Glucocorticoid Receptor Gene (NR3C1) Expression in the Pathogenesis of Depression in Cancer

Background

This study aimed to compare the NR3C1 expression among cancer patients with major depressive disorder (cancer depression), cancer patients without major depressive disorder (cancer non-depression), and major depressive disorder patients without cancer (general depression), as a preliminary investigation of epigenetic changes in the glucocorticoid receptor gene.

Methods

From May 2019 to November 2019, patients were recruited from the Department of Psychiatry, Cancer Center in Busan, Korea. For gene expression studies, primers were designed using the Primer3 web tool (http://frodo.wi.mit.edu/primer3), and amplification reactions were performed.

Results

Expression levels of NR3C1 were lower in cancer depression and general depression than in cancer non-depression group. Given that we observed downregulation of the NR3C1 gene expression in depressive patients regardless of cancer status, it appears that methylation changes in NR3C1 may contribute to the pathophysiology of depression.

Conclusion

The results of this study imply that the expression of NR3C1 may be decreased in major depressive disorder.

Psychiatric comorbidities and quality of life in breast cancer patients undergoing radiation treatment: Risk and protective factors

OBJECTIVE

The primary goal was to evaluate the prevalence of psychiatric comorbidities and changes in psychological distress levels among breast cancer patients receiving radiotherapy (RT). The secondary goal was to determine risk and protective factors for psychiatric comorbidities of these patients.

METHODS

From June 2018 to November 2019, patients were recruited from the hospital, Department of Psychiatry. Patients completed baseline surveys after seeing their radiation oncologist and prior to the first treatment, which was scheduled to take place within 7 days (visit 1, baseline); visit 2 occurred within 7 days after RT completion, and visit 3 occurred at 6 weeks after RT completion. A total of 99 patients participated in the study at visit 1; 56 patients completed the study through visit 3.

RESULTS

Although changes in psychiatric comorbidities and overall quality of life were observed in patients with breast cancer prior to, during, and after RT, the differences were not significant among visits. Patients diagnosed with psychiatric comorbidities after RT had exhibited risk factors at previous visits, including preexisting psychiatric comorbidities, functional deterioration, and more severe symptoms related to breast cancer. Based on the results, the psychological characteristics of optimism and resilience can be considered as protective factors for psychiatric comorbidities.

CONCLUSIONS

The results suggest that early detection and follow-up of psychological distress and poor quality of life at the onset of RT are of paramount importance, and that psychosocial interventions to enhance protective factors (optimism and resilience) may be helpful.

Phase II study of R-CVP followed by rituximab maintenance therapy for patients with advanced marginal zone lymphoma: consortium for improving survival of lymphoma (CISL) study

Background

The response rate and survival improvement for rituximab, a CD20-targeting monoclonal antibody, have been demonstrated in marginal zone lymphoma (MZL) as monotherapy and in combination with chemotherapeutic regimens, yet relapses still occur despite treatment completion. Thus, extending the period of remission in MZL patients remains an essential goal. This multicenter, single-arm, open-label phase II study evaluated the survival efficacy of 2 years of rituximab-maintenance therapy in patients with stage III–IV CD20-positive MZL who had responded to first-line R–CVP (rituximab, cyclophosphamide, vincristine, and prednisolone). The objective of this study was to determine whether rituximab maintenance following R–CVP warrants further investigation.

Methods

Prior to rituximab-maintenance therapy, patients received 6–8 cycles of first-line R–CVP therapy for stage III–IV MZL. Rituximab (375 mg/m²), cyclophosphamide (750 mg/m²), and vincristine (1.4 mg/m²; maximum 2 mg) were administered via an intravenous infusion on day 1 of each 3-week cycle, while oral prednisolone (100 mg) was given on days 1–5 of each 3-week cycle. The patients who achieved complete response (CR), partial response (PR), or stable disease (SD) to R–CVP treatment, were prescribed rituximab-maintenance therapy which was administered intravenously at a dose of 375 mg/m² every 8 weeks for up to 12 cycles. The primary endpoint was progression-free survival (PFS). Secondary endpoints were overall survival (OS) and treatment safety.

Results

47 patients were enrolled, of whom, 45 (96%) received rituximab-maintenance treatment. Fifteen (33%) patients had nodal MZL. Following R–CVP first-line therapy, 20 (44%), 22 (49%), and 3 (7%) patients achieved CR, PR, and SD, respectively. After a median follow-up of 38.2 months, their observed 3-year PFS rate was 81%. During the rituximab-maintenance, 6 PR and 1 SD patients achieved CR following the administration of R–CVP. Elevated LDH and the presence of B symptoms were found to be significant prognostic factors for PFS (P = 0.003) and demonstrated a 3-year OS rate of 90%. Rituximab-maintenance therapy was well tolerated, and the common treatment-emergent adverse events were sensory neuropathy (18%), myalgia (13%), fatigue (9%), and neutropenia (9%).

Conclusion

Rituximab-maintenance therapy following first-line R–CVP demonstrated good PFS in patients with stage III–IV MZL, in addition to a favorable toxicity profile.

