early BC (69.6%) and were from mainland China (79.3%). In the intention-to-treat population, the tpCR rate by IRC was 39.3% in the P arm and 21.8% in the Pla arm; a clinically and statistically significant difference of 17.5% (95% CI 6.9–28.0; p=0.0014). The local pathologist-assessed tpCR rates were 39.3% and 20.9%, respectively. A consistent treatment benefit of P vs Pla was observed in subgroups. Incidences of grade ≥3 adverse events (Aes) were 48.6% in the P arm and 41.8% in the Pla arm. Of the most common grade 3 Aes (≥3% of pts), neutropenia was higher in the P arm (38.1% vs 32.7%). Of the most common any-grade Aes (≥5%), diarrhea was higher in the P arm (38.5% vs 16.4%). No heart failure (New York Heart Association Functional Classification III or IV) or significant left ventricular ejection fraction decline events (≥10 percentage points from baseline and to &lt;50%) were observed during neoadjuvant therapy.

Conclusions

PEONY met its primary endpoint: P+H+D resulted in a clinically meaningful and statistically significant improvement in the tpCR rate by IRC vs Pla+H+D for the neoadjuvant treatment of HER2-positive early/locally advanced BC in Asian pts. Safety data were in line with the known P safety profile and generally comparable between treatment arms. Results were similar to NeoSphere, and confirm that P+H+D provides superior anticancer activity to H+D alone.

Citation Format: Shao Z, Pang D, Yang H, Li W, Wang S, Cui S, Liao N, Wang Y, Wang C, Chang Y-C, Wang H, Kang SY, Jiang Z, Li J, Zhou J, Althaus B, Mao Y, Eng-Wong J. Pertuzumab, trastuzumab, and docetaxel for HER2-positive early or locally advanced breast cancer in the neoadjuvant setting: Efficacy and safety analysis of a randomized phase III study in Asian patients (PEONY) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-17-17.

Surgical Management of Renal Cell Carcinoma Extending Into Venous System: A 20-Year Experience

BACKGROUND AND AIMS

The purpose of this study is to report our 20-year experience with the surgical management of renal cell carcinoma extending into the inferior vena cava using a novel classification system.

MATERIALS AND METHODS

We retrospectively reviewed the data of 103 patients (69 males, 34 females, mean age: 52.9 ± 12.6 years) with renal cell carcinoma involving the venous system treated between 1993 and 2014. The inferior vena cava tumor thrombus was classified into five levels: 0 (renal vein, n = 12), 1 (infrahepatic, n = 33), 2a (low retrohepatic, n = 26), 2b (high retrohepatic, n = 19), and 3 (supradiaphragmatic, n = 13). Clinical data were summarized, and overall survival, cancer-specific survival, and disease-free survival were examined by Cox regression analysis.

RESULTS

All patients underwent radical surgery. Complete resections of the renal tumor and thrombus were achieved in 101 patients (98.1%). Two intraoperative and one postoperative in-hospital deaths (2.9%) occurred. In total, 19 patients (18.8%) had a total of 29 postoperative complications. Mean follow-up time was 46 months (range, 1-239 months). The 5- and 10-year overall survival rates were 62.9% and 56.0%, respectively. Metastasis, rather than thrombus level, was a significant risk factor associated with overall survival (hazard ratio = 4.89, 95% confidence interval: 2.24-10.67, p < 0.001).

CONCLUSION

Our novel classification system can be used to select the optimal surgical approach and method for patients with renal cell carcinoma and venous thrombus. Its use is associated with prolonged survival and relatively few complications. Metastasis is an independent risk factor of overall survival.

