Afatinib as first-line treatment in patients with EGFR-mutated non-small cell lung cancer in routine clinical practice

Background:

Lung cancer is a leading cause of cancer-related death in Germany and worldwide. Non-small cell lung cancer (NSCLC) comprises ~80% of lung cancer diagnoses; in White patients, around 10% of NSCLC cases are epidermal growth factor receptor mutation-positive (EGFRm+). Head-to-head clinical trials have demonstrated superior efficacy with second-/third-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) versus first-generation EGFR TKIs in EGFRm+ NSCLC. Data from routine clinical practice are necessary to confirm that clinical trial findings are transferable to real-world populations.

Methods:

In NCT02047903, a prospective non-interventional study in Germany, patients with EGFRm+ NSCLC received first-line afatinib until disease progression or intolerable adverse events. Key objectives were progression-free survival (PFS) rate at 12 months, objective response rate (ORR) and overall survival (OS). Safety/tolerability was also assessed.

Results:

Of 152 patients, 106 (69.7%) were female, 20 (13.1%) patients had an uncommon EGFR mutation and 51 patients (33.6%) had brain metastases. A starting dose of <40 mg was received by 39 (25.7%) patients. Overall, the 12-month PFS rate was 50.2% while the median PFS was 12.2 months. The ORR was 74.6% and the median OS was 30.4 months. In patients with brain metastases and uncommon mutations, the median PFS was 10.5 and 10.7 months, and the ORR was 77.3% and 83.3%, respectively. Treatment effectiveness was similar in patients with a starting dose of <40 mg (median PFS: 16.4 months; ORR, 81.3%) and a starting dose of 40 mg (median PFS: 10.8 months; ORR, 72.1%). Adverse drug reactions were manageable and consistent with the known afatinib safety profile.

Conclusion:

The results support clinical trial data for afatinib in routine clinical practice, including in patients generally excluded from clinical trials. Outcomes were positive in patients with uncommon EGFR mutations and in those with brain metastases. Treatment benefit was also seen in patients receiving a <40 mg afatinib starting dose, supporting patient-tailored dosing.

Peroxisome proliferator-activated receptor γ, coactivator 1α deletion induces angiotensin II-associated vascular dysfunction by increasing mitochondrial oxidative stress and vascular inflammation

OBJECTIVE

Peroxisome proliferator-activated receptor γ, coactivator 1α (PGC-1α) is an important mediator of mitochondrial biogenesis and function. Because dysfunctional mitochondria might be involved in the pathogenesis of vascular disease, the current study was designed to investigate the effects of in vivo PGC-1α deficiency during chronic angiotensin II (ATII) treatment.

APPROACH AND RESULTS

Although ATII infusion at subpressor doses (0.1 mg/kg per day for 7 days) did not cause vascular dysfunction in wild-type mice, it led to impaired endothelial-dependent and endothelial-independent relaxation in PGC-1α knockout mice. In parallel, oxidative stress was increased in aortic rings from ATII-treated PGC-1α knockout mice, whereas no change in nitric oxide production was observed. By using the mitochondrial-specific superoxide dye MitoSox and complex I inhibitor rotenone, we identified the mitochondrial respiratory chain as the major PGC-1α-dependent reactive oxygen species source in vivo, accompanied by increased vascular inflammation and cell senescence. In vivo treatment with the mitochondria-targeted antioxidant Mito-TEMPO partially corrected endothelial dysfunction and prevented vascular inflammation in ATII-treated PGC-1α mice, suggesting a causative role of mitochondrial reactive oxygen species in this setting.

CONCLUSIONS

PGC-1α deletion induces vascular dysfunction and inflammation during chronic ATII infusion by increasing mitochondrial reactive oxygen species production.

Mast cell-deficient Kit(W-sh) "Sash" mutant mice display aberrant myelopoiesis leading to the accumulation of splenocytes that act as myeloid-derived suppressor cells

Mast cell-deficient Kit(W-sh) "sash" mice are widely used to investigate mast cell functions. However, mutations of c-Kit also affect additional cells of hematopoietic and nonimmune origin. In this study, we demonstrate that Kit(W-sh) causes aberrant extramedullary myelopoiesis characterized by the expansion of immature lineage-negative cells, common myeloid progenitors, and granulocyte/macrophage progenitors in the spleen. A consistent feature shared by these cell types is the reduced expression of c-Kit. Populations expressing intermediate and high levels of Ly6G, a component of the myeloid differentiation Ag Gr-1, are also highly expanded in the spleen of sash mice. These cells are able to suppress T cell responses in vitro and phenotypically and functionally resemble myeloid-derived suppressor cells (MDSC). MDSC typically accumulate in tumor-bearing hosts and are able to dampen immune responses. Consequently, transfer of MDSC from naive sash mice into line 1 alveolar cell carcinoma tumor-bearing wild-type littermates leads to enhanced tumor progression. However, although it can also be observed in sash mice, accelerated growth of transplanted line 1 alveolar cell carcinoma tumors is a mast cell-independent phenomenon. Thus, the Kit(W-sh) mutation broadly affects key steps in myelopoiesis that may have an impact on mast cell research.

