[Pancreatic Acinar Cell Carcinoma with Peritoneal Recurrence Treated with Peritonectomy and Intraoperative Hyperthermic Intraperitoneal Chemotherapy-A Case Report]

A 31-year-old man with a big epigastric mass from pancreas body was completely removed by distal pancreatectomy and segmental gastrectomy. Two years after oral administration of S-1 for 4 courses, peritoneal dissemination on the right subdiaphragmatic space was detected. Laparotomy revealed white colored round nodules were found scattered on the peritoneal surface, and the peritoneal cancer index(PCI)was 18. To achieve complete resection of peritoneal nodules, peritonectomy was performed. After complete removal of macroscopic peritoneal metastasis(PM), intraoperative hyperthermic intraoperative peritoneal chemotherapy using 1 gr of gemcitabine and 60 mg of docetaxel was performed for 40 min with thermal dose of 41.5 min. Postoperative course was uneventful. Drug sensitivity test(HDRA method)showed that gemcitabine that gemcitabine showed the highest inhibition rate. The patient was treated with systemic gemcitabine chemotherapy. He is still alive without recurrence 18 months after peritonectomy plus intraoperative HIPEC. Pathological examination showed pancreatic acinar cell carcinoma(PACC)demonstrating positive for chymotrypsin. In conclusion, we present a PACC-case with PM successfully treated by a comprehensive treatment. Intraoperative HIPEC using gemcitabine may be effective for PACC patients with PM in treating residual micrometastasis after peritonectomy.

Chronic Exercise Mitigates the Effects of Sirtuin Inhibition by Salermide on Endothelium-Dependent Vasodilation

Sirtuins are regulators of eNOS and endothelial function; however, no studies have examined the influence of exercise on sirtuin regulation of endothelial function. Effects of the novel sirtuin inhibitor, salermide, on vascular reactivity in rat aortas were investigated following exercise training of different durations. Male Wistar rats (8-9 months old) were divided into four groups (n = 10-12/group): sedentary (SED), 1 day (1D), 2 weeks (2WK), or 6 weeks (6WK) of exercise. Exercise consisted of running on a motor-driven treadmill at 15 m/min, 15% grade, for 40 min (1D) increased up to 1 h at the end of 2 weeks (2WK) and sustained for an additional 4 weeks (6WK). Dose responses to phenylephrine, sodium nitroprusside, and acetylcholine in the presence or absence of salermide (30 µM) were analyzed. SIRT1 and eNOS protein expression as well as nitrotyrosine levels were determined by immunoblotting. Superoxide dismutase activity was determined by colorimetric assay. Sirtuin inhibition significantly impaired acetylcholine-induced vasorelaxtion in aortas in SED, 1D, and 2WK endurance trained rats but not in 6WK. eNOS expression significantly increased ~ 2.0-fold in 1D, 2WK, and 6WK groups. SIRT1 expression and 3-nitrotyrosine levels were significantly increased in 1D and 2WK but were not significantly elevated in 6WK. SOD levels were significantly elevated in 6WK. These data suggest that chronic endurance training diminishes the role of sirtuins in regulating endothelium-dependent relaxation and appears to be related to changes in SIRT1 expression as well as redox status.

Diagnostic Performance of Four Fecal Immunochemical Tests for Detecting Advanced Colorectal Neoplasia: Preliminary Results

Screening programs based on fecal blood testing have been shown in randomized controlled trials to reduce colorectal cancer incidence and mortality. Professional organizations highly recommend screening average-risk patients with fecal immunochemical testing (FIT). Many patients find these stool tests more acceptable than colonoscopy and stool testing may be the preferred option for areas with limited endoscopic resources. However, the diagnostic performance of FIT testing, particularly for CLIA-waived point-of-care (POC) tests, has not been well studied. Purpose: We are comparing the diagnostic accuracy of 4 FIT tests, one automated (AUTO) and 3 POC, for detecting advanced neoplasia (advanced adenomas and carcinomas) using colonoscopy as a gold standard. Methods. We are enrolling subjects ages 50 to 85 at 3 academic medical centers in Iowa, Texas, and North Carolina who were scheduled for a screening or surveillance colonoscopy. Each subject completed 4 different FIT tests on a single stool specimen. Based on colonoscopy results, we calculated sensitivity, specificity, and predictive values. We used PROC GLIMMIX models in SAS to compare sensitivity and specificity across the different tests, accounting for the within-patient correlation. Results: We currently have 641 subjects who completed FIT and colonoscopy. Mean age is 61.2 (±7.5) years, 63% women, 63% non-Hispanic white, and 31% Hispanic. We found advanced neoplasia, including 5 carcinomas, in 68 subjects. The sensitivities for detecting these neoplasia were 3%, 22%, 28%, and 16% (AUTO), respectively. Corresponding positive predictive values were 18%, 21%, 33%, and 24% (AUTO). Specificities were 97%, 89%, 90%, and 94% (AUTO), respectively, and corresponding negative predictive values were 89%, 91%, 92%, and 90% (AUTO). We found statistically significant differences in sensitivity (P < 0.01) and specificity (P < 0.01) across tests. Conclusions: Early data suggest that FIT products may vary in their sensitivity and specificity for detecting advanced colorectal neoplasia. This variability could have important impacts on the effectiveness of efforts to limit the burden of colorectal cancer by increasing population-based screening rates through fecal blood testing.

Clinical and Psychological Predictors of Switching from Active Surveillance to Active Treatment among Men with Low-Risk Prostate Cancer: the PREPARE Prospective Cohort Study

Numerous observational studies have assessed the clinical predictors of switching from active surveillance (AS) to active treatment (AT), but few have assessed psychological and decisional predictors. In a prospective, comparative effectiveness cohort study of men newly diagnosed with low-risk PCa, we assessed whether psychological and decisional factors predicted switching to AT after adjusting for clinical factors. We conducted pre-treatment telephone interviews (N = 1,139; 69.3% participation) with low-risk PCa patients (PSA < 10, Gleason < 7) and a follow-up assessment 6–10 months post-diagnosis (N = 1057; 93%). Clinical variables were obtained from the medical record. The current analysis included men who were on AS for up to 24 months (N = 515), compared to men on AS for >12 months who switched to AT between 12–24 months (N = 86). In Cox proportional hazard models, we included 2 time-dependent covariates measured between diagnosis and 24-months post-diagnosis: PSA (<4, 4–9.99, 10+) and Gleason score (<7, 7+, no surveillance biopsy). Baseline covariates included age (X = 62.3 (SD = 7.0), first degree relative with PCa (25%), number of positive cores (<2 = 75%), urologist initial treatment recommendation (14% AT). Covariates measured at 6 months included prostate- specific anxiety, decisional satisfaction, decisional uncertainty, and preference for shared vs. independent decisions. The fully adjusted model indicated that switching to an active treatment was more likely among those with a PSA > 10 (HR 5.6, 2.4–13.1), Gleason 7+ (HR 20.2, 12.2–33.4), and the urologist's initial recommendation of AT (HR 2.1, 1.04–4.2). The psychological variables, including preference for making independent treatment decisions (HR 2.7, 1.07–6.9) and concern that disease progression will not be detected (HR 1.5, 0.95–2.4), were independently associated with undergoing AT. After adjusting for clinical evidence of disease progression over the first two years post-diagnosis, men's concerns that disease progression will not be detected and preference for making their own treatment decision each independently predicted undergoing AT. These findings suggest the need to provide information and assistance to men who may be uncertain about remaining on AS, particularly when AS remains clinically indicated.

OBP-401-GFP telomerase-dependent adenovirus illuminates and kills high-metastatic more effectively than low-metastatic triple-negative breast cancer in vitro

We previously described the development of a highly-invasive, triple-negative breast cancer (TNBC) variant using serial orthotopic implantation of MDA-MB-231 human breast cancer in nude mice. The isolated variant is highly invasive in the mammary gland and metastasized to lymph nodes in 10 of 12 mice compared with 2 of 12 of the parental cell line. OBP-401 is a telomerase-dependent cancer-specific, green fluorescent protein (GFP)-expressing adenovirus. OBP-401 was used to infect parental MDA-MB-231P cells and high-metastatic MDA-MB-231H and MDA-MB-231HLN isolated from a lymph node metastasis and MDA-MB-231HLM isolated from a lung metastasis. Time-course imaging showed that OBP-401 labeled MDA-MB-231HP, MDA-MB-231HLN, and MDA-MB-231HLM cells more brightly than MDA-MB-231 parental cells. OBP-401 killed MDA-MB-231H, MDA-MB-231HLN, and MDA-MB-231HLM cells more efficiently than MDA-MB-231P parental cells. These results indicate that OBP-401 could infect, label and then kill high-metastatic MDA-MB-231 more efficiently than low-metastatic MDA-MB-231.