Yttrium-90 radioembolization for colorectal cancer liver metastases in KRAS wild-type and mutant patients: Clinical and ccfDNA studies

Patients with unresectable, chemo-refractory colorectal cancer liver metastases (CRCLM) have limited local treatment options. We report our institutional experience on the efficacy of resin-based yttrium-90 (⁹⁰Y) radioembolization for the treatment of CRCLM and our findings on associated circulating cell-free DNA (ccfDNA) studies. A total of 58 patients treated with ⁹⁰Y for CRCLM at the Medstar Georgetown University Hospital had a median survival of 6 months [95% confidence interval (CI), 4.55–7.45 months] after treatment, with a 12-month survival rate of 33%. The median survival from treatment stratified by mutational status was longer in the wild-type (WT) as compared to the KRAS mutant patients at 7 vs. 5 months, but did not achieve statistical significance (p=0.059). Median tumor local control duration after ⁹⁰Y treatment was 2 months (95% CI, 0.34–3.66 months) for the entire cohort and was longer in the WT vs. the mutant patients (2 vs. 1 month, respectively, p=0.088). Plasma was prospectively collected from a subset of 9 patients both before and after single lobe treatment, and ccfDNA concentration and fragmentation index (FI) were measured using quantitative PCR and atomic-force microscopy (AFM). In the WT and KRAS mutant patients, DNA FI was reduced from a median of 0.73–0.65 after treatment. A reduction in DNA FI after single lobe treatment was associated with an improved overall survival (p=0.046). Analysis by AFM of paired pre- and post-treatment samples from KRAS mutant and WT patients revealed a larger average decrease in fragment size in the WT patients (p=0.013). ⁹⁰Y radioembolization extends local control for CRCLM, however, KRAS mutant tumors may be more radio-resistant to treatment. Changes in the FI of patients following treatment were noted and may be evaluated in a larger study for relevance as a biomarker of response.

Toxicological effects of benzo[a]pyrene on DNA methylation of whole genome in ICR mice

It has been well known that alterations in DNA methylation - an important regulator of gene transcription - lead to cancer. Therefore a change in the level of DNA methylation of whole genome has been considered as a biomarker of carcinogenesis. Previously, a large number of experimental results in genetic toxicology have showed that benzo[a]pyrene could cause DNA mutation and fragmentation. However, there was little to no studies on alterations in DNA methylation of genome directly result from exposure to benzo[a]pyrene. In this paper, possible mechanisms of alterations in whole genomic DNA methylation by benzo[a]pyrene were investigated using ICR mice after benzo[a]pyrene exposure. The blood, liver, pancreas, skin, lung and bladder of ICR mice were removed and checked after a fixed time interval (6 hours) of benzo[a]pyrene exposure, and whole genomic DNA methylation level was determined by high performance liquid chromatography (HPLC). The results exhibited tissue specificity, that is, the level of whole genomic DNA methylation decreases significantly in blood and liver, rather than pancreas, lung, skin and bladder of ICR mice. This study investigated the direct relationship between aberrant DNA methylation level and benzo[a]pyrene exposure, which might be helpful to clarify the toxicological mechanism of benzo[a]pyrene in epigenetic perspectives.

Phosphoglycerate kinase-1 is a predictor of poor survival and a novel prognostic biomarker of chemoresistance to paclitaxel treatment in breast cancer

Background:

Phosphoglycerate kinase-1 (PGK1) has been recently documented in various malignancies; however, the molecular mechanisms of the variable PGK1 expression and its clinical significance in terms of survival status remain unclear.

Methods:

Real-time quantitative PCR (real-time qPCR) and western blotting were used to verify PGK1 expression in 46 fresh breast cancer tissues and matched normal tissues. A tissue microarray (TMA) comprising 401 breast cancer tissues and 123 matched normal tissues was investigated by immunohistochemistry for PGK1 expression. Then, the correlation between PGK1 expression and the clinicopathologic features was analysed.

Results:

PGK1 mRNA and protein expression were significantly increased in breast cancer tissues compared with that in normal breast tissues. High PGK1 expression was significantly associated with higher histologic grade (P=0.009) and positive status of ER (P=0.004), Her-2 (P=0.026) and P53 (P=0.012). High levels of PGK1 expression were associated with worse overall survival (OS, P=0.02). Furthermore, patients who underwent paclitaxel chemotherapy with high levels PGK1 expression had shorter OS than did those with low levels of PGK1 expression (P<0.001). Multivariate analysis indicated that PGK1 (P=0.001) was an independent predictor in the patients treated with paclitaxel.

