Psychiatric-psychotherapeutic and psychosocial care for refugees: effects and future prospects of the refuKey project - perspective of experts

Introduction

Refugees have been shown to be a vulnerable population with increased psychiatric morbidity and lack of access to adequate mental health care. By establishing cooperations between psychosocial centers and psychiatric clinics the state funded project refuKey by NTFN e.V. and DGPPN aims to improve access to and quality of mental health care for traumatized refugees pursuing a stepped-care model.

Objectives

As part of a larger project evaluation study four focus-groups among experts were conducted to explore the impact of refuKey on refugees’ mental health care.

Methods

Data analysis was conducted using Mayring qualitative content analysis as well as an additional quantitative survey with state refugee reception centers’ employees.

Results

The results indicate that refuKey faciliated the access to mental health care for refugees in terms of systematic identification of mental disorders, eased transitions and increased networking between the mental health care institutions and sectors. Planning and implementation of treatment is described as being more coordinated, solution oriented and sustainable due to multiprofessional collaboration and regular use of qualified interpreters. Reduced distress as well as increased transcultural expertise was found for professionals.

Conclusions

The persisting barriers for refugees in access to mental health care, especially to psychotherapeutic treatment and the emotional burden for professionals underlines the need for further support and research. The experts highly endorse the continuance of refuKey. Furthermore, they call for expansion of the project in terms of staff and new sites and changes of health policies to guarantee the access to adequate health care for traumatized refugees.

Disclosure

No significant relationships.

Novel MYC-driven medulloblastoma models from multiple embryonic cerebellar cells

Group3 medulloblastoma (MBG3) that predominantly occur in young children are usually associated with MYC amplification and/or overexpression, frequent metastasis and a dismal prognosis. Physiologically relevant MBG3 models are currently lacking, making inferences related to their cellular origin thus far limited. Using in utero electroporation, we here report that MBG3 mouse models can be developed in situ from different multipotent embryonic cerebellar progenitor cells via conditional expression of Myc and loss of Trp53 function in several Cre driver mouse lines. The Blbp-Cre driver that targets embryonic neural progenitors induced tumors exhibiting a large-cell/anaplastic histopathology adjacent to the fourth ventricle, recapitulating human MBG3. Enforced co-expression of luciferase together with Myc and a dominant-negative form of Trp53 revealed that GABAergic neuronal progenitors as well as cerebellar granule cells give rise to MBG3 with their distinct growth kinetics. Cross-species gene expression analysis revealed that these novel MBG3 models shared molecular characteristics with human MBG3, irrespective of their cellular origin. We here developed MBG3 mouse models in their physiological environment and we show that oncogenic insults drive this MB subgroup in different cerebellar lineages rather than in a specific cell of origin.

PAX7 is a required target for microRNA-206-induced differentiation of fusion-negative rhabdomyosarcoma

Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma of childhood. RMS can be parsed based on clinical outcome into two subtypes, fusion-positive RMS (FP-RMS) or fusion-negative RMS (FN-RMS) based on the presence or absence of either PAX3-FOXO1 or PAX7-FOXO1 gene fusions. In both RMS subtypes, tumor cells show histology and a gene expression pattern resembling that of developmentally arrested skeletal muscle. Differentiation therapy is an attractive approach to embryonal tumors of childhood including RMS; however, agents to drive RMS differentiation have not entered the clinic and their mechanisms remain unclear. MicroRNA-206 (miR-206) expression increases through normal muscle development and has decreased levels in RMS compared with normal skeletal muscle. Increasing miR-206 expression drives differentiation of RMS, but the target genes responsible for the relief of the development arrest are largely unknown. Using a combinatorial approach with gene and proteomic profiling coupled with genetic rescue, we identified key miR-206 targets responsible for the FN-RMS differentiation blockade, PAX7, PAX3, NOTCH3, and CCND2. Specifically, we determined that PAX7 downregulation is necessary for miR-206-induced cell cycle exit and myogenic differentiation in FN-RMS but not in FP-RMS. Gene knockdown of targets necessary for miR-206-induced differentiation alone or in combination was not sufficient to phenocopy the differentiation phenotype from miR-206, thus illustrating that miR-206 replacement offers the ability to modulate a complex network of genes responsible for the developmental arrest in FN-RMS. Genetic deletion of miR-206 in a mouse model of FN-RMS accelerated and exacerbated tumor development, indicating that both in vitro and in vivo miR-206 acts as a tumor suppressor in FN-RMS at least partially through downregulation of PAX7. Collectively, our results illustrate that miR-206 relieves the differentiation arrest in FN-RMS and suggests that miR-206 replacement could be a potential therapeutic differentiation strategy.

Orthotopic models of pediatric brain tumors in zebrafish

High-throughput screens (HTS) of compound toxicity against cancer cells can identify thousands of potential new drug-leads. But only limited numbers of these compounds can progress to expensive and labor-intensive efficacy studies in mice, creating a 'bottle neck' in the drug development pipeline. Approaches that triage drug-leads for further study are greatly needed. Here we provide an intermediary platform between HTS and mice by adapting mouse models of pediatric brain tumors to grow as orthotopic xenografts in the brains of zebrafish. Freshly isolated mouse ependymoma, glioma and choroid plexus carcinoma cells expressing red fluorescence protein were conditioned to grow at 34 °C. Conditioned tumor cells were then transplanted orthotopically into the brains of zebrafish acclimatized to ambient temperatures of 34 °C. Live in vivo fluorescence imaging identified robust, quantifiable and reproducible brain tumor growth as well as spinal metastasis in zebrafish. All tumor xenografts in zebrafish retained the histological characteristics of the corresponding parent mouse tumor and efficiently recruited fish endothelial cells to form a tumor vasculature. Finally, by treating zebrafish harboring ERBB2-driven gliomas with an appropriate cytotoxic chemotherapy (5-fluorouracil) or tyrosine kinase inhibitor (erlotinib), we show that these models can effectively assess drug efficacy. Our data demonstrate, for the first time, that mouse brain tumors can grow orthotopically in fish and serve as a platform to study drug efficacy. As large cohorts of brain tumor-bearing zebrafish can be generated rapidly and inexpensively, these models may serve as a powerful tool to triage drug-leads from HTS for formal efficacy testing in mice.

Abstract P4-02-01: Normalization of compression-induced hemodynamics in patients responding to neoadjuvant chemotherapy using dynamic tomographic optical breast imaging (TOBI)

Background: Diffuse optical imaging using near-infrared light is emerging as a promising non-invasive method for breast neoadjuvant chemotherapy (NAC) monitoring and outcome prediction. While the majority of published studies rely on “static” assessments of tissue oxy- and deoxy- hemoglobin concentration, we have focused on extending diffuse optical tomography to capture hemodynamic changes driven by fractional mammographic compression. These hemodynamic changes are governed by the interplay of tissue biomechanics and oxygen metabolism, and thus form a novel class of optical dynamic biomarkers of breast pathology. In this study we seek to evaluate the predictive value of these biomarkers with respect to treatment outcome.

Methods: We are conducting a pilot feasibility study in female patients with unilateral locally advanced breast cancer undergoing standard of care NAC. In this analysis we focused on pre-treatment and day 30 post-treatment dynamic TOBI scans. Both breasts are compressed in turn to 4-8 lbs of force (depending on size) and optical images are acquired every 2 seconds over 2 minutes. We compute the time course of oxy (HbO), deoxy (HbR)and total (HbT) hemoglobin concentration as well as the hemoglobin oxygen saturation (SO2). Regions of interest are defined in the optical images to correspond to the radiology identified tumor location, and the healthy tissue in the same breast, respectively. We compare the time courses in the two regions at baseline, and 30 days after initiation of treatment.

