Sanford Larson, MD, PhD: a pioneering neurosurgeon, scientist, and educator

Dr. Sanford Larson, MD, PhD (1929-2012), was an influential figure in spinal neurosurgery. Dr. Larson played a pivotal role in establishing neurosurgery's foothold in spinal surgery by serving as the inaugural chair of the Joint Section on Disorders of the Spine and Peripheral Nerves and as a president of the Cervical Spine Research Society. He made many advances in spine care, most notably the modification and popularization of the lateral extracavitary approach to the thoracolumbar spine. Dr. Larson established the neurosurgery residency program at the Medical College of Wisconsin; he also instituted the program's spine fellowship, the first in the United States for neurological surgeons. His mentorship produced numerous leaders in organized neurosurgery and neurosurgical education, including Edward Benzel, MD, Dennis Maiman, MD, PhD, Joseph Cheng, MD, Shekar Kurpad, MD, PhD, and Christopher Wolfla, MD. Dr. Larson was a prominent leader in spinal neurosurgery and his legacy carries on today through his contributions to research, education, and surgical technique.

Patterns and outcomes of intracranial pressure monitoring in traumatic brain injury: An analysis of the National Inpatient Sample

INTRODUCTION

Elevated intracranial pressure (ICP) can cause progressive neurological deterioration following traumatic brain injury (TBI). ICP can be monitored to guide subsequent treatment decisions. However, there is conflicting data in the literature regarding the utility of ICP monitoring. We aim to describe patterns and outcomes of ICP monitoring in the United States with the use of a nationwide healthcare database.

METHODS

We performed a 5-year analysis of the Nationwide Inpatient Sample database. We identified all adult TBI patients with a Glasgow Coma Scale (GCS) measuring 3-8 using International Classification of Diseases diagnostic codes. Propensity score matching (1:2 ratio) was performed to control for demographics, injury parameters and comorbidities. Outcome measures included inpatient mortality, length of stay (LOS), cost of care, and discharge disposition.

RESULTS

After propensity score matching, a cohort of 1664 patients was obtained (monitored, 555; non-monitored, 1109). Index outcomes with respect to monitor and no-monitor are as follows: inpatient mortality (35.1%, 42.4%, P <0.01), median LOS (15 days, 6 days, P<0.001), median total charge (289,797 USD, 154,223 USD, P <0.001), discharge home (7.9%, 19.3%, P <0.001) and discharge to another facility (53.9%, 35.4%, P <0.001).

DISCUSSION

ICP monitoring in TBI patients is associated with decreased inpatient mortality and discharge to home, and it is associated with an increased hospital LOS, total charge, and chance of discharge to another facility.

CONCLUSION

The risks and benefits of ICP monitoring should be seriously considered when managing adults with severe TBI.

Ventriculoureteral shunt: Narrative review of contemporary cases and its historical role in the development of renal transplantation

Ventriculo-ureteral (VU) shunting is a little-known method of managing hydrocephalus. This paper reviews contemporary uses of this shunting technique and describes its historical significance to the field of organ transplantation. The ureter may serve as a possible backup, or alternative, distal drainage site compared to the more common peritoneum, atrium, and pleural space. Sporadic contemporary uses of the VU shunt have been reported in unique situations, demonstrating a possible utility in modern neurosurgery. Interestingly, the VU shunt played an important role in the development of kidney transplantation. In the late 1940s and early 1950s, David Hume, a general surgery resident, and colleagues at the PBBH undertook a series of human kidney transplantations. Concurrently, Donald Matson, a pediatric neurosurgeon at Peter Bent Brigham, was utilizing the VU shunt in hydrocephalic patients. Dr. Matson's VU shunt technique involved total nephrectomy, and some of the kidneys harvested from Dr. Matson's were used by his general surgery colleagues in their transplantation trials. Although none of the transplanted kidneys from this series were successful, the transplant team in Boston, minus David Hume, went on to perform the world's first kidney transplant a few years later. This relatively unfamiliar procedure may be applicable to specific situations, and it is of historical importance to the field of transplantation.

The Cytoskeleton Effectors Rho-Kinase (ROCK) and Mammalian Diaphanous-Related (mDia) Formin Have Dynamic Roles in Tumor Microtube Formation in Invasive Glioblastoma Cells

Glioblastoma (GBM) is a progressive and lethal brain cancer. Malignant control of actin and microtubule cytoskeletal mechanics facilitates two major GBM therapeutic resistance strategies-diffuse invasion and tumor microtube network formation. Actin and microtubule reorganization is controlled by Rho-GTPases, which exert their effects through downstream effector protein activation, including Rho-associated kinases (ROCK) 1 and 2 and mammalian diaphanous-related (mDia) formins (mDia1, 2, and 3). Precise spatial and temporal balancing of the activity between these effectors dictates cell shape, adhesion turnover, and motility. Using small molecules targeting mDia, we demonstrated that global agonism (IMM02) was superior to antagonism (SMIFH2) as anti-invasion strategies in GBM spheroids. Here, we use IDH-wild-type GBM patient-derived cell models and a novel semi-adherent in vitro system to investigate the relationship between ROCK and mDia in invasion and tumor microtube networks. IMM02-mediated mDia agonism disrupts invasion in GBM patient-derived spheroid models, in part by inducing mDia expression loss and tumor microtube network collapse. Pharmacological disruption of ROCK prevented invasive cell-body movement away from GBM spheres, yet induced ultralong, phenotypically abnormal tumor microtube formation. Simultaneously targeting mDia and ROCK did not enhance the anti-invasive/-tumor microtube effects of IMM02. Our data reveal that targeting mDia is a viable GBM anti-invasion/-tumor microtube networking strategy, while ROCK inhibition is contraindicated.

A Population-Based Study of Patients with Sleep-Wake Disorders Undergoing Elective Instrumented Spinal Surgery

BACKGROUND

Sleep-wake disorders are associated with multisystemic pathologies, but the clinical risk that such disorders carry for spinal surgery patients is not well understood. This population-based study comprehensively evaluates the significance of sleep-related risk factors on instrumented spinal surgery outcomes.

METHODS

National Inpatient Sample data for hospitalizations of patients undergoing elective instrumented spine surgery between 2008 and 2014 was analyzed using national estimates. Cohorts were defined as those admissions with or without a coexisting sleep-wake disorder diagnosis identified by ICD-9 codes. Postoperative complications, mortality rate, length of stay, discharge status, and total cost of admission were compared between groups using bivariate and multivariate analyses.