Conclusions:

PGK1 is a prognostic biomarker of chemoresistance to paclitaxel treatment in breast cancer.

Young people's use of NHS Direct: a national study of symptoms and outcome of calls for children aged 0-15

OBJECTIVES

National Health Service (NHS) Direct provides 24/7 expert telephone-based healthcare information and advice to the public in England. However, limited research has explored the reasons to why calls are made on behalf of young people, as such this study aimed to examine call rate (CR) patterns in younger people to enable a better understanding of the needs of this population in England.

SETTING

NHS Direct, England, UK.

PARTICIPANTS AND METHODS

CRs (expressed as calls/100 persons/annum) were calculated for all calls (N=358 503) made to NHS Direct by, or on behalf of, children aged 0-15 during the combined four '1-month' periods within a year (July 2010, October 2010, January 2011 and April 2011). χ² Analysis was used to determine the differences between symptom, outcome and date/time of call.

RESULTS

For infants aged <1, highest CRs were found for 'crying' for male (n=14, 440, CR=13.61) and female (n=13 654, CR=13.46) babies, which is used as a universal assessment applied to all babies. High CRs were also found for symptoms relating to 'skin/hair/nails' and 'colds/flu/sickness' for all age groups, whereby NHS Direct was able to support patients to self-manage and provide health information for these symptoms for 59.7% and 51.4% of all cases, respectively. Variations in CRs were found for time and age, with highest peaks found for children aged 4-15 in the 15:00-23:00 period and in children aged <1 in the 7:00-15:00 period.

CONCLUSIONS

This is the first study to examine the symptoms and outcome of calls made to NHS Direct for and on behalf of young children. The findings revealed how NHS Direct has supported a range of symptoms through the provision of health information and self-care support which provides important information about service planning and support for similar telephone-based services.

Identification and characterization of pig embryo microRNAs by Solexa sequencing

MicroRNAs (miRNAs) are a class of small, non-coding RNAs of approximately 22 nucleotides in length that regulate gene expression by binding to the 3'-untranslated regions of target mRNAs. It is now clear that miRNAs are involved in many biological processes, including proliferation, differentiation and regulation of gene expression during early embryonic development. The miRBase 16.0 (2010) shows that there are 175, 673, 408 and 1048 annotated miRNAs for Caenorhabditis elegans, Mus musculus, Rattus norvegicus and Homo sapiens, respectively. However, there are only 211 miRNAs described for Sus scrofa. In particular, the full set of miRNAs and their expression patterns are still poorly understood in the embryo. Therefore, we combined Solexa sequencing with computational techniques to analyse the sequences and relative expression levels of S. scrofa miRNAs at embryonic day 33 (E33). Of the distinct miRNAs identified, 76 previously known miRNAs and 194 candidate miRNAs were identified in head, and 77 known miRNAs and 130 predicted candidate miRNAs were identified in organ region. Furthermore, we performed additional investigation for identifying the potential target mRNAs using PicTar and TargetScan. Concurrent function analysis suggested that highly expressed miRNAs are mostly involved in the development of nerves, cerebrum, muscle and organs. Our results provide useful information for the investigation into embryonic miRNAs of pig and provide a valuable resource for investigators interested in the regulation of embryonic development in pigs and other animals.