Results: In this analysis we present results from 6 patients including 3 responders (defined as greater than 50% reduction in the largest tumor axis from baseline imaging and final pathology) and 3 non-responders. As the compression plates are held in place the tissue collagen matrix begins to stretch, effectively reducing the compression force. At baseline, all patients exhibited an initial decrease in HbT, HbO and SO2. In the tumor area, this was followed by little or no recovery as the compression plates were held in place. The normal tissue, in contrast, began recovering almost immediately. At day 30, the tumor area in the non-responders displayed similar time-course characteristics to day 0. Interestingly, however, at day 30 responders had a very similar time course in both the tumor and normal area, characterized by a slow recovery that begins soon after the compression plates stop moving. Table 1 summarizes the changes in total hemoglobin at t = 90 seconds.

Conclusions: At day 30 after NAC, responding tumors demonstrated “normalization” of compression induced hemodynamics in the tumor area whereas nonresponding tumors did not. This encouraging data suggests that dynamic TOBI can easily detect changes due to treatment. Complete analysis of the patient data to assess the outcome prediction ability using this novel optical imaging technology is ongoing.

Compression induced changes in total hemoglobin a t = 90 seconds during compressionΔHbTtumor- ΔHbTnormal (μM)RespondersNon-RespondersDay 0-0.65 ± 0.21-0.82 ± 0.24Day 300.10 ± 0.24-1.13 ± 0.74

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-02-01.

Abstract P3-06-27: Dynamic tomographic optical breast imaging (TOBI) to monitor response to neoadjuvant therapy in breast cancer

Background: Near-infrared optical measurements have been recently shown to offer a promising non-invasive way for monitoring breast neoadjuvant chemotherapy (NAC) and predicting outcome. In particular, snapshots of tissue oxy and deoxy-hemoglobin concentration as well as water and lipid content have been demonstrated to be sensitive to therapy-induced changes. In this study, we extend optical measurements to capture additional hemodynamic and metabolic biomarkers revealed by dynamically imaging breast tissue during fractional mammographic compression. Using our dynamic tomographic optical breast imaging (TOBI) system we evaluate the early prediction performance of this advanced technology.

Methods: We are conducting a pilot feasibility study in female patients with unilateral locally advanced breast cancer undergoing standard-of-care NAC. Pre-treatment and day 7 post-treatment TOBI scans are obtained, with additional (optional) scans on day 1 of each subsequent chemotherapy cycle. Both breasts are compressed in turn to 4–8 lbs of force, and optical images are acquired once every 2 seconds over two minutes. Time-resolved oxy-(HbO), deoxy-(HbR), and total-(HbT) hemoglobin concentration and hemoglobin oxygen saturation (SO2) are calculated. The compression-induced rate of change of HbT correlates with changes in tissue blood volume indicative of biomechanical properties. The evolution of tissue SO2 is modeled to obtain an index of the ratio of oxygen metabolism to blood flow. Therapy induced changes are quantified, and comparisons between changes in responders vs. non-responders are performed (response is defined here as >50% reduction in the largest tumor diameter).

Results: We have enrolled 20 patients so far, of which 90% (N = 18) completed both the day 0 and day 7 scans. 17 patients have undergone surgery at this point. We focused our initial analysis on 5 HER2+ patients, of which two were non-responders, and three were responders according to our criteria. Four patients received taxol+herceptin+lapatinib, while the other received taxol+lapatinib only. In this small subgroup, the non-responders had an average increase of 1% in total hemoglobin concentration (HbT) from day 0 to day 7, while the responders had an average 12% decrease in HbT, respectively. We also noted different trends in the evolution of the tissue oxygen consumption to blood flow ratio, which increased 32% in non-responders from day 0 to day 7, while decreasing 11% in responders.

Conclusions: The large percentage of enrolled patients that completed both initial scans demonstrates the feasibility of using dynamic optical breast tomography for breast neoadjuvant chemotherapy monitoring. Results in a small cohort of 5 HER2+ patients suggested a decreasing trend in HbT for responders as observed by previous studies. We also report for the first time an increase in the metabolic ratio of oxygen consumption to blood flow in non-responders vs. a decrease in responders. These initial results of our on-going study suggest that dynamic TOBI can detect changes due to treatment and may have predictive value for the treatment outcome and supports further studies of this non-invasive and portable tool for chemotherapy monitoring.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-06-27.

P1-12-26: Global Patterns of Care for HER2/Neu Overexpressing Breast Cancer

Background: Her2/neu overexpression is an independent adverse prognostic factor present in approximately 25% of invasive breast cancers. HER2−overexpressing breast cancer is particularly common in younger patients and therefore poses a significant public health burden. Anti-Her2/neu adjuvant trastuzumab significantly reduces the risk of recurrence as well as improves survival. In view of the serious potential ramifications of not receiving anti-Her2/neu therapy when appropriate, we undertook this international project to determine clinical access to Her2/neu testing and treatment patterns for women with HER2/neu-positive early breast cancer.

Methods: A web-based survey was sent to 386 physicians from 33 countries who participated in the “TEACH” trial, a double blind placebo-controlled phase III study of a novel anti-Her2/neu therapy, lapatinib, in women with primary Her2/neu-positive breast cancer. The survey contained 27 questions addressing physician and patient demographics, access to Her-2/Neu testing in everyday clinical practice, and anti-Her2/neu treatment options in a variety of clinical scenarios.

Results: One hundred and fifty one participants (39%) from 28 countries answered the survey. Ninety eight percent of the participants reported having Her2/neu tumor expression routinely measured for clinical practice in their institutions by immunohistochemistry (83%), FISH (78%) and other methods (17%). Among Asian physicians, 18% did not have routine testing available and sent primary tumors for central testing for TEACH eligibility. Forty eight percent of physicians surveyed reported instances when they had recommended adjuvant Her2-directed therapy to a patient who eventually did not receive it. The proportion of physicians from developing countries that reported patients not receiving therapy was higher than those from developed countries (68% vs. 38%, respectively). The main reason for not receiving trastuzumab was cost in developing countries, while in more developed countries patient refusal and co-morbidities were the main reasons.

Discussion: This survey reflects availability of HER2 breast tumor testing and anti-Her2/neu therapy among physicians from 28 countries worldwide who participated in an anti-Her2/neu therapy clinical trial of a free anti-Her2/neu therapy. These results indicate that a high proportion of women with Her2/neu-overexpressing breast cancer may not receive standard anti-Her2/neu adjuvant therapy especially in developing countries, the barrier to treatment being cost of therapy. We are extending our access to care survey project to a more unselected diverse group of physicians in developing countries.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-12-26.

P1-08-17: Pregnancy-Associated Breast Cancer Does Not Have a Worse Outcome in the 4912 Women with Breast Cancer of the AMAZONA Project

Introduction: Pregnancy traditionally is considered a protective factor for breast cancer. Recent data suggests that pregnancy-associated breast cancer (PABC), a distinct biologic variant possibly related to breast involution, can occur up to 10 years post-partum and may carry a worse prognosis than that of age matched sporadic or nulliparous breast cancer. The Amazona project is a retrospective cohort of 4,912 Brazilian women with breast cancer that has previously reported on worse outcomes of patients according to type of institution where treatment was received (San Antonio 2009 abstr. 3082). We have assessed the outcomes of PABC in the Amazona cohort.

