Pancreatic cancer prognosis is predicted by an ATAC-array technology for assessing chromatin accessibility

Unlike other malignancies, therapeutic options in pancreatic ductal adenocarcinoma (PDAC) are largely limited to cytotoxic chemotherapy without the benefit of molecular markers predicting response. Here we report tumor-cell-intrinsic chromatin accessibility patterns of treatment-naïve surgically resected PDAC tumors that were subsequently treated with (Gem)/Abraxane adjuvant chemotherapy. By ATAC-seq analyses of EpCAM+ PDAC malignant epithelial cells sorted from 54 freshly resected human tumors, we show here the discovery of a signature of 1092 chromatin loci displaying differential accessibility between patients with disease free survival (DFS) < 1 year and patients with DFS > 1 year. Analyzing transcription factor (TF) binding motifs within these loci, we identify two TFs (ZKSCAN1 and HNF1b) displaying differential nuclear localization between patients with short vs. long DFS. We further develop a chromatin accessibility microarray methodology termed "ATAC-array", an easy-to-use platform obviating the time and cost of next generation sequencing. Applying this methodology to the original ATAC-seq libraries as well as independent libraries generated from patient-derived organoids, we validate ATAC-array technology in both the original ATAC-seq cohort as well as in an independent validation cohort. We conclude that PDAC prognosis can be predicted by ATAC-array, which represents a low-cost, clinically feasible technology for assessing chromatin accessibility profiles.

THU0241 ALTERATIONS OF THE FECAL MICROBIOTA ASSOCIATED WITH EXACERBATION OF LUPUS ACTIVITY BY HCMV PP65 422-439 IMMUNIZATION IN NZB/W F1 MICE

Background:

Systemic lupus erythematosus (SLE) is a multifactorial disease. Gut microbiota is an important environmental factor for SLE1. The perturbation of gut microbiota is often observed at onset or during the disease course. The fragment of HCMV phosphoprotein 65422-439(HCMVpp65422-439) containing B cell epitopes has been reported to elicit humoral immunity and accelerate the autoimmune response in murine lupus2,3. However, little is there to know about the interplay between viral trigger for SLE and the change of gut microbiota during lupus progression.

Objectives:

By using a murine lupus model with NZB/W F1, we investigated the differential alteration in gut microbiota associated with the progression of lupus disease in HCMVpp65422-439immunized mice and control mice.

Methods:

Ten weeks-old NZB/W F1 mice were given or not given an intraperitoneal injection of 100-μg HCMVpp65422-439peptide biweekly for four times. Fecal samples, urine and blood of mice were collected once every two weeks followed by 16S rRNA genes sequencing and ELISA tests. The pathological investigation of renal tissue from sacrificed mice was conducted at 24 weeks of mice age. Statistical analysis for dynamics and alteration of the gut microbiota as well as functional prediction of bacterial communities related to the progression of lupus-like activity was performed.

Results:

HCMVpp65422-439immunization results in the onset of lupus-like activities in NZB/W F1 mice with a higher titer of anti-dsDNA antibody, creatinine and proteinuria, and severe glomerular damage (figure 1). Also, higher diversity and increased family abundance of several bacterial species were observed in HCMVpp65422-439immunized mice (Table 1 and Figure 2a). The predicted metagenomic taxonomic profile in NZB/W F1 mice showed statistically significant enrichment of flagellar assembly, bacterial motility, and chemotaxis (Figure 2b). Spearman’s correlation analysis revealed that a significant association between the increased relative family abundance forSaccharimonadaceae, Marinifilaceae, Desulfovibrionaceae,andRikenellaceaeand HCMVpp65422-439induced lupus-like activity in NZB/W F1 mice (Figure 2c).

Table 1.

Significant test of microbial community structure between two groups

MRPPAdonisAnosimGroupsE-ΔPR2PRPPre-disease vs. Control0.430.10.770.110.112Pre-disease vs. HCMVpp65422-4390.520.0070.550.0090.970.01Control vs. HCMVpp65422-4390.450.0130.350.0140.580.019

Conclusion:

Our results demonstrated that HCMVpp65422-439immunization induced the change in gut microbiota composition and suggested the association of gut microbiota alteration with lupus-like activity in NZB/W F1 mice.

References:

[1]Azzouz D, Omarbekova A, Heguy A, Schwudke D, Gisch N, Rovin BH, et al. Lupus nephritis is linked to disease-activity associated expansions and immunity to a gut commensal. Ann Rheum Dis. 2019;78(7):947-56.

[2]Sebastiani GD, Iuliano A, Canofari C, and Bracci M. Cytomegalovirus infection in Systemic Lupus Erythematosus: report of four cases challenging the management of the disease, and literature review. Lupus. 2019;28(3):432-7.

