Open-label, phase II, multicenter study of lasofoxifene plus abemaciclib for treating women with metastatic ER+/HER2- breast cancer and an ESR1 mutation after disease progression on prior therapies: ELAINE 2

BACKGROUND

Acquired ESR1 mutations in estrogen receptor-positive (ER+) metastatic breast cancer (mBC) drive treatment resistance and tumor progression; new treatment strategies are needed. Lasofoxifene, a next-generation, oral, endocrine therapy and tissue-specific ER antagonist, provided preclinical antitumor activity, alone or combined with a cyclin-dependent kinase 4/6 inhibitor (CDK4/6i) in ESR1-mutated mBC.

PATIENTS AND METHODS

In the open-label, phase II, ELAINE 2 trial (NCT04432454), women with ESR1-mutated, ER+/human epidermal growth factor receptor 2-negative (HER2-) mBC who progressed on prior therapies (including CDK4/6i) received lasofoxifene 5 mg/day and abemaciclib 150 mg b.i.d until disease progression/toxicity. The primary endpoint was safety/tolerability. Secondary endpoints included progression-free survival (PFS), clinical benefit rate (CBR), and objective response rate (ORR).

RESULTS

Twenty-nine women (median age 60 years) participated; all but one were previously treated with a CDK4/6i (median duration 2 years). The lasofoxifene-abemaciclib combination was well tolerated with primarily grade 1/2 treatment-emergent adverse events (TEAEs), most commonly diarrhea, nausea, fatigue, and vomiting. One patient (with no prior CDK4/6i) discontinued treatment due to grade 2 diarrhea. No deaths occurred during the study. Median PFS was 56.0 weeks [95% confidence interval (CI) 31.9 weeks-not estimable; ∼13 months]; PFS rates at 6, 12, and 18 months were 76.1%, 56.1%, and 38.8%, respectively. CBR at 24 weeks was 65.5% (95% CI 47.3% to 80.1%). In 18 patients with measurable lesions, ORR was 55.6% (95% CI 33.7% to 75.4%). ESR1-mutant circulating tumor DNA (ctDNA) allele fraction decreased from baseline to week 4 in 21/26 (80.8%) patients.

CONCLUSIONS

Lasofoxifene plus abemaciclib had an acceptable safety profile, was well tolerated, and exhibited meaningful antitumor activity in women with ESR1-mutated, ER+/HER2- mBC after disease progression on prior CDK4/6i. Observed decreases in ESR1-mutant ctDNA with lasofoxifene concordant with clinical response suggest target engagement. If the ELAINE 2 findings are confirmed in the initiated, phase III, ELAINE 3 trial, these data could be practice-changing and help address a critical unmet need.

Abstract P1-15-05: Is absolute lymphocyte count associated with platinum-sensitivity? A phase II single arm study evaluating the efficacy of neoadjuvant carboplatin and docetaxel in triple negative breast cancer

Background: Platinum-based chemotherapy is still considered investigational for the treatment of sporadic triple negative breast cancer (TNBC). Since patients with TNBC have a high rate of chemotherapy resistance, it is critical to identify platinum-sensitive individuals prior to initiating therapy. Higher absolute lymphocyte count (ALC) is associated with improved clinical response to anthracycline-based chemotherapy, the current standard of care in TNBC. We report the initial results of a phase II single arm study evaluating the efficacy of neoadjuvant carboplatin and docetaxel in TNBC. We also report results of an exploratory analysis assessing whether ALC can be used to predict pathologic complete response (pCR) after treatment with platinum-based chemotherapy.

Patients and Methods: 78 patients with clinical stage II or III TNBC have been enrolled in this ongoing study evaluating the efficacy of neoadjuvant carboplatin and docetaxel (NCT201404107). Patients received docetaxel 75 mg/m2 and carboplatin AUC 6 every three weeks for a total of 6 cycles. Blood samples were collected prior to each cycle, and a posttreatment sample was collected > 3 weeks after completing cycle 6. pCR was defined as no residual invasive disease in the breast, with or without ductal carcinoma in situ, and no tumor deposits in sampled lymph nodes. Baseline characteristics of patients were summarized with descriptive statistics. Univariate and multivariate logistic regression analyses were used to identify factors associated with pCR.

Results: Out of the 78 enrolled patients, 60 have completed all 6 treatment cycles and surgery. The preliminary pCR rate is 46.7%. Age, race, clinical stage, and tumor grade determined at time of diagnosis were not significantly different between pCR patients and non-pCR patients. In univariate analyses, patients with higher ALCs at the posttreatment time point were more likely to have pCR than those who had lower ALCs (OR 5.5, 95% CI 1.5-20.7, p=0.011). Additionally, patients who had higher minimum ALCs were also more likely to have pCR (OR 9.1, 95% CI 1.5-54.9, p=0.016). Baseline ALC values were not associated with pCR. The associations of posttreatment and minimum ALCs to pCR remained statistically significant even after controlling for age and clinical stage at time of diagnosis (posttreatment ALC OR 7.6, 95% CI 1.7-34.8, p=0.009; minimum ALC OR 9.0, 95% CI 1.5-55.2, p=0.018).