RESULTS

A coexisting sleep-wake disorder existed in 234,640 (10.8%) of 2,171,167 instrumented spinal surgery hospitalizations. Multivariate binary logistic regression accounting for these variables confirmed that a sleep-wake disorder is a significant risk factor for postoperative complication (OR 1.160, 95% CI 1.140-1.179, p<0.0001), length of stay above the 75^th percentile (OR 1.303, 95% CI 1.288-1.320, p<0.0001), non-routine discharge (OR 1.147, 95% CI 1.131-1.163, p<0.0001), and death (OR 1.533, 95% CI 1.131-2.078, p<0.01), but not for total charges above the 75^th percentile (OR 0.975, 95% CI 0.962-0.989, p<0.001).

CONCLUSIONS

Sleep-wake disorders confer increased risk of morbidity and mortality in elective instrumented spine surgery. Understanding the specific contributions of sleep-wake disorders to postoperative morbidity and mortality can help physicians implement prophylactic measures to reduce complications and improve postoperative patient recovery.

Abstract 2887: ROCK and mDia have dynamic roles in glioblastoma tumor microtube invasion

Invasive motility limits treatment efficacy and is a significant contributor to poor outcomes in glioblastoma (GBM). GBM tumor microtubes are actin- and microtubule-enriched membrane tubes that facilitate invasive motility and underlie many components of GBM pathophysiology. Rho-GTPases mediate GBM invasion through localized activation of cytoskeletal effector proteins, such as mammalian Diaphanous-related formins (mDia) and Rho-associated protein kinase (ROCK). Active mDia nucleates and polymerizes F-actin and independently stabilizes microtubules, while active ROCK phosphorylates myosin phosphatase and myosin light chain to induce the actomyosin crosslinking required for contractility. GBM invasion depends on a delicate balance between mDia-mediated extension of leading-edge structures (such as tumor microtubes) and ROCK-mediated contraction of trailing cell bodies. In this study, we assessed the roles of ROCK and mDia in tumor microtube-associated GBM invasion using a 3D patient-derived neurosphere model of GBM invasion. Neurospheres were embedded in 3D matrices and treated with the small molecule inhibitor of ROCK (Y-27632) and the small molecule agonist of mDia (IMM-02). Treatment with Y-27632 alone reduced the total distance of cell body migration and increased tumor microtube length without effecting the total area of neurosphere invasion. Tumor microtubes extending from Y-27632 treated neurospheres displayed an atypical undulant morphology, further suggesting that ROCK inhibition modifies primary invasion programs. Treatment with IMM-02 alone profoundly reduced total area of neurosphere invasion, distance of cell body migration, and length of tumor microtubes. Combination treatment effects (Y-27632 + IMM-02) were time dependent. At 24 hours, combination treatment did not significantly reduce total area of invasion over either individual treatment. However, tumor microtubes were shorter with combination treatment than Y-27632 alone and longer than IMM-02 alone. At 96 hours, combination treatment reduced total area invaded and length of tumor microtubes in comparison to Y-27632 alone, but no significant difference was observed in comparison to IMM-02 alone. Western blot analysis of both free-floating patient-derived 3D neurospheres and semi-adherent “2.5D” monolayer cultures demonstrated that agonism of mDia formins with IMM-02 (96-hrs) results in the progressive loss of mDia1 and mDia2 protein expression. Therefore, endogenous mDia regulatory mechanisms triggered in response to continuous agonist-mediated mDia activation may inhibit mDia function more effectively than direct antagonism strategies in GBM. Conclusively, both IMM-02 and Y-27632 treatment disrupt the tumor microtube mechanism of GBM neurosphere invasion. Further studies are warranted to evaluate these small molecule compounds for potential anti-tumor microtube therapeutic effect in vivo.

Citation Format: Kathryn N. Becker, Krista M. Pettee, Amanda Sugrue, Kevin A. Reinard, Jason L. Schroeder, Kathryn M. Eisenmann. ROCK and mDia have dynamic roles in glioblastoma tumor microtube invasion [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2887.

Outcomes and prognostic stratification of patients with recurrent glioblastoma treated with salvage stereotactic radiosurgery

OBJECTIVE

Glioblastoma (GBM) is the most malignant form of astrocytoma. The average survival is 6-10 months in patients with recurrent GBM (rGBM). In this study, the authors evaluated the role of stereotactic radiosurgery (SRS) in patients with rGBMs.

METHODS

The authors performed a retrospective review of their brain tumor database (1997-2016). Overall survival (OS) and progression-free survival (PFS) after salvage SRS were the primary endpoints evaluated. Response to SRS was assessed using volumetric MR images.

RESULTS

Fifty-three patients with rGBM underwent salvage SRS targeting 75 lesions. The median tumor diameter and volume were 2.55 cm and 3.80 cm3, respectively. The median prescription dose was 18 Gy (range 12-24 Gy) and the homogeneity index was 1.90 (range 1.11-2.02). The median OS after salvage SRS was estimated to be 11.0 months (95% CI 7.1-12.2) and the median PFS after salvage SRS was 4.4 months (95% CI 3.7-5.0). A Karnofsky Performance Scale score ≥ 80 was independently associated with longer OS, while small tumor volume (< 15 cm3) and less homogeneous treatment plans (homogeneity index > 1.75) were both independently associated with longer OS (p = 0.007 and 0.03) and PFS (p = 0.01 and 0.002, respectively). Based on these factors, 2 prognostic groups were identified for PFS (5.4 vs 3.2 months), while 3 were identified for OS (median OS of 15.2 vs 10.5 vs 5.2 months).

CONCLUSIONS

SRS is associated with longer OS and/or PFS in patients with good performance status, small-volume tumor recurrences, and heterogeneous treatment plans. The authors propose a prognostic model to identify a cohort of rGBM patients who may benefit from SRS.

Streptococcus Mutans: A Potential Risk Factor in Recurrent Hemorrhagic Stroke

Stroke is the fifth leading cause of death and is responsible for approximately nine percent of all deaths worldwide. Cases of Streptococcus mutans (S. mutans)-induced intracerebral hemorrhage as a result of bloodstream infections have seldom been reported. New reports show that bacteria with specific collagen binding proteins (CBPs), such as the Cnm type produced by S. mutans, may inhibit platelet aggregation and cause bleeding. In this article, we report on a 62-year-old man with a recent history of left frontal intracerebral hemorrhage (ICH) who presented to the emergency department after a fall due to suspected seizure while in rehabilitation. Computed tomography (CT) scan of the brain showed a right cerebellar hemorrhage with surrounding edema and mass effect on the fourth ventricle. A suboccipital craniotomy to evacuate the cerebellar ICH was completed without complication. Radiologic and angiographic assessments regarding the etiology of this patient's stroke did not reveal any evidence of vascular pathology or mycotic aneurysms to explain his recurrent intracranial hemorrhages. Through persistent patient and family interviews, it came to light that a few weeks prior to the patient's first ICH, he was diagnosed with a bloodstream infection by S. mutans. Bacteremia is known to be associated with embolic stroke, but only recently has it been shown that bacteremia can also be implicated in hemorrhagic stroke. S. mutans of the k serotype have specific CBPs that are attracted to exposed collagen in previously damaged small vessel walls. These bacterial proteins can interrupt the blood clotting cascade through the prevention of platelet aggregation, increasing the risk of intracerebral hemorrhage.

