Epidemiology of elderly fractures in a tertiary hospital in Northern Ghana: a 3-year retrospective descriptive review

PURPOSE

The incidence of elderly fractures is closely related to the increasing proportion of the elderly population in sub-Saharan Africa, making it a relevant public health concern. Epidemiological profiles of these fractures and treatment options are necessary for resource-poor settings to optimise planning and patient care.

METHODS

A retrospective descriptive cross-sectional study was conducted at Tamale Teaching Hospital. Data of 69 elderly patients (60 years and above) with fractures admitted to the trauma and orthopaedic unit from January 2017 to December 2019 were collected. Simple descriptive and bivariate analysis was conducted on some variables, whereas the Chi-square was used to test for some associations for categorical data.

RESULTS

The mean age of the study participants was 70.3(± 8.6). Elderly males (55.1%) were three times more likely to sustain fractures than females. The primary mechanism of injury was a road traffic accident (RTA) (59.4%), followed by falls from slips (29.0%). There was a significant association between gender and mechanisms (RTA and Falls from slips) of injury (p = 0.002). The most fractured bone was the femur (50.7%). Hip fractures (33.3%) were more common among females than males and mainly among the (71-80) age group. Open fractures were more common among males than females.

CONCLUSION

RTAs were the most typical cause of fractures in the elderly. Contrary to other studies, males were more commonly involved in accidents than females, albeit females were the majority for hip fractures. Therefore, significant public health policies with resource allocation should address the unmet health needs of this unique age group in our growing populations in low- and middle-income countries.

One-Year Outcomes of Intracorneal Ring-Segment Insertion Assisted by Femtosecond Laser Simultaneously Performed with Corneal Collagen Cross-Linking for Treatment of Keratoconus

Purpose

To assess the results of simultaneously performed femtosecond laser–assisted Keraring intrastromal corneal ring–segment insertion and corneal collagen cross-linking for the treatment of keratoconus.

Patients and Methods

In this retrospective, noncomparative, interventional study, 30 eyes of 24 progressive-keratoconus patients of both sexes aged 18–36 years old with poor best-corrected visual acuity (BCVA) and intolerance to contact lenses were included. All patients had been subjected to complete preoperative and postoperative ophthalmological examinations — unaided VA, BCVA, refraction, Pentacam, and contrast sensitivity examinations at 3-month, 6-month, and 1-year follow-ups.

Results

Mean unaided VA had changed significantly from 0.649±0.239 logMAR preoperatively to 0.514±0.222 (P=0.014), 0.419±0.162 (P<0.001), and 0.379±0.142 (P<0.001) logMAR at the three follow-up visits, respectively. Mean BCVA had changed significantly from 0.326±0.144 logMAR preoperatively to 0.231±0.140 (P=0.006) at 1-year follow-up. Mean spherical equivalent refraction had decreased significantly at 6-month (P=0.0298) and 1-year follow-up (P=0.0081). Mean steep keratometry (K2) had also significantly reduced from 51.89±3.81 D to 49.87±4.57 D (P=0.034) at 6 months and 49.40±4.39 D (P=0.011) at 1 year. Mean refractive and keratometric astigmatism had significantly decreased at all follow-up visits.

Conclusion

At 1-year follow-up, keraring intrastromal corneal ring–segment insertion assisted by femtosecond laser performed simultaneously with corneal collagen cross-linking resulted in an improvement in visual, refractive, and topographic outcomes, which may suggest it is an effective treatment of keratoconus.

Safety and Indicative Effectiveness of Porcine Corneal Lenticular Implants in Patients with Advanced Keratoconus and Post Lasik Ectasia: A Retrospective Clinical Study

Purpose

This study aimed to evaluate the safety and feasibility of implanting decellularized porcine corneal lenticules in a femtosecond laser-assisted pocket for patients with advanced keratoconus and post-Lasik ectasia.

Methods

This is a retrospective clinical study of implanting a porcine corneal lenticular implant in seven eyes: six with advanced keratoconus and clear cornea and one with advanced post-Lasik ectasia with a follow-up for 12 months. The lenticules are extracted from porcine tissue, subjected to a decellularization process, intensely cross-linked, sterilized and packed. They are 7 mm in diameter with at 100–120-micron thickness. The femtosecond laser was used to create an intra-stromal pocket, and then the lenticules were implanted inside the pocket followed by corneal cross-linking 3 months later for six out of seven eyes.