STAT5 is crucial to maintain leukemic stem cells in acute myelogenous leukemias induced by MOZ-TIF2

MOZ-TIF2 is a leukemogenic fusion oncoprotein that confers self-renewal capability to hematopoietic progenitor cells and induces acute myelogenous leukemia (AML) with long latency in bone marrow transplantation assays. Here, we report that FLT3-ITD transforms hematopoietic cells in cooperation with MOZ-TIF2 in vitro and in vivo. Coexpression of FLT3-ITD confers growth factor independent survival/proliferation, shortens disease latency, and results in an increase in the number of leukemic stem cells (LSC). We show that STAT5, a major effector of aberrant FLT3-ITD signal transduction, is both necessary and sufficient for this cooperative effect. In addition, STAT5 signaling is essential for MOZ-TIF2-induced leukemic transformation itself. Lack of STAT5 in fetal liver cells caused rapid differentiation and loss of replating capacity of MOZ-TIF2-transduced cells enriched for LSCs. Furthermore, mice serially transplanted with Stat5(-/-) MOZ-TIF2 leukemic cells develop AML with longer disease latency and finally incomplete penetrance when compared with mice transplanted with Stat5(+/+) MOZ-TIF2 leukemic cells. These data suggest that STAT5AB is required for the self-renewal of LSCs and represents a combined signaling node of FLT3-ITD and MOZ-TIF2 driven leukemogenesis. Therefore, targeting aberrantly activated STAT5 or rewired downstream signaling pathways may be a promising therapeutic option.

α1AMP-activated protein kinase mediates vascular protective effects of exercise

OBJECTIVE

We investigated whether AMP-activated protein kinase (AMPK) may be involved in the signaling processes leading to exercise-mediated vascular protection.

METHODS AND RESULTS

The effects of voluntary exercise on AMPK activity, endothelial NO synthase expression and phosphorylation, vascular reactive oxygen species formation, and cell senescence were tested in α1AMPK knockout and corresponding wild-type mice. Exercise significantly improved endothelial function, and increased plasma nitrite production in wild-type mice, associated with an activation of aortic AMPK assessed by its phosphorylation at threonine 172. In addition, regular physical activity resulted in an upregulation of endothelial NO synthase protein, serine 1177 endothelial NO synthase phosphorylation, and an increase of circulating Tie-2(+)Sca-1(+)Flk-1(+) myeloid progenitor cells. All these changes were absent after α1AMPK deletion. In addition, exercise increased the expression of important regulators of the antioxidative defense including heme oxygenase-1 and peroxisome proliferator-activated receptor γ coactivator 1α, decreased aortic reactive oxygen species levels, and prevented endothelial cell senescence in an α1AMPK-dependent manner.

CONCLUSIONS

Intact α1AMPK signaling is required for the signaling events leading to the manifestation of vascular protective effects during exercise. Pharmacological AMPK activation might be a novel approach in the near future to simulate the beneficial vascular effects of physical activity.

[Visual development of postoperative persistent macular holes with and without surgical revision]

BACKGROUND

Postoperative persistent macular holes after vitrectomy are a rare, but typical phenomenon. Without further surgical intervention the visual acuity remains unchanged. There are no generally accepted treatment recommendations for these cases. We report on 23 cases with postoperative persistent macular holes with and without further surgical treatment and analyzed the clinical outcome.

METHODS

A retrospective case control study was performed and visual acuity and anatomic status of the macular holes were analysed in 23 cases with a persistent macular hole after previous vitrectomy. Seven patients refused further surgical treatment (group 1) and were used as a control group. Three patients received a second intravitreal gas tamponade without further surgical manipulation (group 2). A vitrectomy revision with endotamponade was performed in 13 eyes (group 3). Additional autologous blood on the macular hole was used in 4 cases and adjuvant ICG-assisted peeling of the inner limiting membrane around the macular hole was performed in another 9 cases.

RESULTS

The eyes of group 1 showed a statistically not significant (p = 0.56) change of the median LogMAR visual acuity from 1.3 (range 0.7 - 1.4) to 1.2 (range 0.3 - 2.0) over a median follow-up of 11.8 months. No eye in group 2 developed a closure of the macular hole. After a median follow-up of 3.6 months the LogMAR visual acuity dropped statistically not significantly from 0.7 (range 0.7 - 1.9 to 1.0 (range 0.8 - 1.0; p = 0.5). 61 % of eyes showed a closure of the macular hole after a second vitrectomy (group 3). Eight out of 16 retreated eyes had finally a persistent macular hole. In these cases median LogMAR visual acuity decreased insignificantly from 1.0 (range 0.7 - 1.4) to 1.1 (range 0.7 - 1.4; p = 0.27) during a median follow-up of 13.7 months. In 8 eyes with a finally closed macular hole median LogMAR visual acuity increased statistically significantly from 0.8 (rage 0.4 - 1.3) to 0.35 (range 0.04 - 0.9; p = 0.016) after a median follow-up of 8.1 months.

CONCLUSION

Surgical revision of postoperative persistent macular holes using vitrectomy and endotamponade showed a success rate of 61 %. Eyes that had unsuccessful subsequent surgery had a slight decay of the visual acuity during the follow-up that was similar to that of eyes without further surgical treatment. In contrast, the final closure of the macular hole after a second surgery was associated with a significantly increased visual acuity.

Modeling the absorption behavior of solar thermal collector coatings utilizing graded alpha-C:H/TiC layers

Wavelength selective coatings are of common use in order to enhance the efficiency of devices heated by radiation such as solar thermal collectors. The use of suitable materials and the optimization of coating layer thicknesses are advisable ways to maximize the absorption. Further improvement is achievable by embedding particles in certain layers in order to modify material properties. We focus on optimizing the absorption behavior of a solar collector setup using copper as substrate, a layer of amorphous hydrogenated carbon with embedded titanium carbide particles (a-C:H/TiC), and an antireflection coating of amorphous silicon dioxide (aSiO(2)). For the setup utilizing homogeneous particle distribution, a relative absorption of 90.98% was found, while inhomogeneous particle embedding yielded 98.29%. These results are particularly interesting since until now, absorption of more than 95% was found only by using embedded Cr but not by using the more biocompatible Ti.