Impact of the radiosurgery prescription dose on the local control of small (2 cm or smaller) brain metastases

OBJECTIVE The impact of the stereotactic radiosurgery (SRS) prescription dose (PD) on local progression and radiation necrosis for small (≤ 2 cm) brain metastases was evaluated. METHODS An institutional review board-approved retrospective review was performed on 896 patients with brain metastases ≤ 2 cm (3034 tumors) who were treated with 1229 SRS procedures between 2000 and 2012. Local progression and/or radiation necrosis were the primary end points. Each tumor was followed from the date of radiosurgery until one of the end points was reached or the last MRI follow-up. Various criteria were used to differentiate tumor progression and radiation necrosis, including the evaluation of serial MRIs, cerebral blood volume on perfusion MR, FDG-PET scans, and, in some cases, surgical pathology. The median radiographic follow-up per lesion was 6.2 months. RESULTS The median patient age was 56 years, and 56% of the patients were female. The most common primary pathology was non-small cell lung cancer (44%), followed by breast cancer (19%), renal cell carcinoma (14%), melanoma (11%), and small cell lung cancer (5%). The median tumor volume and median largest diameter were 0.16 cm³ and 0.8 cm, respectively. In total, 1018 lesions (34%) were larger than 1 cm in maximum diameter. The PD for 2410 tumors (80%) was 24 Gy, for 408 tumors (13%) it was 19 to 23 Gy, and for 216 tumors (7%) it was 15 to 18 Gy. In total, 87 patients (10%) had local progression of 104 tumors (3%), and 148 patients (17%) had at least radiographic evidence of radiation necrosis involving 199 tumors (7%; 4% were symptomatic). Univariate and multivariate analyses were performed for local progression and radiation necrosis. For local progression, tumors less than 1 cm (subhazard ratio [SHR] 2.32; p < 0.001), PD of 24 Gy (SHR 1.84; p = 0.01), and additional whole-brain radiation therapy (SHR 2.53; p = 0.001) were independently associated with better outcome. For the development of radiographic radiation necrosis, independent prognostic factors included size greater than 1 cm (SHR 2.13; p < 0.001), location in the corpus callosum (SHR 5.72; p < 0.001), and uncommon pathologies (SHR 1.65; p = 0.05). Size (SHR 4.78; p < 0.001) and location (SHR 7.62; p < 0.001)-but not uncommon pathologies-were independent prognostic factors for the subgroup with symptomatic radiation necrosis. CONCLUSIONS A PD of 24 Gy results in significantly better local control of metastases measuring < 2 cm than lower doses. In addition, tumor size is an independent prognostic factor for both local progression and radiation necrosis. Some tumor pathologies and locations may also contribute to an increased risk of radiation necrosis.

Industry-relevant magnetron sputtering and cathodic arc ultra-high vacuum deposition system for in situ x-ray diffraction studies of thin film growth using high energy synchrotron radiation

We present an industry-relevant, large-scale, ultra-high vacuum (UHV) magnetron sputtering and cathodic arc deposition system purposefully designed for time-resolved in situ thin film deposition/annealing studies using high-energy (>50 keV), high photon flux (>10(12) ph/s) synchrotron radiation. The high photon flux, combined with a fast-acquisition-time (<1 s) two-dimensional (2D) detector, permits time-resolved in situ structural analysis of thin film formation processes. The high-energy synchrotron-radiation based x-rays result in small scattering angles (<11°), allowing large areas of reciprocal space to be imaged with a 2D detector. The system has been designed for use on the 1-tonne, ultra-high load, high-resolution hexapod at the P07 High Energy Materials Science beamline at PETRA III at the Deutsches Elektronen-Synchrotron in Hamburg, Germany. The deposition system includes standard features of a typical UHV deposition system plus a range of special features suited for synchrotron radiation studies and industry-relevant processes. We openly encourage the materials research community to contact us for collaborative opportunities using this unique and versatile scientific instrument.

Residual tumor volume versus extent of resection: predictors of survival after surgery for glioblastoma

Object

The impact of extent of resection (EOR) on survival for patients with glioblastoma (GBM) continues to be a point of debate despite multiple studies demonstrating that increasing EOR likely extends survival for these patients. In addition, contrast-enhancing residual tumor volume (CE-RTV) alone has rarely been analyzed quantitatively to determine if it is a predictor of outcome. The purpose of this study was to evaluate the effect of CE-RTV and T2/FLAIR residual volume (T2/F-RV) on overall survival.

Methods

A retrospective review of 128 patients who underwent primary resection of supratentorial GBM followed by standard radiation/chemotherapy was undertaken utilizing quantitative, volumetric analysis of pre- and postoperative MR images. The results were compared with clinical data obtained from the patients' medical records.

Results

At analysis, 8% of patients were alive, and no patients were lost to follow-up. The overall median survival was 13.8 months, with a median Karnofsky Performance Scale (KPS) score of 90 at presentation. The median contrast-enhancing preoperative tumor volume (CE-PTV) was 29.0 cm3, and CE-RTV was 1.2 cm3, equating to a 95.8% median EOR. The median T2/F-RV was 36.8 cm3. CE-PTV, CE-RTV, T2/F-RV, and EOR were all statistically significant predictors of survival when controlling for age and KPS score. A statistically significant benefit in survival was seen with a CE-RTV less than 2 cm3 or an EOR greater than 98%. Evaluation of the volumetric analysis methodology was performed by observers of varying degrees of experience—an attending neurosurgeon, a fellow, and a medical student. Both the medical student and fellow recorded correlation coefficients of 0.98 when compared with the attending surgeon's measured volumes of CE-PTV, while for CE-RTV, correlation coefficients of 0.67 and 0.71 (medical student and fellow, respectively) were obtained.

Conclusions

CE-RTV and EOR were found to be significant predictors of survival after GBM resection. CERTV was the more significant predictor of survival compared with EOR, suggesting that the volume of residual contrast-enhancing tumor may be a more accurate and meaningful reflection of the pathobiology of GBM.