[3]HoHsieh A, Wang CM, Wu YJ, Chen A, Chang MI, and Chen JY. B cell epitope of human cytomegalovirus phosphoprotein 65 (HCMV pp65) induced anti-dsDNA antibody in BALB/c mice. Arthritis Res Ther. 2017;19(1):65

Disclosure of Interests: :

None declared

COL1A1 gene -1997G/T polymorphism and risk of osteoporosis in postmenopausal women: a meta-analysis

Studies investigating the association between the COL1A1 gene -1997G/T polymorphism and the risk of osteoporosis in postmenopausal women have reported conflicting results. We performed a meta-analysis based on the evidence currently available from the literature to make a more precise estimation of this relationship. We conducted searches of the published literature in the PubMed and Embase databases up to September 2014. We estimated the pooled odds ratios with their 95% confidence intervals to assess the associations using fixed- or random-effect models. Publication bias was investigated by Begg's funnel plot. Meta-analysis was performed using the STATA package version 12.0. No significant association was found between the -1997G/T polymorphism in the COL1A1 gene and osteoporosis risk in the total population analysis (TT vs GG: OR = 1.28, 95%CI = 0.76-2.17; TT vs GT: OR = 1.04, 95%CI = 0.60-1.78; dominant model: OR = 0.84, 95%CI = 0.50-1.40; recessive model: OR = 1.18, 95%CI = 0.84- 1.66). In a subgroup analysis by nationality, the results also showed that no significant associations between the COL1A1 gene -1997G/T polymorphism and osteoporosis risk existed in either Caucasian or Asian populations. No evidence of publication bias was found. In conclusion, the COL1A1 gene -1997G/T polymorphism might not be a risk factor for osteoporosis in postmenopausal women. Further large and well-designed studies are needed to confirm these conclusions.

A phase II study of gemcitabine and cisplatin plus sorafenib in patients with advanced biliary adenocarcinomas

Background:

This study evaluated the addition of sorafenib to gemcitabine and cisplatin in biliary adenocarcinoma first-line therapy.

Methods:

Patients with advanced biliary adenocarcinomas received gemcitabine 1000 mg m⁻² and cisplatin 25 mg m⁻² on a 2 weeks on/1 week off cycle and sorafenib 400 mg twice daily. After the initial 16 patients were enrolled, the chemotherapy doses were amended in view of grade 3 and 4 hand–foot skin reaction and haematologic toxicity. Subsequently, 21 patients received gemcitabine 800 mg m⁻², cisplatin 20 mg m⁻² and sorafenib 400 mg. The primary end point was an improvement in 6-month progression-free survival (PFS6) from historical 57–77% (90% power, type I error of 10%). Pretreatment pERK, evaluated by immunostaining, was correlated with clinical outcome.

Results:

A total of 39 patients were accrued. The most common grade 3–4 toxicities noted in >10% of patients were fatigue, elevated liver function tests and haematologic toxicities including thromboemboli, hyponatraemia and hypophosphataemia. Six-month progression-free survival was 51% (95% confidence interval (CI) 34–66%). Median PFS and overall survival were 6.5 (95% CI: 3.5–8.3) and 14.4 months (95% CI: 11.6–19.2 months), respectively. No correlation was observed between pERK and outcomes.

Conclusion:

The addition of sorafenib to gemcitabine and cisplatin in biliary adenocarcinomas did not improve efficacy over historical data, and toxicity was increased.

Voices From a Minority

In Hong Kong, males constituted only about 10.2% of the nursing workforce in 2010. The learning experiences of male nursing students in Hong Kong during their clinical practicum have rarely been explored. If these students cannot maintain their psychological well-being and psychological health in formal education and clinical placements, then their physical health will also suffer. This ethnographic qualitative study gave male nursing students in Hong Kong a chance to voice their experiences during their clinical practicum. Selected through snowball sampling, 18 male nursing students from a local university participated in individual face-to-face semistructured interviews. The data were processed with content analysis. The findings indicated that male students not only received more support and understanding from male rather than female members of staff but endured a certain amount of oppression while working in female wards. According to the students’ comments on nursing culture, the work climate of male nursing students could be improved by reorganizing the clinical placements and providing extra support to male nursing students.

Cytomegalovirus infection causes morbidity and mortality in patients with autoimmune diseases, particularly systemic lupus: in a Chinese population in Taiwan

To investigate the clinical outcome of cytomegalovirus (CMV) infection in febrile hospitalized patients with autoimmune diseases, mostly systemic lupus erythematosus (SLE). Fifty-four febrile patients were analyzed retrospectively. Half were diagnosed as CMV infection, by positive CMV pp65 antigenemia assay. Clinical and laboratory data between two groups were compared. Correlation between laboratory data and SELENA-SLEDAI scores/mortality were analyzed in the CMV infection group. Receiver operating characteristic analysis was performed to determine the cutoff points of different parameters for predicting mortality or morbidity. The CMV infection group received a higher corticosteroid dosage (mean 26.3 mg/day) and a higher percentage of azathioprine use before admission than the non-CMV infection group. In the former, the deceased subgroup had a significantly higher number of infected leukocytes for CMV (shortened as CMV counts, P = 0.013), more cases of bacterial infection (P = 0.090), and a higher SLE disease activity index score (P = 0.072) than the alive subgroup. The CMV infection group had lower lymphocyte count and more positive bacterial infection than the non-CMV infection group did (P = 0.013 and P = 0.027, respectively). A level of 25 CMV particles/5 × 10(5) polymorphonuclear neutrophils (PMN) was the best cutoff point for predicting CMV-associated mortality, with a sensitivity of 75.0% and specificity of 72.2%. Moderate dose (30 mg/day) of prednisolone or azathioprine use predisposes patients with autoimmune diseases to CMV infection with concurrent bacterial infection. In particular, peak CMV counts at 25/5 × 10(5) PMN or low lymphocyte counts predict mortality or morbidity, respectively.