Trial registration clinicaltrials.gov: NCT01213095

Temsirolimus in Asian Metastatic/Recurrent Non-clear Cell Renal Carcinoma

Purpose

Temsirolimus is effective in the treatment for metastatic non-clear cell renal cell carcinoma (nccRCC) with poor prognosis. We aim to investigate the efficacy and tolerability of temsirolimus in treatment of naïve Asian patients with metastatic/recurrent nccRCC.

Materials and Methods

From January 2008 to July 2017, data of treatment-naïve, metastatic/recurrent nccRCC patients, who were treated with temsirolimus according to the standard protocol, were collected. The primary end-point was progression-free survival (PFS). Secondary end points were overall survival (OS), objective response rate (ORR), and tolerability of temsirolimus.

Results

Forty-four metastatic/recurrent nccRCC patients, 10 from prospective and 34 from retrospective groups, were enrolled; 24 patients (54%) were papillary type, and other histology subtypes included 11 chromophobes (25%), two collecting ducts (5%), one Xp11.2 translocation (2%), and six others (14%). The median PFS and OS were 7.6 months and 17.6 months, res-pectively. ORR was 11% and disease control rate was 83%. Patients with prior nephrectomy had longer PFS (hazard ratio [HR], 0.16; 95% confidence interval [CI], 0.06 to 0.42; p < 0.001) and OS (HR, 0.15; 95% CI, 0.05 to 0.45; p < 0.001). Compared to favorable/intermediate prognosis group, poor prognosis group had shorter median PFS (4.7 months vs. 7.6 months [HR, 2.91; 95% CI, 1.39 to 6.12; p=0.005]) and median OS (9.2 months vs. 17.6 months [HR, 2.84; 95% CI, 1.23 to 6.56; p=0.015]).

Conclusion

Temsirolimus not only benefits poor-risk nccRCC patients, but it is also effective in favorable or intermediate-risk group in Asians. Temsirolimus was well-tolerated with manageable adverse events.

Validity and Reliability of Korean Version of Simplified Nutritional Appetite Questionnaire in Patients with Advanced Cancer: A Multicenter, Longitudinal Study

PURPOSE

Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. Nutrition risk screening aims to increase awareness and allow early recognition and treatment of cancer cachexia. Therefore, screenings should be brief, inexpensive, highly sensitive, and have good specificity. Simplified Nutritional Appetite Questionnaire (SNAQ) is a simple screening tool including four questions, and validated to predict weight loss within 6 months in community-dwelling adults and nursing home residents. Our study aimed to translate the SNAQ into Korean, and to assess the validity and reliability of the translated screening tool in advanced cancer patients.

Materials and Methods

The SNAQ was translated into Korean according to linguistic validation. The internal consistency of the SNAQ was evaluated by Cronbach's alpha coefficient. Test-retest reliability was evaluated using the intraclass correlation coefficient. Concurrent validity was evaluated by measuring the Pearson's correlation coefficient between the SNAQ and Mini-Nutritional Assessment (MNA) and Patient-Generated Subjective Global Assessment (PG-SGA).

RESULTS

In the 194 patients included in full analysis set, cancer stage was predominantly metastatic (98.5%), the mean age was 60 years (range, 23 to 81 years), and the mean body mass index was 24 kg/m2 (range, 15.6 to 39.6 kg/m2). According to MNA score ≤ 11, 57 patients (29.4%) were malnourished. The mean score (±standard deviation) of the Korean version of the SNAQ was 13.8±2.5 with a range of 6-19. Cronbach's alpha coefficient was 0.737, and intraclass correlation coefficient was 0.869. The SNAQ was moderately correlated with MNA (r=0.404, p < 0.001) and PG-SGA (r=-0.530, p < 0.001). A significant weight loss of > 5% of the original bodyweightwithin 6 months occurred in 46 of the 186 patients (24.7%). SNAQ score ≤ 14 predicted > 5% weight loss with a sensitivity of 56.5% and a specificity of 44.3%.

CONCLUSION

The Korean version of the SNAQ had high validity and reliability. SNAQ is useful for the screening tool for advanced cancer patients. The SNAQ had a limitation to predict impending weight loss in advanced cancer patients.

Validity and reliability of Korean version of simplified nutritional appetite questionnaire in patients with advanced cancer: A multicenter, longitudinal study