Results

Five patients had keratoconus (6 eyes) and one patient (one eye) had post-Lasik ectasia. Visual acuity improved in all patients except for one case at 6 and 12 months and this was statistically significant (P=0.002 and 0.007). At one-year follow-up, the mean central corneal thickness increased from 389.43 ± 45.41 to 429.33± 63.20 µm, the maximum keratometry decreased from 64.8 ±5.11 to 62.82± 6.16 D, the mean corneal resistance factor (CRT) increased from 5.67 to 8.42, and the total higher-order aberrations decreased from 1.80 to 1.16. Both changes in the CCT and CRF were statistically significant. One eye had wrinkles and opacified graft, and it was exchanged 3 months postoperatively.

Conclusion

Porcine corneal lenticules implantation is immunologically safe and well tolerated in patients with advanced keratoconus and post-Lasik ectasia and may be feasible as an alternative to keratoplasty.

Active surveillance as a successful management strategy for patients with clinical stage I germ cell testicular cancer

BACKGROUND

Cancer-specific survival for patients with clinical stage I (CSI) germ cell testicular cancer (GCTC) is outstanding after inguinal orchidectomy regardless the treatment utilized. This study evaluated whether active surveillance (AS) of such patients yielded similar health outcomes to other therapeutic strategies such as adjuvant chemotherapy, radiotherapy or primary retroperitoneal lymphadenectomy as described in the literature.

PATIENTS AND METHODS

Patients with CSI GCTC were screened between January 2012 and December 2016. Patients had previously undergone inguinal orchidectomy as the primary treatment and chosen AS as their preferred management strategy after receiving information about all available strategies.

RESULTS

Out of 91 patients screened, 82 patients selected AS as their preferred management strategy. Relapse rate in the overall population was 20% (95% CI 12-30) and median time to relapse was 11.5 months (range 1.0-35.0). In patients with seminomatous tumors, relapse rate decreased to 13% and median time to relapse was 13 months; whereas in patients with non-seminomatous tumors, relapse rate was 33% (IA) or 29% (IB) and median time to relapse was 12 months in stage IA and 4.5 months in stage IB patients. All relapses were rescued with three or four cycles of chemotherapy and two also required a retroperitoneal lymphadenectomy. All patients are currently alive and free of disease.

CONCLUSIONS

The clinical outcomes of patients with CSI GCTC managed by AS in this series were excellent. This strategy limited the administration of active treatments specifically to the minority of patients who relapsed without compromising performance.

Combined femtosecond laser-assisted intracorneal ring segment implantation and corneal collagen cross-linking for correction of keratoconus

Purpose

To assess the safety, predictability, and effectiveness of Keraring intrastromal corneal ring segments (ICRS) insertion assisted by femtosecond laser and corneal collagen cross-linking (CXL) for keratoconus correction.

Patients and methods

In this prospective, noncomparative, and interventional case series, 160 eyes of 100 adult keratoconus patients with poor best-corrected visual acuity (BCVA) (less than 0.7) and intolerance to contact lens wear were included. Patients underwent femtosecond laser-assisted placement of ICRS and CXL. All patients were examined for a complete ophthalmological test: uncorrected visual acuity (UCVA), BCVA, spherical equivalent, keratometry (K1-flat and K2-steep), pachymetry, and Scheimpflug imaging with the Pentacam at 1 week and at 1, 3, and 6 months postoperatively.

Results

At 6 months, a significant difference was observed (P<0.001) in mean UCVA and BCVA from 0.92±0.677 and 0.42±0.600 logMAR preoperatively to 0.20±0.568 and 0.119±0.619 logMAR, respectively. Mean spherical equivalent refractions were significantly lower (P<0.001) at 6 months. Mean keratometry (K) also significantly reduced (P<0.001) from 50.93±5.53 D (K1-flat) and 55.37±5.76 D (K2-steep) to 47.32±4.61 and 51.08±5.38 D, respectively. In terms of pachymetry, no significant difference was observed preoperatively versus postoperatively (P=1.000).

Conclusion

Keraring ICRS insertion assisted by femtosecond laser and corneal CXL provided significant improvement in visual acuity, spherical equivalent, and keratometry, which suggests that it may be effective, safe, and predictable for keratoconus correction.