Feasibility of using interpolated contours of targets and organs at risk in intensity-modulated radiation therapy treatment planning for advanced-stage nasopharyngeal carcinoma

To assess the dosimetric effect of using interpolated contours in planning intensity-modulated radiation therapy (IMRT) for advanced T-stage nasopharyngeal carcinoma. The present study focused on T3-T4 tumours where the proximity of targets to neurological organs poses a stringent test on the feasibility of such an approach. Contours of targets and organs were delineated on CT images of 2.5-mm interval and a reference IMRT plan was generated. An investigative (INV) IMRT plan was then generated with the same planning protocol, but based on interpolated contours that replaced deleted contours on alternate slices. The reference and INV plans were compared. Regarding target coverage, all targets in the INV plans met the acceptance criteria except for the PTV in one case. Regarding organs, the mean dose to 1% volume of the brainstem and spinal cord in the INV plans were kept below their dose limits. No significant differences in the mean doses to others organs were found. Satisfactory target coverage and protection of critical organs to a degree similar to full-scale contouring could be achieved with use of interpolated contours. The saving in manpower time for contouring is expected to significantly improve the throughput of the IMRT planning process.

Efficacy of neoadjuvant docetaxel and cisplatin followed by concurrent cisplatin-radiotherapy in locally advanced nasopharyngeal carcinoma (NPC): A randomized phase II study

6037

Background: The current standard treatment for locally advanced NPC is chemoradiation (CRT) ± adjuvant chemotherapy. However, adjuvant chemotherapy is often poorly tolerated after intensive CRT. Our previous study of neoadjuvant chemotherapy followed by CRT showed encouraging toxicity profile and disease control in advanced NPC (JCO 2004: 22: 3053–60). The current study compared the safety and efficacy of neoadjuvant chemotherapy (neoadj) followed by CRT. Methods: Newly diagnosed patients (pts) with stage III to IVB NPC were randomized (stratified by stage III vs IV) to: (1) Neoadj-CRT: docetaxel 75 mg/m2 D1, cisplatin 75 mg/m2 D1, q3w × 2 cycles, followed by cisplatin 40 mg/m2 weekly × 6–8 cycles concurrent with RT (= 66 Gy in 2-Gy fractions), or (2) CRT: cisplatin-RT (same as arm 1) without neoadj. The primary endpoint was toxicity. Secondary endpoints included survival and quality of life. Planned accrual was 30 pts per arm to detect a 20% difference in toxicity on one side of a 95% confidence interval (CI). Results: From 11/2002 to 11/2004, 65 pts were recruited. Five pts were excluded after randomization but before treatment started (three pts were subsequently found ineligible, and two pts withdrew consent). There was a higher rate of G3–4 neutropenia (100% vs 16%, p<0.001), but not neutropenic fever (3% vs 4%) or other non-hematologic toxicity in the neoadj-CRT vs CRT arm. The proportion of pts progressing at 2-yrs by group was compared by Fisher’s Exact Test (p=0.158). At median follow-up of 2.74 yrs, there were 10 deaths and 13 progressions. The 2-yr progression free survival for neoadj-CRT vs CRT was 80% vs 71% (hazard ratio 0.42; CI 0.14− 1.27; p=0.11). The 2-yr overall survival was 93% vs 76% (hazard ratio 0.17; CI 0.037–0.82; p=0.013). Conclusions: Neoadjuvant docetaxel and cisplatin followed by CRT was well tolerated with a manageable toxicity profile and allowed subsequent delivery of full dose CRT. Preliminary result suggested improved survival. A phase 3 study to definitively test this strategy is warranted. Acknowledgement: Sanofi-Aventis Hong Kong Ltd supported this study in part.

No significant financial relationships to disclose.

Phenylpropanolamine contained in cold remedies and risk of hemorrhagic stroke

In this study, we sought to elucidate whether phenylpropanolamine (PPA) in cold remedies (small and divided doses) increases the risk of hemorrhagic stroke (HS). PPA exposure significantly increased the risk, and the risk was much higher in women. In women, linear trends were also found in recency, duration, and dosage of PPA exposure. PPA contained in cold remedies increases the risk of HS, particularly in women.

Prognostic significance of plasma Epstein-Barr virus (EBV) DNA level in patients with locally advanced head and neck carcinoma treated with concurrent cisplatin and concomitant boost radiotherapy (CBRT)