The role of laser interstitial thermal therapy in enhancing progression-free survival of difficult-to-access high-grade gliomas: a multicenter study

Surgical extent-of-resection has been shown to have an impact on high-grade glioma (HGG) outcomes; however, complete resection is rarely achievable in difficult-to-access (DTA) tumors. Controlled thermal damage to the tumor may have the same impact in DTA-HGGs. We report our multicenter results of laser interstitial thermal therapy (LITT) in DTA-HGGs. We retrospectively reviewed 34 consecutive DTA-HGG patients (24 glioblastoma, 10 anaplastic) who underwent LITT at Cleveland Clinic, Washington University, and Wake Forest University (May 2011-December 2012) using the NeuroBlate(®) System. The extent of thermal damage was determined using thermal damage threshold (TDT) lines: yellow TDT line (43 °C for 2 min) and blue TDT line (43°C for 10 min). Volumetric analysis was performed to determine the extent-of-coverage of tumor volume by TDT lines. Patient outcomes were evaluated statistically. LITT was delivered as upfront in 19 and delivered as salvage in 16 cases. After 7.2 months of follow-up, 71% of cases demonstrated progression and 34% died. The median overall survival (OS) for the cohort was not reached; however, the 1-year estimate of OS was 68 ± 9%. Median progression-free survival (PFS) was 5.1 months. Thirteen cases who met the following two criteria-(1) <0.05 cm(3) tumor volume not covered by the yellow TDT line and (2) <1.5 cm(3) additional tumor volume not covered by the blue TDT line-had better PFS than the other 21 cases (9.7 vs. 4.6 months; P = 0.02). LITT can be used effectively for treatment of DTA-HGGs. More complete coverage of tumor by TDT lines improves PFS which can be translated as the extent of resection concept for surgery.

Absence of immunostaining for growth hormone in a subset of patients with acromegaly

The presence of growth hormone (GH) immunostaining in patients who lack the biochemical and clinical features of acromegaly has been described. In contrast, there is little information on the absence of GH immunostaining in patients with acromegaly. We describe five patients with acromegaly with no intratumoral immunostaining for GH. We reviewed all patients undergoing surgery for acromegaly. Out of 136 patients treated surgically in a 10 year period, five (3.7%) were found to have no GH immunostaining on repetitive testing at pathological examination. Their pathology slides were re-examined by an experienced neuropathologist, along with twenty nonfunctional pituitary tumors and ten GH-positive adenomas as negative and positive controls, respectively. All patients had clinical features consistent with acromegaly and elevated baseline insulin-like growth factor-1 (IGF-1) and GH. All patients had no immunostaining for GH on multiple inspections. Of twenty patients with nonfunctional tumors, two had ≤25% staining for GH in a scattered and non-coherent pattern and the rest were negative. In all ten positive control patients >25% of the tumor cells stained diffusely for GH. All five patients achieved biochemical remission at 1.4-8 years post-op using a combination of primary surgery alone (n = 1), repeat surgery (n = 1), radiotherapy (n = 3) and/or medical therapy (n = 2). GH immunostaining of an adenoma may not be sufficient to confirm the diagnosis of acromegaly. All patients in our small series achieved remission by multimodality therapies. Further studies are needed to evaluate the significance of our observation and whether this subset of patients follows a distinct long term clinical course.

Extent of resection of glioblastoma revisited: personalized survival modeling facilitates more accurate survival prediction and supports a maximum-safe-resection approach to surgery

PURPOSE

Approximately 12,000 glioblastomas are diagnosed annually in the United States. The median survival rate for this disease is 12 months, but individual survival rates can vary with patient-specific factors, including extent of surgical resection (EOR). The goal of our investigation is to develop a reliable strategy for personalized survival prediction and for quantifying the relationship between survival, EOR, and adjuvant chemoradiotherapy.

PATIENTS AND METHODS

We used accelerated failure time (AFT) modeling using data from 721 newly diagnosed patients with glioblastoma (from 1993 to 2010) to model the factors affecting individualized survival after surgical resection, and we used the model to construct probabilistic, patient-specific tools for survival prediction. We validated this model with independent data from 109 patients from a second institution.

RESULTS

AFT modeling using age, Karnofsky performance score, EOR, and adjuvant chemoradiotherapy produced a continuous, nonlinear, multivariable survival model for glioblastoma. The median personalized predictive error was 4.37 months, representing a more than 20% improvement over current methods. Subsequent model-based calculations yield patient-specific predictions of the incremental effects of EOR and adjuvant therapy on survival.

CONCLUSION

Nonlinear, multivariable AFT modeling outperforms current methods for estimating individual survival after glioblastoma resection. The model produces personalized survival curves and quantifies the relationship between variables modulating patient-specific survival. This approach provides comprehensive, personalized, probabilistic, and clinically relevant information regarding the anticipated course of disease, the overall prognosis, and the patient-specific influence of EOR and adjuvant chemoradiotherapy. The continuous, nonlinear relationship identified between expected median survival and EOR argues against a surgical management strategy based on rigid EOR thresholds and instead provides the first explicit evidence supporting a maximum safe resection approach to glioblastoma surgery.

Prognostic factors of overall survival after laser interstitial thermal therapy in patients with glioblastoma

Background:

Laser interstitial thermal therapy (LITT) is a minimally invasive technique for treating intracranial tumors percutaneously. Controlled thermal damage to the tumor may offer an adjunct to the treatment of glioblastoma multiforme (GBM) especially in deep-seated locations. We report our series of patients with GBM treated with LITT.

Methods:

Eleven consecutive patients with GBM who underwent LITT at the Cleveland Clinic using the NeuroBlate

Results:

LITT was delivered as upfront treatment in six cases and delivered as salvage in five cases. After 26.2 months of follow-up, 73% of cases demonstrated progression and 54.5% died. The median overall survival (OS) for the cohort was 8.4 months. Median progression free survival (PFS) was 6.1 months. A tendency towards improved overall survival was discovered in patients who had near complete coverage of tumor by blue and yellow TDT-lines.

Conclusions:

LITT can be used in a safe and effective manner for the treatment of patients with difficult to access GBM. Improved coverage of the tumor by the TDT-treatment lines has a tendency to improve patient overall survival.

Laser interstitial thermal therapy as a novel treatment modality for brain tumors in the thalamus and basal ganglia

Introduction:

Deep-seated hemispheric brain tumors pose unique challenges for surgical treatment. These tumors are often considered inoperable and when surgery is undertaken significant, serious, morbidity and even mortality may complicate the outcome. Laser interstitial thermal therapy (LITT) is a minimally invasive alternative to traditional open surgery that affects tumor cell death by producing a zone of thermal tissue damage that can be monitored and controlled with the aid of real-time magnetic resonance thermography.

Subjects and methods:

A retrospective review of six patients treated with LITT at the Cleveland Clinic between 5/2011 and 8/2013 was performed. We evaluated clinical patient data and pre-, intra-, and post-operative magnetic resonance imaging (MRI) data for correlation.

Results:

Six patients were treated with a total of eight separate LITT procedures for their thalamic (n=5) or basal ganglia (n=1) tumors. All tumors were histologically malignant and five were primary tumors. Pre- and post-operative neurological deficits were recorded. The two patients that underwent multiple procedures were retreated for different reasons – one due to insufficient coverage and the other due to tumor recurrence. Sustained post-operative neurological deficits were observed after three procedures and one patient died within 2 days of surgery from a thalamic hemorrhage.