This is My Story: participatory performance for HIV and AIDS education at the University of Malawi

University students represent a subset of young men and women at risk for HIV in high prevalence settings. Innovative programs are needed to raise awareness on the unique issues around HIV and AIDS in the university campus, while training student leaders for peer-based education. The Process and Collaboration for Empowerment and Discussion (PACED) method engages artists and people living with HIV and AIDS (PLWHA) to create a performance that encourages community dialog about HIV and AIDS and empowers PLWHA. 'This is My Story' was a program at the University of Malawi, Chancellor College, which adapted the PACED approach for university students. A qualitative evaluation conducted 1 year later among students and PLWHA participants and audience members demonstrated retention of the following themes: (i) trust in a relationship and how it affects women,(ii) equality for PLWHA and (iii) life after HIV and AIDS. All of the PLWHA and 90.9% of student participants reported a greater sense of empowerment. Of the audience members, 82.1% discussed the performance with friends and family. We thus present the PACED approach as a valuable tool in HIV and AIDS education and prevention among university students in Malawi.

Systemic delivery of atropine sulfate by the MicroDose Dry-Powder Inhaler

BACKGROUND

Inhaled atropine is being developed as a systemic and pulmonary treatment for the extended recovery period after chemical weapons exposure. We performed a pharmacokinetics study comparing inhaled atropine delivery using the MicroDose Therapeutx Dry Powder Inhaler (DPIA) with intramuscular (IM) atropine delivery via auto-injector (AUTO).

METHODS

The MicroDose DPIA utilizes a novel piezoelectric system to aerosolize drug and excipient from a foil dosing blister. Subjects inhaled a 1.95-mg atropine sulfate dose from the dry powder inhaler on one study day [5 doses × 0.4 mg per dose (nominal) delivered over 12 min] and received a 2-mg IM injection via the AtroPen® auto-injector on another. Pharmacokinetics, pharmacodynamic response, and safety were studied for 12 hr.

RESULTS

A total of 17 subjects were enrolled. All subjects completed IM dosing. One subject did not perform inhaled delivery due to a skin reaction from the IM dose. Pharmacokinetic results were as follows: area under the curve concentration, DPIA=20.1±5.8, AUTO=23.7±4.9 ng hr/mL (means±SD); maximum concentration reached, DPIA=7.7±3.5, AUTO=11.0±3.8 ng/mL; time to reach maximum concentration, DPIA=0.25±0.47, AUTO=0.19±0.23 hr. Pharmacodynamic results were as follows: maximum increase in heart rate, DPIA=18±12, AUTO=23±13 beats/min; average change in 1-sec forced expiratory volume at 30 min, DPIA=0.16±0.22 L, AUTO=0.11±0.29 L. The relative bioavailability for DPIA was 87% (based on output dose). Two subjects demonstrated allergic responses: one to the first dose (AUTO), which was mild and transient, and one to the second dose (DPIA), which was moderate in severity, required treatment with oral and intravenous (IV) diphenhydramine and IV steroids, and lasted more than 7 days.

CONCLUSIONS

Dry powder inhalation is a highly bioavailable route for attaining rapid and consistent systemic concentrations of atropine.

Abstract P4-07-04: Methioninase cell-cycle synchronization potentiates chemotherapy for breast cancer

Deprivation of methionine selectively arrests cancer cells during late S-phase (Proc. Natl. Acad. Sci. USA 77, 7306–7310, 1980; Biochim. Biophys. Acta, Reviews on Cancer 738, 49–87, 1984), where they are highly sensitive to chemotherapy drugs which damage DNA (J. Natl. Cancer Inst. 76, 629–639, 1986). Cancer cells, transformed to express different color fluorescent reporters during specific phases of the cell cycle (Cell 132, 487–498, 2008), were used to monitor the onset of the S/G2-phase block due to methionine deprivation effected by recombinant methioninase (rMETase). The S/G2-phase blocked cancer cells fluoresced yellow or green in contrast to cancer cells in G1 which fluoresced red. Cancer cells, including MCF-7 breast cancer, synchronously blocked in S/G2-phase by rMETase, were identified by their yellow-green fluorescence and allowed to accumulate to the maximum extent. At the point of maximum yellow/green cells in the culture, the cells were administered chemotherapy drugs which interact with DNA or block DNA synthesis such as doxorubicin. We termed this procedure color-coded chemotherapy (CCC). CCC was highly effective against the cancer cells (90% cell kill). In contrast, treatment of cancer cells with drugs only, and without rMETase-effected S/G2-phase synchrony, led to the majority of the cancer cell population being blocked in G1 phase (red fluorescent) where they were resistant to the drugs (40% cell kill). CCC, which identifies, by fluorescent color, when cancer cells are blocked in S/G2-phase by a unique cell-cycle-blocking agent, rMETase, demonstrates the potential of cell-synchronization-based chemotherapy for breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-07-04.

P5-02-05: Real-Time Subcellular Imaging of Breast Cancer Cell Attachment in Blood Vessels Using GFP-Labeled Paxillin in Live Mice

Background: Paxillin is involved in the assembly of focal adhesions. We wish to visualize paxillin behavior in breast cancer cells in vivo, as well as in vitro.

Materials and Methods: Dual-photon confocal microscopy was used to image paxillin behavior by linking it to GFP. MDA-MB-231 human breast cancer cells expressing paxillin-GFP were imaged in vitro and in vivo adhering and trafficking in blood vessels in mice. 106 paxillin-GFP expressing breast cancer cells were injected in the epigastric cranialis vein.

Results: In vitro, round breast cancer cells had greater paxillin movement than stretched cancer cells as seen by fluorescence imaging. Paxillin-GFP breast cancer cells in the epigastric cranialis vein were initially rounded and had GFP-expressing protrusions. At later timepoints, many paxillin-GFP-expressing breast cancer cells stretched. The breast cancer cells then extravasated and subsequently grew around the outer surface of the blood vessel after one week. Two weeks after injection, paxillin-GFP expressing breast cancer cells were imaged migrating along the vessel wall. Most of the paxillin-GFP expressing breast cancer cells were stretched and were not mobile. With anti-VEGF treatment, paxillin was observed in round structures within the cells rather than stretched structures and paxillin movement within the cell was arrested.

Discussion: These results demonstrate that breast cancer cells brightly expressing paxillin-GFP and two-photon confocal microscopy can allow the visualization of the behavior of paxillin within breast cancer cells during adhesion and migration along the walls of blood vessels, as well as during anti-angiogenesis therapy.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-02-05.

Weight prediction from linear measures of growing Thoroughbreds

REASON FOR PERFORMING STUDY

Monitoring weight of foals is a useful management practice to aid in maximising athletic potential while minimising risks associated with deviations from normal growth.

OBJECTIVE

To develop predictive equations for weight, based on linear measurements of growing Thoroughbreds (TBs).

METHODS

Morphometric equations predicting weight from measurements of the trunk and legs were developed from data of 153 foals. The accuracy, precision and bias of the best fitting equation were compared to published equations using a naive data set of 22 foals.

RESULTS

Accuracy and precision were maximised with a broken line relating calculated volumes (V(t + l)) to measured weights. Use of the broken line is a 2 step process. V(t + l) is calculated from linear measures (m) of girth (G), carpus circumference (C), and length of body (B) and left forelimb (F). V(t + I) = ([G2 x B] + 4[C2 x F]) 4pi. If V(t + l) < 0.27 m3, weight is estimated: Weight (kg) = V(t + l) x 1093. If V(t + l) > or = 0.27 m3: Weight (kg) = V(t + l) x 984 + 24. The broken line was more accurate and precise than 3 published equations predicting the weight of young TBs.

CONCLUSIONS

Estimation of weight using morphometric equations requires attention to temporal changes in body shape and density; hence, a broken line is needed. Including calculated leg volume in the broken line model is another contributing factor to improvement in predictive capability.

POTENTIAL RELEVANCE

The broken line maximises its value to equine professionals through its accuracy, precision and convenience.

Targeted therapy of spinal cord glioma with a genetically modified Salmonella typhimurium

OBJECTIVE

Spinal cord tumours are highly malignant and often lead to paralysis and death due to their infiltrative nature, high recurrence rate and limited treatment options. In this study, we measured antitumour efficacy of the Salmonella typhimurium A1-R tumour-targeting bacterium strain, administered systemically or intrathecally, to spinal cord cancer in orthotopic mouse models.

MATERIALS AND METHODS

Tumour fragments of U87-RFP were implanted by surgical orthotopic implantation into the dorsal site of the spinal cord. Five and 10 days after transplantation, eight mice in each group were treated with A1-R (2 x 10(7) CFU/200 microL i.v. injection or 2 x 10(6) CFU/10 microL intrathecal injection).

RESULTS

Untreated mice showed progressive paralysis beginning at day 6 after tumour transplantation and developed complete paralysis between 18 and 25 days. Mice treated i.v. with A1-R had onset of paralysis at approximately 11 days and at 30 days; five mice developed complete paralysis, while the other three mice had partial paralysis. Mice treated by intrathecal injection of A1-R had onset of paralysis at approximately 18 days and one mouse was still not paralysed at day 30. Only one mouse developed complete paralysis at day 30 in this group. Intrathecally treated animals had a significantly better survival than the i.v. treated group as well as over the control group.

CONCLUSIONS

These results suggest that S. typhimurium A1-R monotherapy can effectively treat spinal cord glioma.