Conclusion: The pCR rate of our cohort is similar to that of other trials evaluating neoadjuvant platinum-based chemotherapy in TNBC. Baseline ALC did not predict which patients would achieve pCR. However, the associations of posttreatment and minimum ALCs with pCR indicate patients who are able to maintain a robust population of circulating lymphocytes throughout treatment with platinum-based chemotherapy are more likely to respond favorably. The link between patient immunity and platinum-based chemotherapy suggests addition of immunotherapy agents to neoadjuvant chemotherapy may improve patient outcomes.

Citation Format: Chen I, Guo F, Summa T, Luo J, Ellis MJ, Ma CX, Weilbaecher KN, Naughton MJ, Suresh R, Peterson LL, Cherian MA, Bose R, Frith AE, Hernandez-Aya LF, Gillanders WE, Ademuyiwa FO. Is absolute lymphocyte count associated with platinum-sensitivity? A phase II single arm study evaluating the efficacy of neoadjuvant carboplatin and docetaxel in triple negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-15-05.

Abstract OT1-01-05: Endocrine treatment alone as primary treatment for elderly patients with estrogen receptor positive good prognosis operable breast cancer: A single arm phase II, single institution study

Background: It is estimated that approximately 46,000 women age >75 are diagnosed annually with breast cancer. Due to competing co-morbidities, there is wide variation in treatment recommendations which can lead to over- or under-treatment. Though surgery for breast cancer is considered low-morbidity, many elderly women given a choice, choose not to have surgery. Previous randomized trials comparing surgery with tamoxifen versus endocrine therapy alone in women age >70 unselected for ER status demonstrated similar overall survival with poorer local control in the latter group. A new standard of care needs to be defined for elderly women with good prognosis ER+ tumors, since these women may benefit from endocrine therapy alone to treat their cancer without compromising local and distant control.

Hypothesis: We hypothesize that endocrine therapy alone provides adequate local and systemic control of breast cancer in a subpopulation of women age 70 or older with ER+ breast cancer and good prognostic characteristics.

Primary Objective

To correlate response to neoadjuvant endocrine treatment at 6 months with Oncotype DX Recurrence Score (RS) in women with early-stage ER+ breast cancer who are age >70.

Secondary Objective

1. To determine the breast cancer-specific survival of women with early-stage ER+ breast cancer, age >70, treated with endocrine therapy alone.

2. To determine the rate of overall survival of women with early-stage ER+ breast cancer, age >70 treated with endocrine therapy alone.

Study Design: This is a prospective single arm phase II study. Patients with clinical stage I/II ER+ breast cancer, grade 1-2, Ki67<30 or RS <18 (performed on the diagnostic core biopsy) continue to be enrolled and followed for time to progression. A Kaplan-Meier model will be used to estimate the 5-year local progression rate. If the true 5-year progression rate is 10%, then 50 patients will provide power = .90 at a one-sided .05 significance level to demonstrate that the rate is less than 25.5%. Exploratory objectives include: evaluation of the molecular characteristics of breast cancers of responders versus non-responders, determine compliance with medications, evaluate cost-effectiveness, and quality of life.

Results: Between February 2017 and April 2018, 11 patients were enrolled into the study. Two patients could not tolerate endocrine therapy and received standard of care treatment. For the 9 patients on study, average tumor size was 1.7cm, average Ki67 was 15%, average RS was 14. All of the patients received an aromatase inhibitor. At 6 months, 71% of the patients had a partial response, 28% had stable disease. None of the patients developed progressive disease.

Conclusion: A new standard of care needs to be defined for women age >70 with good prognosis ER+ tumors, since these women may benefit from endocrine therapy alone to treat their cancer without compromising local and distant control. We continue to enroll patients to determine the optimal tumor markers for identifying women who can be treated with PET only to control their cancer.

Citation Format: Aft R, Cherian M, Frith A, Suresh R, Glover-Collins K, Naughton M, Moon C, Conant L, Ma C. Endocrine treatment alone as primary treatment for elderly patients with estrogen receptor positive good prognosis operable breast cancer: A single arm phase II, single institution study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT1-01-05.

Abstract PD6-02: A randomized, controlled trial of high dose vs. standard dose vitamin D for aromatase inhibitor-induced arthralgia in breast cancer survivors

Background: Approximately half of women on aromatase inihbitor (AI) therapy develop AI-induced arthralgia (AIA), and many discontinue the medication because of this common side effect. While Vitamin D has been studied as a treatment for AIA, trial results have been conflicting thus far.

Patients and Methods: All subjects were post menopausal women who were beginning adjuvant AI therapy for stage I-III hormone receptor positive breast cancer. Patients were randomized 1:1 to receive standard dose vitamin D3 (800 IU daily for 52 weeks) or high dose vitamin D3 (50,000 IU weekly for 12 weeks, followed by 2000 IU daily for 40 weeks). All patients also took oral calcium 600 mg daily. The primary endpoint was development of AIA, as defined by pre-specified changes in the Health Assessment Questionnaire II (HAQ-II). Secondary endpoints include compliance with AI therapy, and correlation between grip strength and development of AIA. Exploratory endpoint was measurement of inflammatory cytokine reduction in each arm. The trial was designed to enroll 184 patients, but this futility analysis was performed after 93 patients were enrolled. The futility boundary for stopping the trial early was calculated as p = 0.47.