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Background: Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. Nutrition risk screening aims to increase awareness and allow early recognition and treatment of cancer cachexia. Therefore, screenings should be brief, inexpensive, highly sensitive, and have good specificity. SNAQ is a simple screening tool including 4 questions, and validated to predict weight loss within 6 months in community-dwelling adults and nursing home residents. Our study aimed to translate the SNAQ into Korean, and to assess the validity and reliability of the translated screening tool in advanced cancer patients. Methods: The SNAQ was translated into Korean according to linguistic validation. The internal consistency of the SNAQ was evaluated by Cronbach’s alpha coefficient. Test–retest reliability was evaluated using the intraclass correlation coefficient. Concurrent validity was evaluated by measuring the Pearson’s correlation coefficient between the SNAQ and Mini-Nutritional Assessment (MNA) and Patient-Generated Subjective Global Assessment (PG-SGA). Results: In the 194 patients included in full analysis set, cancer stage was predominantly (98.5%) metastatic, the mean age was 60 years, and the mean BMI was 24 kg/m2. According to MNA score ≤11, 57 patients (29.3%) were malnourished. The mean score of the Korean version of the SNAQ was 13.8 (SD = 2.5) with a range of 6–19. Cronbach’s alpha coefficient was 0.74, and intraclass correlation coefficient was 0.87. The SNAQ was moderately correlated with MNA(r = 0.4043, p < 0.0001) and PG-SGA(r = -0.5297, p < 0.0001). A significant weight loss of 5% of the original body weight within 6 months occurred in 46 (24.7%) of the 186 patients. SNAQ score ≤14 predicted 5% weight loss with a sensitivity of 56.5% and a specificity of 44.3%. Conclusions: The Korean version of the SNAQ had high validity and reliability. SNAQ is useful for the screening tool for advanced cancer patients. The SNAQ had a limitation to predict impending weight loss in advanced cancer patients.

Anti-inflammatory effects of simvastatin in nonsteroidal anti-inflammatory drugs-induced small bowel injury

Small bowel injury can occur as the result of a multifaceted process that includes increased acid secretion, generation of reactive oxygen species, and cyclooxygenase inhibition. However, no effective medication for small bowel ulceration is available. Simvastatin is an important lipid-lowering agent with anti-inflammatory activity. We aimed to validate the effects of simvastatin in vitro and in vivo. In presence or absence of simvastatin, IEC-6 small bowel cell line with 50 ng/ml of tumor nectosis factor α (TNF-α) was investigated by western blotting, qRT-PCR, and DCF-DA assay. In addition, an in vivo study of nonsteroidal anti-inflammatory drugs (NSAID)-induced small bowel inflammation was performed using 7-week-old specific-pathogen-free (SPF) male C57BL/6 mice. Simvastatin treatment reduced the mRNA levels of interleukin-6 and interleukin-8 by approximately 50% in TNF-α-stimulated IEC-6 cells. Treatment with a combination of 50 ng/ml TNF-α and μM simvastatin decreased activation of Akt, IκBα, and nuclear factor-κB p65 level in IEC-6 cells. By DCF-DA staining, intracellular reactive oxygen species (ROS) production was increased in TNF-α-stimulated cells, and treatment with simvastatin decreased the level of ROS. In addition, in vivo mouse model of NSAID-induced small bowel inflammation, the administration of simvastatin reduced the number of small bowel hemorrhagic lesions and the level of ROS production as determined by gross examination and 8-hydroxydeoxyguanosine immunohistochemistry of small bowel tissue, respectively. Simvastatin reduced NSAID-induced injuries by both suppression of ROS generation and modulation of inflammatory cytokines in vitro and in vivo. Therefore, simvastatin, an HMG-CoA reductase inhibitor, has potential as a prophylactic and therapeutic agent for NSAID-induced small bowel injury.

Clinical Features and Survival of Patients With Follicular Lymphoma in Korea

BACKGROUND

The incidence of follicular lymphoma (FL) varies according to geographic location. It is the second most common non-Hodgkin lymphoma in Western countries but has a very low incidence in Asia. Thus, no representative data are available for FL. Therefore, we gathered our own data to build a foundation for FL research.

PATIENTS AND METHODS

We collected a total of 343 patient records. The median age was 53 years, and the ratio of male to female patients was 1.4:1. Most patients received chemotherapy with or without rituximab.

RESULTS

The incidence of grade 1 and 2 FL was 64.9% (n = 205) and of stage III and IV was 51.2% (n = 171). The grade tended to be higher and the stage to be lower compared with Western data. In the chemotherapy group, the complete response rate was 76.0%, and the partial response rate was 17.1%. The median follow-up duration was 38.1 months. The estimated 5- and 10-year progression-free survival and overall survival rates were 68.3% and 84.9% and 63.0% and 71.3%, respectively.

CONCLUSION

We could not find definitive differences between our Korean data and the Western data, although we found some trends in the baseline characteristics. Therefore, we hope to develop an understanding of FL and perform more qualitative studies in the future.

Clinical Significance of Peroxisome Proliferator-Activated Receptor γ and TRAP220 in Patients with Operable Colorectal Cancer

Purpose

The peroxisome proliferator-activated receptor γ (PPARγ) is a nuclear receptor that regulates expression of mediators of lipid metabolism and the inflammatory response. Thyroid hormone receptor-associated proteins 220 (TRAP220) is an essential component of the TRAP/Mediator complex. The objective of this study was to clarify whether PPARγ or TRAP220 are significant prognostic markers in resectable colorectal cancer (CRC).

Materials and Methods

A total of 399 patients who underwent curative resection for CRC were enrolled. We investigated the presence of PPARγ and TARP220 in CRC tissues and adjacent normal tissues by immunohistochemistry. Correlation between the expression of these factors and clinicopathologic features and survival was investigated.