Conclusions:

LITT is a minimally invasive surgical treatment that can lead to successful ablation of tumors of the thalamus or basal ganglia. However, this treatment has the potential for neurological morbidity or even mortality and as such further studies are needed to evaluate the true risk vs. reward potential for LITT with regard to treating deep-seated tumors.

Rapid overlapping-volume acquisition and reconstruction (ROVAR): automated 3D tiling for high-resolution, large field-of-view optical microscopy

Micrometer-scale three-dimensional data from fluorescence microscopes offer unique insight into cellular morphology and function by resolving subcellular locations of fluorescent dyes and proteins. To increase field-of-view size while using a high-resolution multiphoton microscope, we have created an automated system of rapidly acquiring overlapping image stacks from multiple fields-of-view along a nonplanar tissue surface. Each image stack is acquired only between the surface and the maximal penetrating depth, as determined by the image signal-to-background ratio. This results in the acquisition of the volume containing visible tissue along the tissue surface, excluding the empty volume above the tissue and the volume beyond the maximum imaging depth within the tissue. The automated collection of overlapping volumes is followed by reconstruction that can efficiently generate a single three-dimensional volume of the tissue surface. This approach yields data spanning multiple millimetres at micrometre resolution that is faster while requiring less work from the microscope operator. The advantages of the system are demonstrated by acquisition of data from intact, unfixed organs without a coverglass both in vivo and in situ.

Optimizing multiphoton fluorescence microscopy light collection from living tissue by noncontact total emission detection (epiTED)

A benefit of multiphoton fluorescence microscopy is the inherent optical sectioning that occurs during excitation at the diffraction-limited spot. The scanned collection of fluorescence emission is incoherent; that is, no real image needs to be formed on the detector plane. The nearly isotropic emission of fluorescence excited at the focal spot allows for new detection schemes that efficiently funnel all attainable photons to detector(s). We previously showed [Combs, C.A., et al. (2007) Optimization of multiphoton excitation microscopy by total emission detection using a parabolic light reflector. J. Microsc. 228, 330-337] that parabolic mirrors and condensers could be combined to collect the totality of solid angle around the excitation spot for tissue blocks, leading to ∼8-fold signal gain. Using a similar approach, we have developed an in vivo total emission detection (epiTED) instrument modified to make noncontact images from outside of living tissue. Simulations suggest that a ∼4-fold enhancement may be possible (much larger with lower NA objectives than the 0.95 NA used here) with this approach, depending on objective characteristics, imaging depth and the characteristics of the sample being imaged. In our initial prototype, 2-fold improvements were demonstrated in the mouse brain and skeletal muscle as well as the rat kidney, using a variety of fluorophores and no compromise of spatial resolution. These results show this epiTED prototype effectively doubles emission signal in vivo; thus, it will maintain the image signal-to-noise ratio at two times the scan rate or enable full scan rate at approximately 30% reduced laser power (to minimize photo-damage).

Reduction of hypoxia by perfluorocarbon emulsion in a traumatic spinal cord injury model

Object

Few therapies have consistently demonstrated effectiveness in preserving O2 delivery after spinal cord injury (SCI). Perfluorocarbons (PFCs) offer great promise to carry and deliver O2 more efficiently than conventional measures. The authors investigated the use of Clark-type microelectrodes to monitor spinal cord oxygenation directly (intraparenchymal [IP] recording) and indirectly (cerebrospinal fluid [CSF] recording) in the context of SCI, O2 therapy, and PFC treatment.

Methods

After placement of a subdural/CSF Licox probe in rats, incremental increases in the fraction of inspired O2 (FiO2) up to 100% were administered to establish a dose-response curve. The probe was then placed in the parenchyma of the same animals for a second dose-response curve. In a second study, rats with CSF or IP probes underwent SCI with the NYU Impactor and treatment with O2, followed by administration of PFC, or saline in the control group.

Results

All animals in the first experiment responded to the FiO2 dose increase, with changes in PO2 evident in both CSF and IP levels. The SCI in the second experiment caused a marked drop in PO2 from a mean of 21.4 to 10.4 mm Hg, with most animals dropping to less than half their preinjury value. All animals responded to 100% O2 treatment. Every animal that received PFCs showed significant improvement, with a mean increase in PO2 of 23.3 mm Hg. Only 1 saline-treated animal showed any benefit. Oxygen values in the PFC treatment group reached up to 6 times the normal level.

Conclusions

Oxygen levels in SCI show a profound drop almost immediately postinjury. Administration of PFCs combined with 100% O2 therapy can reverse tissue hypoxia and holds promise for reducing ischemic injury.

Averting the gaze disengages the environment and facilitates remembering

When people are asked moderately difficult questions, they often avert their gazes. We report five experiments in which we documented this phenomenon. They demonstrate that (1) the frequency of gaze aversion is related to the difficulty of cognitive processing, (2) this behavior cannot be due solely to demand characteristics or embarrassment, and (3) the behavior is functional: Averting the gaze improves performance. We speculate that averting the gaze helps people to disengage from environmental stimulation and thereby enhances the efficiency of cognitive processing directed by nonenvironmental stimulation.

Photochemical reactions and phototoxicity of sterols: novel self-perpetuating mechanisms for lipid photooxidation

Sterols are important lipid components that may contribute to phototoxicity. We have found that phototoxic response in earthworms is related to sterols extractable with lipophilic solvents. The photochemically active compounds in worm lipids are 5,7,9(11),22-ergostatetraen-3 beta-ol (9-DHE) and 5,7,9(11)-cholestartien-3 beta-ol (9-DDHC), respectively. Human skin lipids are known to contain 9-DHE. We have also found 9-DDHC in human skin, which is reported here for the first time. In the presence of an excess of the corresponding 5,7-dienes (ergosterol of 7-dehydrocholesterol), these photoactive sterols constitute a self-regenerating source of singlet molecular oxygen (1O2) during irradiation in vivo or in vitro with UVA (315-400 nm). The quantum yield for photosensitization of 1O2 by 9-DHE was estimated to be 0.09. The 1O2 is scavenged by the dienes and the rate constant for 1O2 quenching by ergosterol was found to be 1.2 x 10(7) M-1 s-1 in methyl t-butyl ether (MTBE). This scavenging ultimately leads to the production of 5,8-endoperoxide and hydrogen peroxide. Photochemically induced superoxide radical was also produced on irradiation of sterol 5,7,9-trienes and trapped with the spin trap 5,5-dimethyl-1-pyrroline N-oxide (DMPO). The production of singlet oxygen, peroxides and radicals by the sterols may be significant in the cell damaging and tumor promoting action of UVA light on skin.