[Malignant and non-malignant uveitis-masquerade syndromes in childhood]

Diseases that can clinically simulate an uveitis are summarised under the name Masquerade syndromes. They constitute a heterogenous group of malignant and non-malignant entities that must be excluded in the differential diagnosis. Of the malignant diseases lymphomas are only rarely observed as the cause of a pseudo-uveitis, whereas especially leukaemic diseases and, in childhood, retinoblastomas and the extremely rare intraocular medulloepithelioma must be excluded. Of the non-malignant diseases in childhood, besides Coats' disease, a juvenile xanthogranuloma as well as persisting hyperplastic primary vitreous body should also be considered as the cause of an atypical uveitis. Systemic diseases such as tuberous sclerosis or neurofibromatosis are usually diagnosed in good time by means of the accompanying symptoms. In case of doubt in childhood, an examination under anaesthesia and, if necessary, further imaging diagnostics should be performed in order to avoid with certainty a false diagnosis having possibly serious consequences.

[Endoresection of large uveal melanomas after pretreatment by single-dose stereotactic convergence irradiation with the leksell gamma knife--first experience on 46 cases]

BACKGROUND

The aim of this non-comparative, consecutive case series is to evaluate the short-term results after endoresection of large uveal melanomas in combination with pretreatment with stereotactic gamma knife radiosurgery.

METHODS

Between March 2000 and November 2002, forty-six patients with large uveal melanomas underwent stereotactic radiosurgery followed by endoresection of the tumour via a standard three-port vitrectomy including laser photocoagulation and silicone oil tamponade. The average tumour height was 9.5 mm. The minimum dose delivered to the tumour volume was 25 Gy.

RESULTS

The median follow-up time was 410 days. In 40 cases (87 %), the eye was retained with a VA of 20/200 or better in 30 cases (65.2 %) and 20/63 or better in ten cases (21.7 %). In 12 eyes with a follow-up of >/= 0.5 years, the median VA was 20/80 after silicone oil removal and cataract surgery had been performed. Six eyes (13 %) were enucleated due to serious complications caused by the radiosurgery (3 cases) or endoresection (3 cases). In 13 patients (28.2 %), additional major surgery was required. Seven patients developed liver metastases during follow-up and six patients died. No local tumour recurrences were observed.

CONCLUSIONS

Eyes with large uveal melanomas can be salvaged by stereotactic radiotherapy followed by endoresection.

Spectrum of gross deletions and insertions in the RB1 gene in patients with retinoblastoma and association with phenotypic expression

Quantitative multiplex PCR and genomic real-time PCR were used to complete an RB1 mutation analysis in 57 of 433 and 72 of 262 patients with hereditary and isolated unilateral retinoblastoma, respectively. These patients were selected because in previous analyses, which focused mainly on the identification of point mutations, no RB1 mutation was found. We identified gross deletions and insertions in peripheral blood DNA from 26 of 57 patients (46%) with hereditary retinoblastoma, and in six of 72 patients (8.3%) with isolated unilateral disease. In addition, we identified 32 somatic mutations in tumor DNA from 31 of 72 patients (43%) with isolated unilateral retinoblastoma. Together with our previous results, we found that gross RB1 alterations were present in the peripheral blood DNA from 65 of 433 (15%) and 17 of 262 (6.5%) patients with bilateral or familial and isolated unilateral retinoblastoma, respectively. Including reported gross deletions, an analysis of the frequency of breakpoints per intron length shows higher densities in introns 13, 16, 23, and 24. Genotype-phenotype analyses showed that on the whole, carriers of gross deletions develop fewer retinoblastomas compared to patients who are heterozygous for other types of RB1 null mutations. Specifically, carriers of cytogenetic and submicroscopic whole gene deletions often have unilateral tumors only. By contrast, almost all patients with gross deletions with one breakpoint in RB1 have bilateral retinoblastoma.

[Retinoblastoma]

Retinoblastomas are the most frequent intraocular tumors in childhood. Untreated, the tumor is almost always fatal. Using a multidisciplinary approach combining the efforts of ophthalmologists, radiation oncologists, pediatric oncologists and geneticists a survival rate of more than 95% can be achieved. Molecular genetic research on the origin of retinoblastomas has substantially helped in our understanding of the origin of malignant tumors in general, as well as to the key role of the Rb-1 gene as a tumor suppressor.

Age at diagnosis of isolated unilateral retinoblastoma does not distinguish patients with and without a constitutional RB1 gene mutation but is influenced by a parent-of-origin effect

Patients with hereditary cancer are usually diagnosed earlier than patients with non-hereditary tumours. In children with isolated unilateral retinoblastoma, some of whom have a hereditary predisposition, this rule has been subject to debate. We have analysed the clinical manifestation of disease in 188 children with completely resolved mutational status. In 24 (13%) of these patients, testing of blood DNA showed a constitutional RB1 mutation. The distribution of age at diagnosis was not different between patients with and without a constitutional mutation. However, patients with loss of the maternally inherited RB1 allele had an earlier age at diagnosis than patients with loss of the paternally inherited RB1 allele. Our data show that early age at diagnosis does not identify patients with isolated unilateral retinoblastoma that have a higher risk of being carriers of a RB1 gene mutation. Our findings suggest that, at least in some patients, age at diagnosis is modified by a parent-of-origin effect.

Photodynamic therapy using verteporfin in circumscribed choroidal haemangioma

AIM

To investigate the safety and efficacy of photodynamic therapy with verteporfin in patients with choroidal haemangioma.