Results

Median age of the patients was 63 years (range, 22 to 87 years), and median follow-up duration 61.1 months (range, 2 to 114 months). PPARγ and TRAP220 expression showed significant correlation with depth of invasion (p=0.013 and p=0.001, respectively). Expression of TRAP220 also showed association with lymph node metastasis and TNM stage (p=0.001). Compared with patients with TRAP220 negative tumors, patients with TRAP220 positive tumors had longer 5-year disease-free survival (DFS) tendency (p=0.051). Patients who were PPARγ positive combined with TRAP220 positive had a better 5-year DFS (64.8% vs. 79.3%, p=0.013). In multivariate analysis expression of both PPARγ and TRAP220 significantly affected DFS (hazard ratio, 0.620; 95% confidence interval, 0.379 to 0.997; p=0.048).

Conclusion

TRAP220 may be a valuable marker for nodal metastasis and TNM stage. Tumor co-expression of PPARγ and TRAP220 represents a biomarker for good prognosis in CRC patients.

Clinical features and treatment of collecting duct carcinoma of the kidney from the korean cancer study group genitourinary and gynecology cancer committee

Purpose

Collecting duct carcinoma (CDC) of the kidney is an aggressive disease with a poor prognosis, accountings for less than 1% of all renal cancers. To date, no standard therapy for CDC has been established. The aim of this study is an investigation of clinicopathologic findings of CDC and correlation of the disease status with a prognosis.

Materials and Methods

From 1996 to 2009, 35 patients with CDC were treated at eight medical centers. The diagnosis of CDC was made based on nephrectomy in 27 cases and renal biopsy in eight cases.

Results

Median PFS and OS for all patients were 5.8 months (95% CI 3.5 to 9.2) and 54.4 months (95% CI 0 to 109.2), respectively. The OS of patients with Stages I-III was 69.9 months (95% CI 54.0 to 85.8), while that of patients with Stage IV was 8.6 months (95% CI 0 to 23.3), which showed a statistically significant difference (p=0.01). In addition, among patients with Stage IV, the OS of patients who received a palliative treatment (immunotherapy, chemotherapy, or targeted therapy) was 18.4 months, which was higher than the OS of patients without treatment of 4.5 months.

Conclusion

CDC is a highly aggressive form of renal cell carcinoma. Despite most of the treatments, PFS and OS were short, however, there were some long-term survivors, therefore, conduct of additional research on the predictive markers of the several clinical, pathological differences and their treatments will be necessary.

Predictive value of in vitro adenosine triphosphate-based chemotherapy response assay in advanced gastric cancer patients who received oral 5-Fluorouracil after curative resection

Purpose

To assess the usefulness of adenosine triphosphate-based chemotherapy response assay (ATP-CRA) results in advanced gastric cancer patients receiving adjuvant chemotherapy.

Materials and Methods

Sixty-two patients underwent curative surgical resection between January, 2006 and December, 2008. Their highly purified surgical specimens were evaluated by ATP-CRAs. Of the 62, 49 had successful assay results and they received either oral 5-fluorouracil or other chemotherapies. We retrospectively analyzed data for 24 patients who were treated with oral 5-fluorouracil and whose assays were successful.

Results

The median observation time was 24.6 months (range, 10.1 to 40.9 months). The median treatment time was 11.2 months (range, 1.2 to 17.7 months). The median age was 66 years (range, 30 to 81 years). Patients were grouped into sensitive- and resistant-groups according to adenosine triphosphate-based chemotherapy response results for fluorouracil. The sensitive-group showed a significantly longer time to relapse (not reached in the sensitive-group vs. 24.8 months in the resistant-group, p=0.043) and longer overall survival compared to the resistant-group (not reached in the sensitive-group vs. 35.7 months in the resistant-group, p=0.16, statistically insignificant).

Conclusion

Patients who receive curative surgical resection significantly benefit from sensitive adjuvant chemotherapy according to ATP-CRA results for time to relapse.

Phase II Study of Vinorelbine Plus Trastuzumab in HER2 Overexpressing Metastatic Breast Cancer Pretreated with Anthracyclines and Taxanes

Purpose

The role of first-line trastuzumab-based therapy has been firmly established in patients with human epidermal growth factor receptor-2 (HER2) positive metastatic breast cancer. In this trial, we evaluated the efficacy and safety of a vinorelbine and trastuzumab combination chemotherapy in patients who were pretreated with anthracyclines and taxanes.

Methods

Thirty-three patients with HER2 overexpressing metastatic breast cancer, all of whom had previously been treated with anthracyclines and taxanes, were included in this study. The patients were treated with 25 mg/m² of vinorelbine (over a 15-minute infusion) on days 1 and 8 every 3 weeks. Additionally, trastuzumab was administered at an initial dose of 4 mg/kg over 90 minutes, and was subsequently administered at weekly doses of 2 mg/kg (over 30 minutes).