Results: All 93 patients (46 in the high dose arm, and 47 in the standard dose arm) enrolled in the study at the time of the interim analysis were evaluable. The HAQ-II was completed at 12 weeks in 76% on the high dose arm, and 68% in the standard dose arm. Subjects who did not complete the questionnaire were deemed as study failures (i.e. development of AIA was assumed). In the high dose arm, 25 patients (54%) developed AIA, compared to 27 patients (57%) in the standard dose arm. The one-tailed p value is 0.3818, and the Z-score is 0.3, yielding only a 38% conditional power that that study would find a significant difference between the two arms. Thus, the study was terminated early for futility. There was no significant difference between the two arms in adherence to AI therapy. The grip strength and inflammatory cytokine data are pending at this time. They will be ready by the time of the conference.

Conclusions: There was no significant signal for benefit of high dose vitamin D supplementation, as compared to standard dose vitamin D, for AIA prevention in post menopausal women taking adjuvant AI therapy. These results further characterize the role of Vitamin D in AIA, and they inform future clinical trials in this arena. Further research is necessary, as this remains an important cause of non-adherence to this highly effective therapy.

Citation Format: Niravath P, Wang T, Hilsenbeck SG, Lipscomb K, Pavlick A, Jiralerspong S, Nangia J, Ellis M, Ademuyiwa F, Cherian M, Frith A, Ma C, Park H, Rigden C, Suresh R, Osborne CK, Rimawi MF. A randomized, controlled trial of high dose vs. standard dose vitamin D for aromatase inhibitor-induced arthralgia in breast cancer survivors [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD6-02.

Abstract P5-21-30: Retrospective review of palbociclib (Pal) efficacy and benefit from subsequent treatments following Pal progression in patients (pts) with hormone receptor positive (HR+) and HER2 negative (HER2-) metastatic breast cancer (MBC)

Background

The cyclin-dependent kinase (CDK) 4/6 inhibitor Pal is approved for HR+ HER2- MBC. However, the optimal therapy following Pal progression is unknown. Therefore we conducted this retrospective study to review Pal efficacy and summarize the practice pattern and responses to subsequent treatments post Pal progression.

Methods

We performed a chart review of pts with HR+ HER2- MBC who began Pal treatment at Washington University Siteman Cancer Center between Feb 16, 2015 and July 13, 2016 and collected information on pts demographics, diagnosis, and treatment history. Duration of therapy was used to calculate the progression free survival (PFS) for each regimen. Treatment was considered first-line if administered without any prior systemic therapy or at least 1 year from completion of adjuvant hormonal therapy (HT). Treatments received after progression on 1st line therapy or upon relapse during or within 1 year from the completion of adjuvant HT were considered second-line regimens.

Statistical analyses were performed on SAS software, version 9.4. The Kaplan-Meier method was used to generate time-to-event curves, from which median PFS was calculated. A stratified log-rank test was used for all comparisons, and the P value derived from the comparison was reported.

Results

We completed a chart review for 81 pts (78 female and 3 male; 63 Caucasian, 14 African American, and 4 other races) with HR+ HER2- MBC (68 were ER+PR+, 13 were ER+PR-) who received Pal plus letrozole (n=65) or fulvestrant (n=15) or anastrozole (n=1), with a median age of 62.0 years (range 28.1 - 85.6) at the start of Pal.

The median follow up was 20.0 months (mos) (range 10.8 – 27.9). 25 pts were still on Pal treatment. The median PFS on Pal was 19.9 mos in the first-line setting (n=20), compared to 12.1 mos and 4.4 mos in the second-line (n=14) and subsequent lines (n=47), respectively (p=0.0287). Among the 54 pts who progressed on Pal, 38 moved on to the next treatment. 20 pts received chemotherapy and 16 pts received HT or a HT combination. 2 pts received fulvestrant plus Pal upon progression on letrozole plus Pal, and treatment was still ongoing at 4 mos and 7 mos of follow up, respectively. The most common treatments post Pal were single-agent capecitabine (Cape) (n=9) and the combination of exemestane (Exe) and everolimus (Eve) (n=8). The median PFS was 4.7 mos with Cape compared to 8.4 mos with Exe and Eve (p=0.60). The median PFS was 4.7 mos for the 20 pts who received chemo, whereas the median PFS was 4.9 mos with subsequent HT (n=16) (p=0.75).

Conclusion

Pal plus letrozole or fulvestrant is effective for the treatment of HR+ HER2- MBC, with activity observed beyond the 1st and 2nd line treatment settings. The PFS of Pal observed in this single center retrospective study is consistent with that of published data. Single-agent cape or the Exe and Eve combination were common treatment choices following progression on Pal. Although the study is limited by its small sample size, the median PFS of 8.4 mos with Exe and Eve indicates its potential efficacy in the setting of Pal progression. Additional pts and followup data will be presented.

Citation Format: Xi J, Oza A, Thomas S, Naughton M, Ademuyiwa F, Weilbaecher KN, Suresh R, Bose R, Cherian MA, Hernandez-Aya L, Frith A, Peterson LL, Krishnamurthy J, Ma CX. Retrospective review of palbociclib (Pal) efficacy and benefit from subsequent treatments following Pal progression in patients (pts) with hormone receptor positive (HR+) and HER2 negative (HER2-) metastatic breast cancer (MBC) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-21-30.