20003

Background: EBV DNA is detectable in the plasma in most patients (Pts) with lymphoepithelial carcinoma (LECA) and in some Pts with squamous cell carcinoma (SCC) of the HN. We investigated the prognostic significance of plasma EBV DNA level in a prospective phase II trial of concurrent cisplatin and CBRT for locally advanced HN carcinomas. Methods: Eligibility criteria included newly-diagnosed SCC or LECA of non-nasopharyngeal HN sites; stage III or IV disease; ECOG performance status ≤ 1; and age ≤ 70 years. Plasma EBV DNA levels were measured by real-time quantitative polymerase chain reaction (PCR) before treatment and at 6 weeks post-treatment. Pre-treatment gross tumor volume (GTV) was measured on CT, and invasion of bone and cartilage was assessed on CT and MRI. Cisplatin 40–50 mg/m2 was given on days 1, 8, 15 and 22 of CBRT. Radiotherapy consisted of 54 Gy/30 fractions/6 weeks and a concomitant boost (18 Gy/12 fractions) in the last 12 treatment days. The primary endpoint was overall survival (OS) and the secondary endpoint was progression-free survival (PFS). Survival curves were compared by the log-rank test and multivariate analysis was performed with Cox regression. Results: Between March 2001 and January 2005, 46 Pts were recruited (36 with SCC and 10 with LECA). Thirty-four Pts had stage III and 12 had stage IV disease. Pre-treatment plasma EBV DNA level was > 0 copy/ml in all Pts with LECA (range, 37 - 211737 copies/ml) and in 8 Pts with SCC (range, 10 - 48734 copies/ml). Ten Pts had plasma EBV DNA level > 0 copy/ml at 6 weeks post-treatment. With a median follow-up of 1.6 years, the 1-year OS rate was 87.7 % and 1-year PFS rate was 68.3%. On multivariate analysis, plasma EBV DNA > 0 copy/ml at 6 weeks post-treatment was the only independent predictive factor of decreased OS [hazard ratio (HR) 3.59, p = 0.04] for the entire group. In the subgroup of Pts with SCC, pre-treatment EBV DNA > 0 copy/ml was the only independent predictive factor of decreased locoregional PFS (HR 7.08, p = 0.03). Conclusions: Plasma EBV DNA level is a prognostic factor in Pts with locally advanced HN SCC and LECA. Further studies are warranted to confirm the finding and to elucidate its biological basis.

No significant financial relationships to disclose.

Pattern of local failure after primary 2-dimensional radiotherapy (2DRT) in non-metastatic nasopharyngeal carcinoma patients: Predominance of within-field failure and hints on dose escalation effect

15506

Background: To investigate the pattern of local failure and explore any dose-response effect in locally recurred NPC patients treated by 2DRT. Methods: Based on a retrospective review on 2DRT-planned, non-metastatic NPC patients treated between 1996–99, 50 patients had local recurrence (LR). Computer tomography (CT) images at primary treatment and at LR were co-registered for each patient. The pre-treatment gross tumor volumes (GTV) and LR volumes were mapped, and 3-dimensional (3D)dosimetric reconstruction were performed. 20 patients were excluded due to insufficient data. All patients (n = 30) were treated with 2DRT (median dose 66 Gy), and 15 received additional external boost (median dose 20 Gy). The 66 Gy isodose level (IL) was taken as prescription reference. Patterns of LR were classified according to the table below. Comparisons of mean dose (D mean) between LR volume and non-recurrent GTV (GTV-LR) were performed using Wilcoxon signed ranks test. Results: The proportion of within-field (IF) failure, marginal failure, and outside-field failure for the entire cohort were 83.3% (25/30), 13.3% (4/30), and 3.3% (1/30), respectively. Elements of sub-optimal target coverage and radiographic miss were identified in 13.3% (4/30) and 16.6% (5/30) of patients, respectively. The D mean within the non-recurrent GTV was statistically higher than that in the LR volume (73.3 Gy v.s. 69.9 Gy, p = 0.037). Conclusions: Improvement in target localization or dose distribution alone can only avoid less than 20% of local failure that is attributable to radiographic miss or sub-optimal target coverage. Within-field failure was the predominant mode of local recurrence. The dose-response effect observed in this study is hypothesis-generating and forms the background for future randomized trials to verify the dose-escalation benefit using modern radiotherapy technique with high conformal capacity.

[Table: see text]

No significant financial relationships to disclose.

Multiplicity of medication safety terms, definitions and functional meanings: when is enough enough?

OBJECTIVES

To identify the terms and definitions used by organisations involved in medication safety and to examine differences in functional meaning using a novel scenario assignment method.

METHODS

Medication safety related terms and definitions were sought from websites of organisations associated with medication safety. The functional meanings of terms and definitions were analysed and compared using a scenario assignment method where each definition found was assessed against four scenarios with a central theme.

MAIN OUTCOME MEASURES

Medication safety related terms and definitions currently in use, similarities and differences in their functional meanings, and practical implications of the use of these terms and definitions.

RESULTS

Thirty three of 160 websites searched were found to have one or more definitions for medication safety related terms. Twenty five different terms with 119 definitions were found. The most frequently defined groups of terms were "adverse event" (8 different definitions), "error" (n = 9), "near miss" (n = 12), "adverse reaction" (n = 8), and "incident" (n = 4). Substantial diversity of functional meanings of definitions was demonstrated using the scenario-assignment method. Of the five groups of frequently defined terms, definitions within the "adverse event", "near miss", and "incident" groups resulted in three functional meanings each, while two functional meanings resulted for "error" and "adverse reaction".

CONCLUSION

The multiplicity of terms, definitions and, most importantly, functional meanings demonstrates the urgent need for agreement on standardisation of nomenclature describing medication related occurrences. This is an essential prerequisite to enable meaningful analysis of incidence data and development of medication safety improvement strategies.