Analysis of myostatin and its related factors in various porcine tissues

Myostatin is expressed in skeletal muscle tissue where it functions to suppress myoblast proliferation and myofiber hypertrophy. Recently, myostatin was detected in the tendon, mammary gland, and adipose tissue of mice. We sought to determine whether myostatin is expressed in the liver, spleen, lung, and kidney of pigs. Real-time PCR and Western blots demonstrated that myostatin, follistatin, decorin, and activin receptor IIB (ActRIIB) mRNA and proteins were expressed in skeletal muscle, heart muscle, and adipose tissue, and also in liver, spleen, lung, kidney, and cultured fibroblasts. The relative abundance of myostatin was closely related to follistatin and decorin in porcine tissues. Immunohistochemical analysis further demonstrated the presence of myostatin, follistatin, and decorin in the skeletal muscle, adipose tissue, heart muscle, liver, spleen, lung, and kidney of pigs. These results suggest that myostatin could be associated with certain functions of the internal organs, such as energy metabolism or fibrosis. We conclude that myostatin is a factor broadly expressed in the internal organs and muscle tissues of pigs.

Change in plasma Aß peptides and onset of dementia in adults with Down syndrome

OBJECTIVE

To examine changes in levels of plasma amyloid-β (Aβ) peptides, Aβ42 and Aβ40, in relation to onset of Alzheimer disease (AD) in adults with Down syndrome (DS).

METHODS

Plasma Aβ42 and Aβ40 were measured at initial examination and at follow-up in a community-based cohort of 225 adults with DS who did not have dementia at baseline and were assessed for cognitive/functional abilities and health status and followed at 14- to 20-month intervals. We used Cox proportional hazards modeling to estimate the cumulative incidence of AD by Aβ peptide change group (increasing, no change, or decreasing), adjusting for covariates.

RESULTS

Sixty-one (27.1%) of the participants developed AD. At follow-up, a decrease in Aβ42 levels, a decrease in the Aβ42/Aβ40 ratio, and an increase in Aβ40 levels were related to conversion to AD. Compared with the group with increasing levels of Aβ42, the likelihood of developing AD was 5 times higher for those whose plasma Aβ42 levels decreased over follow-up (hazard ratio [HR] = 4.9, 95% confidence interval [CI] 2.1-11.4). Decreasing Aβ42/Aβ40 was also strongly related to AD risk (HR = 4.9, 95% CI 1.8-13.2), while decreasing Aβ40 was associated with lower risk (HR = 0.4, 95% CI 0.2-0.9).

CONCLUSIONS

Among adults with DS, decreasing levels of plasma Aβ42, a decline in the Aβ42/Aβ40 ratio, or increasing levels of Aβ40 may be sensitive indicators of conversion to AD, possibly reflecting compartmentalization of Aβ peptides in the brain.

Elevated breast cancer risk among mothers of a population-based series of 2668 children with cancer

AIMS

Although a previous study found high risk of breast cancer in mothers of children with soft tissue sarcomas, breast cancer risks in mothers of sufferers of other childhood cancers largely remain unknown. The aetiology is not fully understood. The present study explored this excess by varying type of childhood solid cancer and formulated a hypothesis.

METHODS

Mothers of 2668 children with solid tumours included in the Manchester Children's Tumour Registry, 1954-96, were traced and followed up to 31 December 2000 through the UK National Health Service Central Register. Standardized incidence ratio (SIR), p-values and 95% confidence intervals were calculated from age and calendar-year-specific female breast cancer incidence rates for England and Wales.

RESULTS

There was a significant excess of breast cancer in mothers overall (SIR=1.3, 95%CI=1.0-1.5) mainly due to mothers of children with rhabdomyosarcoma (RMS) (SIR=2.2, 95%CI=1.0-4.0), skin cancer (SIR=7.9, 95%CI=2.9-17.1) and central nervous system tumours (SIR=1.2, 95%CI=0.9-1.8). Maternal breast cancer risk was associated with late age at birth of the index child, and male sex and young age at diagnosis in the index child. Risk was highest in the ten years, following the birth of the index. The pattern was seen most strongly in mothers of children with embryonal RMS.

CONCLUSION

There are excesses of breast cancer in mothers of children with solid tumours in general and specifically in RMS, skin and central nervous system (CNS). There appears to be a temporal relationship between certain tumours in children and breast cancer in their mothers, suggesting an origin of their respective pregnancy. We propose a mother-foetal interaction mechanism to explain this association.