Results

The median age of the patients was 53 years (range, 39-72 years). The overall response rate was 30.3% (10 patients; 95% confidence interval [CI], 23-57%). The median time to progression was 6.8 months (95% CI, 5.3-8.2 months). The median overall survival was 12.4 months (95% CI, 10.3-14.6 months). In the 194 cycles of treatment, the incidence rates of grade ≥3 neutropenia and anemia were 7.2% and 1.0%, respectively. Neutropenic fever was detected in three cycles (1.5%). The non-hematological toxicities were not severe: grade 1 or 2 nausea or vomiting was detected in 15.2%, and grade 2 neuropathy was noted in 6.1% of patients. None of the patients experienced any serious cardiac toxicity, and no treatment-related deaths occurred.

Conclusion

These results show that a combination chemotherapy consisting of vinorelbine and trastuzumab is useful in patients with HER2-overexpressing metastatic breast cancer who were pretreated with anthracyclines and taxanes, with a favorable toxicity profile.

Incidence and clinical characteristics of clonal cytogenetic abnormalities of acquired aplastic anemia in adults

Background

Cytogenetic abnormalities (CAs) have been reported frequently in patients with otherwise typical aplastic anemia (AA), but their implications in the prognosis and in the evolution to hematologic malignancies are controversial.

Methods

We retrospectively analyzed 127 adult AA patients who had successful cytogenetic analysis at initial diagnosis.

Results

The patients were classified into 3 groups according to the initial and follow-up results of cytogenetic profiles. Group 1 included patients who had persistent AA with normal cytogenetic profiles (N=117); Group 2, those who had a normal cytogenetic profile at initial diagnosis but later acquired CA (N=4, 3.1%); and Group 3, those who had CA at the initial diagnosis, regardless of follow-up cytogenetic status (N=6,4.7%). In Group 2, 2 patients later developed CA without progression to acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS); the other 2 patients later progressed to AML. None of the patients in Group 3 progressed to AML or MDS. There was no significant difference in overall survival between Groups 1 and 3.

Conclusion

AA patients with CA at initial diagnosis or follow-up may not be at greater risk for evolution to AML or MDS, or show shorter survival periods. Prospective studies and a larger patient samples are needed to establish the clinical relevance of CA.

Clinicopathologic significance of ERCC1, thymidylate synthase and glutathione S-transferase P1 expression for advanced gastric cancer patients receiving adjuvant 5-FU and cisplatin chemotherapy

The objective of this study was to determine whether the expressions of the excision cross-complementing (ERCC1), thymidylate synthase (TS) and glutathione S-transferase P1 (GSTP1) are predictive of clinical outcomes in advanced gastric cancer (AGC) patients receiving treatment with adjuvant 5-fluorouracil (5-FU) and cisplatin (FP) chemotherapy. One hundred forty nine patients were included in this study. ERCC1 and GSTP1 expression was correlated significantly with tumor size (p = 0.040, p = 0.018, respectively). Stage and positive lymph node ratio were associated independently with disease free survival (DFS) and overall survival (OS). Both ERCC1 and GSTP1 expression had a significant impact on OS (hazard ratio = 0.069, p = 0.021). TS expression was not related to DFS and OS.

Clinicopathological significance of p53, hypoxia-inducible factor 1alpha, and vascular endothelial growth factor expression in colorectal cancer

BACKGROUND

The principal objective of this study was to evaluate the prognostic significances of p53, hypoxia inducible factor-1 alpha (HIF-1α), and vascular endothelial growth factor (VEGF) expression in colorectal cancer.

MATERIALS AND METHODS

The tumor tissues of 311 patients with colorectal carcinoma that had undergone potentially curative resections were immunohistochemically assessed using monoclonal antibodies against p53, HIF-1α, and VEGF.

RESULTS

Positivity rates of p53, HIF-1α, and VEGF were 42.4%, 63.0%, and 56.6%, respectively. HIF-1α expression in tumor tissues was determined to be correlated significantly with the expression of VEGF (p=0.040), and depth of invasion (p=0.019). Multivariate analysis demonstrated that HIF-1α was independently associated with poor overall survival (p=0.002).

CONCLUSION

HIF-1α expression is associated with VEGF expression and angiogenesis in colorectal carcinoma. Additionally, the expression of HIF-1α in tumor tissue is associated with angiogenesis and poor overall survival in patients with colorectal cancer.

Improvement of the WHO classification-based prognostic scoring system (WPSS) by including age for Korean patients with the myelodysplastic syndrome

BACKGROUND

The aim of this study was to improve the predictive power of the WHO classification-based prognostic scoring system (WPSS) by including age in patients with the myelodysplastic syndrome (MDS).

PATIENTS AND METHODS

136 Korean patients with de novo MDS between 1995 and 2008 were evaluated retrospectively. All patients were reclassified according to WHO criteria. 114 patients were included in the final analysis. An individualized age-adapted scoring system was developed to improve the accuracy of prognosis of the WPSS.

RESULTS

The WPSS was significantly associated with the prediction of survival and the leukemia-free survival. While the risk of a patient with the WPSS was best represented by the values 0 (very low), +1 (low), +2 (intermediate), +3 (high), and +4 (very high), these values were found to vary between -1.0 and 4.2 in the same patients when age was included as a factor. The WPSS may vary according to age, <55 or ≥55 years. The estimated difference in median survival was more prominent in the lower risk groups of the WPSS than in the higher-risk groups.