Objectives: 1- To identify whether women who were diagnosed with breast cancer up to 10 years after their first pregnancy had worse disease free survival (DFS) and overall survival (OS) than nulliparous women (NW); 2- to assess if age at first pregnancy is related to age of breast cancer diagnosis and worse DFS or OS; 3- to assess whether number of pregnancies is associated with worse DFS or OS; 4- to assess whether time from first pregnancy to diagnosis or age of first pregnancy are associated with histological grade, clinical stage or tumor expression of ER, PR, and HER2.

Methods: We analyzed 4836 women for whom parous history was available, in respect to DFS, OS, tumor clinical stage, histological grade, expression of ER, PR and HER2, according to age of first pregnancy, diagnosis up to 5 and 10 years after first pregnancy, and number of pregnancies, using NW as controls. Analysis of DFS and OS was done by Cox regression modeling adjusted for institution type, stage, ER, PR, HER2 and grade.

Results: Our cohort had 1996 nulliparous women and 2840 parous women. The median follow up was 28 months and there were 318 deaths and 735 recurrences. We did not find any correlation between PABC with DFS (5 year interval HR 1.15, 95%CI 0.43−3.07; 10 year interval HR 1.01, 95%CI 0.57−1.81) or OS (5 year interval HR 1.88, 95%CI 0.6−5.94; 10 year interval HR 0.5, 95%CI 0.73−3.09), nor was there a correlation between age at first pregnancy with age of breast cancer diagnosis. We also did not see any difference between age of first pregnancy and DFS or OS.

Women with 3 or more pregnancies had worse OS (HR 0.71, 95%CI 0.54−0.93) but not worse DFS (HR 0.93, 95%CI 0.76−1.13).Tumors diagnosed within 5 or 10 years from first pregnancy did not differ by grade, ER, PR, HER2, and clinical stage from those of NW. Women who had their first pregnancy after age 20 tended to have more ER positive (OR 1.99, 95%CI 1.49−2.65), PR positive (OR 1.40, 95%CI 1.06−1.87), and HER2 positive (OR 1.85, 95%CI 1.22−2.79) tumors than NW.

Conclusions: In this large cohort of breast cancer patients from the diverse geographic and socioeconomic spectrum of Brazil we did not find any association between PABC or age of first pregnancy to DFS or OS. The association with worse OS but not DFS for women with 3 or more pregnancies might be due to confounding factors. PABC was not associated with worse clinical prognostic factors. Women who had their first pregnancy after age 20 were more likely to have ER+, PR+ and HER2 + tumors than nulliparous patients.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-08-17.

OT1-01-03: A Phase 3 Randomized, Double-Blind, Placebo-Controlled Multicenter Study Comparing Denosumab with Placebo as Adjuvant Treatment for Women with Early-Stage Breast Cancer Who Are at High Risk of Disease Recurrence (D-CARE)

Background

Bone is a common site of distant recurrence in women with early-stage breast cancer. Cancer cells are thought to stimulate osteoclast-mediated bone resorption, which releases growth factors and cytokines that promote tumor growth. RANK Ligand (RANKL) is the key mediator of osteoclast-induced bone destruction. In preclinical studies, RANKL inhibition reduced the incidence of bone and lung metastases, suppressed tumor progression, and prolonged survival of tumor-bearing mice. Effects were additive with hormonal, chemotherapy, or targeted therapies. Denosumab is a fully human monoclonal antibody against RANKL, approved in the U.S. for the prevention of skeletal-related events in patients with bone metastases from solid tumors. In patients with castrate-resistant prostate cancer, denosumab significantly improved bone metastasis-free survival (BMFS) compared to placebo. The D-CARE trial evaluates BMFS effects of denosumab in women with stage II or III breast cancer.

Methods: Women with node-positive or locally advanced (T3 or T4) disease, and known hormone and HER-2 receptor status are eligible. Standard-of-care adjuvant or neoadjuvant chemo-, endocrine, or HER-2 targeted therapy, alone or in combination must be planned with curative intent. Women with a prior history of breast cancer (other than ductal carcinoma in situ [DCIS] or lobular carcinoma in situ [LCIS]) or distant metastasis, oral bisphosphonate (BP) use within 1 year or any intravenous BP use are excluded. Patients are randomized 1:1 to receive denosumab 120 mg or placebo subcutaneously monthly for 6 mos, then every 3 mos, for a total of 5 yrs treatment. All patients receive vitamin D (≥ 400 IU) and calcium (≥ 500 mg) supplements. Primary endpoint of this event-driven trial is BMFS. Secondary endpoints include disease-free (DFS) and overall survival. The study is powered for both, BMFS and DFS. Safety, quality of life assessments and biomarkers are additional endpoints. The trial, sponsored by Amgen Inc. and registered with the ClinicalTrials.gov identifier NCT01077154 began enrolling patients in June 2010. PG and DF are supported in part by the Avon Foundation, NY.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT1-01-03.

P1-11-12: Patterns of Care of Newly Diagnosed Patients with Breast Cancer in Mexico

Background: Breast cancer is the most common form of cancer and the leading cause of cancer death in women worldwide. More than 55% of breast cancer deaths occur in low and middle income countries. Although incidence rates for breast cancer are lower in developing countries, mortality rates are higher. This phenomenon has been attributed to limited access to care for breast cancer patients, including screening and early diagnosis as well as primary surgical, radiation and systemic therapies. Similar to trends in other poor and middle income countries, breast cancer mortality in Mexico is rising. The goal of this survey of physicians caring for patients with breast cancer in Mexico is to obtain information about current treatment patterns of newly diagnosed patients and to describe their clinical characteristics. Methods: A web-based closed survey has been sent to 854 physicians providing care to newly diagnosed breast cancer patients across Mexico, including medical oncologists and breast cancer surgeons. The survey instrument contains 35 questions assessing demographic data, access to diagnosis and treatment in a variety of clinical patient scenarios. The responses will be anonymous and entered automatically into a secure database for analysis. Fisher exact test will be used for the frequency analysis. Chi-squared statistics and Kendall correlation will be used for nominal and ordinal variables respectively. Results: The results will be presented at the 2011 San Antonio Breast Cancer Symposium.

Conclusions: The results of this survey will highlight potential disparities in care received by breast cancer patients across the full geographic and socioeconomic spectrum of Mexico in order to highlight the need for uniform, quality based approaches for the diagnosis and treatment of breast cancer patients in Mexico, and will serve as an example of how one middle income country faces challenges and unmet medical needs regarding access to care of women with breast cancer.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-11-12.