Formation of N-7-(2-carbamoyl-2-hydroxyethyl)guanine in DNA of the mouse and the rat following intraperitoneal administration of [14C]acrylamide

Acrylamide is an alkylating agent which reacts very slowly in direct reactions with DNA and is negative in the Ames test, but is carcinogenic in mice and rats. In order to explain the cancer-initiating properties of acrylamide we have studied DNA adduct formation in vitro with a metabolizing system and in vivo in mice and rats following i.p. administration of 14C-labeled acrylamide. A major adduct found in both species was N-7-(2-carbamoyl-2-hydroxy-ethyl)guanine, formed by reaction of the DNA with the epoxide metabolite glycidamide. The levels of this adduct were similar in the different organs of the two rodent species, which supports the notion that glycidamide is relatively evenly distributed among tissues and that the organ-specificity in acrylamide carcinogenesis cannot be explained by a selective accumulation of the DNA-reactive metabolite in target organs.

Doubly allylic hydroperoxide formed in the reaction between sterol 5,7-dienes and singlet oxygen

Ergosterol and 7-dehydrocholesterol, common 5,7-conjugated diene sterols, react with photochemically produced singlet oxygen very efficiently to yield, in parallel pathways, the corresponding 5,8-endoperoxides and the 7 beta-hydroperoxy-5,8(9),22-trienol or -5,8(9)-dienol, respectively. The hydroperoxides decompose in an acid-catalyzed reaction to generate hydrogen peroxide and the 5,7,9(11),22-tetraenol or 5,7,9(11) trienol, respectively, with 1:1 stochiometry. The molar ratio of endoperoxide to hydroperoxide was constant (16:5) with two different reaction solvents, two different photosensitizers, and at all time points between 5 min and 3 h from the start of irradiation. Ergosterol did not react with either hydrogen peroxide or superoxide ion under our reaction conditions. Inhibition studies with nitrogen, 2,5-dimethylfuran, beta-carotene, and tert-butanol confirmed the involvement of singlet oxygen in these reactions. The unstable hydroperoxide would be expected to have undesirable biological consequences if formed in vivo.

Endogenous lipids of the earthworm Lumbricus terrestris

Earthworms (Lumbricus terrestris) were given [1-14C]-labeled palmitic acid by gavage on days 0 and 3, and sacrificed on day 7. The distribution of label among lipid classes indicated that glycerides, sterol esters, cerebrosides, sulfatides, phosphatidylethanolamine, phosphatidylserine and (or) phosphatidylinositol, phosphatidylcholine, and sphingomyelin turn over in, or are synthesized by, the earthworm. Free fatty acids still had the highest specific radioactivity of any lipid class at the end of the experiment. Incorporation of label into sterol and hydrocarbon fractions was insignificant and there was no detectable label incorporated into gangliosides. Phosphatidylethanolamine apparently turned over quite slowly compared with other lipid classes, while the cerebroside fraction became highly labeled. Elongation of palmitic acid to stearate and oxidation to CO2 occurred extensively, but there was no evidence for desaturation.

The metabolism of di(2-ethylhexyl)phthalate in the earthworm Lumbricus terrestris

1. Earthworms can hydrolyze di-(2-ethylhexyl) phthalate (DEHP) to mono-2-ethylhexyl phthalate (MEHP) and phthalic acid (PA). 2. They apparently cannot produce the side-chain-oxidized derivatives of MEHP that constitute the major DEHP metabolites in higher animals. 3. With the assistance of intestinal bacterial Pseudomonas, the worm-derived PA is degraded through protocatechuic and beta-carboxymuconic acids to CO2. 4. There is an indication of a second pathway for degradation of PA leading through benzoic acid.

Isolation and characterization of the initial radical adduct formed from linoleic acid and alpha-(4-pyridyl 1-oxide)-N-tert-butylnitrone in the presence of soybean lipoxygenase

The spin trapping agent alpha-(4-pyridyl-1-oxide)-N-tert-butylnitrone (POBN) was used to trap the initial radical formed from [U-14C]linoleic acid in the reaction with soybean lipoxygenase. By using low levels of enzyme and relatively short incubation times it was possible to avoid the formation of secondary oxidation products and polymers. The adduct was extracted after methyl esterification, and isolated by a combination of open column chromatography on silicic acid and high pressure liquid chromatography on Spherisorb S5 CN with non-aqueous solvents. The 1:1 POBN-linoleate adduct was characterized by UV, IR and ESR spectra of the appropriate HPLC column fraction, by the ratio of the UV absorption to 14C content, and by mass spectrometry of the reduced (hydroxylamine) form. The results indicated that POBN trapped a linoleic acid carbon-centered radical such that POBN was attached to the fatty acid chain at C-13 or C-9 (two isomers), the linoleate double bonds having become conjugated in the process. The exact locations of the bridges in the two isomers were only tentatively determined. There was no evidence for the presence of oxygen-bridged adducts. The trapped linoleoyl radical adduct provides evidence for the production of a free radical as part of the enzymatic mechanism of soybean lipoxygenase.

Lipids of the earthworm Lumbricus terrestris

The lipid composition of the earthworm Lumbricus terrestris has been reexamined under conditions intended to avoid enzymatic and chemical alterations during storage, extraction, and fractionation procedures. The simple lipids included aliphatic hydrocarbons, steryl esters, glycerides, and at least nine different sterols, all thought to be derived from the diet. Free fatty acids, previously considered to be major components of worm lipids, comprised only 0.3% of the total lipid weight. Phospholipids included (in order of relative abundance) phosphatidylcholine, phosphatidylethanolamine, phosphatidylserine, and phosphatidylinositol, as well as sphingomyelin. Glycolipids included cerebrosides and sulfatides containing both glucose and galactose, and gangliosides containing glucosamine and sialic acid. The fatty acid compositions of these lipid classes appeared to be a mixture of what are considered typical plant, bacterial, and animal acids. Several fatty acids found in the worms, including cis-vaccenic and eicosapentaenoic acids, were essentially absent from the dietary components, and it is concluded that these acids were synthesized in the worms. The earthworm derives much of its lipid adventitiously, but exerts at least some control over its tissue lipid composition.

Chamber and gavage technique for metabolic studies of earthworms

Earthworms make very suitable laboratory animals for metabolic studies in vivo using radiolabeled test chemicals. We describe the construction and operation of a metabolic chamber to enable the collection of labeled CO2, volatile organics, material excreted into the bedding, and labeled material remaining in the worms. A gavage technique has been developed that permits the administration of water-soluble and lipid-soluble test chemicals in spite of the extremely low level of triglyceride lipase activity in the earthworm gut. This technique is less likely to puncture the worm tissue than previous methods. Radiolabeled DDT and diethylhexyl adipate were used to provide examples of the use of these techniques and the metabolic chamber. Results were qualitatively similar to those that have been noted in vertebrates.