Clinically-relevent orthotopic metastatic models of pancreatic cancer imageable with fluorescent genetic reporters

This article describes authors' cumulative experience with the development and preclinical application of clinically-relevant, metastatic orthotopic mouse models of pancreatic cancer made imageable with genetic reporters. These models utilize the human pancreatic cancer cell lines which have been genetically engineered to selectively express high levels of green fluorescent protein (GFP) or red fluorescent protein (RFP). Tumors with fluorescent genetic reporters are established subcutaneously in nude mice, and fragments of the subcutaneous tumors are then surgically transplanted onto the pancreas. Loco-regional tumor growth and distant metastasis of these orthotopic implants occurs spontaneously and rapidly throughout the abdo-men in a manner consistent with clinical human disease. Highly specific, high-resolution, real-time quantitative fluorescence imaging of tumor growth and metastasis may be achieved in vivo without the need for contrast agents, invasive techniques, or expensive imaging equipment. A high correlation between florescence optical imaging, magnetic resonance imaging, and ultrasound in these models has been demonstrated. Transplantation of RFP-expressing tumor fragments onto the pancreas of GFP- or cyan fluorescent protein-expressing transgenic mice was used to facilitate visualization of tumor-host interaction between the pancreatic cancer cells and host-derived stroma and vasculature. Such in vivo models have enabled visualization in real time and acquisition of images of the progression of pancreatic cancer in the live animal, the models also demonstrate the real-time antitumor and antimetastatic effects of several novel therapeutic strategies on pancreatic malignancy. These fluorescent models are therefore powerful and reliable tools with which to investigate metastatic human pancreatic cancer and novel therapeutic strategies directed against it.

A color-coded orthotopic nude-mouse treatment model of brain-metastatic paralyzing spinal cord cancer that induces angiogenesis and neurogenesis

OBJECTIVE

Cancer of the spinal cord is highly malignant and often leads to paralysis and death. A realistic mouse model would be an important benefit for the better understanding and treatment of spinal cord glioma.

MATERIALS AND METHODS

To develop an imageable, patient-like model of this disease, U87 human glioma tumour fragments (expressing red fluorescent protein), were transplanted by surgical orthotopic implantation into the spinal cord of nontransgenic nude mice or transgenic nude mice expressing nestin-driven green fluorescent protein (ND-GFP). In ND-GFP mice, GFP is expressed in nascent blood vessels and neural stem cells. The animals were treated with temozolomide or vehicle control.

RESULTS

The intramedullary spinal cord tumour grew at the primary site, caused hind-limb paralysis and also metastasized to the brain. Temozolomide inhibited tumour growth (P<0.01) and prevented metastasis, as well as prevented paralysis in four mice and delayed paralysis in two mice of the six tested (P=0.005). In the ND-GFP-expressing host, ND-GFP cells staining positively for neuronal class III-beta-tubulin or CD31, surrounded the tumour. These results suggest that the tumour stimulated both neurogenesis and angiogenesis, respectively.

CONCLUSION

A patient-like model of spinal cord glioma was thus developed, which can be used for the discovery of new agents, including those that inhibit invasion and metastasis of the disease as well as those that prevent paralysis.

Variable stiffness colonoscope versus regular adult colonoscope: meta-analysis of randomized controlled trials

BACKGROUND AND STUDY AIMS

The variable stiffness colonoscope (VSC) may have theoretical advantages over standard adult colonoscopes (SACs), though data are conflicting. We conducted a meta-analysis to compare the efficacies of the VSC and SAC.

STUDY DESIGN

We searched Medline (1966 - 2008) and abstracts of gastroenterology scientific meetings in the 5 years to February 2008, only for randomized clinical trials (RCTs) of adult patients. Trial quality was assessed using the Delphi list. In a meta-analysis with a fixed effects model, cecal intubation rates, cecal intubation times, abdominal pain scores, sedation used, and use of ancillary maneuvers, were compared in separate analyses, using weighted mean differences (WMDs), standardized mean differences (SMDs), or odds ratios (ORs).

RESULTS

Seven RCTs satisfied the inclusion criteria (1923 patients), four comparing VSC with SAC procedures in adults, and three evaluating the pediatric VSC. There was no significant heterogeneity among the studies. The overall trial quality was adequate. Cecal intubation rate was higher with the use of VSC (OR = 2.08, 95 % confidence interval [CI] 1.29 to 3.36). The VSC was associated with lower abdominal pain scores and a decreased need for sedation during colonoscopy. Cecal intubation time was similar for the two colonscope types (WMD = - 0.21 minutes, 95 % CI - 0.85 to 0.43). Because of the nature of the intervention no studies were blinded. There was no universal method for using the VSC.

CONCLUSIONS

Compared with the SAC, VSC use was associated with a higher cecal intubation rate, less abdominal pain, and decreased need for sedation. However, cecal intubation times were similar for the two colonoscope types.

Imaging of cell trafficking and metastases of paediatric rhabdomyosarcoma

OBJECTIVE

The aim of this study was to establish a preclinical mouse model to study metastases of paediatric rhabdomyosarcoma at the macroscopic and cellular levels, with different imaging methods.

EXPERIMENTAL DESIGN

The alveolar rhabdomyosarcoma cell line Rh30 was stably transfected with the red fluorescent protein (DsRed2) then was xenotransplanted (intravenous injection [n = 8], and footpad injection [n = 8]) into nude mice (NMRI nu/nu). Macroscopic imaging of metastases was performed using DsRed2-fluorescence and flat-panel volumetric computed tomography scan. In a further series of animals (n = 8), in vivo cell trafficking of rhabdomyosarcoma cells using cellular imaging with an Olympus OV100 variable-magnification small-animal imaging system was used.

RESULTS

Metastases in the pelvis, thoracic wall and skin were visualized by fluorescence imaging. Pelvic metastases were found after tail vein injection and at other metastatic sites after footpad injection. Flat-panel volumetric computed tomography scan data allowed highly specific analysis of contrast between tumour and surrounding tissue. Correlation between fluorescence and flat-panel volumetric computed tomography scan imaging data was observed. Single-cell imaging visualized tumour cells in the vessels and demonstrated the arrest of tumour cells at vessel junctions followed by extravasation of the tumour cells.

CONCLUSION

We established a model for visualization of experimental metastatic invasion and describe relevant tools for imaging childhood rhabdomyosarcoma metastases at the macroscopic and cellular levels. Imaging of cell trafficking visualized the behaviour of tumour cells and development of metastases by accumulation and extravasation of rhabdomyosarcoma cells.

Microwave thermotherapy for benign prostatic hyperplasia

BACKGROUND

Transurethral resection of the prostate (TURP) has been the gold-standard treatment for alleviating urinary symptoms and improving urinary flow in men with symptomatic benign prostatic hyperplasia (BPH). However, the morbidity of TURP approaches 20%, and less invasive techniques have been developed for treating BPH. Preliminary data suggest that microwave thermotherapy, which delivers microwave energy to produce coagulation necrosis in prostatic tissue, is a safe, effective treatment for BPH.

OBJECTIVES

To assess the therapeutic efficacy and safety of microwave thermotherapy techniques for treating men with symptomatic benign prostatic obstruction.

SEARCH STRATEGY

Randomized controlled trials were identified from the Cochrane Collaboration Library, MEDLINE, EMBASE, bibliographies of retrieved articles and reviews, and by contacting expert relevant trialists and microwave manufacturers.

SELECTION CRITERIA

All randomized controlled trials evaluating transurethral microwave thermotherapy (TUMT) for men with symptomatic BPH were eligible for this review. Comparison groups could include transurethral resection of the prostate, minimally invasive prostatectomy techniques, sham thermotherapy procedures, and medications. Outcome measures included urinary symptoms, urinary function, prostate volume, mortality, morbidity, and retreatment. Two reviewers independently identified potentially relevant abstracts and then assessed the full papers for inclusion.

DATA COLLECTION AND ANALYSIS

Two reviewers independently abstracted study design, baseline characteristics and outcomes data and assessed methodological quality using a standard form. We attempted to obtain missing data from authors and/or sponsors.

MAIN RESULTS

Fourteen studies involving 1493 patients met inclusion criteria, including six comparisons of microwave thermotherapy with TURP, seven comparisons with sham thermotherapy procedures, and one comparison with an alpha blocker. Study durations ranged from 3 to 60 months. The mean age of subjects was 66.8 years, and the baseline symptom scores and urinary flow rates, which did not differ across treatment groups, demonstrated moderately severe lower urinary tract symptoms. The pooled mean urinary symptom scores decreased by 65% with TUMT and by 77% with TURP. The weighted mean difference (WMD) (95% confidence interval) for the symptom score was -1.36 (-2.25 to -0.46), favoring TURP. The pooled mean peak urinary flow increased by 70% with TUMT and by 119% with TURP. The WMD for peak urinary flow was 5.08 (3.88 to 6.28) mL/s, favoring TURP. Compared to TURP, TUMT was associated with decreased risks for retrograde ejaculation, treatment for strictures, hematuria, blood transfusions, and the transurethral resection syndrome, but increased risks for dysuria, urinary retention, and retreatment for BPH symptoms. Microwave thermotherapy improved symptom scores (IPSS WMD -4.75, 95% CI -3.89 to -5.60) and peak urinary flow (WMD 1.67 mL/s, 95% CI 0.99 to 2.34) compared with sham procedures. Microwave thermotherapy also improved symptom scores (IPSS WMD -4.20, 95% CI -3.15 to -5.25) and peak urinary flow (WMD 2.30 mL/s, 95% CI 1.47 to 3.13) in the one comparison with alpha blockers. No studies evaluated the effects of symptom duration, patient characteristics, prostate-specific antigen levels, or prostate volume on treatment response.