Human pregnane X receptor compromises the function of p53 and promotes malignant transformation

The pregnane X receptor (PXR) is well established as a nuclear receptor that has a central role in xenobiotic metabolism and disposition. However, emerging evidence suggests that PXR is also a regulator of apoptosis, promoting a malignant phenotype both in vitro and in vivo. The tumor suppressor p53 can be activated in the presence of DNA damage and induce cell cycle arrest to allow for DNA repair or, ultimately, apoptosis to suppress tumor formation. We previously identified p53 as a novel PXR-associated protein by using a mass spectrometric approach. In the current study, we identified a novel inhibitory effect of PXR on p53, revealing an anti-apoptotic function of PXR in colon carcinogenesis. PXR expression reduced p53 transactivation and the expression of its downstream target genes involved in cell cycle arrest and apoptosis by decreasing p53 recruitment to the promoter regions of these genes. Consistent with the inhibitory effect of PXR on p53, elevated PXR levels decreased doxorubicin- or nutlin-3a-mediated toxicity and promoted malignant transformation in colon cancer cells. Our findings show for the first time that PXR expression modulates p53 target gene promoter binding and contributes to the downregulation of p53 function in human colon cancer cells. These results define the functional significance of PXR expression in modulating p53-mediated mechanisms of tumor suppression.

Two rare cases of Epstein-Barr virus-associated lymphoproliferative disorders in inflammatory bowel disease patients on thiopurines and other immunosuppressive medications

The setting of chronic immunosuppression in inflammatory bowel disease (IBD) may promote the proliferation of Epstein-Barr virus-positive neoplastic clones. We report two rare cases of Epstein-Barr virus-associated lymphoproliferative disorder in IBD patients: one resembled lymphomatoid granulomatosis, and the other was a lymphoma resembling Hodgkin lymphoma. There are currently no guidelines for the prevention of lymphoproliferative disorder in IBD patients on immunosuppressive therapy.

Emergency and surgery services of primary hospitals in the United Republic of Tanzania

OBJECTIVE

The primary objective was to evaluate the capacity of first-referral health facilities in Tanzania to perform basic surgical procedures. The intent was to assist in planning strategies for universal access to life-saving and disability-preventing surgical services.

DESIGN

Cross-sectional survey.

SETTING

First-referral health facilities in the United Republic of Tanzania.

PARTICIPANTS

48 health facilities.

MEASURES

The WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was employed to capture a health facility's capacity to perform basic surgical (including obstetrics and trauma) and anaesthesia interventions by investigating four categories of data: infrastructure, human resources, interventions available and equipment. The tool queried the availability of eight types of care providers, 35 surgical interventions and 67 items of equipment.

RESULTS

The 48 facilities surveyed served 18.6 million residents (46% of the population). Supplies for basic airway management were inconsistently available. Only 42% had consistent access to oxygen, and only six functioning pulse oximeters were located in all facilities surveyed. 37.5% of facilities reported both consistent running water and electricity. While very basic interventions (suturing, wound debridement, incision and drainage) were provided in nearly all facilities, more advanced life-saving procedures including chest tube thoracostomy (30/48), open fracture management (29/48) and caesarean section delivery (32/48) were not consistently available.

CONCLUSIONS

Based on the results in this WHO country survey, significant gaps exist in the capacity for emergency and essential surgical services in Tanzania including deficits in human resources, essential equipment and infrastructure. The information in this survey will provide a foundation for evidence-based decisions in country-level policy regarding the allocation of resources and provision of emergency and essential surgical services.

Outcomes of Endovascular Coiling in Patients with Intracranial Aneurysms Presenting with Poor Clinical and SAH Grade

Although the treatment of intracranial aneurysms has made significant advances, prediction of outcomes in poor grades has always been difficult. We present our findings of patients in poor clinical and SAH grade treated with endovascular coiling. We aimed to evaluate the clinical outcomes in patients presenting with poorer neurological and SAH grades treated by endovascular techniques. Of 190 patients who presented with SAH over a period of nine years, 34 were of poorer clinical grade (Hunt & Hess Grades 4 and 5), of whom 30 presented with H&H grade 4 and four with grade 5. 44.1% of the 34 patients belonged to Fischer grade 4. We assessed the technical success and final outcomes based on the Glasgow outcome scale. Of the 30 patients with grade 4, 81.4% had a good outcome. Two out of four patients with grade 5 had a poor outcome. 82.5% of the patients with Fischer grade 4 had a good outcome. None of the poor outcomes were procedure-related. Endovascular treatment with its higher rates of technical success, lower complication rates and better outcomes should be recommended as the treatment of choice in patients with intracranial aneurysms even in patients with poorer clinical and SAH grades.

An Unusual Case of Coil Migration

Migration of endovascular coils from aneurysms has been reported in the past. However, we report a case where the entire coil mass migrated out of the aneurysm into the anterior cerebral artery with associated doubling of aneurysm diameter in the intervening two weeks period post-coiling.

Isolated unilateral cerebellar hypoplasia. A case report

Isolated cerebellar malformations are relatively rare CNS anomalies, when they do occur they are frequently symptomatic. Some cases of asymptomatic cerebellar malformations have been reported. Unilateral cerebellar hypoplasia is one such entity. We describe a case of unilateral cerebellar hypoplasia presenting with non-specific neurological complaints.

