Response of treatment-naive brain metastases to stereotactic radiosurgery

With improvements in survival for patients with metastatic cancer, long-term local control of brain metastases has become an increasingly important clinical priority. While consensus guidelines recommend surgery followed by stereotactic radiosurgery (SRS) for lesions >3 cm, smaller lesions (≤3 cm) treated with SRS alone elicit variable responses. To determine factors influencing this variable response to SRS, we analyzed outcomes of brain metastases ≤3 cm diameter in patients with no prior systemic therapy treated with frame-based single-fraction SRS. Following SRS, 259 out of 1733 (15%) treated lesions demonstrated MRI findings concerning for local treatment failure (LTF), of which 202 /1733 (12%) demonstrated LTF and 54/1733 (3%) had an adverse radiation effect. Multivariate analysis demonstrated tumor size (>1.5 cm) and melanoma histology were associated with higher LTF rates. Our results demonstrate that brain metastases ≤3 cm are not uniformly responsive to SRS and suggest that prospective studies to evaluate the effect of SRS alone or in combination with surgery on brain metastases ≤3 cm matched by tumor size and histology are warranted. These studies will help establish multi-disciplinary treatment guidelines that improve local control while minimizing radiation necrosis during treatment of brain metastasis ≤3 cm.

Additive Value of MR Simulation Prior to Chemoradiation in Evaluating Treatment Response and Pseudoprogression in High-Grade Gliomas

BACKGROUND

A dedicated MRI Simulation(MRsim) for radiation treatment(RT) planning in high-grade glioma(HGG) patients can detect early radiological changes, including tumor progression after surgery and before standard of care chemoradiation. This study aimed to determine the impact of using post-op MRI vs. MRsim as the baseline for response assessment and reporting pseudo-progression on follow-up imaging at one month(FU1) after chemoradiation.

METHODS

Histologically confirmed HGG patients were planned for six weeks of RT in a prospective study for adaptive RT planning. All patients underwent post-op MRI, MRsim, and follow-up MRI scans every 2-3 months. Tumor response was assessed by three independent blinded reviewers using Response Assessment in Neuro-Oncology(RANO) criteria when baseline was either post-op MRI or MRsim. Interobserver agreement was calculated using light's kappa.

RESULTS

30 patients (median age 60.5 years; IQR 54.5-66.3) were included. Median interval between surgery and RT was 34 days (IQR 27-41). Response assessment at FU1 differed in 17 patients (57%) when the baseline was post-op MRI vs. MRsim, including true progression vs. partial response(PR) or stable disease(SD) in 11 (37%) and SD vs. PR in 6 (20%) patients. True progression was reported in 19 patients (63.3%) on FU1 when the baseline was post-op MRI vs 8 patients (26.7%) when the baseline was MRsim (p=.004). Pseudo-progression was observed at FU1 in 12 (40%) vs. 4 (13%) patients, when the baseline was post-op MRI vs. MRsim (p=.019). Interobserver agreement between observers was moderate (κ = 0.579; p<0.001).

CONCLUSIONS

Our study demonstrates the value of acquiring an updated MR closer to RT in patients with HGG to improve response assessment, and accuracy in evaluation of pseudo-progression even at the early time point of first follow-up after RT. Earlier identification of patients with true progression would enable more timely salvage treatments including potential clinical trial enrolment to improve patient outcomes.

Early Outcomes from Proton Craniospinal Irradiation (pCSI) for Leptomeningeal Disease from Solid Tumors

PURPOSE/OBJECTIVE(S)

Prospective data suggest that proton craniospinal irradiation (pCSI) improves overall survival (OS) in patients with leptomeningeal disease (LMD) from solid tumors, compared to the historical standard of involved field radiation. To evaluate outcomes of this novel approach in a real-world setting, our institutional experience with treating adults with pCSI for LMD from solid malignancies was evaluated.

MATERIALS/METHODS

On an IRB-approved protocol, medical records of adults with LMD from solid tumors treated with pCSI were retrospectively reviewed for patient, disease and treatment characteristics and outcomes. CNS-PFS and OS were calculated from the last day of pCSI, and survival was modeled using Kaplan-Meier analysis.

RESULTS

From December 2021 to November 2022, 17 patients with median age 51y (range 22-71y) were treated with pCSI for LMD from solid tumors. Thirteen patients (76%) were female. Ten had ECOG PS of 0-1, and seven had PS 2-3. Nine patients (53%) had breast cancer, 3 (18%) had non-small cell lung cancer (NSCLC), 2 (12%) had melanoma, 1 (6%) had colorectal adenocarcinoma, 1 (6%) had endocervical adenocarcinoma, and 1 (6%) had two synchronous primaries (adenocarcinoma of the gastro-esophageal junction and neuroendocrine carcinoma of the lung). All patients had prior radiation; ten had prior radiation to the brain, one had prior radiation to the spine, and six had other sites previously radiated. Fourteen patients (82%) were treated to 30 Gy in 10 fractions and 3 (18%) were treated to 25 Gy in 10 fractions due to overlap with prior radiation fields. Median follow-up was 4 months (range, 1-13 months). Among 15 evaluable patients, median CNS-PFS and median OS were 3.6 months and 4.7 months, respectively. For patients with breast cancer or NSCLC, 62% were alive at 6 months; median OS has not been reached. Treatment was well tolerated with no grade 3-4 non-hematologic adverse events.