AUTHORS' CONCLUSIONS

Microwave thermotherapy techniques are effective alternatives to TURP and alpha-blockers for treating symptomatic BPH for men with no history of urinary retention or previous prostate procedures and prostate volumes between 30 to 100 mL. However, TURP provided greater symptom score and urinary flow improvements and reduced the need for subsequent BPH treatments compared to TUMT. Small sample sizes and differences in study design limit comparison between devices with different designs and energy levels. The effects of symptom duration, patient characteristics, or prostate volume on treatment response are unknown.

Anticoagulant drugs increase natural killer cell activity in lung cancer

BACKGROUND

In preclinical studies in animal models and in initial clinical trials, anticoagulation drugs have been shown to be effective in the prevention and treatment of haematogenous metastasis, and in the prolongation of survival in animal models. However, only a few studies have been performed on the direct influence of anticoagulation drugs on the immune system.

OBJECTIVE

The purpose of this study is to determine the effect of warfarin, unfractioned heparin, low molecular weight heparins (LMWHs), and acetylsalicylic acid anticoagulants on the functional activity of natural killer (NK) cells.

PATIENTS AND METHOD

Cytotoxic activity in patients with early, operable stages of non-small-cell lung cancer was compared with healthy volunteers. Cytotoxic studies were also carried out in tumor-bearing animals.

RESULTS

Lung-cancer patients were characterized by significantly lower NK cell cytotoxicity (7.07 +/- 3.15) than healthy donors (44.12 +/- 10.62, P < 0.001). NK cell activation was found in both in vitro experiments using peripheral blood mononuclear cells (PBMC) from healthy donors and ex vivo in lung carcinoma patients after treatment with unfractionated heparin and fraxiparine. Similarly, potentiation of NK cell activity in Lewis lung carcinoma-bearing mice was found after therapy with unfractionated heparin. NK cell activity is lower in lung cancer patients than in normal subjects.

CONCLUSIONS

NK cell activation was increased by LMWHs. Other anticoagulants augment the effector function of NK cells in cancer patients and in an animal model of lung cancer. This is a novel effect of these compounds, which were thought previously to exert their effect only via their anticoagulant properties.

Monitoring of skeletal progression of prostate cancer by GFP imaging, X-ray, and serum OPG and PTHrP

BACKGROUND

Prostate cancers (PCas) produce factors that can serve as biomarkers for tumor metastasis and bone progression. Transduced GFP expression by cancer cells can be imaged to monitor therapy. We exploited both concepts by developing a GFP-expressing PCa cell line that expresses PTHrP and studying it in an animal model of malignancy with methods that assess the skeletal progression of this tumor.

METHODS

We developed a GFP-producing PCa cell line by stable transduction of PC-3 PCa cells. This PC-3 variant was used to study tumor progression in an immunocompromised mouse model. Skeletal progression of the PCa cells and the effects of pamidronate administration were evaluated radiologically, fluorometrically, and by measurement of serum tumor markers.

RESULTS

The PC-3 cells produced extensive bone lesions when injected into the tibia of immunocompromised mice. The skeletal progression of the PC-3 cells could be monitored by GFP optical imaging, X-ray, and by measurements of tumor products in serum, notably PTHrP and OPG. Pamidronate treatment reduced tumor burden as assessed at autopsy by imaging and biomarkers.

CONCLUSIONS

Pamidronate treatment exhibited anti-tumor effects that were reflected by decreases in serum PTHrP, OPG, and by GFP and radiological imaging procedures. Imaging of GFP expression enables real-time monitoring of tumor growth in the bone. PTHrP and OPG may be useful as tumor biomarkers for PCa that has metastasized to bone. This novel human PCa model can be used to study the clinical potential of diagnostic and therapeutic modalities in the skeletal progression of PCas.

Antioxidant supplementation and subsequent oxidative stress of horses during an 80-km endurance race1

This study tested the development of oxidative stress and the effects of antioxidant supplementation in an 80-km ride. A precompetition survey revealed that no competitor would participate without vitamin E supplementation; therefore, 46 horses were paired for past performances and randomly assigned to two groups of 23 each for 3 wk of supplementation before the ride. One group (E) was orally supplemented with 5,000 IU of vitamin E per day; the other group (E+C) received that dose of vitamin E plus 7 g/d of vitamin C. Blood samples, temperature, and heart rate were taken the day before the race, at 21 and 56 km during the ride, at completion, and after 20 min of recovery. Plasma was assayed for lipid hydroperoxides, alpha-tocopherol, total ascorbate, albumin, creatine kinase (CK), and aspartate aminotransferase (AST). Total glutathione and glutathione peroxidase activity were determined in red blood cells and white blood cells. Thirty-four horses completed the race, 12 horses (six in E and six in E+C) did not finish for reasons including lameness, metabolic problems, and rider option. Plasma ascorbate was higher (P = 0.045) in the E+C group than in the E group. Other than ascorbate, neither antioxidant status nor CK and AST activities were affected by supplementation with E+C vs. E. Red blood cell glutathione peroxidase, white blood cell total glutathione, lipid hydroperoxides, CK, and AST increased, and red blood cell total glutathione and white blood cell glutathione peroxidase activity decreased with distance (P < 0.001). Positive correlations were found for plasma lipid hydroperoxides on CK (r = 0.25; P = 0.001) and AST (r = 0.33; P < 0.001). These results establish an association between muscle leakage and a cumulative index of oxidative stress.

Obesity and diet affect glucose dynamics and insulin sensitivity in Thoroughbred geldings

Insulin resistance is considered a risk factor in obesity, laminitis, exertional rhabdomyolysis, and osteochondrosis. The objective was to use the minimal model to estimate glucose effectiveness (Sg) and insulin sensitivity (Si) in nonobese to obese horses initially adapted to forage only, then adapted to forage plus supplements rich in starch and sugar (SS) or fiber and fat (FF). Ten Thoroughbred geldings, with BCS of 5 (nonobese), 6 (moderately obese), and 7 to 8 (obese), were adapted to pasture and hay, allocated to two groups, and fed SS or FF in a switch-back design with 8 wk of adaptation. Modified frequent-sampling i.v. glucose tolerance tests were applied after adaptation to forage, SS, and FF. For the tolerance tests, horses were kept in stalls overnight and provided hay, and venous catheters were placed the next morning. Baseline samples were collected, 0.3 g of glucose/kg of BW was given i.v., and blood was sampled at 1, 2, 3, 4, 5, 6, 7, 8, 10, 12, 14, 16, and 19 min. At 20 min, 30 mU of insulin/kg of BW was given, followed by sampling at 22, 23, 24, 25, 27, 30, 35, 40, 50, 60, 70, 80, 90, 100, 120, 150, and 180 min. Plasma was analyzed for glucose and insulin, and Si, Sg, acute insulin response to glucose, and the disposition index were calculated. Normality was tested using the Shapiro-Wilk statistic. Body condition effects were analyzed using a mixed model with repeated measures. Diet effects were analyzed using a Wilcoxon signed rank test. The Sg was higher in obese than nonobese (P = 0.003) and moderately obese (P = 0.007) horses; Si was lower in obese than nonobese (P = 0.008) horses, and acute insulin response to glucose was higher in obese than nonobese (P = 0.039) horses. Effects of diet were likely confounded by body condition, but horses had lower Si (P = 0.066) when fed SS compared with FF, especially when nonobese. In conclusion, the minimal model effectively estimated Sg, Si, acute insulin response to glucose, and disposition index in horses. Obese geldings were insulin-resistant and seemed to rely primarily on Sg for glucose disposal. Feeding a diet rich in sugar and starch decreased insulin sensitivity of horses. Maintenance of body condition and avoidance of grain-based meals rich in sugar and starch would be beneficial to decrease the risk of developing insulin resistance and associated metabolic syndromes in horses, especially for horses at risk for these syndromes.

Factors affecting diabetes knowledge in Type 2 diabetic veterans

AIMS/HYPOTHESIS

To describe the clinical, psychological and social factors affecting diabetes knowledge of veterans with established Type 2 diabetes.

METHODS

We conducted an observational study of 284 insulin-treated veterans with stable Type 2 diabetes. All subjects completed the University of Michigan Diabetes Research and Training Centre Knowledge Test, the Diabetes Care Profile, the Mini-Mental State Examination, the Geriatric Depression Scale, and the Diabetes Family Behaviour Checklist. Stepwise multiple linear regression was used to develop a model for the diabetes knowledge score based upon clinical and psychosocial variables.