Biochemical and clinical profile after organophosphorus poisoning--a placebo-controlled trial using pralidoxime

BACKGROUND

Organophosphorus (OP) compounds are the most common suicidal poison in developing countries and mortality continues to be high.

METHODS

A study was done to see butyryl cholinesterase (BuChE) profile after OP poisoning in pralidoxime (P2AM) and placebo treated cases. Highest recommended dose of P2AM was used to study the reactivation of cholinesterase. Clinical outcomes like, correlation of BuChE and severity of poisoning, mortality and complications like Type I and II paralysis, need for ventilation and ICU stay were also studied.

RESULTS

Twenty one cases of moderate and severe poisoning with OP compounds were included in the study. Mean BuChE levels came up gradually over 6-7 days, some taking up to two weeks. There was no. difference between the treatment and placebo groups. BuChE levels did not correlate with severity of poisoning nor did it correlate with Type I or II paralysis, need for ventilation, ICU stay or mortality.

CONCLUSIONS

Treatment with P2AM does not make any difference in BuChE reactivation or complications of moderate and severe OP poisoning. We have not been using P2AM for OP poisoning in our medical ICU with good patient outcomes.

Facio-cervical transfixion by a metallic rod: a case report

Foreign bodies penetrating into the neck may cause extensive neurovascular and aerodigestive tract injuries. Facio-cervical transfixion by a metallic rod without such injuries is very rare. The patient presented in this article reported to our center 5 hours after the road traffic accident with impacted hollow metallic rod traversing through the tongue, pharynx, and neck after causing fracture to maxilla. Exploration under general anesthesia after tracheostomy resulted in an uneventful extraction of the metallic rod. Postoperatively, the patient recovered completely and had no neurologic deficits. [Editorial comment: This case report demonstrates an approach to an extremely difficult and potentially dangerous clinical problem. The authors decision to forego angiography is based on physical examination with evidence of palpable flow in the superficial temporal artery.]

Fatal methane and cyanide poisoning as a result of handling industrial fish: a case report and review of the literature

The potential health hazards of handling industrial fish are well documented. Wet fish in storage consume oxygen and produce poisonous gases as they spoil. In addition to oxygen depletion, various noxious agents have been demonstrated in association with spoilage including carbon dioxide, sulphur dioxide, and ammonia. A fatal case of methane and cyanide poisoning among a group of deep sea trawler men is described. Subsequent independent investigation as a result of this case led to the discovery of cyanides as a further potential noxious agent. This is thus the first case in which cyanide poisoning has been recognised as a potentially fatal complication of handling spoiled fish. The previous literature is reviewed and the implications of the current case are discussed.

Minimal access approach for surgical management of cardiac tumors

BACKGROUND

Following our experience with minimally invasive valve replacement operation, we utilized this technique for surgical management of cardiac tumors.

METHODS

Between April 1997 and September 1999, 5 consecutive patients with cardiac tumors underwent minimally invasive excision of the tumors. The patients were 4 women and 1 man with an age range of 32 to 50 years. The tumor was located in the left atrium in 4 patients and the right atrium in 1 patient. The common presenting symptoms were dyspnea on exertion (100%), chest pain (60%), palpitation (60%), and transient ischemic attack (20%). Diagnosis was established preoperatively by echocardiography only.

RESULTS

In 2 patients the approach was right parasternal and the subsequent 3 patients had direct-access partial sternotomy. The myxoma was resected transseptally in all patients. There was no hospital mortality. One patient had postoperative embolic episode leading to left hemiparesis. Follow-up did not reveal any complication related to this technique and all were in New York Heart Association (NYHA) functional class I.

CONCLUSIONS

Minimal access partial sternotomy is an effective approach that adheres to all the identified surgical principles in successful removal of these tumors. The smaller incision does not compromise the efficacy or safety of the operation, reduces hospital stay, and has a good cosmetic result.

Mature teratoma of the nasal vestibule: a case report

Teratomas are rare congenital neoplasms that arise from pluripotent cells. They consist of tissue from all three embryonic germ layers. According to most studies, teratomas of the head and neck account for only 2 to 9% of all cases. In this article, we report the first case of a teratoma of the nasal vestibule in a newborn. We also discuss methods of diagnosis and treatment of upper airway teratomas, and we include a brief review of the literature.

Randomized trial of preoperative cimetidine in patients with colorectal carcinoma with quantitative assessment of tumor-associated lymphocytes

BACKGROUND

Previous studies have suggested that cimetidine, a histamine-2 receptor antagonist with immunostimulatory effects, may improve survival in patients with colorectal carcinoma. This effect may be apparent by an increase in the number of peritumoral lymphocytes. A prospective, double blind, randomized, placebo-controlled trial of a short course of preoperative treatment with cimetidine in patients with colorectal carcinoma was performed to assess the effect of cimetidine on survival and on the number of peritumoral lymphocytes.

METHODS

One hundred and twenty-five patients who were scheduled to undergo elective colon or rectal excision for carcinoma were randomized to receive either placebo or cimetidine preoperatively for 5 days. In addition to standard histopathology, immunohistochemistry and computer video image analysis were used to assess the number of peritumoral lymphocytes in an objective manner. Interim survival analysis according to the Kaplan-Meier method was performed.