CONCLUSION

In addition to the WPSS, age was found to significantly influence the prognosis of patients with MDS and provided a more individualized prognosis for the patients with MDS.

A case of 5-fluorouracil induced encephalopathy

Patients with reduced dihydropyrimidine dehydrogenase (DPD) activity are at risk for experiencing serious adverse effects following 5-fluorouracil (5-FU) based chemotherapy. Neurotoxicity is considered an extremely rare side effect of 5-FU. We report here on an unusual case of 5-FU induced encephalopathy. A 38-year-old woman with advanced gastric carcinoma was treated with adjuvant chemotherapy that consisted of infused 5-FU (1,000 mg/m²) for 5 days and cisplatin (60 mg/m²) on day 1 following total gastrectomy. Nineteen days after starting chemotherapy, the patient displayed a sudden onset of slurred speech, confusion, cognitive disturbances and paranoia. A magnetic resonance image (MRI) of the brain showed no structural abnormalities, and the other laboratory tests provided no explanations for her symptoms, other than a slightly elevated ammonia level. The patient was treated with a lactulose retention enema and thiamine infusion, the 5-FU was halted and her symptoms then recovered after 7 days.

Fludarabine-based myeloablative regimen as pretransplant conditioning therapy in adult acute leukemia/myelodysplastic syndrome: comparison with oral or intravenous busulfan with cyclophosphamide

Background

A combination of busulfan (Bu) and cyclophosphamide (Cy) has been used as a standard myeloablative regimen for allogeneic hematopoietic stem cell transplantation (HSCT). Recent studies postulate that fludarabine (Flu) is a less toxic substitute for Cy.

Methods

Forty-two patients who were diagnosed with acute leukemia or myelodysplastic syndrome and received BuFlu (n=17) or BuCy (n=25) from August, 1999 to July, 2009 at Dong-A University Medical Center were retrospectively analyzed.

Results

The median follow-up duration was 39.75 months. The BuFlu group showed a lower incidence of mucositis (P=0.005), but there was no significant intergroup difference in the time of engraftment, nausea/vomiting, acute/chronic graft-versus-host disease, hepatic veno-occlusive disease, or hemorrhagic cystitis. Moreover, the 2 groups showed no significant difference in the cumulative risk of relapse, event-free survival, or overall survival.

Conclusion

BuFlu administration can be employed as a preparative regimen for allogeneic HSCT and shows efficacy and transplant-adverse effects comparable to those of BuCy. However, randomized prospective studies in more patients are warranted.

Clinical significance of preoperative serum vascular endothelial growth factor, interleukin-6, and C-reactive protein level in colorectal cancer

Background

Angiogenesis is a multistep process in which many growth factors and cytokines have an essential role. Vascular endothelial growth factor (VEGF) is a potent angiogenic agent that acts as a specific mitogen for vascular endothelial cells through specific cell surface receptors. The interleukin-6 (IL-6) pathway is another mechanism linking angiogenesis to malignancy. C-reactive protein (CRP), a representative marker for inflammation, is known for its association with disease progression in many cancer types. The aim of this study was to determine preoperative serum levels of VEGF, IL-6, and CRP in colorectal carcinoma, and to correlate them with disease status and prognosis.

Methods

A 132 of 143 patients who underwent curative resection for colorectal cancer were enrolled in this study. 11 patients with resection margin positive were excluded. Factors considered in analysis of the relationship between VEGF, IL-6, and CRP and histological findings. Patient prognosis was investigated. Serum levels of VEGF and IL-6 were assessed using Enzyme-Linked Immuno-Sorbent Assay (ELISA), and CRP was measured using immunoturbidimetry.

Results

Median follow-up duration was 18.53 months (range 0.73-43.17 months) and median age of the patients was 62 years (range, 26-83 years). Mean and median levels of VEGF and CRP in colorectal cancer were significantly higher than in the normal control group; 608 vs. 334 pg/mL and 528 (range 122-3242) vs. 312 (range 16-1121) (p < 0.001); 1.05 mg/dL vs. 0.43 mg/dL and 0.22 (range 0.00-18.40) vs. 0.07 (range 0.02-6.94) (p = 0.002), respectively. However mean and median level of IL-6 in patients were not significantly higher than in control; 14.33 pg/mL vs. 5.65 pg/mL and 6.00 (range 1.02-139.17) vs. 5.30 (4.50-13.78) (p = 0.327). Although IL-6 and CRP levels were not correlated with other pathological findings, VEGF level was significantly correlated with tumor size (p = 0.012) and CEA (p = 0.038). When we established the cutoff value for VEGF (825 pg/mL), IL-6 (8.09 pg/mL), and CRP (0.51 mg/dL) by Receiver Operating Characteristic (ROC) curve, we noted that high VEGF levels tended to reduce overall survival (p = 0.053), but not significantly. However, IL-6 and CRP demonstrated no significance with regard to disease free survival (p = 0.531, p = 0.701, respectively) and overall survival (p = 0.563, p = 0.572, respectively). Multivariate analysis showed that VEGF (p = 0.032), CEA (p = 0.012), lymph node metastasis (p = 0.002), and TNM stage (p = 0.025) were independently associated with overall survival.