Parental smoking and childhood cancer: results from the United Kingdom Childhood Cancer Study

There are strong a priori reasons for considering parental smoking behaviour as a risk factor for childhood cancer but case - control studies have found relative risks of mostly only just above one. To investigate this further, self-reported smoking habits in parents of 3838 children with cancer and 7629 control children included in the United Kingdom Childhood Cancer Study (UKCCS) were analysed. Separate analyses were performed for four major groups (leukaemia, lymphoma, central nervous system tumours and other solid tumours) and more detailed diagnostic subgroups by logistic regression. In the four major groups, after adjustment for parental age and deprivation there were nonsignificant trends of increasing risk with number of cigarettes smoked for paternal preconception smoking and nonsignificant trends of decreasing risk for maternal preconception smoking (all P-values for trend >0.05). Among the diagnostic subgroups, a statistically significant increased risk of developing hepatoblastoma was found in children whose mothers smoked preconceptionally (OR=2.68, P=0.02) and strongest (relative to neither parent smoking) for both parents smoking (OR=4.74, P=0.003). This could be a chance result arising from multiple subgroup analysis. Statistically significant negative trends were found for maternal smoking during pregnancy for all diagnoses together (P<0.001) and for most individual groups, but there was evidence of under-reporting of smoking by case mothers. In conclusion, the UKCCS does not provide significant evidence that parental smoking is a risk factor for any of the major groups of childhood cancers.

Genetic covariation of neuroticism with monoamine oxidase activity and smoking

Variation in the personality trait of neuroticism is known to be affected by genetic influences, but despite a number of association studies, the genes involved have not yet been characterized. In a recent study of platelet monoamine oxidase in 1,551 twin subjects, we found a significant association between monoamine oxidase activity and scores on the Eysenck Personality Questionnaire neuroticism scale. Further analyses presented here indicate that both neuroticism and monoamine oxidase activity are associated with variation in smoking habits, and that adjusting for the effect of smoking strengthens the association between MAO and neuroticism. Analysis of the genetic and environmental sources of covariation between neuroticism, smoking, and monoamine oxidase activity show that approximately 8% of the genetic variance in neuroticism is due to the same additive genetic effects that contribute to variation in monoamine oxidase activity, suggesting that variation in neuroticism is associated in part with aspects of serotonin metabolism.

High-Average-Power Self-Starting Mode-Locked Ti:sapphire Laser With a Broadband Semiconductor Saturable-Absorber Mirror

We present a novel high-power, self-starting mode-locked Ti:sapphire laser with a semiconductor saturable-absorber mirror as the starter element. This laser, whose slope efficiency is 22%, generates pulses with an average power as high as 1.7 W and a pulse width as short as 16 fs. The self-starting process is also investigated.

Ventral tethering in split cord malformation

OBJECT

The author studied the specific issue of ventral tethering in cases of type II split cord malformation (SCM). He also discussed the issue of ventral tethering in patients with type I SCM in whom a bony septum and dural sleeve have been resected.

METHODS

Eleven (21%) of 52 patients with type II SCM were found to have a ventral fibrous septum tethering the hemicords to the ventral dura. Four categories of ventral septa were noted: 1) pure ventral intradural septa (three patients); 2) complete dorsoventral intradural septa (three patients); 3) dorsoventral septa continuous with a dermal sinus tract (two patients); and 4) ventral or complete septa continuous with ventral intestinal bands causing intestinal malrotation or diverticulum (three patients). Excluding one autopsy case, all 10 patients had symptoms or progressive neurological syndromes at diagnosis. Magnetic resonance imaging was completely ineffective, and computerized tomography (CT) myelography was only partially effective in detecting ventral tethering in 50% of cases. The only other positive predictor of ventral tethering is the association of dermal sinus tract and intestinal malformations. Combining this predictor with CT myelography, only 60% of the cases of ventral tethering could be suspected before surgery.

CONCLUSIONS

The author recommends examining all patients with type II SCM, and at surgery the ventral surface of the split length and reunion site should be thoroughly inspected to reveal a ventral band.