METHODS

A non-randomised, prospective clinical investigation of 19 patients with symptomatic circumscribed choroidal haemangioma was performed. Unsuccessful pretreatment (external beam irradiation, laser photocoagulation) was performed in four patients. Patients were included when (1) subretinal exudation involving the fovea, (2) a decrease in visual function, and (3) additional symptoms (for example, metamorphopsia) were present. Photodynamic therapy (PDT) was performed with verteporfin at a concentration of 6 mg/m(2) body surface area and a light dose of 100 J/cm(2) at 692 nm.

RESULTS

The mean follow up time was 10.6 months (2-24 months). The mean number of treatment sessions was 2.15 (range 1-5). Visual acuity improved by at least one line in 73.3%, by at least two lines in 42.1%, was stable in 21.1%, and decreased by one line in 5.2% of the patients. Exudation was completely resolved in 94.8% of the cases. Regression of tumour height was documented in all 19 tumours. Patients receiving any pretreatment before PDT, a visual acuity of 0.1 and less, a history of more than 30 months, and no significant response after the first PDT session, did not show any significant improvement. Cox regression analysis revealed that the number of PDT treatment sessions was inversely associated with the improvement in visual acuity of at least two lines. No recurrences and no local or systemic side effects were observed during the follow up time.

CONCLUSION

PDT using verteporfin is a safe and effective therapy for the treatment of symptomatic choroidal haemangioma even in tumours located beneath the fovea.

[Endoscopic resection of malignant melanomas of the uvea after preoperative stereotactic single dose convergence irradiation with the Leksell gamma knife]

In cases of large volume and highly prominent melanomas of the uvea, it is rare for conventional methods of radiation therapy to enable salvage of the globe or even residual functionality of the affected eye. Complications due to the massive amount of accumulated necrotic tissue often necessitate subsequent enucleation of the blinded eye. Tumor-destroying, single-dose convergence irradiation (radiosurgery) of such tumors applied shortly before endoresection can represent a possible therapeutic alternative in these types of cases.

Acute Budd-Chiari syndrome, portal and splenic vein thrombosis in a patient with ulcerative colitis associated with antiphospholipid antibodies and protein C deficiency

We report the case of a female patient who had severe thrombotic complications in peripheral (V. jugularis, subclavia, brachialis, poplitea) and visceral (portal and splenic) veins 4 years after the first diagnosis of severe ulcerative pancolitis. A thrombolysis therapy for subclavian and jugular vein thrombosis was performed without complication, but she soon developed acute thrombosis of the hepatic veins (acute Budd-Chiari syndrome). She quickly recovered after liver transplantation and now - 6 years later - she lives a normal life with continuous anticoagulation and medical therapy of the colitis.3 possible causes for the severe coagulation defect in this patient can be supposed: Thrombocytosis, protein C deficiency and an antiphospholipid antibody syndrome.

Marked differences in unilateral isolated retinoblastomas from young and older children studied by comparative genomic hybridization

Although it is established that the loss of function of both alleles of the RB1 gene is a prerequisite for the development of retinoblastoma, little is known about the genetic events that are required for tumor progression. We used comparative genomic hybridization (CGH) to search for DNA copy number changes in isolated unilateral retinoblastomas. From a series of 66 patients with retinoblastomas with somatic mutations in both RB1 alleles, tumor samples from 13 children with the youngest (2.0-9.8 months) and 13 with the oldest (36.2-84.1 months) age at operation were studied. Loss at 13q14, the location of RB1, was demonstrated in two tumors only. Recurring chromosome imbalances included gains at 6p (11/26), 1q (10/26), 2p (4/26), and 17q (4/26), gains of the entire chromosome 19 (3/26), and losses at 16q (9/26). A commonly gained region at 1q32 was identified. Increased dosage of GAC1, a candidate oncogene located in 1q32, was found in two of four tumors by Southern blot analysis. Comparison of the CGH findings revealed that retinoblastomas from children with an older age at operation showed significantly more frequent (13/13 cases vs 4/13 cases; P = 0.0005) and more complex genetic abnormalities (median, 5 changes/abnormal tumor vs median, 1.5 changes/abnormal tumor; P = 0.003) than retinoblastomas from children with a young age at operation. Gains at 1q, 2p, 17q, of the entire chromosome 19 and losses of 16q were restricted to the older age group. Our results suggest that the progression of retinoblastomas from older patients follows mutational pathways different from those of younger patients.

Significant reduction of the incidence of ovarian hyperstimulation syndrome (OHSS) by using the LHRH antagonist Cetrorelix (Cetrotide) in controlled ovarian stimulation for assisted reproduction

A prospective, randomized study was performed to compare the efficiency of hormonal stimulation for IVF (in vitro fertilization) in either the long luteal protocol, using the LHRH agonist Buserelin, or the multiple dose LHRH antagonist protocol, using the LHRH antagonist Cetrorelix. Here we present the data on the incidence of ovarian hyperstimulation syndromes (OHSS). 85 and 188 patients were recruited for the stimulation in the LHRH agonist and in the LHRH antagonist protocol, respectively. The groups were comparable regarding anamnestic data. The incidence of WHO degrees II and degrees III OHSS was significantly lower in the Cetrorelix than in the Buserelin group (1.1% vs. 6.5%, p=0.03). Additionally 3 patients in the Cetrorelix group (1.6%) and 5 patients in the Buserelin group (5.9%) did not receive hCG because of a threatening OHSS. The follicle maturation was more homogeneous in the Cetrorelix protocol, with less small follicles on the day of hCG administration but a similar number of oocyte cumulus complexes retrieved. The pregnancy rates per cycle were not significantly different in the Cetrorelix and Buserelin protocol (22% vs. 26%). The Cetrorelix multiple dose protocol is advantageous compared to the long protocol regarding the incidence of OHSS, a potentially life threatening complication of controlled ovarian stimulation.

Patients with chronic hepatitis C--who should not be treated?