Clinicopathological features and prognostic factors of cutaneous melanoma among Hong Kong Chinese

Cutaneous melanoma is rare among Chinese people. The clinicopathologic features and prognostic factors of 63 Hong Kong ethnic Chinese cases were analysed. We found that the mean age of onset was 65.5 years with a female : male ratio of 1 : 1.33. Forty-two (66.7%) patients had their tumours on their feet. More than 50% had the acral lentiginous histologic subtype. The mean tumour thickness was 5.73 mm with 92.1% (n = 58) having a Clark's level of III or more. Of the tumours, 57.1% were ulcerated. Stage I and II tumours comprised 73% (n = 46) while stage III and IV tumours made up of 26% (n = 17). The 1-, 3- and 5-year survival rates were 75%, 30% and 17%, respectively. Univariate analysis for overall survival showed that advanced clinical staging (stage III and IV), tumour ulceration and thicker tumour (>4 mm) had a significantly poorer prognosis. Multivariate analysis demonstrated that advanced clinical staging was the most decisive prognostic factor followed by tumour ulceration. Our study showed that cutaneous melanoma in Chinese people is a disease predominantly of an older age group with the acral lentiginous histologic type located mainly on the feet. The prognosis depends on clinical staging and ulceration status.

Overall Survival After Concurrent Cisplatin-Radiotherapy Compared With Radiotherapy Alone in Locoregionally Advanced Nasopharyngeal Carcinoma

This phase III randomized study compared concurrent cisplatin-radiotherapy (CRT) versus radiotherapy (RT) alone in patients with locoregionally advanced nasopharyngeal carcinoma. A total of 350 patients were randomly assigned to receive external RT alone or concurrently with cisplatin at a dosage of 40 mg/m(2) weekly. The primary endpoint was overall survival, and the median follow-up was 5.5 years. The 5-year overall survival was 58.6% (95% confidence interval [CI] = 50.9% to 66.2%) for the RT arm and 70.3% (95% CI = 63.4% to 77.3%) for the CRT arm. In Cox regression analysis adjusted for T stage, age, and overall stage, the difference in overall survival was statistically significantly in favor of concurrent CRT (P = .049, hazard ratio [HR] = 0.71 [95% CI = 0.5 to 1.0]). Subgroup analysis demonstrated that there was no difference between overall survival in the arms for T1/T2 stage (P = .74, HR = 0.93 [95% CI = 0.59 to 1.4]), whereas there was a difference between the arms for T3/T4 stage (P = .013, HR = 0.51 [95% CI = 0.3 to 0.88]), favoring the CRT arm. The regimen of weekly concurrent CRT is a promising standard treatment strategy for locoregionally advanced nasopharyngeal carcinoma patients.

Phase II study of neoadjuvant carboplatin and paclitaxel followed by radiotherapy and concurrent cisplatin in patients with locoregionally advanced nasopharyngeal carcinoma: therapeutic monitoring with plasma Epstein-Barr virus DNA

PURPOSE

To assess the efficacy of neoadjuvant paclitaxel and carboplatin (TC) followed by concurrent cisplatin and radiotherapy (RT) in patients with locoregionally advanced nasopharyngeal carcinoma (NPC) and to monitor treatment response with plasma Epstein-Barr virus (EBV) DNA.

PATIENTS AND METHODS

Thirty-one patients with International Union Against Cancer stages III and IV undifferentiated NPC had two cycles of paclitaxel (70 mg/m2 on days 1, 8, and 15) and carboplatin (area under the curve 6 mg/mL/min on day 1) on a 3-weekly cycle, followed by 6 to 8 weeks of cisplatin (40 mg/m2 weekly) and RT at 66 Gy in 2-Gy fractions. Plasma EBV DNA was measured serially using the real-time quantitative polymerase chain reaction method. Results All patients completed planned treatment. Response to neoadjuvant TC was as follows: 12 patients (39%) achieved partial response (PR) and 18 achieved (58%) complete response (CR) in regional nodes; five patients (16%) achieved PR and no patients achieved CR in nasopharynx. At 6 weeks after RT, one patient (3%) achieved PR and 30 patients (97%) achieved CR in regional nodes, and 31 patients (100%) achieved CR in nasopharynx; 29 patients (93%) had EBV DNA level of less than 500 copies/mL. Neoadjuvant TC was well tolerated, and the most common acute toxicity of cisplatin plus RT was grade 3 mucositis (55%). At median follow-up of 33.7 months (range, 7 to 39.3 months), six distant and three locoregional failures occurred. Plasma EBV DNA level increased significantly in eight of nine patients who experienced treatment failure but did not increase in those who did not. The 2-year overall and progression-free survival rates were 91.8% and 78.5%, respectively. CONCLUSION This strategy was feasible and resulted in excellent local tumor control. Serial plasma EBV DNA provides a noninvasive method of monitoring response in NPC.

Skin metastasis from nasopharyngeal carcinoma in four Chinese patients

Nasopharyngeal carcinoma (NPC) is a common malignancy among southern Chinese. The tumours are mostly undifferentiated carcinomas and are associated with Epstein-Barr virus. Patients present with a blood-stained postnasal discharge, impaired hearing, tinnitus or cervical lymph node enlargement. Radiotherapy with or without chemotherapy is the standard treatment. Though metastatic lung, bone or liver disease is not uncommon on relapse, skin metastasis is rarely reported. The small number of reports in the literature are either brief or have only a few patients. In this report, we describe our series of four Hong Kong Chinese patients with NPC who had distant cutaneous metastases.