Therapeutic management of massive subcutaneous emphysema, bilateral pneumothorax and pneumomediastinum after anterior cordectomy for in situ vocal cord carcinoma - case report

We present the case of a 70 year-old smoker patient, who was admitted in hospital for removal of a tumour located on the left vocal cord. After direct suspension laryngoscopy (with tumorbiopsy sampling), preliminary histopathological exam revealed an in situ carcinoma. At 2 weeks after histopathological confirmation, the left vocal cord was removed by anterior approach, under general anesthesia. In the first 24 hours after surgery, the patient presented an ischaemic stroke, with a deep coma and left hemiplegia, which necessitated mechanical ventilation and specific neurological treatment. Under mechanical ventilation, the patient developed massive subcutaneous emphysema, bilateral pneumothorax and pneumomediastinum,which required tracheostomy and bilateralpleural drainage, in order to limit suddenly installed respiratory insufficiency. After an 18-day interval of intensive care therapy,the patient was released at home, considered to be surgically cured and had a moderate remaining left brachial monoplegia,which was almost totally cured in the next six months.

Seminal plasma oxytocin and oxidative stress levels in infertile men with varicocele

This study aimed to assess seminal plasma oxytocin (OT) and oxidative stress (OS) levels in infertile men with varicocele (Vx). A total of 131 men were divided into fertile men (n = 20), fertile men with Vx (n = 17), infertile men without Vx (n = 40) and infertile men with Vx (n = 54). OT, malondialdehyde (MDA) and glutathione peroxidase (GPx) were estimated in seminal plasma. Mean levels of seminal OT, MDA were significantly decreased, and the mean level of GPx was significantly increased in fertile men with/without Vx compared with infertile men with/without Vx. Mean levels of OT, MDA were increased, and mean level of GPx was significantly decreased in Vx grade III cases compared with Vx grades I, II cases and in bilateral Vx cases compared with unilateral Vx. There was significant negative correlation between seminal OT with sperm count, sperm motility, seminal GPx and significant positive correlation with sperm abnormal forms, seminal MDA. It is concluded that seminal OT is significantly decreased in fertile men with/without Vx compared with infertile men with/without Vx. Seminal OT demonstrated significant negative correlation with sperm count, sperm motility, seminal GPx and significant positive correlation with sperm abnormal forms, seminal MDA. Seminal OT is associated with Vx grade and its bilaterality.

Histopathological and immunohistochemical study of laterocervical lymph node metastases of unknown primary origin

In this study, we examined histopathologically and immunohistochemically 24 cases of laterocervical lymph node metastases with unknown primary origin. For immunohistochemical study, we used a large panel of antibodies represented by CK7, CK19, CK20, CKAE1/AE3, CK34betaE12, TTF1, HBME-1, CEA, MUC5AC and EBV. In the cases studied tumors accompanied by seemingly primitive adenopathies were located in the thyroid, lung, esophagus, stomach, rhinopharynx, hypopharynx, oropharynx and larynx.

Seminal plasma reactive oxygen species-antioxidants relationship with varicocele grade

This work aimed to assess seminal plasma reactive oxygen species (ROS)-antioxidants relationship with varicocele grade in infertile men with oligoasthenoteratozoospermia (OAT). The study included 89 infertile OAT men with varicocele divided into grade I (n = 22) and grade II (n = 43), grade III (n = 24) and compared with 20 healthy fertile controls. In their seminal plasma, two ROS parameters (malondialdehyde [MDA], hydrogen peroxide [H(2) O(2) ]) and four antioxidants (superoxide dismutase [SOD], catalase [Cat], glutathione peroxidase [GPx], vit.C) were estimated. There was significant increase in seminal MDA, H(2) O(2) and significant decrease in seminal SOD, Cat, GPx, vit.C in varicocele-associated OAT cases when compared with the controls. Compared with grade I cases, varicocele cases with grades II, III demonstrated significant increase in estimated seminal MDA, H(2) O(2) and significant decrease in seminal SOD, Cat, GPx, vit.C. It is concluded that seminal oxidative stress (OS) is related to increased varicocele grade in infertile OAT men associated with varicocele.