Abstract P3-10-26: Quantitative Protein and Gene Expression Biomarkers of Tamoxifen and Letrozole Recurrence in the NCIC CTG MA.17 Cohort

Background: The MA.17 study showed that extended adjuvant endocrine therapy with letrozole (LET) after completing 5 years of tamoxifen (TAM) markedly reduced the risk of recurrence in women with ER+ early stage breast cancer and improved overall survival in women presenting with node +ve disease. The HOXB 13:IL17BR gene expression ratio (signature) has been shown to predict outcome in breast cancer patients treated with adjuvant tamoxifen monotherapy and provides additional information beyond that from known positive (ER and PR) and negative (Her-1 and Her-2) predictors of responsiveness to tamoxifen in node-ve women. We report a case control evaluation of the Breast Cancer Index (BCI; bioTheranostics, Inc.), which combines the HOXB13 and IL17BR twogene and the molecular grade index (MGI) gene expression signatures, with respect to distinguishing which patients are at risk of late recurrences and who would respond to extended endocrine therapy with LET. The prognostic and predictive utility of quantitative immunofluorescence of ER, PR, Her-2, tumor aromatase, COX-2, GATA3 and Nat1 in the TAM-PLACEBO and the TAM-LET cohorts will also be evaluated and compared to results derived by standard immunohistochemistry. Methods: FFPE tumor blocks were collected from patients who experienced a breast cancer recurrence up to unblinding of MA.17. Controls were matched 2:1 for age, tumor size, lymph node status, and prior chemotherapy, and were all disease free for longer than cases. All cases were reviewed for standard histopathology by two independent pathologists. RNA was extracted, amplified, converted to cDNA and subjected to RT-PCR with primers and probes to HOXB13, IL17BR, BUB1A, CENPA, NEK2, RACGAP1 and RRM2. ER, PR HER1, HER2, COX2, Aromatase, GATA3 and NAT1 will be analyzed by routine IHC techniques and by immunoflourescent Automated Quantitative Analysis (AQuA).

Results: 105 cases and 210 matched controls are available for evaluation. All sections are under review and tissue microarrays have been performed on all cases and controls. Detailed results on the BCI and ER, PR, Her-2 will be available at the SABCS.

Discussion: MA.17 has shown that extended adjuvant endocrine therapy after tamoxifen is effective at preventing disease recurrence given for an additional 5 years. Numerous clinical trials are exploring whether extending AIs will show this benefit, and there is an increasing need to improve the therapeutic index by distinguishing those at risk from those who are not. It is also important to determine which patients will benefit from the therapy and which will recur without benefit. The latter patients could be triaged to clinical trials of novel therapies to overcome endocrine resistance. This study will help to define these issues and pave the way for more effective selection of specific patients for adjuvant endocrine strategies.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-10-26.

ADME transcriptome in Hispanic versus White donor livers: Evidence of a globally enhanced NR1I3 (CAR, constitutive androstane receptor) gene signature in Hispanics

Previous studies have found that, compared with Whites, Hispanic donor livers had elevated expression of CYP2 enzymes, gene products regulated by the constitutive androstane receptor (CAR). The objectives of the current study were to determine (1) the CAR activation signature in human liver (2) whether other drug detoxification (absorption, distribution, metabolism and excretion (ADME)) genes were differentially expressed in Hispanic versus White livers, and (3) the extent of overlap in the CAR and Hispanic liver transcriptomes. The CAR transcriptome (ADME genes differentially expressed following phenobarbital versus vehicle treatment of human hepatocytes) and the Hispanic liver transcriptome (ADME genes differentially expressed in Hispanic versus White livers) were identified using Affymetrix oligonucleotide arrays. Quantitative real-time polymerase chain reaction (PCR) was used to verify candidate genes in a larger sample size. Comparison of the CAR and Hispanic liver ADME transcriptomes revealed a significant association between the gene changes. Sixty-four per cent of the ADME genes induced more than twofold by phenobarbital were also induced in Hispanics, and 14% of the ADME genes repressed more than twofold by phenobarbital were repressed in Hispanics. In conclusion, compared with Whites, Hispanic donor livers have increased expression of many genes that are transcriptionally regulated by CAR. This result has practical implications to the drug treatment of Hispanic patients.

How patients experience progressive loss of visual function: a model of adjustment using qualitative methods

BACKGROUND

People with retinitis pigmentosa (RP) experience functional and psychological challenges as they adjust to progressive loss of visual function. The authors aimed to understand better the process of adjusting to RP in light of the emotional suffering associated with this process.

METHODS

Adults with RP were recruited from the Foundation Fighting Blindness and the Wilmer Eye Institute in Baltimore. Focus groups and semistructured interviews addressed the process of adjusting to RP and were audiotaped and transcribed. The transcripts were analysed qualitatively in order to generate a model of adjustment.

RESULTS

A total of 43 individuals participated. It was found that, on diagnosis, people with RP seek to understand its meaning in their lives. Mastering the progressive functional implications associated with RP is contingent upon shifting personal identity from a sighted to a visually impaired person. In this sample, six participants self identified as sighted, 10 self identified as in transition, and 27 self identified as visually impaired. This adjustment process can be understood in terms of a five stage model of behaviour change.

CONCLUSIONS

The proposed model presents one way to understand the process of adjusting to RP and could assist ophthalmologists in meeting their moral obligation to lessen patients' suffering, which arises in the course of their adjustment to progressive loss of visual function.

A reliable method of demonstrating HER-2/neu, estrogen receptors, and progesterone receptors on routinely processed cytologic material

Estrogen (ER) and progesterone receptors (PR) and HER-2/neu (c-erbB-2) protein overexpression are important prognostic factors for breast carcinoma. This study describes a simple, rapid method that demonstrates the applicability of these tests to cytology smears. Smears were made from scrape samples of fresh breast tumors and were fixed in 95% alcohol for immunohistochemical staining for ER and PR and HER-2/neu protein overexpression. Scraped material was suspended in phosphate-buffered saline, and cytospin slides were prepared from the suspension and air dried for fluorescence in situ hybridization (FISH). The results for ER performed on cytology compared with the gold standard (immunohistochemistry on histology) showed 94% accuracy (95% confidence bounds (0.8432 0.9823)); PR results showed 71% accuracy (95% confidence bounds (0.5805 0.8180)) and HER-2/neu results showed 77% accuracy (95% confidence bounds (0.6500 0.8709)). Using HER-2/neu gene overamplification detected by FISH as the gold standard, immunohistochemistry for HER-2/neu protein overexpression showed sensitivity, specificity, and a positive predictive value of 88.8%, 77.7%, and 80% for histology, respectively, and 69%, 87%, and 90% for cytology, respectively. This study showed that fixation and storage of smears in 95% alcohol were effective for receptor studies, whereas air-dried cytospin smears were well suited to FISH.

A prospective study of discontinuing primary and secondary Pneumocystis carinii pneumonia prophylaxis after CD4 cell count increase to > 200 x 106 /l

OBJECTIVE

To assess the incidence of Pneumocystis carinii pneumonia (PCP) after discontinuation of either primary or secondary prophylaxis.

DESIGN

This was a prospective, non-randomized, non-blinded study.

SETTING

Twenty-five University-based AIDS Clinical Trials Group units.

PARTICIPANTS

Participants either had a CD4 cell count < or = 100 x 106/l at any time in the past and no history of confirmed PCP (group I; n = 144), or had a confirmed episode of PCP > or = 6 months prior to study entry (group II; n = 129). All subjects had sustained CD4 cell counts > 200 x 106/l in response to antiretroviral therapy.

INTERVENTIONS

Subjects discontinued PCP prophylaxis within 3 months or at the time of study entry. Evaluations for symptoms of PCP and CD4 cell counts were performed every 8 weeks. Prophylaxis was resumed if two consecutive CD4 cell counts were < 200 x 106/l.

MAIN OUTCOME MEASURE(S)

The main outcome was development of PCP.