The decision to treat a patient with chronic hepatitis C (CHC) is based on what is known about the risk factors for developing liver cirrhosis or hepatocellular carcinoma, as well as on conditions that contraindicate therapy or impair therapy effectiveness. Several factors, including age, treatment side effects, disease severity, concurrent diseases and life conditions, may render treatment decisions more difficult. This review focuses on identifying CHC patients who should not receive treatment.

Uveal melanoma: correlation of histopathologic and radiologic findings by using thin-section MR imaging with a surface coil

PURPOSE

To evaluate whether the different signal intensities at magnetic resonance (MR) imaging of melanoma are associated with a higher content of melanin.

MATERIALS AND METHODS

In a prospective study, MR imaging and ophthalmoscopic examination findings in 42 patients (19 women, 23 men; age range, 30-87 years) with uveal melanoma were compared with histopathologic examination findings obtained after enucleation. MR imaging was performed with 2-mm sections by using a 5-cm surface coil. T1- and T2-weighted images were obtained before and after contrast material administration.

RESULTS

In 33 (79%) of the patients, there was homogeneous tumor pigmentation, whereas in nine (21%) patients, there was inhomogeneous bipartite tumor pigmentation. Compared with the histopathologic data, the results of qualitative evaluation were accurate in 29 (58%) of 50 and in 26 (53%) of 49 tumorous areas on T1- and T2-weighted images, respectively. Quantitative evaluation yielded better results, especially at T1-weighted imaging; an 86% correlation was found. Because of methodological reasons, only the superficial pigmentation of inhomogeneous tumors could be evaluated with ophthalmoscopy.

CONCLUSION

Thin-section MR imaging of the eye enables an accurate prediction of melanomatous pigmentation with quantitative evaluation of plain T1-weighted images and is superior to ophthalmoscopy in cases of inhomogeneous pigmentation.

[Is combination therapy of chronic hepatitis C with interferon alpha and ribavirin in primary interferon nonresponders indicated?--An analysis of personal experiences and review of the literature]

Combination therapy of chronic hepatitis C with interferon alpha and ribavirin has been proven to be highly effective in naive and relapse patients with two to ten-fold increase of the response rate. However, combination therapy of primary non-responders to interferon alpha is discussed controversially. Therefore, to analyze the response rate to retreatment with a combination therapy with interferon alpha and ribavirin, we compared data of 555 patients described in 23 publications to the data of 16 non-responders treated in our center. The patients received interferon alpha (at least 3 MU tiw) and ribavirin in a dose of 1,000/1,200 mg per day. At the end of treatment 14% of our patients had normal ALT values and were HCV-RNA-negative compared to 34% of all patients described in the literature. In our patients the viral load decreased from 1,110 +/- 670 x 10(3) copies/ml prior to therapy to 300 +/- 480 x 10(3) copies/ml at the end of treatment (p = 0.002). After a follow-up period of six months quantitative RNA-levels rose again to 1,485 +/- 755 x 10(3) copies/ml. Whereas only 7.4% (24/325) of all patients described showed a response with normal ALT values and negative HCV-RNA at the end of follow-up, no sustained response was observed in our patients. In contrast to naive and relapse patients, the response rate of combination therapy in patients previously not responding to interferon alpha alone is only low. Thus, standard regime (IFN 3MU twi plus ribavirin for six months) as a regular therapy for non-responders is not recommended.

Expression patterns of cyclin D1 and related proteins regulating G1-S phase transition in uveal melanoma and retinoblastoma

BACKGROUND/AIMS

A checkpoint mechanism in late G1, whose regulation via loss of retinoblastoma protein (pRB) or p16, or overexpression of cyclin D1 or cyclin dependent kinase 4 (CDK4), has been proposed to constitute a common pathway to malignancy. The aims of this study were (a) to compare markers of cell cycle G1-S phase transition in an intraocular tumour with known pRB deficiency (retinoblastoma) and compare it with one with an apparently functional pRB (uveal melanoma); (b) to determine if one of these markers may have a role in the pathogenesis of uveal melanoma; and (c) to determine if there is a difference in cell cycle marker expression following treatment of uveal melanoma and retinoblastoma.

METHODS

90 eyes were enucleated from 89 patients for retinoblastoma (n = 24) or for choroidal or ciliary body melanoma (n = 66). Conventional paraffin sections were assessed for cell type and degree of differentiation. Additional slides were investigated applying standard immunohistochemical methods with antibodies specific for cyclin D1 protein, pRB, p53, p21, p16, BCL-2, and MIB-1.

RESULTS

Cyclin D1 protein and pRB were negative in retinoblastoma using the applied antibodies. In contrast, cyclin D1 protein expression was observed in 65% of uveal melanomas; a positive correlation between cyclin D1 cell positivity and tumour cell type, location, growth fraction, as well as with pRB positivity was observed. p53, p21, and p16 could be demonstrated in both tumours. An inverse relation between p53 and p21 expression was demonstrated in most choroidal melanomas and in some retinoblastomas. Apart from a decrease in the growth fractions of the tumours as determined by MIB-1, a significant difference in the expression of G1-S phase transition markers in vital areas of uveal melanoma and retinoblastoma following treatment with radiotherapy and/or chemotherapy was not observed.

CONCLUSION

Retinoblastomas and uveal melanomas, two tumours of differing pRB status, differ also in their immunohistochemical pattern for markers of the G1-S phase transition of the cell cycle. The results of the present study support the concept of (a) an autoregulatory loop between pRB and cyclin D1 in tumours with a functional pRB and the disruption of this loop in the presence of pRB mutation, as well as (b) a checkpoint mechanism in late G1, whose regulation via loss of p16 or pRB, or overexpression of cyclin D1 constitutes a common pathway to malignancy. Further, the results raise the possibility of cyclin D1 overexpression having a role in the pathogenesis of uveal melanoma.