Thyroid regional metastasis from a giant cell malignant fibrous histiocytoma of the larynx in a patient with history of trichinellosis and tuberculosis

Sarcomas represent less than 1% of malignant laryngeal tumors and giant cell malignant fibrous histiocytoma is exceptionally rare. Diagnosis is histologically based and immunohistochemistry allows differentiation from other fibro-histiocytic neoplasms. We present the case of a 53-year-old male patient with positive medical history for trichinellosis and tuberculosis, and a laryngeal tumor invading the thyroid and causing respiratory distress by airway obstruction. Total laryngectomy and thyroidectomy were performed followed by thyroxine replacement therapy and radiotherapy. Histologically, the tumor consisted of spindle shaped cells with prominent mitoses, and abundant, osteoclast-like, multinucleated giant cells. Similar lesions were identified in the thyroid, adipose and muscular tissues. Parasitic elements were present in muscles. Tumoral cells showed positive immunostaining for Ki67 (40-50%) and vimentin and negative for AE1/AE3, CD31, S100 and myoglobin; the giant multinucleated cells were CD68-positive. Chronic infection might have had a pathogenic significance.

Prospective analysis of predictors of survival in melanoma patients with brain metastases

9074

Background: Melanoma patients (pts) with brain metastases (BM) have limited survival, and BM remains an exclusion criterion in most clinical trials. A recent retrospective analysis at Memorial Sloan Kettering Cancer Center (MSKCC) identified 4 clinical variables that were associated with worse post BM survival (Raizer J et al, Neuro Oncol 2008). In this study, we investigated whether primary tumor features could improve the predictability of post BM survival and examined the reproducibility of the variables identified in MSKCC study. Methods: Melanoma pts with BM prospectively enrolled in an interdisciplinary database at NYU Medical Center from 2002 to 2008 were studied. Six primary tumor characteristics, 21 clinical variables, and treatments were examined. Univariate associations were analyzed using Kaplan Meier survival analysis and the independent effect of identified predictors was assessed by multivariate cox proportional hazards regression analysis. Results: Eighty-nine pts (36 F, 53 M, median age 57) were identified. Median post BM survival was 5.75 months. Median follow-up time based on survivors was 4.2 months. Ulceration and mitotic index ≥3/field were univariately associated with worse post BM survival (p=0.004, p=0.009 respectively). Age >65, ≥3 BM lesions, presence of neurological symptoms, and extracranial metastases were also univariately associated with worse post BM survival (the same 4 variables identified in MSKCC retrospective study). An additional 4 clinical parameters were significant by univariate analysis: frontal lobe location (p=0.01), bilateral lesions (p=0.01), ≥2 neurological symptoms (p=0.005), and weakness/fatigue (p<0.0001). After reproducing the significance of the 4 MSKCC variables in a multivariate model, ulceration of the primary tumor was also an independent predictor of post BM survival (hazard ratio [HR] = 2.75; 95% CI = 1.30, 5.83; p=0.008) whereas mitotic index ≥3/field was not (HR=1.24; 95% CI = 0.57, 2.71; p=0.59). Conclusions: Data suggest that ulceration of the primary melanoma might indicate an adverse biologic behavior that impacts post BM survival. Our data also lend independent support for the predictive model of post BM survival.

No significant financial relationships to disclose.

Evaluation of the melanocortin-1-receptor gene in melanoma predisposition, progression, and recurrence

9018

Background: The melanocortin-1-receptor (MC1R) gene is highly polymorphic in humans. Multiple studies have shown the association between MC1R allelic variants and increased risk of melanoma. Over seventy MC1R single nucleotide polymorphisms (SNPs) have been identified making MC1R a likely target for the development of genetic markers for melanoma predisposition and progression. Alleles described as R and r result in a protein with reduced function compared to wild type, with r alleles having the greatest effect. We sought to investigate the impact of MC1R genotype on risk of developing melanoma and will test for association with disease progression and recurrence in a cohort of melanoma patients enrolled in a prospective study. Methods: Our cohort includes 291 newly diagnosed melanoma patients seen at the New York University Langone Medical Center. The control cohort included 449 subjects. DNA was isolated from leukocytes and analyzed for MC1R SNP status by PCR and direct sequencing. Associations were tested for R-variant R151C and r-variants V60L and V92M. Fisher's Exact test was used to detect significant differences in allele frequency. Odds ratios and confidence intervals were computed for each SNP. Results: Allele frequencies were significantly different in cases and controls for each of the variants (p<0.01). The greatest effect was seen with V60L (Odds Ratio=6.281 95% Confidence Interval 1.77- 22.20). Conclusions: Variants that result in reduced MC1R function increase an individual's risk of developing melanoma. We will continue to test associations with additional variants and determine if these alleles also contribute to risk of disease progression and recurrence. In addition, these variants will be tested for utility as biomarkers for risk assessment of melanoma in a clinical setting.