RESULTS

A trend toward a survival advantage in the group of patients receiving cimetidine (800 mg twice daily) compared with the placebo group was observed (P = 0.20, log rank test) that was most marked in patients with replication error negative tumors (P = 0.04). Similarly, in these two groups there was a trend toward an increase in the number of patients with a conspicuous lymphocytic infiltration (P = 0.10, chi-square test). However, there was no difference in the number of peritumoral lymphocytes as measured by image analysis.

CONCLUSIONS

Based on the results of the current study, a short course of preoperative treatment with cimetidine does appear to have an effect on patient survival; however, the exact mechanism is unknown. The failure of this study to demonstrate a clear increase in the local lymphocyte response does not exclude an immunologic mechanism of action.

Randomized trial of preoperative cimetidine in patients with colorectal carcinoma with quantitative assessment of tumor-associated lymphocytes

BACKGROUND

Previous studies have suggested that cimetidine, a histamine-2 receptor antagonist with immunostimulatory effects, may improve survival in patients with colorectal carcinoma. This effect may be apparent by an increase in the number of peritumoral lymphocytes. A prospective, double blind, randomized, placebo-controlled trial of a short course of preoperative treatment with cimetidine in patients with colorectal carcinoma was performed to assess the effect of cimetidine on survival and on the number of peritumoral lymphocytes.

METHODS

One hundred and twenty-five patients who were scheduled to undergo elective colon or rectal excision for carcinoma were randomized to receive either placebo or cimetidine preoperatively for 5 days. In addition to standard histopathology, immunohistochemistry and computer video image analysis were used to assess the number of peritumoral lymphocytes in an objective manner. Interim survival analysis according to the Kaplan-Meier method was performed.

RESULTS

A trend toward a survival advantage in the group of patients receiving cimetidine (800 mg twice daily) compared with the placebo group was observed (P = 0.20, log rank test) that was most marked in patients with replication error negative tumors (P = 0.04). Similarly, in these two groups there was a trend toward an increase in the number of patients with a conspicuous lymphocytic infiltration (P = 0.10, chi-square test). However, there was no difference in the number of peritumoral lymphocytes as measured by image analysis.

CONCLUSIONS

Based on the results of the current study, a short course of preoperative treatment with cimetidine does appear to have an effect on patient survival; however, the exact mechanism is unknown. The failure of this study to demonstrate a clear increase in the local lymphocyte response does not exclude an immunologic mechanism of action.

Influence of protein-glutathione mixed disulfide on the chaperone-like function of alpha-crystallin

In an earlier report we showed that incubation of alpha-crystallin with oxidized glutathione results in significant loss of its chaperone-like activity. In the present study, we determined the effect of protein-glutathione mixed disulfides (PSSG), formed at Cys-131 in bovine alphaA-crystallin, and Cys-131 and Cys-142 in human alphaA-crystallin, on the function of alpha-crystallin as a molecular chaperone. After incubation of calf and young human alphaL-crystallin fractions with oxidized glutathione, levels of PSSG were determined by performic acid oxidation of the mixed disulfides followed by reversed-phase high pressure liquid chromatography separation of phenylisothiocyanate-derivatized glutathione sulfonic acid. Levels of PSSG increased from 0.01 to 0.14 nmol/nmol (20 kDa) in bovine alphaL-crystallin and from 0.022 to 0.25 nmol/nmol in human alphaL-crystallin. The presence of glutathione adducts at Cys-131 and Cys-142 were confirmed by mass spectral analysis. The chaperone-like activity was determined by the heat denaturation assay using betaL-crystallin as the target protein. To examine the reversibility of the effect of mixed disulfides on chaperone activity, studies were done before and after reduction with the glutathione reductase system. Increased levels of PSSG resulted in lower chaperone activities. Treatment with the glutathione reductase system led to 80% reduction in PSSG levels with a concomitant recovery of the chaperone activity. These results suggest that cysteine(s) in the alphaA-crystallin subunit play an important role in the function of alpha-crystallin as a molecular chaperone.

Athetosis-dystonia in intramedullary lesions of spinal cord

Athetosis and dystonia are well known clinical signs, described in disorders of basal ganglia. As opposed to pseudoathetosis, true athetosis was hitherto not reported in cord lesions. We here report three patients with athetosis and dystonia of hands due to intramedullary lesions of cervical cord: two patients with syringomyelia and one with glioma. Even though pseudoathetosis can be produced by lesions of posterior columns and likely to be confused with the involuntary movements of our patients, they had clinical and EMG findings consistent with true athetosis. A possible explanation for the athetosis and dystonia due to cord lesion is being postulated.