RESULTS

No cases of PCP occurred in 144 subjects (median follow-up, 82 weeks) in group I or in the 129 subjects (median follow-up, 63 weeks) in group II (95% upper confidence limits on the rates of 1.3 per 100 person-years and 1.96 per 100 person-years for groups I and II, respectively). Eight subjects (five in group I and three in group II) resumed PCP prophylaxis after two consecutive CD4 cell counts < 200 x 106/l.

CONCLUSIONS

The risk of developing initial or recurrent PCP after discontinuing prophylaxis is low in HIV-infected individuals who have sustained CD4 cell count increases in response to antiretroviral therapy. Neither lifelong primary nor secondary PCP prophylaxis is necessary.

Fine-needle aspiration cytology of the breast: Invasive vs. in situ carcinoma

The surgical management of invasive breast carcinoma differs from that of in situ disease. Invasive carcinoma necessitates axillary lymph node dissection, a procedure that has associated morbidity. We studied 80 cases (66 invasive, 14 in situ) of breast carcinoma that had a histological diagnosis and a preoperative fine-needle aspirate. All slides were reviewed, with 17 cytologic features assessed. We found that six of these features showed a statistically significant difference between the invasive and in situ cases. These were infiltration of fat or stroma by malignant cells (72% of invasive cases demonstrated this feature, but it was not present in any of the in situ cases, P = 0.0002), the presence of myoepithelial cells overlying clusters of tumor cells (seen in 86% of in situ tumors and 7% of invasive cases, P < 0.00001), calcification (present in 71% of in situ and 15% of the invasive group, P = 0.001), foamy macrophages (noted in 64% of in situ tumors and 16% of invasive carcinomas, P = 0.0007), intracytoplasmic vacuoles (seen in 50% of invasive cases and 21% of in situ lesions, P = 0.08), and tubules (present in 30% of invasive and 7% of in situ tumors, P = 0.10). We demonstrate that invasion can be suggested in fine-needle aspirates of carcinomas, provided that true infiltration of fibrofatty connective tissue by neoplastic cells is present. In situ disease has characteristic features, but the presence of invasion cannot be excluded, even in the presence of stromal or adipose tissue fragments without tumor infiltration.

Hypothalamic/pituitary function following high-dose conformal radiotherapy to the base of skull: demonstration of a dose-effect relationship using dose-volume histogram analysis

PURPOSE

To evaluate the incidence and pattern of hypopituitarism from hypothalamic (HT) and pituitary gland (PG) damage following high-dose conformal fractionated proton-photon beam radiotherapy (PPRT) to the base of skull (BOS) region in adults. The relationship between dose, volume, and PG function is explored.

METHODS AND MATERIALS

Between May 1982 to October 1997, 107 adults with non-PG and non-HT neoplasms (predominantly chordoma and chondrosarcomas) of the BOS were treated with PPRT after subtotal resection(s). The median age was 41.2 years (range, 17-75) with 58 males and 49 females. Median prescribed target dose was 68.4 cobalt gray equivalent (CGE) (range, 55.8-79 CGE) at 1.80-1.92 CGE per fraction per day (where CGE = proton Gy x 1.1). The HT and PG were outlined on planning CT scans to allow dose-volume histograms (DVH) analysis. All patients had baseline and follow-up clinical testing of anterior and posterior pituitary function including biochemical assessment of thyroid, adrenal, and gonadal function, and prolactin secretion.

RESULTS

The 10-year actuarial overall survival rate was 87%, with median endocrine follow-up time of 5.5 years, thus the majority of patients were available for long-term follow-up. Five-year actuarial rates of endocrinopathy were as follows: 72% for hyperprolactinemia, 30% for hypothyroidism, 29% for hypogonadism, and 19% for hypoadrenalism. The respective 10-year endocrinopathy rates were 84%, 63%, 36%, and 28%. No patient developed diabetes insipidus (vasopressin deficiency). Growth hormone deficiency was not routinely followed in this study. Minimum target dose (Dmin) to the PG was found to be predictive of endocrinopathy: patients receiving 50 CGE or greater at Dmin to the PG experiencing a higher incidence and severity (defined as the number of endocrinopathies occurring per patient) of endocrine dysfunction. Dmax of 70 CGE or greater to the PG and Dmax of 50 CGE or greater to the HT were also predictive of higher rates of endocrine dysfunction.

CONCLUSION

Radiation-induced damage to the HT & PG occurs frequently after high-dose PPRT to the BOS and is manifested by anterior pituitary gland dysfunction. Hyperprolactinemia was detected in the majority of patients. Posterior pituitary dysfunction, represented by vasopressin activity with diabetes insipidus, was not observed in this dose range. Limiting the dose to the HT and PG when feasible should reduce the risk of developing clinical hypopituitarism.

Adult-onset foveomacular pigment epithelial dystrophy: clinicopathologic correlation of three cases

PURPOSE

The authors describe the clinicopathologic features of three patients with adult onset foveomacular pigment epithelial dystrophy (AOFPED).

METHODS

The eyes of three patients were studied ophthalmoscopically and by fluorescein angiography, and obtained postmortem and studied by light and electron microscopy.

RESULTS

Histopathologic study of the three patient's eyes disclosed central loss of the retinal pigment epithelium and photoreceptor cell layer with a moderate number of pigment-containing macrophages present in the subretinal space and outer retina. To either side, the retinal pigment epithelium was distended with much lipofuscin. Basal laminar and basal linear deposits were present throughout the central area. No discontinuities of Bruch membrane were present.

CONCLUSION

The findings in the eyes of three patients with AOFPED included marked aging changes that are similar to those seen in age-related macular degeneration. Pigmented cells with lipofuscin in the subretinal space account for the vitelliform appearance.

Evidence for an association between cutaneous melanoma and non-Hodgkin lymphoma

BACKGROUND

Over the past 2 decades both cutaneous melanoma (CM) and non-Hodgkin lymphoma (NHL) incidence rates have increased substantially. One approach to better understanding the etiologic basis for these increases is to examine the risk of NHL in CM survivors and the risk of CM in NHL survivors.

METHODS

To explore the possible association between CM and NHL, the authors followed cohorts of CM and NHL patients registered through the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program between 1973 and 1996 and identified patients who developed CM after NHL and NHL after CM. The number of observed cases then were compared with the number of expected cases to see if CM survivors were at an increased risk of NHL or if NHL survivors were at an increased risk of CM.

RESULTS

Between 1973 and 1996, 54,803 CM patients and 62,597 NHL patients who met the authors' inclusion criteria were identified through SEER. The authors found statistically significant elevated risks of NHL among CM survivors (standardized incidence ratio [SIR], 1.42; 95% confidence interval [CI], 1.23-1.63) and CM among NHL survivors (SIR, 1.75; 95% CI, 1.48-2.07).

CONCLUSIONS

These results support an association between CM and NHL. Although detection bias and posttherapy effects may explain part of this association, shared genetic or etiologic factors, such as sunlight exposure, also may play a role.

Bronchioloalveolar carcinoma of the lung: recurrences and survival in patients with stage I disease

OBJECTIVES

The aim of our study was to retrospectively compare the patient characteristics, the frequency and pattern of recurrent disease, and survival in patients with stage I bronchioloalveolar carcinoma and adenocarcinoma of the lung.

METHODS

Patients with stage I bronchioloalveolar carcinoma or adenocarcinoma other than bronchioloalveolar carcinoma resected between 1984 and 1992 with adequate clinical follow-up were studied. The clinical characteristics of the patients, extent of initial surgical resection, sites of recurrent disease, and overall survival were examined and compared between the 2 groups. The median follow-up for patients with bronchioloalveolar carcinoma and adenocarcinoma was 6.2 years and 5.9 years, respectively.