No significant financial relationships to disclose.

Developing genetic markers for melanoma risk assessment

9046

Background: Risk assessment for melanoma is currently based on phenotype, family and exposure history. This approach is subject to recall bias and excludes at-risk groups such as those with darker skin pigmentation. Poorly stratified risk pools also result in unnecessary dermatologist visits and biopsies for those at lower risk. Use of genetic markers may improve risk assessment; however few susceptibility markers have been developed to date. There have been a number of reports of association between melanoma and genetic markers though few have been replicated or validated. In addition, these studies frequently utilized specific coding region variants as markers and failed to test the entire gene. We have therefore assembled a case-control cohort in which to search for potential biomarkers for melanoma risk by interrogating genes using recently developed tools for genetic analysis. A pilot study was performed to test the utility of our cohort. Methods: A cohort of 326 individuals diagnosed with melanoma and treated at the New York University Langone Medical Center and 400 controls obtained from the New York Cancer project was assembled. Candidate genes were selected based on involvement in determining melanoma predisposition factors (skin pigmentation and DNA repair capability) and previous studies showing association. Three genes, ERCC1, ERCC4 (DNA repair) and MATP (skin pigmentation) were selected. Tag Single Nucleotide Polymorphisms (tSNPs) were selected using Haploview (Hapmap.org) and DNA genotyped (Sequenom Inc, San Diego, CA). Odds ratios and confidence intervals were computed for each SNP. Results: An association was found between SNP rs11615 at the ERCC1 locus and melanoma (Odds ratio = 1.718, 95% Confidence interval: 1.259 - 2.343 for TT vs TC/CC). Conclusions: A tSNP approach is thus useful in identifying associations in our melanoma case-control cohort. Sequence variation at the ERCC1 locus contributes to melanoma risk and the gene will now be screened for clinically useful susceptibility biomarkers. Additional DNA repair and pigmentation genes will also be interrogated using this approach. Genes found to be associated with melanoma will be screened by high- density SNP analysis to identify the most appropriate biomarker/s for use in risk assessment.

No significant financial relationships to disclose.

Clinical relevance of miRNA expression in metastatic melanoma

9006

Background: We recently reported the identification of a specific miRNA cluster frequently overexpressed in melanoma which enhances the metastatic behavior (Segura et al., 2009. PNAS. In press). In this study, we aim to define the clinical relevance of miRNA expression, in particular whether miRNAs can serve as prognostic biomarkers for melanoma patients. Methods: Total RNA was extracted from formalin-fixed paraffin embedded (FFPE) tissue samples from 61 metastatic melanoma specimens (25 lymph node, 16 soft tissue/skin, 13 brain and 7 visceral) accrued by the NYU Interdisciplinary Melanoma Cooperative Group (IMCG). RNA was hybridized into miRNA arrays (miRdicatorTM, Rosetta Genomics, Inc) containing probes for more than 600 miRNA sequences, including all the human miRNAs in the 9.0 version of miRBase. The Significance Analysis of Microarrays (SAM) was used to identify miRNAs significantly associated with survival, and the False Discovery Rate (FDR) approach was used to adjust for multiple comparisons. Results: We identified a signature of 18 miRNAs, whose up-regulation significantly associates with better prognosis (increased overall survival and post-recurrence survival) using the FDR of 0%. Quantitative RT-PCR on the same tissues has verified the array results in 15 out of 15 miRNAs analyzed. Some of these miRNAs were significantly associated with stage at recurrence, while others significantly correlated with the site of metastasis (i.e. visceral, brain, soft-tissue). Using cross-validation, we selected a miRNA signature consisting of 10 of these significant miRNAs with lowest misclassification error in predicting 1.5-year post-recurrence survival. We are currently validating these findings in a separate cohort of metastatic patients. Furthermore, we are investigating whether these ‘protective' miRNAs can be detected in the corresponding primary lesions and thus, whether they already hold prognostic value at early stages of the disease. Conclusions: Our data suggest a role for miRNAs as melanoma biomarkers, and support the development of miRNA- based monitoring assays. These analyses are also expanding our understanding of the molecular alterations underlying melanoma progression, by revealing miRNAs whose down-regulation associates with a more aggressive biological behavior.