RESULTS

One hundred eighty subjects were evaluated in a derivation set. The mean age +/- SD was 65.4+/-9.6 years, 94% were men, and 36% were members of a minority group. Performance on the diabetes knowledge test was poor (64.9+/-15.3% correct). Self-perceived understanding of all management objectives explained only 6% of the variance in the knowledge scores. Multivariate analysis showed that age, years of schooling, duration of treatment, cognitive function, sex, and level of depression were independent determinants of the knowledge score. When the model was applied to 104 subjects in a validation set, there was a strong correlation between observed and predicted scores (r=0.537; p<0.001).

CONCLUSIONS/INTERPRETATION

Stable, insulin-treated veterans have major deficiencies in diabetes knowledge that could impair their ability to provide self-care. A multivariate model comprised of demographic variables and psychosocial profiling can identify patients who have limited diabetes knowledge and be used to assess individual barriers to ongoing diabetes education.

Glucose clearance in grazing mares is affected by diet, pregnancy, and lactation

The glucose tolerance test in the horse may be used to determine metabolic responses to diet, disease, or physiologic state. The objective of this study was to determine the effect of reproductive stage (gestation and lactation) and supplemental dietary energy source (sugar and starch [SS] or fiber and fat [FF]) on glucose metabolism in grazing mares using an oral glucose tolerance test. Twelve mares, six on each supplement, were examined on three occasions: one in the third trimester of pregnancy, the second in early lactation, and the third in late lactation. During each test, venous samples were taken at 30 and 1 min before, and 30, 60, 90, 120, 150, 180, 240, and 300 min after a nasogastric dose of glucose at 0.2 g/kg of BW. Plasma was assayed for glucose, insulin, and cortisol. Statistical analysis was a mixed model with repeated measures with horse, diet, and reproductive stage as fixed effects. The incremental glucose area under the curve (AUC) in response to oral glucose was lower in SS than in FF mares (P = 0.022). Mares tended to have a lower incremental glucose AUC in early lactation than in late gestation (P = 0.057), and insulin AUC was lower in early lactation than in late gestation (P = 0.002) and late lactation (P = 0.013). Glucose clearance was more rapid (P = 0.007) in SS than in FF mares. The glycemic response to the oral glucose tolerance test was consistent with adaptation to dietary sugar and starch as well as metabolic changes associated with pregnancy and lactation. Feeding twice-daily grain meals rich in SS influenced glucose metabolism in horses to an extent that the natural adaptation of glucose metabolism to pregnancy was moderated. Feeding a diet rich in FF more closely mimics the natural grazing state of pasture and allows for adaptation of glucose metabolism to pregnancy and lactation.

Methioninase gene therapy with selenomethionine induces apoptosis in bcl-2-overproducing lung cancer cells

We have previously shown that the toxic pro-oxidant methylselenol is released from selenomethionine (SeMET) by cancer cells transformed with the adenoviral methionine alpha,gamma-lyase (methioninase, MET) gene cloned from Pseudomonas putida. Methylselenol damaged the mitochondria via oxidative stress, and caused cytochrome c release into the cytosol thereby activating caspase enzymes and thereby apoptosis. However, gene therapy strategies are less effective if tumor cells overexpress the antiapoptotic mitochondrial protein bcl-2. In this study, we investigated whether rAdMET/SeMET was effective against bcl-2-overproducing A549 lung cancer cells. We established two clones of the human lung cancer A549 cell line that show moderate and high expression levels of bcl-2, respectively, compared to the parent cell line, which has very low bcl-2 expression. Staurosporine-induced apoptosis was inhibited in the bcl-2-overproducing clones as well as in the parental cell line. In contrast to staurosporine, apoptosis was induced in the bcl-2-overproducing clones as well as the parental cell line by AdMET/SeMET. Apoptosis in the rAdMET-SeMET-treated cells was determined by fragmentation of nuclei, and release of cytochrome c from mitochondria to the cytosol. A strong bystander effect of AdMET/SeMET was observed on A549 cells as well as the bcl-2-overproducing clones. rAdMET/SeMET prodrug gene therapy is therefore a promising novel strategy effective against bcl-2 overexpression, which has blocked other gene therapy strategies.

Combination efficacy of doxorubicin and adenoviral methioninase gene therapy with prodrug selenomethionine

We have previously demonstrated an enzyme activation prodrug gene therapy strategy using the methionine alpha,gamma-lyase gene (MET) cloned from Pseudomonas putida, in combination with selenomethionine (SeMET) as a prodrug. MET gene transfer via a recombinant adenovirus (Ad-MET) converts the physiologic compound SeMET to highly toxic methylselenol. In this study, we have developed a combination therapy approach using Ad-MET/SeMET gene therapy and doxorubicin (DOX). The combination significantly delayed the growth of H460, an aggressively-growing human lung cancer cell line, in nude mice. H460 cells were injected intra-dermally in nude mice. Tumor-bearing mice were divided into 12 groups [Control (Ctrl), DOX, SeMET, SeMET + DOX, Ad-Ctrl, Ad-Ctrl + SeMET, Ad-Ctrl + DOX, Ad-Ctrl + SeMET + DOX, Ad-MET, Ad-MET + DOX, Ad-MET + SeMET, and Ad-MET + SeMET + DOX]. DOX (2 mg/kg body weight) was given intra-peritoneally twice at 7-day intervals. SeMET (1 microM/mouse) was given by intra-tumor injection everyday, starting the following day after transfection with adenovirus. Tumor growth in the untreated group showed a 10-fold increase in tumor volume after two weeks. In contrast, the increase was only 2.5-fold in the DOX + Ad-MET/SeMET group. The treatment with DOX alone at the low-dose used showed no effect compared to the control group. There was a 5.8-fold increase in tumor volume in mice treated with Ad-MET/SeMET gene therapy alone. The tumor doubling-time was increased to approximately 10 days with the combination therapy of Ad-MET + SeMET + DOX as opposed to 2-3 days in all other treatment groups.

Speed associated with plasma pH, oxygen content, total protein and urea in an 80 km race

To test the hypothesis that endurance performance may be related quantitatively to changes in blood, we measured selected blood variables then determined their reference ranges and associations with speed during an 80 km race. The plan had 46 horses in a 2 x 2 factorial design testing a potassium-free electrolyte mix and a vitamin supplement. Blood samples were collected before the race, at 21, 37, 56 and 80 km, and 20 min after finishing, for assay of haematocrit, plasma pH, pO2, pCO2, [Na+], [K+], [Ca++], [Mg++], [Cl-], lactate, glucose, urea, cortisol, alpha-tocopherol, ascorbate, creatine kinase, aspartate amino transferase, lipid hydroperoxides, total protein, albumin and creatinine, and erythrocyte glutathione and glutathione peroxidase. Data from 34 finishers were analysed statistically. Reference ranges for resting and running horses were wide and overlapping and, therefore, limiting with respect to evaluation of individual horses. Speed correlations were most repeatable, with variables reflecting blood oxygen transport (enabling exercise), acidity and electrolytes (limiting exercise) and total protein (enabling then, perhaps, limiting). Stepwise regressions also included plasma urea concentration (limiting). The association of speed with less plasma acidity and urea suggests the potential for fat adaptation and protein restriction in endurance horses, as found previously in Arabians performing repeated sprints. Conditioning horses fed fat-fortified and protein-restricted diets may not only improve performance but also avoid grain-associated disorders.

Disagreement between height/weight classifications of underweight, normal weight, and obesity in peritoneal dialysis patients

Peritoneal dialysis (PD) patients are classified as underweight, normal weight, or obese by height/weight indices including body mass index (BMI) and the body weight/desired weight (W/DW) ratio. We compared these classifications of degree of obesity in 378 women and 555 men on PD. We used these cut-off values: for underweight, BMI < or = 18.5 and W/DW < or = 0.9; for obesity, BMI > or = 30.0 and W/DW > or = 1.2. The W/DW values were calculated assuming first a small frame, then a medium frame, and finally a large frame for all subjects. Regardless of sex or skeletal frame, BMI correlated highly with W/DW (r value between 0.98 and 0.99); however, the range of BMI values corresponding by linear regression to the normal range of W/DW (0.9-1.2) was narrower than the range of "normal" BMI (18.5-30.0). Consequently, regardless of sex or skeletal frame, smaller fractions of the patient population were classified as underweight or obese by BMI standards than by W/DW standards. The degree of agreement of the classifications of subjects as underweight, normal weight, or obese by BMI and W/DW was evaluated by Cohen's kappa ratio. The kappa ratio varied between 0.47 and 0.58, indicating a reasonable--but not high--degree of agreement beyond chance. The highest kappa ratios were obtained assuming a medium skeletal frame for both women and men. Substantial discrepancies are observed in the classification of PD patients as underweight, normal weight, or obese by BMI and W/DW. Further research is needed to identify the height/weight index that has the strongest association both with clinical outcomes and with other, more precise measurements of body fat content.