Limited knee joint range of motion due to invisible gouty tophi

OBJECTIVES

Tophi deposits are a well-known cause of joint destruction, gouty nephropathy and spinal cord compression. This study reports another major complication of gout, namely tophi deposition causing limited knee joint excursion.

METHODS

Seven gout patients with limited knee joint excursion owing to tophi deposition were studied to reveal clinical features and magnetic resonance imaging (MRI) findings. None of the patients were able to assume a full squatting posture.

RESULTS

No patients had visible subcutaneous tophi over the knee joints, except for one case in which a pea-sized subcutaneous tophus was noted. Additionally, two patients even lacked visible tophi elsewhere. All knee problems in the study group were initially regarded as being due to degenerative or other internal derangements, but MRI unexpectedly revealed multiple tophaceous depositions within and around the joint.

CONCLUSIONS

Intra-articular and periarticular tophi limiting knee joint range of motion are a rare but important cause of walking disability in gout patients. Although most patients do not display visible subcutaneous tophi over the knee on physical examination, the differential diagnosis should consider intra-articular tophi and MRI is valuable in this clinical setting.

Gout in systemic lupus erythematosus and overlap syndrome ? a hospital-based study

The negative association between gout and rheumatoid arthritis is widely accepted, and gout is also speculated to be rare in systemic lupus erythematosus (SLE), as only a few sporadic cases have been reported. From 1985 to 2001 we encountered 15 lupus patients at Chang-Gung Memorial Hospital, including two with lupus-scleroderma and one with lupus-scleroderma-polymyositis overlap syndrome coexisting with gout. This study retrospectively analyses the clinical and laboratory characteristics of these patients. A lower female predominance is found, and most patients developed gout after the onset of SLE, although gout preceded SLE in two cases. Measurement of serum uric acid and 24-h urine uric acid found all of the patients to be hyperuricaemic and underexcretors of uric acid. Furthermore, most of the patients (14/15) were receiving diuretics. Also, many had hypertension and serious cardiovascular diseases. Renal impairment during gouty attacks seemed to be a predisposing factor for developing end-stage renal disease. Gouty arthritis usually occurred during relative SLE inactivity, podagra was frequent, and tophi were found in a few patients. Compared with the unselected population of SLE patients, the cases studied here had a higher incidence of chronic arthritis, malar rash, haematologic disorder, photosensitivity, serositis and neurologic disorder. Renal disease in the patients sampled was frequently membranous nephropathy.

Concomitant septic and gouty arthritis--an analysis of 30 cases

OBJECTIVES

To analyse the clinical features and outcomes of gouty patients with concomitant septic arthritis in a medical centre.

METHODS

From the hospital database, we collected 30 hospitalized cases with concomitant septic arthritis and gouty arthritis from 1987 to 2001. All patients had positive bacterial culture and monosodium urate crystals in the affected joints. Medical records of the patients were analysed in detail.

RESULTS

The mean age of patients was 52.8+/-12.5 yr. One-third of patients were afebrile at presentation, 30% had a normal blood leucocyte count and 10% had a synovial fluid leucocyte count less than 6000/mm3. The knee joint was the most common site of involvement, followed by the ankle, shoulder and wrist joints. Most patients had long-standing disease and subcutaneous tophi. Subcutaneous tophi rupture with secondary wound infection is the most common route of infection. Causative micro-organisms were Staphylococcus aureus (16 cases, 7 of whom were oxacillin-resistant), Streptococcus sp. (5 cases), Pediococcus sp. (1 case), and Gram-negative bacilli (9 cases). Fourteen patients received surgical debridement, among them two patients had an arthrodesis owing to severe joint destruction and one received above-knee amputation. Two patients died. One died of septic complications and the other died of acute myocardial infarction.

CONCLUSIONS

Septic arthritis coexistent with gout presented a diagnostic difficulty. An early diagnosis requires a high level of suspicion. Prompt aspiration and analysis of the synovial fluid is imperative, regardless of the absence of fever or leucocytosis. Culture of the aspirated synovial fluid is warranted in gouty attack, even when it has a low white cell count or the Gram stain reveals no organisms.

Extramammary Paget's disease: outcome of radiotherapy with curative intent

Six patients with extramammary Paget's disease were treated with curative intent radiotherapy. Two of the patients had associated underlying adenocarcinoma. Radiotherapy was given as primary treatment (two patients), definitive treatment for postexcisional relapse (three patients) and adjuvant treatment (one patient). Radiotherapy techniques included high dose rate mould brachytherapy, electron beam, superficial X-ray and photon treatments. Follow-up durations after radiotherapy were 1.2-14.8 years. Complete response was obtained in five patients while one patient had a partial response. Marginal failure occurred in one complete-responder who was successfully salvaged by surgery. The two patients with underlying adenocarcinoma died of distant metastasis. Radiotherapy side effects were acute confluent wet desquamation and mild late skin atrophy. Our results confirmed the useful role of radiotherapy in the management of extramammary Paget's disease.