[Table: see text]

Association between HU177 serum level and prognosis in patients with primary melanoma

9044

Background: Cleavage of type IV collagen during extracellular matrix (ECM) remodeling leads to exposure of cryptic regulatory sites within the ECM shown to be involved in tumor angiogenesis. Increased levels of a soluble form of the cryptic epitope HU177 in sera of melanoma patients have been shown to be associated with greater tumor thickness and nodular histological subtype. In this study, we investigate the association between HU177 serum levels and melanoma patients' clinical outcomes. Methods: Sera from 209 patients with primary melanoma prospectively enrolled in the Interdisciplinary Melanoma Cooperative Group at the New York University Langone Medical Center (85 females, 124 males, mean age=58, mean thickness=2.09 mm, Stage I n=140, Stage II n=40, Stage III n=29) were analyzed for HU177 level. HU177 serum levels at the time of diagnosis were then correlated with disease-free survival (DFS) and overall survival (OS). Results: Median follow-up time for survivors was 54.9 months (range 2–81 months). Thirty-eight of the 209 (18%) patients developed recurrences, and 34 of the 209 (16%) patients died during follow-up. HU177 sera levels ranged from 0–139.9 ng/ml (mean=6.2 ng/ml; median=3.7 ng/ml). Because the distribution of HU177 levels was positively skewed, we analyzed the data using the median in addition to the mean. HU177 level > 3.7 ng/ml (the median) was associated with a higher rate of melanoma recurrence (p=0.04) and increasing mortality (p=0.01) in a Kaplan Meier analysis. HU177 remained an independent prognostic factor for DFS and OS when controlling for tumor thickness and histological subtype in multivariate Cox proportional hazards regression models. In the DFS hazard model controlling for tumor thickness and histology, the hazard ratio for HU177 >3.7 ng/ml (the median) was 2.01 (95% CI= 1.002, 4.04; p=0.049). In the OS hazard model controlling for tumor thickness and histology, the hazard ratio for HU177 >3.7 ng/ml (the median) was 2.23 (95% CI=1.06, 4.70; p=0.03). Conclusions: Increased serum level of HU177 identifies a subset of primary melanoma patients with worse prognosis and suggests that anti-angiogenic therapy in the adjuvant setting may be a rational approach.

[Table: see text]

Impact of race on survival of prostate cancer patients treated with noncurative intent

5069

Background: We previously reported that African American (AA) men have a higher recurrence rate than Caucasian (CA) men treated with radical prostatectomy at the New York Veteran Administration Medical Center (NY-VAMC), an equal access to care facility (J Urol. 2006). In the current study, we attempted to examine the differences in survival of AA and CA prostate cancer (PC) patients with clinically detected localized disease treated with non curative intent. We hypothesized that comparing patients whose PC was not altered by primary treatment might give a better idea about the difference, if any, of the natural history of PC in AA compared to CA patients. Methods: Men diagnosed with PC at NY-VAMC during 1990–2005 were identified. Inclusion criteria were: 1) biopsy confirmed PC; 2) no evidence of metastatic disease within 6 months after diagnosis; 3) no curative intent treatment. Results: The study included 530 men (288 AA and 242 CA) with median follow-up of 8.1 years (range: 0.6–17.6 years). AA men presented with significantly higher PSA compared to CA patients (median 18.5 versus 11.4 respectively, p = 0.004), however, there were no differences in age at presentation (median 73 versus 74, p = 0.98) or Gleason score (23% of AA and CA had Gleason >7, p = 0.92). Of the 530 patients, 198 (37%) are alive with disease, 67 (13%) died of prostate cancer, 206 (39%) died of other causes, and 59 (11%) died of unknown causes. AA patients had shorter median overall survival compared to CA patients (8 versus 9 years, respectively), however, the difference was not significant (p = 0.29). Factors most predictive of mortality by Cox regression multivariable analysis were PSA at diagnosis (p = 0.001), Gleason score (p = 0.04), and age of patient at diagnosis (p < 0.0001). Race was not an independent predictor of mortality in this model (p = 0.37). Competing risk analysis distinguishing the types of death is underway. Conclusions: The extended follow up available for our study cohort points to non PC related mortality as the major cause of death in patients treated with non-curative intent.