Risk of hepatitis A superinfection in patients with underlying liver disease

During recent years the outcome of acute hepatitis A in chronic liver disease has been discussed controversially. Data from large hepatitis A epidemics and surveillance data from the United States suggest a significantly higher risk of fatal outcome in patients with chronic hepatitis B. Patients with chronic active hepatitis or liver cirrhosis seem to be at highest risk, while HBsAg carriers may exhibit a benign course of the disease. Patients with chronic hepatitis C also seem to have a significantly higher risk of fulminant hepatic failure when superinfected with hepatitis A. The recently reported unsuspected coincidence of autoimmune markers with a fulminant course of hepatitis A in those patients needs to be confirmed. Vaccination against hepatitis A in patients with chronic liver disease has been shown to be safe and effective.

Preliminary results of primary chemotherapy in retinoblastoma

BACKGROUND

Eye retention rates after external beam therapy for advanced retinoblastoma are close to 90% with very few ocular side effects like radiation retinopathy or radiation induced optic neuropathy. Late complications, however, comprise a sixfold increase of secondary non-ocular cancers like soft tissue sarcomas demanding alternative treatment options in the management of advanced retinoblastoma.

PURPOSE

A phase I study on primary chemotherapy using vincristine, cyclophosphamide, etoposide and carboplatin in advanced bilateral retinoblastoma was undertaken to evaluate the potential of a treatment regimen not including external beam therapy.

PATIENTS AND METHODS

12 eyes with 17 tumors in 9 children were treated with primary chemotherapy as first treatment option with a mean follow-up of 16.7 months. Planned enucleation of a tumor containing eye was performed in 2 eyes. In one of these enucleated eyes no viable tumor cells were visible on histopathological examination while in the other eye marked tumor regression was detectable. Of the remaining 10 eyes clinical regression of the intraocular tumors was present in all eyes; on average the tumor size was reduced by 50% within 3-6 weeks. Most of the tumors showed a type I (cottage cheese) regression indistinguishable from regression patterns found after external beam radiotherapy. Ancillary treatments including laser photocoagulation, beta-ray brachytherapy, external beam radiotherapy and cryotherapy were performed in 15 out of the 17 tumors.

CONCLUSION

Based on the results of this study and on the results published by others primary chemotherapy may result in the same eye retention rate as conventional external beam therapy avoiding the unacceptable high rate of secondary non-ocular cancers in the latter. A prospective study to be undertaken by the GPOH (Gesellschaft für Pädiatrische Onkologie und Hämatologie) and the RG (Retinologische Gesellschaft) is planned to further evaluate this new and promising approach.

Keratokyphosis in rabbits: a functional and morphologic study

Keratokyphosis, a "nonfreeze keratomileusis" procedure, was applied in rabbits. The refractive changes were -6.5 +/- 0.7 (SD), -9.5 +/- 2.6, and -13.0 +/- 3.2 D for convex applanation surfaces with a vertex of +100 microns, +125 microns, and +150 microns in the microkeratome and +1.5 +/- 2.0 and +2.5 +/- 2.6 D for concave applanation surfaces with a vertex of -100 microns and -125 microns. The pachymetric corneal changes were +43 +/- 24 microns, +39 +/- 32 microns, and +71 +/- 24 microns for the convex applanation surfaces and -21 +/- 40 microns and -17 +/- 24 microns for the concave. Wound healing was uncomplicated. The scar at the interface was 0-5 microns wide. The mean central density of nerve endings was 1,255 +/- 532/mm2. The endothelial cell size was 25.1% (p < 0.01) greater as measured by specular microscopy than by vital preparation technique; this difference was greater with higher (33.4%) than with lower (18.02%) corneal refraction (p = 0.02). In addition, there was a method-independent correlation (correlation coefficient, -0.63) between endothelial cell count and corneal thickness. This may indicate an increased demand on corneal endothelium in thickened corneas.

Ionised and total magnesium serum concentrations in renal and hepatic diseases

Ionised and total magnesium concentrations were determined in the serum of different groups of patients suffering from renal or hepatic diseases. Ionised magnesium was measured by Microlyte 6 (KONE, Espoo, Finland) and total magnesium by atomic absorption spectrometry. In renal insufficiency ionised and total magnesium concentrations were almost equally increased. In proteinuria with a normal glomerular filtration rate, "pseudohypomàgnesaemia" was observed, i.e. decreased total magnesium concentration in parallel with a decreased albumin concentration with no significant change in the concentration of ionised magnesium. Hypermagnesaemia occurred in liver diseases combined with renal insufficiency, whereas "pseudohypomagnesaemia" was most often found in the absence of renal failure. Also treatment with an aldosterone antagonist was associated with a normal ionised magnesium concentration, but the total magnesium concentration was decreased; when additional magnesium was administered, the total magnesium concentration approached a normal value, while ionised magnesium slightly exceeded reference values. Only during cyclosporin treatment did both ionised and total magnesium concentrations become lowered. However, the decrease of total magnesium exceeded that of ionised magnesium due to concomitant hypoalbuminaemia with reduction of the protein-bound fraction. It is concluded that especially low total magnesium concentrations should be investigated by measurement of ionised magnesium to exclude "pseudohypomagnesaemia".