Concurrent chemotherapy-radiotherapy compared with radiotherapy alone in locoregionally advanced nasopharyngeal carcinoma: progression-free survival analysis of a phase III randomized trial

PURPOSE

Nasopharyngeal carcinoma (NPC) is highly sensitive to both radiotherapy (RT) and chemotherapy. This randomized phase III trial compared concurrent cisplatin-RT (CRT) with RT alone in patients with locoregionally advanced NPC.

PATIENTS AND METHODS

Patients with Ho's N2 or N3 stage or N1 stage with nodal size > or = 4 cm were randomized to receive cisplatin 40 mg/m(2) weekly up to 8 weeks concurrently with radical RT (CRT) or RT alone. The primary end point was progression-free survival (PFS).

RESULTS

Three hundred fifty eligible patients were randomized. Baseline patient characteristics were comparable in both arms. There were significantly more toxicities, including mucositis, myelosuppression, and weight loss in the CRT arm. There were no treatment-related deaths in the CRT arm, and one patient died during treatment in the RT-alone arm. At a median follow-up of 2.71 years, the 2-year PFS was 76% in the CRT arm and 69% in the RT-alone arm (P =.10) with a hazards ratio of 1.367 (95% confidence interval [CI], 0.93 to 2.00). The treatment effect had a significant covariate interaction with tumor stage, and a subgroup analysis demonstrated a highly significant difference in favor of the CRT arm in Ho's stage T3 (P =.0075) with a hazards ratio of 2.328 (95% CI, 1.26 to 4.28). For T3 stage, the time to first distant failure was statistically significantly different in favor of the CRT arm (P =.016).

CONCLUSION

Concurrent CRT is well tolerated in patients with advanced NPC in endemic areas. Although PFS was not significantly different between the concurrent CRT arm and the RT-alone arm in the overall comparison, PFS was significantly prolonged in patients with advanced tumor and node stages.

Phenylbutyrate-induced G1 arrest and apoptosis in myeloid leukemia cells: structure-function analysis

The aromatic fatty acid phenylbutyrate (PB) induces cytostasis, differentiation, and apoptosis in primary myeloid leukemic cells at clinically achievable concentrations. In the present study, we have investigated the structural and cellular basis for PB-induced cytostasis, using the ML-1 human myeloid leukemia cell line as a model system. PB induced a dose-dependent increase in cells in G1 with a corresponding decrease in cells in S-phase of the cell cycle. At comparable doses, PB induced expression of CD11b, indicating myeloid differentiation. At higher doses, the drug induced apoptosis. The antitumor activity was independent of the aromatic ring, as butyric acid (BA) was of equal or greater potency at producing these biological changes. In contrast, shortening of the fatty acid carbon chain length, as demonstrated with phenylacetate (PA), significantly diminished drug potency. Consistent with their effects on cell cycle, PB and BA, but not PA, induced the cyclin-dependent kinase inhibitor, p21(WAF1/CIP1), and led to the appearance of hypophosphorylated Rb, suggesting a role for p21(WAF1/CIP1) in PB-induced cytostasis. Therefore, it appears that the fatty acid moiety of PB, rather than its aromatic ring, is critical for its activity in myeloid leukemic cells. These data provide a potential mechanistic basis for the increased potency of PB over PA previously demonstrated in primary leukemic samples, and support the further clinical development of PB in the treatment of hematologic malignancies.

Augmentation of phenylbutyrate-induced differentiation of myeloid leukemia cells using all-trans retinoic acid

Despite preliminary evidence of clinical activity of the putative differentiating agent sodium phenylbutyrate (PB) in the treatment of myeloid neoplasms, it has proven difficult to maintain therapeutic levels of PB above 0.5 mM, well below the ED50 of 1-2 mM. We have studied the impact of combining PB with all-trans retinoic acid (ATRA) on the ML-1 myeloid leukemia cell line. ATRA augmented PB-induced differentiation, cell-cycle arrest, and apoptosis. ATRA augmented PB induction of the myelomonocytic marker CD11b at all doses of ATRA tested (0.0025-1 microM). Although ATRA did not significantly affect the ED50 of PB, the combination of ATRA (1 microM) and PB (0.5 mM) augmented PB-induced CD11b expression eight-fold. Compared to PB alone, this combination of ATRA and PB induced greater cell cycle arrest (S-phase 14% vs 38%; G0/G1-phase cells 72% vs 52%) and greater apoptosis (24% vs 16% by TUNEL assay). Treatment with ATRA (0.5 microM) in combination with PB (0.5 mM) led to significantly greater inhibition of colony formation (4.8% vs 48% inhibition). ATRA combined synergistically with PB to augment CD11b expression and inhibit colony formation. This combination also showed significant interaction in terms of S-phase inhibition. However, this interaction varied as a function of ATRA concentration: antagonistic at low concentrations of ATRA, synergistic at higher concentrations of ATRA. These data suggest that retinoids may significantly augment the cytostatic and differentiating activity of PB, leading to increased potency of the latter drug at clinically achievable doses.

Nasal lymphoma: results of local radiotherapy with or without chemotherapy

BACKGROUND

Primary nasal lymphoma is a rare disease. Although most patients are initially seen in early Ann Arbor stages, their prognosis is poor. The prognostic significance of local tumor bulk has not been well studied.