No significant financial relationships to disclose.

Prognostic factors for survival in patients with stage (stg) IV malignant melanoma (MM)

9072

Background: Prognosis for survival in MM is not uniform with some pts being long-term survivors. Identifying this subset of pts may have implications on surveillance and treatment (tx). Unfortunately, prognostic data available for MM and the utility of AJCC staging in predicting survival is limited. We analyzed prospectively collected data from the NYUCI Interdisciplinary Melanoma Cooperative Group program (IMCG) to identify clinicopathological variables predictive of MM survival. Methods: We identified 185 pts enrolled in the IMCG with MM diagnosed and treated at NYUCI. Demographic, clinical, and tx-related factors were included in the analysis. Kaplan-Meier (KM) survival analysis was used to identify univariate predictors of post-stage IV survival and their independent effect was assessed in a multivariate Cox proportional hazards regression model. Results: Median age at diagnosis (dx) of metastatic MM was 64 years (22–92). Median overall survival: 13.8 months(m) (128 deaths and a median follow up of 18.6 m (4–141) for survivors). Factors identified on univariate analysis at p<0.20 were evaluated in the multivariate model ( table ). Co-morbidities, site and histology of primary melanoma, initial staging, prior loco-regional recurrences, and adjuvant tx of primary melanoma were not associated with MM survival. Univariate analysis also showed significant survival advantage (p value 0.0011) for patients with AJCC stages M1a and M1b (21.6 m and 17.2 m respectively) over those with AJCC stage M1c (9 m). Conclusions: This cohort study of MM identified female gender, nl serum LDH, nl albumin, and solitary organ involvement as independent survival predictors. Patients who received systemic therapy± local measures had survival benefit over those that had surgery and/or radiation alone suggesting a role for systemic treatment in MM. Patients with personal history of another malignancy (n=37) showed a trend towards improved survival. This novel observation needs to be validated and studied further.

[Table: see text]

No significant financial relationships to disclose.

Effect of celastrol on temozolomide cytotoxicity in melanoma cells and inhibition of NF-kB signaling

9076

Background: Temozolomide (TMZ) exhibits clinical activity in the treatment of melanoma and glioblastoma, but response rates are low. Identification of agents that improve TMZ's efficacy and overcome resistance is of great interest. In this study, we have identified celastrol as a natural product that significantly enhances TMZ-induced cytotoxicity by testing a library of drugs and natural products for cytotoxic activity against glioma and melanoma cell lines and have examined its mechanism of action in melanoma cells. Methods: A preliminary screening of a library of 2000 drugs and natural products was performed and a short list of drugs was identified as able to enhance TMZ-induced cell killing in TMZ-resistant cancer cell lines. The effects of these compounds were further confirmed in five melanoma cell lines. A cell proliferation assay was used to compare growth inhibitory effects of single agent TMZ versus combination treatments. Synergy in inhibiting cell proliferation was assessed using combination-index methods. The expression of NF-kB, IkB, MAPK, and PARP were examined using Western blot analysis. The effect of treatments on the cell cycle was examined by flow cytometry. The localization of NF-kB in melanoma cells was evaluated through immunofluorescence microscopy. Results: Combining celastrol and TMZ synergistically inhibited cell proliferation, enhanced cell cycle arrest, and increased apoptosis in a series of melanoma cell lines, compared to treatment with TMZ alone. We further found that celastrol inhibited proteasome activity, TNF-α induced IkB phosphorylation and NF-kB translocation to the nucleus. Inhibition of NF-kB with siRNA mimicked the ability of celastrol to sensitize melanoma cells to TMZ-induced cell killing, suggesting inhibition of NF-kB was indeed involved in TMZ/celastrol-induced cytotoxicity. Furthermore, combination treatment induced phosphorylation of JNK. Conclusions: Our data suggest that combined use of TMZ with celastrol, a natural product derived from a vine extract that has been used orally in Chinese medicine for over a thousand years, may enhance the chemotherapeutic efficacy of TMZ in melanoma.

No significant financial relationships to disclose.