Conclusions

Preoperative serum VEGF and CRP level increased in colorectal cancer patients. High VEGF level has been proposed as a poor prognostic factor for overall survival in patients with colorectal cancer.

A case of subdural hematoma in patient with chronic myeloid leukemia treated with high-dose imatinib mesylate

Imatinib mesylate (IM) is used to treat a wide range of diseases, including Philadelphia chromosome-positive chronic myeloid leukemia (CML), on account of its high tolerability and low incidence of minor adverse events. Hemorrhage is thought to be a rare complication of IM. Recently, IM has been associated with reduced α2-plasmin inhibitor and platelet dysfunction. We report here the case of a 33-year-old female patient with CML who experienced subdural hematoma after an incremental increase in IM dosage due to a loss of complete molecular response. This case indicates that physicians should be alert to this atypical cause of headache in patients taking high-dose IM.

Clinicopathological significance of nuclear factor-kappa B, HIF-1 alpha, and vascular endothelial growth factor expression in stage III colorectal cancer

Nuclear factor-kappaB (NF-kappaB), hypoxia-inducible factor 1alpha (HIF-1alpha), and vascular endothelial growth factor (VEGF) are involved in cell proliferation, invasion, angiogenesis, and metastases. The principal objective of this study was to assess the prognostic significance of NF-kappaB, HIF-1alpha, and VEGF expression in stage III colorectal cancer. Tumor tissues from 148 patients with stage III colorectal carcinoma, all of whom underwent potentially curative resection, were immunohistochemically evaluated using monoclonal antibodies against NF-kappaB, HIF-1alpha, and VEGF. Positivity rates of NF-kappaB, HIF-1alpha, and VEGF were 47.3%, 42.6%, and 61.5%, respectively. NF-kappaB expression in tumor tissues was correlated significantly with HIF-1alpha expression (P < 0.001), VEGF expression (P = 0.044), and the presence of vascular invasion (P = 0.013). Univariate analysis demonstrated that NF-kappaB expression was associated with poor 5-year overall survival (55.8 months vs 76.9 months, P = 0.012). Multivariate analysis verified that NF-kappaB was independently associated with adverse outcomes (relative risk: 1.92, P = 0.049). However, HIF-1alpha and VEGF did not appear to be related to clinical outcomes. NF-kappaB expression in tumor tissue is associated with angiogenesis and poor 5-year overall survival in stage III colorectal cancer patients.

Clinical significances of preoperative serum interleukin-6 and C-reactive protein level in operable gastric cancer

BACKGROUND

The interleukin-6 (IL-6) pathway is one of the mechanisms that link inflammation and angiogenesis to malignancy. Because the C-reactive protein (CRP) is a representative marker for inflammation, CRP has recently been associated with the progression of disease in many cancer types. The principal objective of this study was to determine the preoperative serum levels of IL-6 and CRP in gastric carcinoma, and to correlate them with disease status and prognosis.

METHODS

A total of 115 patients who underwent gastrectomy were enrolled in this study. Serum levels of IL-6 were assessed via Enzyme-Linked Immuno-Sorbent Assay (ELISA), and CRP was measured via immunoturbidimetry. Histological findings included tumor size, depth of tumor invasion, lymph node (LN) metastasis, and TNM stage (6th AJCC Stage Groupings: The staging systems; Primary tumor, regional LN, metastasis).

RESULTS

Increases in cancer invasion and staging are generally associated with increases in preoperative serum IL-6 levels. IL-6 and CRP levels were correlated with invasion depth (P < 0.001, P = 0.001), LN metastasis (P < 0.001, P = 0.024) and TNM stage (P < 0.001, P < 0.001). The presence of peritoneal seeding metastasis is associated with IL-6 levels (P = 0.012). When we established the cutoff value for IL-6 level (6.77 pg/dL) by ROC curve, we noted significant differences in time to progression (TTP; P < 0.001) and overall survival (OS; P = 0.010). However, CRP evidenced no significance with regard to patients' TTP and OS levels. Serum IL-6 levels were correlated positively with CRP levels (r2 = 0.049, P = 0.018).

CONCLUSION

Preoperative serum IL-6 and CRP levels might be markers of tumor invasion, LN metastasis, and TNM stage. Preoperative high IL-6 levels were proposed as a poor prognostic factor for disease recurrence and overall survival in patients with gastric cancers.

Prognostic significance of glycaemic control in patients with HBV and HCV-related cirrhosis and diabetes mellitus

AIMS

Diabetes mellitus (DM) is frequently observed in patients with cirrhosis, particularly that due to hepatitis C virus (HCV) infection. However, no studies have focused on the clinical significance of glycaemic control in cirrhotic patients because of their short life expectancy and poor hepatic function. The aim of this study was to evaluate the prognostic impact of glycaemic control in patients with hepatitis B virus (HBV) and HCV-related cirrhosis and DM.

METHODS

A total of 434 patients with HCV-related (HCV group, n = 88) or HBV-related (HBV group, n = 346) cirrhosis were studied retrospectively. We determined the prevalence of DM and treatment methods for hyperglycaemia and status of glycaemic control, and the patients' outcome.