METHODS

Twenty-one patients with nasal lymphoma treated between 1985 and 1992 were retrospectively studied. Sixteen patients (76%) below the age of 75 years received combined radiotherapy and chemotherapy. One young patient with early disease and 4 elderly patients had radiotherapy alone. Twelve cases (57%) were diagnosed as pleomorphic T-cell lymphoma based on typical histologic features alone. Immunophenotyping was performed in 10 cases; 8 were T cell and 2 were B cell. Seventeen patients (81%) had Ann Arbor clinical stage IE disease, and 4 had stage IIE disease. The local tumor extent was assessed by endoscopy in all patients and by computerized tomography (CT) in 14 patients. Eleven local tumors (52%) extended to the posterior ethmoids, sphenoid sinus, orbit, or beyond. Using a T-stage system, the prognostic significance of local tumor bulk was evaluated for stage IE patients.

RESULTS

At a median follow-up time of 16.8 months, the lymphoma recurred in 13 patients; 10 patients had systemic relapse and 10 patients, local relapse. The 5-year actuarial overall survival rate was 24%. Complete response to chemotherapy was achieved in 5 of 16 patients (31%). Four of the 6 patients who remained alive and disease-free were chemotherapy complete responders. Among stage IE patients, those with early and those with advanced local disease did not have significantly different survival.

CONCLUSIONS

In view of the high systemic and local relapse rates, more-effective chemotherapy is needed to improve the survival rates, and the role of combined chemotherapy and radiotherapy should be evaluated. Further studies are required to identify patients at high risk of relapse for clinical trials with investigational treatment.

Significant prognosticators after primary radiotherapy in 903 nondisseminated nasopharyngeal carcinoma evaluated by computer tomography

PURPOSE

To evaluate the significant prognosticators in nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

From 1984 to 1989, 903 treatment-naive nondisseminated (MO) NPC were given primary radical radiotherapy to 60-62.5 Gy in 6 weeks. All patients had computed tomographic (CT) and endoscopic evaluation of the primary tumor. Potentially significant parameters (the patient's age and sex, the anatomical structures infiltrated by the primary lesion, the cervical nodal characteristics, the tumor histological subtypes, and various treatment variables were analyzed by both monovariate and multivariate methods for each of the five clinical endpoints: actuarial survival, disease-free survival, free from distant metastasis, free from local failure, and free from regional failure.

RESULTS

The significant prognosticators predicting for an increased risk of distant metastases and poorer survival included male sex, skull base and cranial nerve(s) involvement, advanced Ho's N level, and presence of fixed or partially fixed nodes or nodes contralateral to the side of the bulk of the nasopharyngeal primary. Advanced patient age led to significantly worse survival and poorer local tumor control. Local and regional failures were both increased by tumor infiltrating the skull base and/or the cranial nerves. In addition, regional failure was increased significantly by advancing Ho's N level. Parapharyngeal tumor involvement was the strongest independent prognosticator that determined distant metastasis and survival rates in the absence of the overriding prognosticators of skull base infiltration, cranial nerve(s) palsy, and cervical nodal metastasis.

CONCLUSIONS

The significant prognosticators are delineated after the advent of CT and these should form the foundation of the modern stage classification for NPC.

Perineal Paget's disease: effective treatment with fractionated high dose rate brachytherapy

A patient with perineal extramammary Paget's disease is described. He was treated successfully with fractionated high dose rate brachytherapy.

Patterns of early treatment failure in non-metastatic nasopharyngeal carcinoma: a study based on CT scanning

Six hundred and twenty-eight patients with non-metastatic nasopharyngeal carcinoma were staged by CT scanning and treated with radical locoregional radiotherapy. Parapharyngeal boost radiation for bulky parapharyngeal involvement, neoadjuvant chemotherapy for bulky nodal metastases, and intracavitary 192Ir treatment for local persistence of tumour after external radiotherapy were also used as appropriate. Forty-eight patients had Ho's (1978) Stage I disease (7.6%), 167 Stage II (26.6%), 312 Stage III (49.7%) and 101 Stage IV (16.1%). At 2 years after treatment, 185 patients (29.5%) had developed recurrence; 112 had distant metastases (60.5%), and 75 had local failure (40.5%). Eighty-three patients had developed distant metastases alone, 73 patients locoregional failure alone and 29 patients had both locoregional and metastatic failure. The overall 2-year actuarial distant and local failure rates were 18.4% and 12.7% respectively. Distant metastasis is the major form of treatment failure which limits early survival. Seventy-four per cent of distant metastases were not associated with locoregional recurrence and had probably arisen from pre-existing occult foci. Our data also suggest that the advent of CT scanning has improved local tumour delineation and radiotherapy planning, and hence local control.

Radiation absorbed dose estimates at the cellular level for some electron-emitting radionuclides for radioimmunotherapy

Calculation of the radiation dose at the cellular level is given for several radionuclides that appear promising for radioimmunotherapy using the radiation dose distribution from a point source. The radionuclides have half-lives in the 1-3 day range and have electron ranges up to several hundred micrometers. The investigation emphasizes the physical considerations in radionuclide choice for the radiolabeling of monoclonal antibodies or antibody fragments.