RESULTS

A total of 138 patients were identified. Thirty-three patients had bronchioloalveolar carcinoma and 105 patients had adenocarcinoma. Eleven (33%) of the patients with bronchioloalveolar carcinoma had never smoked cigarettes versus 9 (9%) of the patients with adenocarcinoma (P =.0036). There were no significant differences between patients with bronchioloalveolar carcinoma and adenocarcinoma in sex distribution and overall recurrence rate. Of the 12 patients with recurrent bronchioloalveolar carcinoma, 1 patient (8%) had extrathoracic disease develop at the site of first recurrence compared with 49% of patients with recurrent adenocarcinoma (P <.001). The 5-year survival in patients with bronchioloalveolar carcinoma and in those with adenocarcinoma was 83% and 63%, respectively (P =.04).

CONCLUSIONS

Stage I bronchioloalveolar carcinoma is more likely to occur in nonsmokers. Survival is longer in patients with bronchioloalveolar carcinoma. Further research is warranted to define the etiology, clinical course, and molecular abnormalities in patients with bronchioloalveolar carcinoma to generate more effective therapeutic approaches.

Benign meningioma: partially resected, biopsied, and recurrent intracranial tumors treated with combined proton and photon radiotherapy

PURPOSE/OBJECTIVE

To evaluate the recurrence-free survival and complications of combined proton and photon radiotherapy of patients with incompletely resected or recurrent histologically-confirmed benign meningioma.

METHODS AND MATERIALS

Between May 1981 and November 1996, 46 patients with partially resected, biopsied, or recurrent meningiomas (median age of 50 years; range 11-74 years) were treated with combined photon and 160-MeV proton beam therapy at the Massachusetts General Hospital (MGH) and the Harvard Cyclotron Laboratory, using computed tomography-based conformal 3D treatment planning. Nine patients were treated after incomplete tumor resection, 8 patients after tumor biopsy only, and 29 patients after tumor recurrence following gross total (10/29 patients) or progression after subtotal (19/29 patients) resection. All patients were classified as benign meningioma on review slides at MGH. The median dose to the macroscopic gross tumor volume was 59.0 CGE (range 53.1-74.1 CGE, CGE = proton Gy x 1.1 RBE). The median follow-up was 53 months (range 12-207).

RESULTS

Overall survival at 5 and 10 years was 93 and 77%, respectively, and the recurrence-free rate at 5 and 10 years was 100% and 88%, respectively. Survival without severe toxicity was 80% at 5 and 10 years. Three patients presented with local tumor recurrence at 61, 95, and 125 months. One patient developed distant intradural metastasis at 21 and 88 months. No patient died from recurrent meningioma; however, 4 patients died of other causes. A fifth patient died from a brainstem necrosis after 22 months. Eight patients developed severe long-term toxicity from radiotherapy, including ophthalmologic (4 patients), neurologic (4 patients), and otologic (2 patients) complications. All patients with ophthalmologic toxicity received doses higher than those allowed for the optic nerve structures in the current protocol.

CONCLUSION

Combined proton and photon radiotherapy is an effective treatment for patients with recurrent or incompletely resected benign intracranial menigiomas. Observed toxicity appears to be dose-related; with currently employed dose constraints, toxicity should not exceed that seen in patients treated with conformal fractionated supervoltage photon radiotherapy.

Genetic susceptibility to breast cancer: HLA DQB*03032 and HLA DRB1*11 may represent protective alleles

Tumors are believed to emerge only when immune surveillance fails. We wished to ascertain whether the failure to inherit putative protective alleles of HLA class II genes is linked to the development of breast cancer. We molecularly typed HLA DPB1, DQB1, DRB1, and DRB3 alleles in 176 Caucasian women diagnosed with early-onset breast cancer and in 215 ethnically matched controls. HLA DQB*03032 was identified in 7% of controls but in no patients with early-onset breast cancer (P = 0.0001). HLA DRB1*11 alleles were also significantly overrepresented (P < 0.0001) in controls (16. 3%) as compared with patients with early-onset breast cancer (3.5%). HLA DQB*03032 and HLA DRB1*11 alleles may have a protective role in human breast cancer.

A proportional hazards model for multivariate interval-censored failure time data

This paper focuses on the methodology developed for analyzing a multivariate interval-censored data set from an AIDS observational study. A purpose of the study was to determine the natural history of the opportunistic infection cytomeglovirus (CMV) in an HIV-infected individual. For this observational study, laboratory tests were performed at scheduled clinic visits to test for the presence of the CMV virus in the blood and in the urine (called CMV shedding in the blood and urine). The study investigators were interested in determining whether the stage of HIV disease at study entry was predictive of an increased risk for CMV shedding in either the blood or the urine. If all patients had made each clinic visit, the data would be multivariate grouped failure time data and published methods could be used. However, many patients missed several visits, and when they returned, their lab tests indicated a change in their blood and/or urine CMV shedding status, resulting in interval-censored failure time data. This paper outlines a method for applying the proportional hazards model to the analysis of multivariate interval-censored failure time data from a study of CMV in HIV-infected patients.

Correcting for noncompliance and dependent censoring in an AIDS Clinical Trial with inverse probability of censoring weighted (IPCW) log-rank tests

AIDS Clinical Trial Group (ACTG) randomized trial 021 compared the effect of bactrim versus aerosolized pentamidine (AP) as prophylaxis therapy for pneumocystis pneumonia (PCP) in AIDS patients. Although patients randomized to the bactrim arm experienced a significant delay in time to PCP, the survival experience in the two arms was not significantly different (p = .32). In this paper, we present evidence that bactrim therapy improves survival but that the standard intent-to-treat comparison failed to detect this survival advantage because a large fraction of the subjects either crossed over to the other therapy or stopped therapy altogether. We obtain our evidence of a beneficial bactrim effect on survival by artificially regarding the subjects as dependently censored at the first time the subject either stops or switches therapy; we then analyze the data with the inverse probability of censoring weighted Kaplan-Meier and Cox partial likelihood estimators of Robins (1993, Proceedings of the Biopharmaceutical Section, American Statistical Association, pp. 24-33) that adjust for dependent censoring by utilizing data collected on time-dependent prognostic factors.

Low prevalence of germline CDKN2A and CDK4 mutations in patients with early-onset melanoma

BACKGROUND

In patients with cutaneous melanoma, early age at disease onset is characteristic in familial cases and in individuals with multiple primary melanomas. Both subsets of patients with melanoma are at risk for harboring germline CDKN2A or CDK4 mutations.

OBJECTIVE

We set out to prospectively determine the prevalence of CDKN2A and CDK4 mutations in a group of young patients with melanoma.

DESIGN

We prospectively screened 913 patients over a 6-month period and identified 519 patients with invasive melanomas. We invited 172 patients with melanoma who were younger than 40 years to participate in the study, and 49 patients consented and donated peripheral blood samples. Forty-nine percent (n = 24) of our patients developed cutaneous melanoma before the age of 30 years.

SETTING

A melanoma clinic in the Boston, Mass, area.

MAIN OUTCOME MEASURE

We used a combination of single-strand conformation analysis and direct sequencing of samples of peripheral blood leukocyte DNA to search for mutations in exons 1alpha, 1beta, 2, and 3 of CDKN2A and in exon 2 of CDK4.