Effect of germanium-132 on galactose cataracts and glycation in rats

Germanium compounds have been shown to be effective in preventing the formation of advanced glycation end-products and for reversible solubilization of glycated proteins. As protein glycation has been proposed to play a role in lens opacification, we initiated studies to evaluate the effects of 2-carboxyethyl germanium sesquioxide (germanium compound 132 or Ge-132) on galactose-induced cataractogenesis. For this study young Sprague-Dawley rats were fed a 50% galactose diet. One group of rats received topical saline and another group was administered Ge-132 in saline four times a day. The lenses were periodically examined with an ophthalmoscope and at desired intervals processed for light and scanning electron microscopy. Our observations, beginning at 3 days and continuing to 21 days of galactose feeding, exhibited the characteristic galactose-induced morphological alterations, which include the formation of vacuoles, cysts, membrane disruption and swelling of fibers and epithelial cells as well as disorganization of the bow in lenses of rats in both groups. However, in the majority of rats administered Ge-132 these alterations were delayed as compared to the lenses of rats administered saline. Our findings show that, although the initiation, progression and pattern of lens opacification in rats receiving saline and Ge-132 were similar, in the majority of lenses the progression and establishment of mature cataracts in the Ge-132 group of rats were delayed. Analysis of the water-soluble and water-insoluble lens-protein fractions for glycated proteins showed increased levels of the Amadori products and advanced glycation related fluorescent products in galactosemic rats treated with saline eye drops. In rats receiving the topical Ge-132 treatment the levels of these glycation products were substantially reduced to levels lower than control values. Prevention of glycation seems to be a mechanism by which cataract progression is delayed.

Diabetes affects alpha-crystallin chaperone function

In vitro glycation was previously shown to influence alpha-crystallin chaperone function. In the present study we show that this function is compromised in diabetes. The alpha H, alpha L and the total alpha fractions were isolated by gel permeation chromatography from the water-soluble protein of streptozotocin-diabetic as well as age-matched normal rats. Based on the beta L-crystallin thermal denaturation assay the chaperone function was significantly decreased in the diabetic rats.

Decreased molecular chaperone property of alpha-crystallins due to posttranslational modifications

We studied the effect of oxidation, mixed disulfide formation and glycation of alpha-crystallins on their molecular chaperone property. The ability of alpha-crystallins to protect heat-induced denaturation and aggregation of beta L-crystallin was significantly diminished by these modifications. alpha-Crystallin from senile human lenses also showed significant loss of chaperone-like property. Age-dependent increase in posttranslationally modified alpha-crystallins is the likely cause for this change.

Comparison between endocardial and great vessel endothelial cells: morphology, growth, and prostaglandin release

The release of vasoactive mediators by vascular (VEC) and endocardial endothelial cells (EEC) has not been directly compared. In this study, in vitro morphological and cell growth characteristics and the rate of prostanoid release were compared in cultured sheep endothelial cells from great vessels (VEC; pulmonary artery and aorta) and endocardium (EEC; right and left ventricles) harvested from the same animals. Morphologically, in flasks, VEC demonstrated the classic cobblestone pattern, whereas EEC developed numerous cytoplasmic interdigitations and overlaps. Rate of cell proliferation was greater for EEC than for VEC (P < 0.05): doubling time was shorter for EEC (34 +/- 3 h) than for VEC (45 +/- 5 h). Under static (no-flow) conditions, in response to arachidonic acid and calcium ionophore A-23187, the rate of prostacyclin (PGI2) and prostaglandin E2 release by VEC and EEC was not different. In contrast, in response to flow and acute hypoxia (O2 tension = 35 Torr), the rate of PGI2 release was greater in EEC than in VEC (P < 0.0001). After 2 h of perfusion, the rate of PGI2 release was 19-fold greater for EEC than for VEC during normoxia and 34-fold greater during hypoxia. Thus our study showed anatomic site of origin-dependent heterogeneity in prostanoid release between VEC and EEC. Endocardial endothelium is a greater source of PGI2 than great vessel endothelium; in vivo, endocardial endothelial PGI2 may inhibit local platelet aggregation and modulate downstream vascular tone.

Site selectivity in the glycation of alpha A- and alpha B-crystallins by glucose

We determined the site selectivity of glycation by glucose (glucosylation) in alpha A- and alpha B-crystallins using two independent approaches. HPLC purified 14C-glucose labeled chymotryptic peptides and affinity chromatography/HPLC purified fully glycated peptides were identified by FAB-MS. Lys 11 and 78 of alpha A-crystallin and Lys 90 and/or 92 of alpha B-crystallin were the fast reacting sites of glucosylation.

Glycation of human lens crystallins: effect of age and aspirin treatment

Human lenses of three different ages were used to study the effect of age and aspirin treatment on glycation of alpha-, beta- and gamma-crystallins. Soluble lens proteins were subjected to in vitro glycation with 5 mM [14C]glucose in the presence and absence of 10 mM aspirin. With crystallins from a 27-year-old lens alpha-crystallin was the most readily glycated protein. Glycation of all crystallins decreased substantially (37-77%) in 46- and 67-year-old lenses indicating an age-dependent decline in glycation sites. On the basis of a sensitive chemical assay for protein-bound glycogroups in lenses of 2-82 years of age this decline is apparently due to a 60% increase in in vivo glycation. Aspirin did not show any selectivity with regard to its ability to inhibit glycation of various crystallins. Irrespective of the age glycation of all crystallins was inhibited to a varying extent.