RESULTS

The prevalence of DM was 43.2% (38/88) in the HCV group and 19.7% (68/346) in the HBV group. Patients in the HCV group were older with a female preponderance. DM was detected before the diagnosis of cirrhosis or simultaneously in 92% and 79% in the HCV and HBV groups, respectively. Most patients were treated with insulin or oral hypoglycaemic agents. However, blood glucose levels were maintained within the normal range in 34.2% of the HCV group and in 23.5% of the HBV group. Forty-six patients died during the observation period in both groups. Hepatic failure was the most common cause of death, and sepsis and variceal bleeding were more frequent in the HCV group than in the HBV group. Multivariate analysis showed that Child-Pugh class was the most important factor for survival in both groups. In the HCV group, the status of glycaemic control was a significant independent factor of survival (P = 0.018). In the HBV group, age and the development of spontaneous bacterial peritonitis were significant.

CONCLUSION

DM is more frequent in patients with HCV-related cirrhosis than in patients with HBV. Strict control of blood glucose levels could improve survival in HCV patients. A precise assessment of the risks and benefits of glycaemic control is required to reduce the mortality and morbidity of patients with cirrhosis and DM.

Dose uniformity of ophthalmic suspensions

PURPOSE

To quantify the rate of redispersion of three commercially available ophthalmic preparations as well as the drug content of single drops during the course of emptying a full container of suspension eyedrops.

SETTING

Department of Ophthalmology, University of Köln, and Department of Pharmaceutical Technology, University of Bonn, Germany.

METHODS

In a computer-controlled test apparatus used to simulate the shaking and dropping behavior of humans under strictly reproducible conditions, we studied the rate of redispersion of three ophthalmic suspensions: 50 mg indomethacin, 50 mg prednisolone-21-acetate, and 50 mg dexamethasone in 5 mL of aqueous fluid. The degree of shaking intensity essential for the redispersion of the ophthalmic suspensions was quantified in healthy persons and patients by an acceleration sensor.

RESULTS

The mean dose delivered and the coefficient of variation of prednisolone were satisfactory. However, only 25% of the dexamethasone was available for administration; the rest remained in the bottle as a cake of sediment. Also, the variability of the drug content between drops was unacceptably high. The mean dose of indomethacin was adequate, but the between-drop variability was excessive.

CONCLUSION

The dose uniformity of suspension eyedrops depends on their homogeneity immediately before administration. Among the formulation factors studied, particle size appears to be the most important. The various redispersion rates of the three drugs underline their clinical profile.

[Dosage problems in suspension eyedrops]

PURPOSE

In opthalmic suspensions, the mean dose and the uniformity of amounts administered in single drops depend upon the redispersibility of drug particles by shaking. The present article is a contribution to the development of the experimental and theoretical basis for a reproducible test, by which the dose uniformity of suspension eyedrops can be assessed under therapeutically relevant conditions. The requirement that suspension eyedrops and similar dosage forms should be redispersable after sedimentation upon storage is stated in the monographs on eyedrops of the German Pharmacopoeia and can be found in similar contexts in other pharmacopoeias. Until now, however, no corresponding test method has been specified.

METHODS

Shaking profiles were recorded in 31 subjects and 27 patients using an acceleration sensor. They were compared with the acceleration profile of a computer-controlled pneumatic shaker and sampler. Both frequency and intensity of the shaking action were quantified by Fourier analysis of the acceleration profiles. The drug content of single drops of Isopto-dex (0.1% dexamethasone), Chibro-Amuno 3 (1% indomethacin), and Inflanefran-forte (1% prednisolone acetate) was assessed exhaustively in four 5-ml specimens of each ophthalmic suspension using the apparatus. The dose uniformity of single drops of suspension eyedrops was measured by UV-spectrophotometry for the entire contents of bottles. Four samples per day were drawn after six shaking cycles for approximately 4 weeks with three intervals of 4 h during daytime and 1 interval of 12 h during the night.

RESULTS

The shaking intensity of patients was lower than that of healthy subjects, while the frequency was similar for both groups. The intensity of the apparatus corresponds to the 67th percentile of the patients and to the 18th percentile of the healthy subjects. It was sufficiently close to the central values of both distributions to allow comparisons. for Isopto-dex, the mean drug content of 9.5 microns per drop amounted to only 25% of the value expected after complete redispersion, with a coefficient of variation (CV) of 23%. The mean value for Chibro-Amuno 3 was 93% of the expected quantity of indomethacin with a CV of 34%, while the mean content of Inflanefran-forte drops was 95% of the labelled dose with a CV as low as 9%.

CONCLUSION

The drug content of single drops of ophthalmic suspensions can be studied under well-defined and reproducible conditions by means of a computer-controlled pneumatic shaking and sampling apparatus. Under the conditions prevailing in this study, the solidified sediment of Isopto-dex was incompletely redispersed, so that doses were significantly too low. A variable dosing pattern with acceptable mean was observed for Chibro-Amuno 3, while the results for Inflanefran-forte were fully satisfactory.