Acquisition of multidrug resistance in recurrent breast cancer demonstrated by the histoculture drug response assay

Recurrent breast cancer has a very poor response rate to chemotherapy. To understand the degree of acquisition of multidrug resistance in recurrent disease, 24 recurrent breast tumors and 127 primary tumors were evaluated and compared for chemosensitivity in the histoculture drug response assay (HDRA). The evaluation rate was 98.8%. The HDRA utilizes 3-dimensional culture of human tumors on collagen-gel rafts. Doxorubicin (DXR), 5-fluorouracil (5-FU) and mitomycin C (MMC) were tested as standard agents and cisplatin (CDDP) as a candidate agent on surgical specimen of breast cancer in the HDRA. In vitro drug exposure in the HDRA was for 7 days. At the end of the assay, tumor response was assessed by the reduction of 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT). The mean inhibition rates of primary tumors vs. recurrent tumors were 57.9% and 38.6% for DXR (p<0.0005); 59.9% and 42.8% for MMC (p<0.01); 49.0% and 33.4% for 5-FU (p<0.01); and 34.5% and 16.0% for CDDP (p<0.005), respectively. The recurrent cases were pretreated clinically with CAF (cyclophosphamide, DXR and 5-FU), CEF (cyclophosphamide, epirubicin and 5-FU) or CMF (cyclophosphamide, methotrexate and 5-FU). In the CAF and CEF group, the HDRA sensitivity to CDDP was significantly lower in recurrent disease (p<0.005) than that of primary breast cancer suggesting that one agent can induce resistance to another. This is further suggested by the fact that 64.7% of the recurrent cases were resistant to all 4 agents tested as opposed to 27% of the primary cases and that only 5.9% of the recurrent cases were sensitive to three or more agents as opposed to 18% of the primary cases. The correlation of the HDRA results to clinical outcome in the study was 80.0% with 15 cases evaluated consisting of 5 true positives, 3 false positives, 7 true negatives and no false negatives. Thus, the HDRA gives useful clinical information, in particular for the specific individualized treatment design necessary to overcome the multidrug resistance problem of recurrent breast cancer.

Step-down management of gastroesophageal reflux disease

BACKGROUND & AIMS

As the economic burden of gastroesophageal reflux disease (GERD) is largely weighted to maintenance as opposed to initial therapy, switching from more potent to less expensive medication once symptoms are alleviated (step-down therapy) may prove to be most cost-effective. This study aimed to prospectively evaluate the feasibility of step-down therapy in a cohort of patients with symptoms of uncomplicated GERD.

METHODS

Patients whose GERD symptoms were alleviated by proton pump inhibitors (PPIs) were recruited from outpatient general medicine clinics. After baseline demographic and quality of life information were obtained, PPIs were withdrawn from subjects in a stepwise fashion. Primary outcome was recurrence of symptoms during follow-up that required reinstitution of PPIs. Secondary outcomes included changes in quality of life and overall cost of management. Predictors of nonresponse to step-down were assessed.

RESULTS

Seventy-one of 73 enrolled subjects completed the study. Forty-one of 71 (58%) were asymptomatic off PPI therapy after 1 year of follow-up. Twenty-four of 71 (34%) required histamine 2-receptor antagonists, 5/71 (7%) prokinetic agents, 1/71 (1%) both, and 11/71 (15%) remained asymptomatic without medication. Quality of life did not significantly change, whereas management costs decreased by 37%. Multivariable analysis revealed younger age and a dominant symptom of heartburn to predict PPI requirement.

CONCLUSIONS

Step-down therapy is successful in the majority of patients and can decrease costs without adversely affecting quality of life.

Methioninase cancer gene therapy with selenomethionine as suicide prodrug substrate

In this study, we report a novel approach to gene-directed enzyme prodrug therapy for cancer. This gene therapy strategy exploits the toxic pro-oxidant property of methylselenol, which is released from selenomethionine (SeMET) by cancer cells with the adenoviral-delivered methionine alpha,gamma-lyase (MET) gene cloned from Pseudomonas putida. In MET-transduced tumor cells, the cytotoxicity of SeMET is increased up to 1000-fold compared with nontransduced cells. A strong bystander effect occurred because of methylselenol release from MET gene-transduced cells and uptake by surrounding tumor cells. Methylselenol damaged the mitochondria via oxidative stress and caused cytochrome c release into the cytosol, thereby activating the caspase cascade and apoptosis. Adenoviral MET-gene/SeMET treatment also inhibited tumor growth in rodents and significantly prolonged their survival. Recombinant adenovirus-encoding MET gene-SeMET treatment thereby offers a new paradigm for cancer gene therapy.

Comparison of self-reported initial treatment with medical records: results from the prostate cancer outcomes study

Medical records are generally accepted as the most accurate source of information documenting cancer treatments. However, as the health care system becomes more decentralized and more cancer care is delivered in outpatient settings, it is increasingly difficult and expensive to review records from the many surgeons and medical/radiation oncologists who administer cancer therapies in the community setting. Using 1994-1995 data, the authors compared initial treatment for prostate cancer self-reported (from a mailed questionnaire or telephone/in-person interview) by 3,196 US men in the population-based Prostate Cancer Outcomes Study with information obtained from medical records. Agreement between self-reports and medical records varied by type of treatment. Generally, agreement was excellent for more invasive procedures such as prostatectomy or radiation (kappa values > 0.8), with decreasing agreement for hormone shots and pills (kappa values < 0.7). If the medical record abstract is assumed to be the "gold standard," the estimated sensitivity was generally high (>80%) for prostatectomy and radiation but low (68%) for hormone pills, although the estimated specificity was 90% or greater for all treatments. These results can serve as a useful guide to researchers contemplating the use of surveys as an alternative to medical record abstraction to ascertain treatment in studies of patient outcomes.

Quality-of-life outcomes after primary androgen deprivation therapy: results from the Prostate Cancer Outcomes Study

PURPOSE

To compare health-related quality-of-life outcomes after primary androgen deprivation (AD) therapy with orchiectomy versus luteinizing hormone-releasing hormone (LHRH) agonists for patients with prostate cancer.

PATIENTS AND METHODS

Men (n = 431) newly diagnosed with all stages of prostate cancer from six geographic regions who participated in the Prostate Cancer Outcomes Study and who received primary AD therapy but no other treatments within 12 months of initial diagnosis were included in a study of health outcomes. Comparisons were statistically adjusted for patient sociodemographic and clinical characteristics, timing of therapy, and use of combined androgen blockade.

RESULTS

More than half of the patients receiving primary AD therapy had been initially diagnosed with clinically localized prostate cancer. Among these patients, almost two thirds were at high risk of progression on the basis of prognostic factors. Sexual function outcomes were similar by treatment group both before and after implementation of AD therapy. LHRH patients reported more breast swelling than did orchiectomy patients (24.9% v 9.7%, P <.01). LHRH patients reported more physical discomfort and worry because of cancer or its treatment than did orchiectomy patients. LHRH patients assessed their overall health as fair or poor more frequently than did orchiectomy patients (35.4% v 28.1%, P =.01) and also were less likely to consider themselves free of prostate cancer after treatment.

CONCLUSION

Most endocrine-related health outcomes are similar after surgical versus medical primary hormonal therapy. Stage at diagnosis had little effect on outcomes. These results provide representative information comparing surgical and medical AD therapy that may be used by physicians and patients to inform treatment decisions.

Effect of preventing Staphylococcus aureus carriage on rates of peritoneal catheter-related staphylococcal infections. Literature synthesis

OBJECTIVE

To determine whether specific preventive measures reduce the rate of peritoneal catheter-related infections and peritoneal catheter loss due to Staphylococcus aureus.

DESIGN

Structured literature synthesis.

METHODS

Relevant studies were identified by MEDLINE search, from personal files, and from the reference lists of retrieved articles. We analyzed English-language studies on treatment targeted at S. aureus, with at least 10 subjects and at least 3 months of follow-up, and data on staphylococcal peritoneal dialysis catheter infections. We excluded noncontrolled studies. Two investigators abstracted data using a structured form.

RESULTS

We evaluated six studies with concurrent controls and eight studies with historical controls. In one randomized, placebo-controlled, blinded study, periodic nasal mupirocin ointment reduced the rate of staphylococcal exit-site infection from 0.42 to 0.12 episodes/patient-year (p = 0.006), but had no effect on the rates of staphylococcal tunnel infection, peritonitis, or catheter loss. In one randomized study without placebo control, periodic oral rifampin reduced the rate of staphylococcal exit-site infection from 0.65 to 0.22 epi/pt-yr (p = 0.011), but had no effect on the rate of staphylococcal peritonitis. In another nonblinded, randomized, controlled study, the use of either rifampin or mupirocin was associated with low rates of staphylococcal catheter infections and catheter loss. In one study with historical controls, the rate of staphylococcal exit-site infection and peritonitis was lower after oral rifampin prophylaxis. In seven other studies comparing nasal or exit-site mupirocin to historical controls, the rate of staphylococcal exit-site infection decreased from 0.17 to 0.05 epi/pt-yr, the rate of staphylococcal peritonitis decreased from 0.18 to 0.06 epi/pt-yr, and the rate of catheter loss decreased from 0.09 to 0.05 epi/pt-yr during the mupirocin period.