In vitro glycation and acetylation (by aspirin) of rat crystallins

In vitro studies with rat lens crystallins were conducted to explore the mechanism by which aspirin (ASA-acetylsalicylic acid) could inhibit cataractogenesis. The purpose of the present study is to show whether gamma-crystallin is the primary target for glycation by glucose and acetylation by ASA. Lens soluble fractions from one and seven month old Sprague-Dawley rats were incubated with 5 mM [14C]glucose with and without 10 mM ASA. alpha, beta, and gamma-crystallins were separated by molecular sieve HPLC and specific activities of each crystallin determined. In vitro acetylation was also studied by measuring protein bound [14C]acetyl groups after incubation with [14C]acetyl ASA. There was 2 to 4-fold faster glycation of gamma-crystallin than all other crystallins from 1-month-old rats and ASA inhibited glycation of gamma-crystallin four times more than that of alpha and beta-crystallins, thus showing preferential glycation of gamma-crystallin and its selective inhibition by ASA. [14C]acetyl incorporation showed increased acetylation of gamma-crystallin in one month old rats, whereas in older lenses acetylation of other crystallins predominated. Treatment with 10 mM ASA showed 35% decrease in free -NH2 groups but protein thiols remained unchanged.

The spectrum of acute Epstein-Barr virus infection in Saudi children

Most of the primary infections caused by Epstein-Barr virus in children are asymptomatic. In symptomatic patients, clinical presentation is variable. We describe 33 patients admitted to Suleimania Children's Hospital, Riyadh from 1409 too 1411H (1988 to 1990G) with acute primary infection caused by Epstein-Barr virus. The clinical presentation was mostly with upper respiratory tract infection, fever, lymphadenopathy, and hepatosplenomegaly. Three patients had arthralgia and three had neurological manifestations. Only four patients had atypical lymphocytes > 10%. Elevated serum alanine and aspartate aminotransferase levels were found in about 54.55 of the patients.

Childhood bacterial meningitis in Riyadh

One hundred and six patients with culture-positive bacterial meningitis were admitted to Sulemania Children's Hospital, Riyadh, from February 1985 to July 1990. The most common organisms causing meningitis in children older than 1 month were Hemophilus influenzae type b (N = 61), Streptococcus pneumoniae (N = 19), and Neisseria meningitidis (N = 14). Among neonates, the most common organism causing meningitis was Group B beta-hemolytic Streptococcus (N = 4). Of the cases of Hemophilus influenzae, 4.9% were resistant to both ampicillin and chloramphenicol. Forty-two patients were pretreated with antibiotics. The mortality rate was 2.8%. We describe the clinical and laboratory findings in these patients. We also discuss the implications of our findings in relation to the choice of antibiotics.

Lens epithelial cell density and histomorphological study in cataractous lenses

Human epithelial cell density was determined from flat preparation of 195 cataractous lenses from 108 males and 87 females between 30 and 80 years of age. The mature cataracts had significantly lower cell counts than the other cataracts. Cell density was significantly higher in the females than in the males. Morphohistological study of the epithelia was focused on the following cataract types: (1) nuclear, (2) posterior subcapsular, (3) mature, (4) mixed, (5) hypermature, and (6) black. The major cataractous changes in all types involved vacuolization of the cytoplasm. The mature types of cataractous epithelia showed 56% superimposed cells; the epithelia in nuclear, posterior subcapsular, and black cataracts showed between 6% and 16%. In the hypermature cataracts, four of five tissues analyzed showed superimposed cells. The superimposed areas are probably the source of increased and altered cell activity. We propose that the metaplastic processes leading to posterior capsular opacification originate from these areas. The majority of nuclear and black cataracts were almost similar to the normal human lens epithelium with more or less uniform distribution of cells. Nucleus shrinkage (5 microns) was more evident in nuclear cataracts; in subcapsular cataracts most of the nuclei were large (average 9 microns diameter). Variation in morphological changes like vacuolization of cytoplasm and nuclei, pyknotic nuclei, and superimposed cells was more evident in the mixed type of cataracts.

Glutathione and glutathione-related enzymes in busulfan treated rat lens

Glutathione (GSH) and GSH-related enzymes, glutathione reductase (GR), gamma-glutamyl cysteine synthetase (gamma-GCS), gamma-glutamyl transpeptidase (gamma-GTP), glutathione S-transferase (GST) and adenosine triphosphatase (ATPase) enzymes were analysed to study the effect of busulfan on the defence mechanisms of the lens. All these enzymes were found to increase significantly except GSH which showed only 7.9% increase as compared to controls in precataractous stage. These results affirm that busulfan is capable of evoking a response from the enzymes involved in the various pathways of GSH enabling the lens to prolong its clarity. The cataractous lenses showed significant decrease in all these parameters. Here, the impairment of the defense mechanism (GST, GR) and the total ATPase may be attributed to the cumulative action of the drug which can react with -SH groups of these enzymes, ultimately causing opacification.

Endoscopic diagnosis of small flat carcinoma of the colon. Report of three cases

Most small carcinomas arise from polyps. Small lesions with cellular features of malignancy and early invasion, but with no histologic evidence of residual adenoma, are rare. Diagnosed by endoscopy, three such lesions are described. They were recognized as mucosal plaques, measuring between 6 and 8 mm in diameter. In each case, there was either synchronous or metachronous carcinoma elsewhere in the colon, as well as benign adenomatous polyps. Colonoscopic identification of such lesions allows inclusion of that bowel segment in any planned resection.