Indications, results, and complications of refractive corneal surgery with mechanical methods

Radial keratotomy (RK) incisions permanently weaken the cornea. This structural weakening can cause several complications and side effects, including diurnal fluctuation, progressive hyperopic shift, and the potential for traumatic rupture of the keratotomy scars. Minimally invasive-RK may be a useful alternative to reduce the invasiveness of RK while retaining its efficacy. Mild myopia can be treated by either RK or photorefractive keratectomy. Patients treated by RK in the first eye and photorefractive keratectomy in the second eye preferred the speed of recovery and the clarity of vision with RK. Combining the microkeratome and the excimer laser appears to be an ideal technique to correct high myopia. Laser ablation of the corneal lenticule while securely fixed by the suction ring in the Berlin microkeratome offers the advantage of perfect centration and fixation. Hexagonal keratotomy, used to treat hyperopia, appears to be an unpredictable, unsafe surgical procedure.

Accuracy of corneal lenticules produced for lamellar refractive corneal surgery

The layer thickness of the corneal lenticules separated with the Berlin microkeratome and shaped by keratomileusis, keratophakia, keratokyphosis, and intrastromal excimer-laserkeratomileusis was measured with the Universal Measuring Microscope. The vertices of most corneal lenticules showed an undercorrection of the measured values compared with the calculated ones. In keratomileusis, the vertex of the central part of the optical zone of 3.6 mm attained 79 +/- 19 microns instead of 80 microns (99%); in keratophakia, 74 +/- 19 microns instead of 80 microns (93%); in myopic keratokyphosis, 77 +/- 11 microns instead of 105 microns (74%); in hyperopic keratokyphosis, 72 +/- 28 microns instead of 105 microns (69%); and in excimer-laserkeratomileusis, 52 +/- 12 microns instead of 39 microns (120%). The undercorrection of myopic and hyperopic keratokyphosis indicate that this type of nonfreeze keratomileusis is not capable to cut a tissue lens of predicted refraction from compressed corneal tissue. Near symmetrical profiles were achieved in all types of refractive corneal surgery but excimer-laserkeratomileusis had the smallest standard deviation. It was significantly smaller than in hyperopic keratokyphosis (p < 0.05). Intrastromal excimer-laserkeratomileusis of tightly fixed corneal lenticule in the Berlin microkeratome might be the most predictable method of lamellar refractive corneal surgery.

[Lumbar spondylodiscitis caused by Salmonella enteritidis]

A 19-year-old boy developed paravertebral muscular pain in the lumbar region after an episode of extremely arduous sporting activity, with fever followed by meningism. The cerebrospinal fluid showed a reactive pleocytosis. Initially, no acute inflammatory changes were present on serum and blood analysis, although the erythrocyte sedimentation rate was moderately increased to 25/60 mm. Pyrexia of up to 38.5 degrees C developed 6 days after admission. Because Borrelia IgM and IgG titres were positive, the diagnosis was at first thought to be atypical borreliosis and the patient was treated with antibiotics. However, after a further episode of fever. Salmonella antibody titres, which had initially been normal, rose to 1: 3200 (Salmonella typhi O and H antigens) and 1: 12800 (Salmonella enteritidis, H antigen). At this stage, the erythrocyte sedimentation rate rose to 86/120 mm and the C-reactive protein to 77 mg/dl. The white cell count remained normal throughout. Blood cultures grew Salmonella enteritidis. Abnormalities on bone scintigraphy were confirmed by CT and MRI scans, showing spondylodiscitis of lumbar vertebrae 1 and 2 with limited osteolysis. The lesion resolved completely on 6 week's treatment with ciprofloxacin (200 mg twice a day intravenously) and conservative supportive treatment. Spondylodiscitis is an uncommon complication of salmonellosis and may occur long after the diarrhoea. Cross reactions with Borrelia flagellin antigens may lead to the wrong diagnosis being made.

Cytokine-based biotherapy of gastrointestinal tumors

Over the past 20 years the administration of cytokines has emerged as an important fourth modality for the treatment of human cancer. Advances in the field of therapy of gastrointestinal tumors have become a major focus of current research, given the lack of progress of conventional antineoplastic therapy in most of these tumors. Among the heterogeneous group of gastrointestinal malignancies, novel therapeutic strategies have been employed for each individual tumor type, and cytokines (interferon-alpha) have gained an established role in the treatment of advanced carcinoid tumors. Although our understanding of the mechanisms of biological response modification is still limited, further improvement in the management of gastrointestinal malignancies can be expected from multimodality therapy regimens employing cytokines in combination with other biological response modifiers, chemotherapeutic agents, active-specific immunotherapy, and immunotoxin- and radionuclide-conjugated monoclonal antibodies. A wide range of clinical and preclinical studies have been conducted in colorectal carcinoma; however, potential therapeutic benefit of cytokine-based biotherapy has not been fully defined. Therefore, largescale, i.e., multicenter, studies are required to quantify the potential therapeutic effects of cytokines in gastrointestinal tumors.

Comparison of corneal lenticules produced for keratokyphosis and keratophakia

Apart from the original freezing technique, there are three non-freeze keratomileusis procedures, in which the cornea is first deformed before a tissue lens is severed from the side. Two measuring procedures were used to measure corneal lamellae separated from pig eyes by means of the microkeratome. The following parameters were determined: the size of the severed lamellae, given as the two diameters in the feed direction of the microkeratome and perpendicular to it, and the profiles of the axial sections of these lamellae as determined by means of the universal measuring microscope (UMM). Both measuring procedures had a precision of +/- 3 microns. The results obtained with different blade types were compared, and an optimized blade was developed. The corneal lamellae separated parallel to the surface using the optimized blade were of higher quality than those cut with the Barraquer microkeratome. The variation coefficient was 0.9% for the Berlin microkeratome and 6.0% for the Barraquer microkeratome. The profile studies demonstrated that rotationally symmetrical tissue sections can be obtained with the Berlin microkeratome. The lens-shaped tissue sections separated from pig cornea showed an undercorrection. Further studies are needed to determine whether a higher refraction precision can be achieved in lamellae cut from human donor cornea.