RESULTS

The mean and median ages at diagnosis in our group were 30 and 32 years, respectively. Among a group of 49 patients, we detected 1 (2%; 95% confidence interval, 0.07%-10.8%) Met 53 Ile CDKN2A mutation, which was found in a patient with a strong family history of melanoma. This alteration has been previously shown to impair p16 function. One patient had an Ala 148 Thr change in CDKN2A, which has also been shown to be a polymorphism. We also detected a sequence polymorphism (in the 3' untranslated region [3'UTR] of CDKN2A) in 27% of our patients. A similar incidence of this 3'UTR polymorphism was observed in a control population. We found no CDK4 mutations.

CONCLUSIONS

Germline CDKN2A and CDK4 mutations are not common in patients who develop melanoma at an early age. This finding contrasts with other cancer-predisposition syndromes, in which there is an increased incidence of germline mutations among young patients. Selection of patients with melanoma for genetic testing based solely on age at onset may not be warranted at the current time.

Reduced toxicity with gradual initiation of trimethoprim-sulfamethoxazole as primary prophylaxis for Pneumocystis carinii pneumonia: AIDS Clinical Trials Group 268

Trimethoprim-sulfamethoxazole (TMP/SMX) is recognized as the superior agent for Pneumocystis carinii pneumonia (PCP) prophylaxis but a high incidence of adverse drug reactions, which may be due to toxic drug metabolites, limits its use. AIDS Clinical Trials Group protocol 268 was a randomized, double-blind, controlled two-arm trial designed to determine whether gradual initiation of TMP/SMX suspension reduced the incidence of treatment-limiting adverse drug reactions compared with routine initiation of double-strength (DS; 160 mg/800 mg) tablets. In all, 372 HIV-1-infected study subjects with a CD4+ cell count <250 x 10 cells/mm3 who had not previously received TMP/SMX for PCP prophylaxis were randomized to receive either daily TMP/SMX DS tablets or a gradually increasing dose of TMP/SMX suspension. The suspension dose was increased to reach the equivalent of a DS tablet by study day 13. During the first 2 weeks, study subjects also received a matching placebo tablet/suspension. After week 2, all study subjects received TMP/SMX tablets for the next 10 weeks. There were significantly fewer study subjects who discontinued prophylaxis during the first 12 weeks when TMP/SMX therapy was initiated gradually (17%) than when initiated in DS tablet formulation (33%) (p =.0002). Gradual initiation was also associated with significantly fewer adverse drug reactions. Gradual initiation of TMP/SMX for primary PCP prophylaxis reduces the incidence of its treatment-limiting adverse effects.

Predictors of skeletal complications in patients with metastatic breast carcinoma

BACKGROUND

The high rate of incidence of skeletal complications in women with metastatic breast carcinoma appears to contribute significantly to their morbidity. Although recent trials have demonstrated the efficacy of bisphosphonates in preventing skeletal complications in selected patients, to the authors' knowledge the incidence rate of skeletal complications in an unselected population of women with metastatic breast carcinoma is unknown. The current study was designed to examine the incidence rate of skeletal complications in a large unselected group of women with metastatic breast carcinoma to determine predictors of these complications.

METHODS

All women (n = 718) diagnosed with metastatic breast carcinoma between 1981-1991 at the study institution were studied retrospectively.

RESULTS

Greater than 50% of the women developed skeletal complications; among these women, 51% had > 1 complication. Approximately 80% of those with bone-limited disease at the time of diagnosis developed complications, as did 60% of those with bone and visceral disease and 21% of those with no bone disease. By univariate analysis, the site of initial metastatic disease, abnormal alkaline phosphatase, and a disease free interval of < 3 years were predictive of skeletal complications. Multivariate analysis revealed that bone involvement at the time of diagnosis was predictive of subsequent skeletal complications.

CONCLUSIONS

In this large retrospective study with extensive follow-up, skeletal complications were extremely common and repetitive, although complications predated patient death by >/= 1 year in the group of women presenting with any bone disease. The presence of bone disease at the time of initial presentation was predictive of skeletal complications. In this group of patients, the authors were unable to identify a subgroup with a low rate of skeletal complications.

Thymidine kinase activation of ganciclovir in recurrent malignant gliomas: a gene-marking and neuropathological study

OBJECT

The gene therapy paradigm of intratumoral activation of ganciclovir (GCV) following transduction of tumor cells by retroviral vectors bearing the thymidine kinase (tk) gene has produced dramatic remissions of malignant gliomas in animal models. In human trials, although the technique has been deemed safe, little antitumor effect has been demonstrated. To evaluate the basis of this inefficacy in human gliomas, the authors conducted a gene-marking trial involving neuropathological and biochemical studies of treated tumor specimens.

METHODS

Five patients with malignant recurrent gliomas underwent stereotactic biopsy sampling and intratumoral implantation procedures with three aliquots of 10(6) vector-producing cells (VPCs) in columns. After 5 days, the tumor was resected and the tumor bed reimplanted with VPCs, and a course of GCV was given. Patients received clinical and radiological follow up for 6 months. Tumor specimens were analyzed neuropathologically and for tk gene expression by anti-TK immunohistochemistry and TK enzymatic activity. Four patients tolerated the treatment well but experienced tumor progression. The other developed an abscess after the second operation and died. Increased TK enzymatic activity was demonstrated in the one tumor specimen analyzed. Immunohistochemical evidence of tk gene expression was limited to VPCs. Transduction of tumor cells was not seen. Viable tumor cells were seen near VPCs containing TK. The lymphocytic immune response was mild.

CONCLUSIONS

Except for the risk of infection inherent in reoperation, this tk-GCV paradigm was both feasible and safe. Pathological studies indicated that limited dissemination of VPCs and vector from the infusion site and failure to transduce tumor cells with the tk gene are major barriers to efficacy.

Thymosin beta-15 predicts for distant failure in patients with clinically localized prostate cancer-results from a pilot study

OBJECTIVES

To report the results of a pilot study on the prognostic value of a newly identified actin-binding protein, thymosin beta-15 (Tbeta15), in predicting prostate-specific antigen (PSA) and bone failure in patients with Gleason 6/10 clinically localized prostate cancer.

METHODS

Thirty-two patients (median age 70 years) with clinically localized, moderately differentiated (Gleason 6/10) prostate cancer treated by external beam radiotherapy alone (68.4 Gy) with available paraffin blocks at the Massachusetts General Hospital were evaluated for this pilot study. All patients had clinical Stage M0 disease at initial presentation, which was documented by bone scan (T1c-4,NX). Their corresponding biopsy specimens were stained immunohistochemically for Tbeta15, which was then correlated with the clinical outcome in a blinded manner. The median follow-up was 6 years (range 1 to 19) for all of the patients.

RESULTS

The outcomes of the 32 patients can be grouped into three categories: patients with no evidence of disease (n = 11), patients with PSA failure without documented bone failure (n = 11), and patients with PSA failure and documented bone failure (n = 10). Tbeta15 staining intensity strongly correlated with clinical outcome. Of those patients whose specimens stained 3+ (strongest staining), 62% developed bone failure compared with 13% of those patients whose specimens stained 1+ (weakest staining) (P = 0.01). The 5-year freedom from PSA failure was only 25% for those patients with 3+ staining compared with 83% for those with 1+ staining (P = 0.02).