In vitro studies of the inhibition of protein kinase C from rat brain by di-(2-ethylhexyl)phthalate

The environmental contaminant di(2-ethylhexyl)phthalate (DEHP) has been shown to inhibit the phosphorylation of histone by purified protein kinase C (PK-C) from rat brain in a concentration-dependent manner. The inhibition does not involve making the substrate unavailable, although DEHP does bind to some extent to histone. DEHP displaces phorbol dibutyrate from PK-C, indicating that DEHP binds to the regulatory domain of the enzyme. Since DEHP does not affect the PK-C dependent phosphorylation of protamine, DEHP probably does not bind at the catalytic site. DEHP non-competitively blocked activation of PK-C by either phosphatidyl serine or calcium ion. Inhibition of histone phosphorylation by DEHP was enhanced if diglyceride was present, and the enhancement was stereoselective for the isomeric form of the diglyceride. The mechanism of the inhibition is thought to involve interference with the interaction between calcium ion and the regulatory domain of PK-C, and would have significance only for those PK-C substrates that require calcium activation of the enzyme. Thus the presence of DEHP in the high nanomolar concentration range alters the effective substrate specificity of PK-C.

Comparison of the effects of carbon tetrachloride and of 2,3,7,8-tetrachlorodibenzo-p-dioxin on the disposition of linoleic acid in rat liver in vitro

Both 2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) and carbon tetrachloride (CCl4) have conspicuous effects on lipid metabolism in rat liver. Although it is generally accepted that CCl4 administration leads to hepatic lipid peroxidation in vivo, conflicting reports from different laboratories make it unclear whether or not lipid peroxidation is involved in the mechanism of toxicity of TCDD. The present study involved pretreating F344 rats with CCl4 or TCDD, then at predetermined times thereafter, giving [U-14C]linoleic acid. A variety of compound classes were monitored in extracts of liver taken 30 min after the label was given. A previously unreported effect of CCl4 was a conspicuous increase in turnover of 1,2-diglycerides. That CCl4 did cause lipid peroxidation was evident from the presence of allylic hydroxyacids not seen in vehicle-treated controls, greatly increased radioactivity in protein-bound material, and decreased levels of arachidonate without decreased synthesis from linolate. Where effects of TCDD pretreatment could be seen, they were much less than the corresponding effects of CCl4. No allylic hydroxyacids were detected in livers of TCDD-treated rats. The concentration of arachidonate was not reduced, and elongation of linolate was not stimulated, indicating that TCDD did not cause extensive-but-repaired peroxidation. It is concluded that while TCDD may slightly increase hepatic lipid peroxidation in rats in vivo, the extent of such stimulation appears to be too slight to account for the toxicity of TCDD.

Rapid isolation of microsomes for studies of lipid peroxidation

Conventional isolation of microsomes by high-speed centrifugation from isotonic sucrose requires exposure to air for several hours, leading to the formation of low levels of lipid peroxidation products. Sucrose interferes in protein and malondialdehyde assays and provides no protection against lipid peroxidation during workup. A new procedure for the purification of microsomes from rat liver substitutes mannitol (a hydroxyl radical scavenger) for sucrose and takes advantage of the properties of morpholinopropane sulfonic acid (MOPS) buffer and triethylenetetramine to provide protection against lipid peroxidation during the rapid (less than one hour) workup and subsequent low-temperature storage. The microsomal fractions prepared by the proposed method are free of detectable mitochondrial contamination and at least as pure overall as those prepared by the conventional method, but they have higher glucose-6-phosphatase and laurate hydroxylase activities and significantly less malondialdehyde than conventional microsomes at the time isolation is complete. Laurate hydroxylase activity is more stable during frozen storage in mannitol medium. The kinetics of lipid peroxidation in vitro are quite different for microsomes prepared by the two methods.

Carpal predominance in rheumatoid arthritis

Radiographic and clinical evaluation of the relative severity of wrist versus hand involvement in 101 patients with rheumatoid arthritis revealed more severe changes in the wrists in 60%, equal involvement in wrists and hands in 37%, and more severe changes in the hands in 3%. There were severe changes in the wrists but little or no bone or joint change in the metacarpophalangeal and proximal interphalangeal joints in 43 (21%) of the 202 extremities studied. Serial examinations showed that, in time, the hand changes tended to overtake those in the wrist. Appreciation of this progression of wrist and hand changes can help the physician avoid diagnostic difficulties in a significant percentage of patients.

Application of the thiobarbiturate assay to the measurement of lipid peroxidation products in microsomes

By applying two different thiobarbiturate assay procedures in parallel to aliquots of a microsomal incubation mixture one can simultaneously monitor free malondialdehyde and malondialdehyde plus labile lipid peroxidation products. The levels of malondialdehyde increase continuously during the incubation of microsomes, NADPH and ferrous-ADP complex, while the lipid precursors of MDA stop forming when the system becomes depleted in NADPH. In contrast to systems in which lipids are undergoing autooxidation, NADPH-dependent lipid peroxidation does not appear to generate significant amounts of water-soluble malondialdehyde precursors. As a result, quantitative interpretation of results is straightforward in the microsomal system. In spite of the lack of specificity of the thiobarbiturate coupling reaction, interferences can be easily compensated for by using zero time controls.

Generation of hydrogen peroxide by incidental metal ion-catalyzed autooxidation of glutathione

Autooxidation of reduced glutathione in 50 mM buffer at pH 7.9 is indetectably slow in the presence of 1 mM DETAPAC, EDTA, TET, or tripyridine, but passing buffer through Chelex resin was insufficient to remove traces of catalytically active metals. Production of hydrogen peroxide during glutathione autooxidation was catalyzed by traces of Fe+2 or Cu+2, and to a much lesser extent by Cu+1 and Ni+2, but not to a detectable extent by Na+1, K+1, Fe+3, Al+3, Cd+2, Zn+2, Ca+2, Mg+2, Mn+2, or Hg+2. Cysteine was a much better precursor for hydrogen peroxide production than were cysteine sulfinic or sulfonic acids. The chelators EGTA, NTA, bipyridine, dimethyl glyoxime, salicylate, and Desferal were ineffective at preventing autooxidation. EDDA and 8-hydroxyquinoline were partially effective. Catalase could completely prevent the accumulation of detectable H2O2, but superoxide dismutase was only slightly inhibitory. Hydroxyl radical and singlet oxygen quenching agents (mannitol and histidine) stimulated. A mechanism for the production of H2O2 during trace metal catalyzed oxidation of glutathione is proposed, involving glutathione-complexed metal and dissolved oxygen. Although a radical intermediate can not be ruled out, no radical initiated chain reaction is necessary.