Detection of BRAF kinase mutations in melanoma, ovarian, and prostate carcinomas: Evidence for tumor heterogeneity in clinical samples

11031

Background: Several studies have provided evidence that solid tumors are polyclonal malignancies, an observation which may contribute to difficulties in achieving durable treatment responses. In some patients, molecularly targeted therapies may be compromised due to heterogeneity among tumor subclones. In this study we compared conventional DNA sequencing with a fluorescent-based mutant-specific PCR (MS-PCR) assay to detect the BRAF hotspot mutation V600E in a large panel of patient tumors, including paired primary and metastatic tumors from individual patients. Methods: BRAF MS-PCR and conventional sequencing were performed on DNA from 304 tumors (112 melanoma, 110 ovarian, 82 prostate) to determine the presence of the BRAFV600E hot-spot mutation. Among the melanomas were 18 matched primary and metastatic specimens, and 40 metastatic specimens from 19 patients, each of whom had 2 or more metastases. Results: DNA sequencing detected mutations in 5/110 (4.5%) ovarian tumors, 1/82 (1.2%) prostate tumors, and 36/112 (32%) melanomas. In contrast, the MS-PCR assay detected mutations in 12/110 (11%) ovarian tumors, 15/82 (18%) prostate tumors and 85/112 (76%) melanomas. The presence of contaminating normal tissue was scored for each melanoma sample, but excess normal tissue did not influence the results using either methodology. In all cases mutations detected by sequencing were also detected by MSPCR. Among 18 patients with matched primary and metastatic melanoma, 8/18 (44%) had discordant results including 2 patients with mutant primary tumors and wild-type metastases; among the 19 patients with multiple metastases 5/19 (26%) had discordant (both wild-type and mutant) tumors. Conclusions: Using a highly sensitive BRAF mutation detection method, we observed substantial evidence for heterogeneity within clinical tumor specimens. This was especially true in melanoma samples, where multiple specimens from individual patients differed with respect to the presence of the mutant BRAF allele. These results suggest that failures of molecularly targeted therapies, such as those directed against mutant BRAF, may be due in part to a lack of clonality among the tumors under treatment.

No significant financial relationships to disclose.

The unique molecular signatures of nodular and superficial spreading melanoma

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Background: Primary nodular melanoma (NM) patients have a relatively poor prognosis compared to superficial spreading melanoma (SSM) patients. The disparity is generally attributed solely to NM's advanced thickness at presentation. In this study we attempted to define molecular signatures of NM and SSM that may explain their clinical differences. Methods: We performed an in silico gene expression analysis of 2 public data sets consisting of 36NM and 54 SSM primary melanoma tissues (CCR 2007;13 and JNCI 2006;98). We then utilized DNA microarray to generate gene expression profiles of a panel of 22 melanoma cell lines (2SSM, 4 NM, 12 met, 4 melanocytes). Differentially expressed genes and over-represented pathways in NM and SSM were identified based on a pooled analysis of the 3 data sets. We then used SNP array to define genomic alterations unique to NM and SSM but not altered in normal melanocytes. Finally, we correlated SNP array with gene expression. Results: Genes significantly overexpressed (p<0.05) in NM showed over-representation of pathways related to MAPK signaling (p=0.05) and cytoskeleton organization (p=0.02), while SSM showed over-representation of cell communication (p=0.05) and primary metabolic processes (p=0.002). Notable correlations between gene expression and copy number alteration in NM include increased copy number/overexpression of SOX5 (transcription factor related to embryonic development and cell fate) and the downregulation/deletion of ST14 (suppression of tumorigenicity 14). SSM demonstrated concordance of increased copy number/overexpression of EZR (cell adhesion protein implicated in human cancer) as well as PALLD (a protein related to motility, adhesion, and extracellular matrix interactions). Notable SSM genes showing correlation between downregulation/deletion include BNIP3 (a pro-apoptotic protein) and MTAP (often co- deleted with tumor suppressor p16). Conclusions: Simultaneous integration of gene expression with SNP array revealed molecular signatures characteristic of NM and SSM. These results suggest that NM and SSM are distinct biologic entities and that molecularly targeted adjuvant therapy may be more effective if tailored to the molecular signatures of melanoma subtypes. Validation is necessary to draw further conclusions.

No significant financial relationships to disclose.