Mechanical methods in refractive corneal surgery

Keratorefractive surgery has developed rapidly over the past decade. For patients with aphakia, however, posterior chamber lenses are safer and more predictable than refractive corneal surgery; myopia is the greatest challenge to this type of surgery. No technique as yet has an accuracy that is adequate for the general treatment of myopia. Keratotomy is the most common procedure currently performed for the correction of mild myopia and astigmatism. Results are less accurate and less stable with myopic than with aphakic epikeratoplasty. Although it is technically more difficult, keratomileusis seems to be more predictable than epikeratophakia. Nonfreeze lamellar corneal surgery accelerates wound healing. Synthetic lenses and ring-shaped implants are also being developed to modify corneal refraction. Current research is directed toward laser stromal keratomileusis on discs that are removed from the cornea using a microkeratome.

[Chemoembolization of hepatocellular carcinoma in cases of isolated liver involvement]

Chemoembolization is an effective treatment for hepatocellular carcinoma, giving results equally as good as surgical therapy for T2 tumours. Survival can be prolonged and side-effects can be reduced by combining Lipiodol and Gelfoam for chemoembolization, employing a modified technique, with repeated procedures, and using appropriate follow-up treatment. The toxicity of the procedure is acceptable, but it requires supportive therapy necessitating an intense interdisciplinary co-operation.

Circadian pattern of intragastric acidity in duodenal ulcer patients: a study of variations in relation to ulcer activity

The relation between intragastric acidity and duodenal ulcer activity was studied prospectively in 21 patients with endoscopically proved duodenal ulcers. The 24 hour intragastric acidity was measured on four separate occasions by continuous recording using combined glass electrodes: (a) in the presence of an ulcer crater without treatment; (b) during active ulceration being treated with ranitidine; (c) during early healing after a six week course of ranitidine; (d) during late healing six months after acute ulceration. Intragastric acidity was also monitored in 20 healthy subjects. At all stages of ulcer activity and during all predefined time periods, duodenal ulcer patients had significantly higher gastric acidity than healthy control subjects. Duodenal ulcer patients showed a similar circadian pattern of intragastric acidity during exacerbation of ulcer disease and in remission during the early and late ulcer healing periods. These results argue against a direct relation between the activity of duodenal ulcer disease and gastric acidity. It is concluded that the chronic recurrent course of duodenal ulcer disease does not result from a fluctuation in intragastric acidity.

Barium carbonate intoxication

A 22-year-old man attempted to commit suicide by swallowing an unknown amount of barium carbonate dissolved in hydrochloric acid. Shortly after ingestion, he developed crampy abdominal pain and generalized muscle weakness. About 2 h later, respiratory failure ensued necessitating orotracheal intubation and mechanical ventilation. Concomitantly, life-threatening arrhythmias including ventricular fibrillation occurred, and he had to be resuscitated for 45 min. After correction of severe hypokalemia (serum potassium 1.5 mmol/l), cardiac rhythm stabilized. In an attempt to accelerate removal of barium from the circulation hemodialysis was begun. During hemodialysis muscle strength returned. Pharmacokinetic analysis of serum barium levels suggest that hemodialysis shortened the serum half-life of barium. Subsequently, the patient made a complete and uneventful recovery. Our case demonstrates that severe barium poisoning can be survived provided that early aggressive therapeutic measures are undertaken. Hemodialysis seems to be efficacious in the therapy of barium intoxication.

Accuracy of the microkeratome keratectomies in pig eyes

Keratokyphosis is a procedure of lamellar refractive corneal surgery in which corneal tissue does not have to be frozen. Corneal lamellae of 30 pig eyes were separated with either the Berlin microkeratome developed for keratokyphosis or the Barraquer microkeratome. The layer thickness was measured within the optical area at 25 measuring points 0.2-mm apart using the Universal Measuring Microscope. Corneal lamellae separated parallel to the surface by means of the Berlin microkeratome showed layer-thickness differences of 0.008 +/- 0.028 mm in the optical zone between the beginning and end of the incision. When using a convex applanation surface in the microkeratome with an optical zone of 5 mm and a vertex of 0.22, 0.2, and 0.15 mm, the vertex of the central part of the optical zone in the corneal disc attained a value of 0.114 +/- 0.018 mm instead of 0.114 mm (100%), 0.075 +/- 0.015 mm instead of 0.105 mm (72%), and 0.076 +/- 0.014 mm instead of 0.080 mm (84%) (mean +/- standard deviation [SD]). When using a concave applanation surface with the same vertex, it attained 0.076 +/- 0.020 mm (67%), 0.075 +/- 0.019 mm (72%), and 0.067 +/- 0.027 mm (84%). The measured vertex of the corneal lamellae was shifted up to 0.8 +/- 0.5 mm in the feed direction of the microkeratome, probably due to the frictional forces acting on the blade during the cutting process. After separation of the lamellae, the cut surface of the eye was measured planimetrically.(ABSTRACT TRUNCATED AT 250 WORDS)

[Chemoembolization of hepatocellular carcinoma with lipiodol, epirubicin and cisplatin]

The therapeutic effect of combined chemoembolization with lipiodol, epirubicin and cisplatin in 22 patients with nonresectable tumours, predominantly in livers with cirrhotic transformation, was analysed. Lipiodol was demonstrated in tumour tissue on average three months, maximally six months, after injection. Repeat embolization was done, if possible, after storage had subsided. There were only minor side effects. Quality of life suffered only from the, though delayed, continuing cancer growth. Survival rate was 73% after six months, 54% after one year.