CONCLUSION

The literature provides strong evidence that staphylococcal carriage prophylaxis using either oral rifampin or mupirocin ointment in the nares or exit site reduces significantly the rate of exit-site infection due to Staphylococcus aureus. Weaker evidence based on studies with historical controls suggests that rifampin or mupirocin prophylaxis also reduces the rate of staphylococcal peritonitis and peritoneal catheter loss. Studies with a stronger level of evidence are needed to verify this last point.

Spatial-temporal imaging of bacterial infection and antibiotic response in intact animals

We describe imaging the luminance of green fluorescent protein (GFP)-expressing bacteria from outside intact infected animals. This simple, nonintrusive technique can show in great detail the spatial-temporal behavior of the infectious process. The bacteria, expressing the GFP, are sufficiently bright as to be clearly visible from outside the infected animal and recorded with simple equipment. Introduced bacteria were observed in several mouse organs including the peritoneal cavity, stomach, small intestine, and colon. Instantaneous real-time images of the infectious process were acquired by using a color charge-coupled device video camera by simply illuminating mice at 490 nm. Most techniques for imaging the interior of intact animals may require the administration of exogenous substrates, anesthesia, or contrasting substances and require very long data collection times. In contrast, the whole-body fluorescence imaging described here is fast and requires no extraneous agents. The progress of Escherichia coli-GFP through the mouse gastrointestinal tract after gavage was followed in real-time by whole-body imaging. Bacteria, seen first in the stomach, migrated into the small intestine and subsequently into the colon, an observation confirmed by intravital direct imaging. An i.p. infection was established by i.p. injection of E. coli-GFP. The development of infection over 6 h and its regression after kanamycin treatment were visualized by whole-body imaging. This imaging technology affords a powerful approach to visualizing the infection process, determining the tissue specificity of infection, and the spatial migration of the infectious agents.

Chronologically-specific metastatic targeting of human pancreatic tumors in orthotopic models

Pancreatic cancer is a highly metastatic disease that responds poorly to currently-available treatment. In order to better visualize and understand the chronology and specificity of metastatic targeting of pancreatic cancer, two human pancreatic cancer cell lines, expressing green fluorescent protein (GFP), were studied in orthotopic models. MIA-PaCa2-GFP and BxPC-3-GFP tumor fragments were transplanted by surgical orthotopic implantation (SOI) to the nude mouse pancreas for fluorescence visualization of the chronology of pancreatic tumor growth and metastatic targeting. BxPC-3-GFP tumors developed rapidly in the pancreas and spread regionally to the spleen and retroperitoneum as early as six weeks. Distant metastases in BxPC-3-GFP were rare. In contrast, MIA-PaCa-2-GFP grew more slowly in the pancreas but rapidly metastasized to distant sites including liver and portal lymph nodes. Regional metastases in MIA-PaCa-2-GFP were rare. These studies demonstrate that pancreatic cancers have highly specific and individual 'seed-soil' interactions governing the chronology and sites of metastatic targeting.

Synergy between methionine stress and chemotherapy in the treatment of brain tumor xenografts in athymic mice

This study describes a novel approach to the treatment of brain tumors with the combination of recombinant L-methionine-alpha-deamino-gamma-lyase and chemotherapeutic regimens that are currently used against such tumors. The growth of Daoy, SWB77, and D-54 xenografts in athymic mice was arrested after the depletion of mouse plasma methionine (MET) with a combination of a MET- and choline-free diet and recombinant L-methionine-alpha-deamino-gamma-lyase. The treated tumor-bearing mice were rescued from the toxic effects of MET withdrawal with daily i.p. homocystine. This regimen suppressed plasma MET to levels below 5 microM for several days, with no treatment-related deaths. MET depletion for 10-12 days induced mitotic and cell cycle arrest, apoptotic death, and widespread necrosis in tumors but did not prevent tumor regrowth after cessation of the regimen. However, when a single dose of 35 mg/m(2) of N,N'-bis(2-chloroethyl)-N-nitrosourea (BCNU), which was otherwise ineffective as a single therapy in any of the tumors tested, was given at the end of the MET depletion regimen, a more than 80-day growth delay was observed for Daoy and D-54, whereas the growth of SWB77 was delayed by 20 days. MET-depleting regimens also trebled the efficacy of temozolomide (TMZ) against SWB77 when TMZ was given to animals as a single dose of 180 mg/m(2) at the end of a 10-day period of MET depletion. The enhanced responses of both Daoy and SWB77 to DNA alkylating agents such as BCNU and TMZ could be attributed to the down-regulation of O(6)-methylguanine-DNA methyltransferase activity. However, the synergy of MET depletion and BCNU observed with D-54 tumors, which do not express measurable O(6)-methylguanine-DNA methyltransferase protein, is probably mediated by a different mechanism. MET depletion specifically sensitizes tumors to alkylating agents and does not significantly lower the toxicity of either BCNU or TMZ for the host. In this regard, the combination approach of MET depletion and genotoxic chemotherapy demonstrates significant promise for clinical evaluation.

CT features of pulmonary alveolar proteinosis

OBJECTIVE

This investigation describes the CT features of pulmonary alveolar proteinosis in a large group of patients.

MATERIALS AND METHODS

A retrospective review of 139 chest CT scans (79 thick-section scans and 60 thin-section scans) from 27 patients with pathologically proven pulmonary alveolar proteinosis was performed. Two independent observers assessed the intraslice patterns and zonal distribution of disease on three CT images of each lung. The observers also graded the percentage of ground-glass opacities, air-space opacities, fibrosis, interlobular opacities, intralobular opacities, and emphysema in each slice. CT scans obtained before and after lavage related to 12 whole-lung lavage treatments on nine patients were evaluated.

RESULTS

The dominant intraslice pattern was geographic, but a diffuse pattern was sometimes seen. The most common zonal pattern was uniform; a lower zone predominance was next most frequent. Ground-glass, air-space, and fibrotic opacities had a generally homogeneous craniocaudal distribution, but there was a trend toward more interlobular opacities at the lung bases (p < 0.002). Ground-glass opacities were seen on at least one scan in 100% of the patients. Interlobular opacities (85%), air-space opacities (78%), substantial fibrosis (7%), and intralobular opacities (7%) occurred less frequently. Compared with thick-section images, thin-section images showed more interlobular opacities, but no difference in ground-glass, air-space, or fibrotic disease. The proportion of lung affected by ground-glass and interlobular opacities decreased significantly (p < 0.05) after lavage.

CONCLUSION

Pulmonary alveolar proteinosis does not present only with alveolar disease. The CT appearance typically combines different types of opacities with a geographic pattern and a uniform zonal distribution with variation over time.

Visualization of GFP-Expressing Tumors and Metastasis In Vivo

We have developed mouse models of metastatic cancer with genetically fluorescent tumors that can be imaged in fresh tissue, in situ, as well as externally. To achieve this capability, we have transduced the green fluorescent protein (GFP) gene, cloned from the bioluminescent jellyfish Aequorea victoria, into a series of human and rodent cancer cell lines that were selected in vitro to stably express GFP in vivo after transplantation to metastatic rodent models. Techniques were also developed for transduction of tumors by GFP in vivo. With this fluorescent tool, we detected and visualized for the first time tumors and metastasis in fresh viable tissue or in situ in host organs down to the single-cell level. GFP tumors on the colon, prostate, breast, brain, liver, lymph nodes, lung, pancreas, bone, and other organs can also be visualized externally, transcutaneously by quantitative whole-body fluorescence optical imaging. Real-time tumor and metastatic growth and angiogenesis and inhibition by representative drugs can be imaged and quantified for rapid antitumor, antimetastatic, and antiangiogenesis drug screening. The GFP-transfected tumor cells enabled a fundamental advance in the visualization of tumor growth and metastasis in real time in vivo.

Health outcomes after external-beam radiation therapy for clinically localized prostate cancer: results from the Prostate Cancer Outcomes Study

PURPOSE

Studies reporting effects of radiotherapy for prostate cancer on sexual, bowel, and urinary function have been conducted primarily in referral centers or academic institutions. Effects of external-beam radiotherapy for prostate cancer among a population-based cohort were assessed.

PATIENTS AND METHODS

The study population included 497 white, Hispanic, and African-American men with localized prostate cancer from six US cancer registries who were diagnosed between October 1, 1994, and October 31, 1995, and treated initially with external-beam radiotherapy. They were interviewed at regular intervals, and medical records were reviewed. Distributions of responses for bowel-, urinary-, and sexual-related functions at 6, 12, and 24 months after diagnosis and adjusted mean composite change scores for each domain were analyzed.

RESULTS

Declines of 28.9% in the sexual function score and 5.4% in the bowel function score occurred by 24 months, whereas at this time, the urinary function score was relatively unchanged. A total of 43% of those who were potent before diagnosis became impotent after 24 months. More than two thirds of the men were satisfied with their treatment and would make the same decision again.

CONCLUSION

Sexual function was the most adversely affected quality-of-life domain, with problems continuing to increase between 12 and 24 months. Bowel function problems increased at 6 months, with partial resolution observed by 24 months. Despite the side effects, satisfaction with therapy was high. These results are representative of men in community practice settings and may be of assistance to men and to clinicians when making treatment decisions.