CONCLUSIONS

The results of this pilot study have demonstrated that Tbeta15 staining intensity may be a potentially important marker to identify high-risk patients with moderately differentiated, clinically localized prostate cancer.

Stage III thymoma: pattern of failure after surgery and postoperative radiotherapy and its implication for future study

PURPOSE

With the conventional approach of surgery and postoperative radiotherapy for patients with Masaoka Stage III thymoma, progress has been slow for an improvement in the long-term survival rate over the past 20 years. The objective of this study was to evaluate the pattern of failure and survival after surgery and postoperative radiotherapy in Stage III thymoma and search for a new direction for better therapy outcome.

METHODS AND MATERIALS

Between 1975 and 1993, 111 patients with thymoma were treated at Massachusetts General Hospital. Of these, 32 patients were determined to have Masaoka Stage III thymoma. The initial treatment included surgery for clinically resectable disease in 25 patients and preoperative therapy for unresectable disease in 7 patients. Surgical procedure consisted of thymectomy plus resection of involved tissues. For postoperative radiotherapy (n = 23), radiation dose consisted of 45-50 Gy for close resection margins, 54 Gy for microscopically positive resection margins, and 60 Gy for grossly positive margins administered in 1.8 to 2.0 Gy of daily dose fractions, 5 fractions a week, over a period of 5 to 6.6 weeks. In preoperative radiotherapy, a dose of 40 Gy was administered in 2.0 Gy of daily dose fractions, 5 days a week. For patients with large tumor requiring more than 30% of total lung volume included in the target volume (n = 3), a preoperative radiation dose of 30 Gy was administered and an additional dose of 24-30 Gy was given to the tumor bed region after surgery for positive resection margins.

RESULTS

Patients with Stage III thymoma accounted for 29% (32/111 patients) of all patients. The median age was 57 years with a range from 27 to 81 years; gender ratio was 10:22 for male to female. The median follow-up time was 6 years. Histologic subtypes included well-differentiated thymic carcinoma in 19 (59%), high-grade carcinoma in 6 (19%), organoid thymoma in 4 (13%), and cortical thymoma in 3 (9%) according to the Marino and Müller-Hermelink classification. The overall survival rates were 71% and 54% at 5 and 10 years, respectively. Ten of the 25 patients who were subjected to surgery as initial treatment were found to have incomplete resection by histopathologic evaluation. The 5- and 10-year survival rates were 86% and 69% for patients (n = 15) with clear resection margins as compared with 28% and 14% for those (n = 10) with incomplete resection margins even after postoperative therapy, p = 0.002. Survival rates at 5 and 10 years were 100% and 67% for those with unresectable disease treated with preoperative radiation (n = 6) and subsequent surgery (n = 3). Recurrence was noted in 12 of 32 patients and 11 of these died of recurrent thymoma. Recurrences at pleura and tumor bed accounted for 77% of all relapses, and all pleural recurrences were observed among the patients who were treated with surgery initially.

CONCLUSION

Incomplete resection leads to poor results even with postoperative radiotherapy or chemoradiotherapy in Stage III thymoma. Pleural recurrence is also observed more often among patients treated with surgery first. These findings suggest that preoperative radiotherapy or chemoradiotherapy may result in an increase in survival by improving the rate of complete resection and reducing local and pleural recurrences.

Serotonin function following remission from bulimia nervosa

Abnormal serotonergic regulation in bulimia nervosa is thought to contribute to recurrent binge eating, depressed mood, and impulsivity. To follow-up on previous studies showing decreased neuroendocrine responses in symptomatic patients, this study assessed serotonin-mediated prolactin responses in individuals who had remitted from bulimia nervosa. Subjects included 21 women with a history of bulimia nervosa and 21 healthy female controls, as well as an additional comparison group of 19 women with current bulimia nervosa. Placebo-controlled neuroendocrine response studies utilized a single oral dose (60 mg) of the indirect serotonin agonist d,l-fenfluramine. For the bulimia nervosa remitted group, the fenfluramine-stimulated elevation in serum prolactin concentration was not significantly different from the response in healthy controls, but was significantly larger than the response in patients with current bulimia nervosa (p < .01). These findings suggest that diminished serotonergic neuroendocrine responsiveness in bulimia nervosa reflects a state-related abnormality. The results are discussed in relationship to recent reports indicating that some alterations in central nervous system serotonin regulation may persist in symptomatically recovered individuals.

A phase I study of gemcitabine and docetaxel in patients with metastatic solid tumors

BACKGROUND

A Phase I study was initiated to determine the maximum tolerated dose of weekly gemcitabine combined with monthly, fixed-dose docetaxel.

METHODS

Patients with metastatic solid tumors were treated with docetaxel, 60 mg/m(2), on Day 1 every 28 days. Gemcitabine was administered on Days 1, 8, and 15 and underwent dose adjustment in cohorts of 3-6 patients. At the maximum tolerated dose, 11 additional patients were enrolled.

RESULTS

Twenty-six patients received 85 cycles of therapy. At the first dose level, the planned gemcitabine dose on Days 1, 8, and 15 was 800 mg/m(2). Two of the 6 patients treated at this dose level experienced dose-limiting toxicities (DLTs) requiring the reduction of gemcitabine to 600 mg/m(2) per dose and the administration of ciprofloxacin, 500 mg orally twice daily, on Days 8-18. At the second dose level the first 3 patients experienced no DLTs and the dose of gemcitabine was increased to 700 mg/m(2). Two of the 6 patients treated at the 700 mg/m(2) dose level experienced DLTs. Eleven additional patients were enrolled at the recommended Phase II dose of gemcitabine (600 mg/m(2)). At this dose level, Grade 3/4 (according the National Cancer Institute's common toxicity criteria) neutropenia and thrombocytopenia occurred in 12.5% and 2.1% of cycles, respectively. Grade 3 and 4 nonhematologic toxicities were uncommon. Three of seven evaluable patients with pancreatic carcinoma had evidence of significant antineoplastic activity (three partial responses). In addition, two complete responses (one patient with gastric carcinoma and one patient with ovarian carcinoma) and one partial response (patient with hepatocellular carcinoma) were noted in patients with other solid tumors.

CONCLUSIONS

The regimen comprised of docetaxel, 60 mg/m(2), on Day 1 and gemcitabine, 600 mg/m(2), on Days 1, 8, and 15 with ciprofloxacin on Days 8-18 every 28 days is safe, well tolerated, and active.

A non-parametric maximum likelihood estimator for bivariate interval censored data

We derive a non-parametric maximum likelihood estimator for bivariate interval censored data using standard techniques for constrained convex optimization. Our approach extends those taken for univariate interval censored data. We illustrate the estimator with bivariate data from an AIDS study.

An extension of Kendall's coefficient of concordance to bivariate interval censored data

Non-parametric tests of independence, as well as accompanying measures of association, are essential tools for the analysis of bivariate data. Such tests and measures have been developed for uncensored and right censored failure time data, but have not been developed for interval censored failure time data. Bivariate interval censored data arise in AIDS studies in which screening tests for early signs of viral and bacterial infection are done at clinic visits. Because of missed clinic visits, the actual times of first positive screening tests are interval censored. To handle such data, we propose an extension of Kendall's coefficient of concordance. We apply it to data from an AIDS study that recorded times of shedding of cytomegalovirus (CMV) and times of colonization of mycobacterium avium complex (MAC). We examine the performance of our proposed measure through a simulation study.