Effects of 2,3,7,8-tetrachlorodibenzo-p-dioxin on lipid peroxidation in microsomal systems in vitro

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) when added to suspensions of rat hepatic microsomes in the presence of NADPH has little influence on the peroxidation of microsomal lipids unless the system also contains complexed ferric ion, in which case TCDD stimulates. This stimulation does not appear to require metabolism of the TCDD. Peroxidation was monitored by production of thiobarbiturate-reactive substances (malondialdehyde and dienals), production of conjugated dienes, and disappearance of polyunsaturated fatty acids. Stimulation of lipid peroxidation by TCDD in a mixed lysosome-microsome preparation resulted in significantly decreased 'leakage' of acid phosphatase into the medium, implying an effect on lysosomal membranes. Consideration both of the present results and data in the literature leads to the conclusion that it is premature to attempt to define the relationship between enzyme induction, lipid peroxidation and TCDD lethality.

Prepaid entitlements. A new challenge for physician-patient relationships

The transition from a fee-for-service model to a prepaid health care system creates new challenges for both physicians and patients. Occasionally both can feel trapped in the new setting and must rely on new or different strategies to reach sometimes divergent objectives. This may alter the physician-patient relationship in ways that neither likes. Based on our experience in a large multispecialty academic group practice, we have developed management strategies to mitigate such stresses on both parties. These include review of marketing efforts; education of new patients to foster realistic expectations; a physician-generated, prospective internal policy for dealing with dissatisfied patients and physicians; a strong central administrative physician to serve as a "lightning rod" and counselor; and continuing physician orientation and education to improve judgment and attitudes. These strategies promote the physician's role as expert consultant-educator with the best interests of the patient as the first priority.

Metabolism of methyl n-amyl ketone (2-heptanone) and its binding to DNA of rat liver in vivo and in vitro

Methyl n-amyl ketone (2-heptanone), a reported metabolite of 2-ethylhexanol which in turn is a primary metabolite of plasticizers such as di-(2-ethylhexyl) phthalate, is metabolized in male Fischer 344 rats to CO2, acetate and a variety of compounds that could be either anabolic or catabolic or a combination of the two. A significant percentage of the radioactivity given orally (gavage) as [2-14C]-2 heptanone, at least 10%, was not excreted from the body in 48 h. Radioactivity was incorporated into liver protein in the form of three unidentified products as well as [14C]arginine, and into DNA both as 14C-labeled normal nucleosides (50-75%) and as presently unidentified hydrophobic materials (25-50%). Urea and cholesterol were significantly labeled, indicative of anabolic reutilization of [2-14C]-2-heptanone breakdown products. The 2-heptanone also bound to DNA spontaneously in vitro, to the extent of 400 pmol/mg DNA.

A computer package for DNA sequence analysis

We have developed a comprehensive software-hardware package for a CP/M based or other microcomputer which can perform four major functions in a molecular biology laboratory: (1) the acquisition and analysis of DNA sequence data, (2) word processing in the preparation of scientific manuscripts and figures, (3) general lab computation and data reduction, and (4) as a data terminal for communication of data over the phone line.

Incorporation of radioactivity from labeled Di-(2-ethylhexyl)phthalate into DNA of rat liver in vivo

Di-(2-ethylhexyl)phthalate (DEHP), when fed at high levels in the diet for two years, is reportedly an hepatocarcinogen to rats and mice. Radioactivity from ethylhexyl-labeled, but not from phthalate-labeled, [14C]-DEHP is associated with highly purified DNA from the livers of treated rats and this radioactivity is not accounted for by assumptions of adsorption, intercalation, attachment to RNA or histones, an impurity in the labeled DEHP, or artifactual binding during sample workup. Spontaneous binding of radioactivity to DNA from either ethylhexyl-labeled DEHP or its total urinary metabolites could not be detected. Although rat liver slices generated all of the known metabolites of DEHP in vitro, no binding to DNA occurred. Administration of dual 3H/14C-labeled DEHP to rats yielded liver DNA whose 3H/14C ratio was inconsistent with the attachment of any reasonable multi-carbon fragment from the ethylhexyl portion to the DNA. The observation that roughly 100 times as high a percentage of the 14C administered was found in urea as in total DNA suggests that the 14C entered DNA through carbamyl phosphate, a precursor of both urea and pyrimidine bases. If this is the case, the association of C-1 from the ethylhexyl portion of DEHP with DNA may not involve alteration of the DNA or genetic damage.

Pharmacokinetics, interactions with macromolecules and species differences in metabolism of DEHP

The recent long-term carcinogenesis bioassay of di(2-ethylhexyl) phthalate (DEHP) in rats and mice reported by the National Toxicology Program was the first such bioassay to implicate DEHP as a hepatocarcinogen. At the levels of DEHP fed (up to 1.2% of the diet for two years), the livers of the rats would have been exposed to unhydrolyzed diester; this would not have been the case at lower dosages. Extrapolation to lower dosages is therefore questionable. We do not have sufficient pharmacokinetic data in mice to evaluate the dose relationships as yet. Rodents differ conspicuously from primates in their manner of metabolizing DEHP, both in terms of the demand made on the oxidation potential of the liver and in the chemical properties of the major metabolites. The relevance of these differences must be determined before rodent species can be considered models for the effects of DEHP in humans. Radioactivity from carbonyl-labeled DEHP did not associate with purified protein, RNA or DNA from rat liver in vivo. Label from 2-ethyl-(1-14C)-hexyl-labeled DEHP or mono(2-ethylhexyl) phthalate (MEHP) did appear to associate strongly with purified DNA, but label from free 14C-labeled 2-ethylhexanol did not. The apparent binding from DEHP and MEHP was not exchangeable, but was not proven to be covalent. This phenomenon needs additional study.

Chromatographic separation and quantitative determination of the metabolites of di-(2-ethylhexyl) phthalate from urine of laboratory animals

Free, glycine-conjugated, and glucuronide-conjugated metabolites of di-(2-ethylhexyl) phthalate may be stripped from urine with XAD-2 resin, derivatized, and quantitatively analyzed by liquid chromatography on a nitrile column with UV and/or radioactivity monitors. One class of metabolites requires reversed-phase chromatography or gas-liquid chromatography for its resolution. Relative molar responses of the hydrogen flame-ionization detector to these metabolites have been determined. Packed gas chromatography columns (OV-3, OV-210, cyclohexanedimethanol succinate) and fused-silica capillary columns (SP2100 and FFAP) are useful for quantitative analysis under appropriate conditions. The simplest gas chromatographic procedure permitting complete quantitative analysis requires hydrolysis of conjugates, formation of methyl esters of carboxyl groups, butyration of hydroxyl groups and chromatography on OV-3. Typical distributions of di-(2-ethylhexyl) phthalate metabolites in urine from mice, hamsters, and guinea pigs are presented.