Cytotoxic synergism of methioninase in combination with 5-fluorouracil and folinic acid

Potentiation of the cytotoxic activity of 5-fluorouracil (FUra) by folinic acid (5-HCO-H4folate) is due to elevation of the methylene tetrahydrofolate (CH2-H4folate) level, which increases the stability of the ternary complex of thymidylate synthase (TS), fluorodeoxyuridine monophosphate, and CH2-H4folate that inactivates the TS. Methionine deprivation results in the production of tetrahydrofolate (H4folate) and, subsequently, CH2-H4folate from methyl tetrahydrofolate, as a consequence of the induction of methionine synthesis. We hypothesized that the efficacy of FUra could be augmented by the combination of high-concentration 5-HCO-H4folate and recombinant methioninase (rMETase), a methionine-cleaving enzyme. Studies in vitro were performed with the cell line CCRF-CEM. Cytotoxic synergism of FUra + rMETase and FUra + 5-HCO-H4folate + rMETase was demonstrated with the combination index throughout a broad concentration range of FUra and rMETase. A subcytotoxic concentration of rMETase reduced the IC50 of FUra by a factor of 3.6, and by a factor of 7.5, in the absence and in the presence of 5-HCO-H4folate, respectively. 5-HCO-H4folate increased the intracellular concentrations of CH2-H4folate and H4folate from their baseline levels. Concentrations of folates were not changed by exposure to rMETase. Levels of free TS in cells treated with FUra + 5-HCO-H4folate and with FUra + rMETase were lower than those in cells exposed to FUra alone. The decrease of TS was still more pronounced in cells treated with FUra + 5-HCO-H4folate + rMETase. The synergism described in this study will be a basis for further exploration of combinations of fluoropyrimidines, folates, and rMETase.

Racial and ethnic differences in advanced-stage prostate cancer: the Prostate Cancer Outcomes Study

BACKGROUND

African-Americans have twice the risk of non-Hispanic whites for presenting with advanced-stage prostate cancer. To investigate the reasons for this difference, we evaluated the association between race/ethnicity and advanced-stage prostate cancer, adjusting for demographic, socioeconomic, clinical, and pathologic factors.

METHODS

A population-based cohort of 3173 men diagnosed with prostate cancer between October 1, 1994, and October 31, 1995, was analyzed. Medical record abstracts and self-administered survey questionnaires were used to obtain information regarding race/ethnicity, age, marital status, insurance status, educational level, household income, employment status, comorbidity, urinary function, prostate-specific antigen level, tumor grade, and clinical stage. The odds ratio (OR) for advanced-stage prostate cancer was estimated with weighted logistic regression analysis. All P: values were two-sided.

RESULTS

Clinically advanced-stage prostate cancers were detected more frequently in African-Americans (12.3%) and Hispanics (10.5%) than in non-Hispanic whites (6.3%). Socioeconomic, clinical, and pathologic factors each accounted for about 15% of the increased relative risk. After adjusting for all covariates, the risk remained statistically significantly increased for African-Americans (OR = 2.26; 95% confidence interval [CI] = 1.43 to 3.58) but not for Hispanics (OR = 1.23; 95% CI = 0.73 to 2.08).

CONCLUSION

Traditional socioeconomic, clinical, and pathologic factors accounted for the increased relative risk for presenting with advanced-stage prostate cancer in Hispanic but not in African-American men.

A highly metastatic Lewis lung carcinoma orthotopic green fluorescent protein model

The Lewis lung carcinoma has been widely used for many important studies. However, the subcutaneous transplant or orthotopic cell-suspension injection models have not allowed the expression of its full metastatic potential. A powerful new highly metastatic model of the widely-used Lewis lung carcinoma is reported here using surgical orthotopic implantation (SOI) of tumor fragments and enhanced green fluorescent protein (GFP) transduction of the tumor cells. To achieve this goal, we first developed in vitro a stable high-expression GFP transductant of the Lewis lung carcinoma with the pLEIN retroviral expression vector containing the enhanced Aequorea victoria GFP gene. Stable high-level expression of GFP was found maintained in vivo in subcutaneously-growing Lewis lung tumors. The in vivo GFP-expressing tumors were harvested and implanted as tissue fragments by SOI in the right lung of additional nude mice. This model resulted in rapid orthotopic growth and extensive metastasis visualized by GFP-expression. 100% of the animals had metastases on the ipsilateral diaphragmatic surface, contralateral diaphragmatic surface, contralateral lung parenchima, and in mediastinal lymph nodes. Heart metastases were visualized in 40%, and brain metastases were visualized in 30% of the SOI animals. Mice developed signs of respiratory distress between 10-15 days post-tumor implantation and were sacrificed. The use of GFP-transduced Lewis lung carcinoma transplanted by SOI reveals for the first time the high malignancy of this tumor and provides an important useful model for metastasis, angiogenesis and therapeutic studies.

Transduction of liver cells by lentiviral vectors: analysis in living animals by fluorescence imaging

Viral vectors based on lentiviruses, such as the human immunodeficiency virus, are able to transduce a broad spectrum of nondividing cells in vivo. This ability of lentiviral vectors makes them an attractive vehicle for gene transfer into the liver. In order to determine the requirements for efficient lentiviral gene transfer, we used a fluorescence imaging system, which allows the detection of cells and tissues that express fluorescent reporter genes (e.g., green fluorescence protein) in the living animal. We show that the latest generation of lentiviral vectors efficiently transduces the murine liver. Further analysis demonstrated that neither cell-cycle activation nor division of liver cells is a prerequisite for lentiviral gene transfer in vivo.

Whole-body and intravital optical imaging of angiogenesis in orthotopically implanted tumors

The development of drugs for the control of tumor angiogenesis requires a simple, accurate, and economical assay for tumor-induced vascularization. We have adapted the orthotopic implantation model to angiogenesis measurement by using human tumors labeled with Aequorea victoria green fluorescent protein for grafting into nude mice. The nonluminous induced capillaries are clearly visible against the very bright tumor fluorescence examined either intravitally or by whole-body luminance in real time. The orthotopic implantation model of human cancer has been well characterized, and fluorescence shadowing replaces the laborious histological techniques for determining blood vessel density. Intravital images of orthotopically implanted human pancreatic tumors clearly show angiogenic capillaries at both primary and metastatic sites. A quantitative time course of angiogenesis was determined for an orthotopically growing human prostate tumor periodically imaged intravitally in a single nude mouse over a 19-day period. Whole-body optical imaging of tumor angiogenesis was demonstrated by injecting fluorescent Lewis lung carcinoma cells into the s.c. site of the footpad of nude mice. The footpad is relatively transparent, with comparatively few resident blood vessels, allowing quantitative imaging of tumor angiogenesis in the intact animal. Capillary density increased linearly over a 10-day period as determined by whole-body imaging. Similarly, the green fluorescent protein-expressing human breast tumor MDA-MB-435 was orthotopically transplanted to the mouse fat pad, where whole-body optical imaging showed that blood vessel density increased linearly over a 20-week period. These powerful and clinically relevant angiogenesis mouse models can be used for real-time in vivo evaluation of agents inhibiting or promoting tumor angiogenesis in physiological microenvironments.

Hydrolyzable carbohydrates in pasture, hay, and horse feeds: direct assay and seasonal variation

Carbohydrates may be hydrolyzed or fermented in the digestive tract, and this distinction is important for the evaluation of the diet of herbivores. Both hydrolyzable and fermentable carbohydrates are included in the nonstructural carbohydrate (NSC) fraction as estimated by difference using proximate analysis. Our objectives were to measure hydrolyzable carbohydrates in forages and concentrates, to compare these values with nonstructural carbohydrate, to test for prediction of hydrolyzable carbohydrate concentration in forages from its near-infrared spectrum, and to examine seasonal variation of carbohydrates in pasture. Samples of forages (107) and concentrates (25) were collected, dried, ground, and analyzed for NSC (calculated as 100 - water - CP - fat - ash - NDF), hydrolyzable carbohydrate (CHO-H, direct analysis), and rapidly fermentable carbohydrate (NSC minus CHO-H). Hydrolyzable carbohydrate accounted for 97% or more of the NSC in the concentrates but only 33% in pasture and hay. A two-term polynomial equation fit all the data: CHO-H = 0.154 x NSC + 0.00136 x NSC2, R2 = 0.98, P < 0.0001, n = 132. In 83 pasture samples, CHO-H concentrations were predicted by near-infrared spectra with a calibration R2 of 0.97, a mean of 48 g/kg, and a SE of calibration of 3.5 g/kg DM. In pasture samples collected between September 1995 and November 1996, the coefficient of variation was 31% for both CHO-H and rapidly fermentable carbohydrate (CHO-FR); the largest increments were 31 g/kg of CHO-H from September to October and 41 g/kg of CHO-FR from February to March. The increased risk of certain diseases, such as laminitis and colic, that have been previously associated with an abrupt overload of NSC may be more precisely attributed to CHO-H in grain concentrates, and to CHO-H as well as CHO-FR in pastures.