CONCLUSION

pCSI is a novel method for treatment of LMD from solid tumors that has been rapidly adopted. Based on our preliminary review, it is safe and well-tolerated; patient selection is critical. As these patients are often heavily pretreated, prior radiation fields must be considered in pCSI planning.

Frameless Fractionated Linear Accelerator-Based Stereotactic Radiotherapy for Brain Metastases: Results of a Single-Arm Phase II Multi-Institutional Clinical Trial

PURPOSE/OBJECTIVE(S)

Stereotactic radiotherapy (SRT) yields high rates of local control for brain metastases while minimizing neurocognitive side effects. While advanced SRT platforms are widely available in urban centers, rural/suburban patients face geographic and socioeconomic barriers to access SRS. For this reason, we conducted a multi-institutional Phase 2 clinical trial to test the safety and efficacy of 3-5 fraction frameless fractionated stereotactic radiotherapy (FFSRT) for brain metastases in an integrated academic satellite network MATERIALS/METHODS: This IRB-approved Phase 2 trial was conducted for patients ≥18-years-old with 1-4 brain metastases. Brain metastases involving the optic pathway or brainstem were excluded. Gross tumor volume (GTV) was delineated with a volumetric brain MRI and planning target volume (PTV) was GTV + 2 mm margin. Radiation dose was based on GTV size: < 3.0 cm, 27 Gy in 3 fractions, and 3.0-3.9 cm, 30 Gy in 5 fractions. Toxicity was evaluated using the Common Terminology Criteria for Adverse Events (CTCAE) version 4.

RESULTS

Of 76 evaluable patients, the median age was 67 years, 56.6% were female, 82.9% were white/Caucasian and 89.6% had an Eastern Cooperative Oncology Group performance status ≤ 2. Most brain metastases were from lung cancer (51.3%) and breast cancer (15.7%). With median follow-up of 10 months, local control was 93%, median survival was 1.8 years (95% confidence interval (CI): 1.5-2.4 years), 1-year OS was 73.8% (95% CI: 0.59-0.84), and 2-year OS was 31% (95% CI: 0.12-0.52). There were no CTCAE Grade ≥ 3 protocol-related adverse events.

CONCLUSION

Outcomes of this trial compare favorably with contemporary SRT trials for brain metastases. FFSRT may provide opportunities to expand SRS access for underserved populations across the MDACC enterprise and in future clinical trials for brain metastases.

MD Anderson Phase III Randomized Preoperative Stereotactic Radiosurgery (SRS) vs. Postoperative SRS for Brain Metastases Trial

PURPOSE/OBJECTIVE(S)

Postoperative stereotactic radiation therapy/radiosurgery (SRT/SRS) is being evaluated in comparison to Preoperative SRT for brain metastases (mets) in a limited number of prospective clinical trials. Our objective is to address the significant knowledge gap concerning the logistics of preoperative SRT in comparison to postoperative SRT in a randomized controlled study.

MATERIALS/METHODS

Patients with brain mets with at least 1 surgically operable met were randomized (1:1) to Preop vs Postop SRT. In this abstract, we present non-primary endpoint data on the trial concept and logistics of treatment for this data safety monitoring board reviewed study. Patients enrolled had 1-2 lesions resected and <15 lesions treated at time of SRT to best reflect the standard population that receive SRT and surgery at our institution.

RESULTS

From 12/2018 to 12/2022, 99 patients with 1-2 operable brain mets were enrolled and randomized to Preop (n = 49) or Postop (n = 50) SRT. Males represented 56% of the cohort compared to females, and <25% were age 18-49 years, while 27%, 29, and 19% respectively were 50-59, 60-69, and > = 70. The most frequent histologies enrolled were lung (29%), renal cell (15%), melanoma (14%), and breast (11%) cancers. The majority of patients (83%) had 1-4 brain mets on their baseline MRI and 91% subsequently had a single lesion resected. Seventy-nine patients completed both SRT and surgery, while 9% received no therapy due to drop out before study therapy initiation. Among patients receiving both therapies in the combined cohort, 68% received a non-invasive stereotactic radiosurgery instrument to the randomized cavity lesion compared to 32% receiving LINAC based SRT. Treatment of the lesion or cavity with single fraction SRT was 51% in the Preop arm vs 31% in the Postop arm. Multi-fraction (3-5 SRT) was 67% in the Postop cohort in contrast to 47% in the Preop cohort. Time from randomization to RT was 5.6 days and 33.7 days in the Preop and Postop cohorts respectively, and for surgery was 10.2 days vs 12.9 days in the Postop vs Preop cohorts. The average time from RT to surgery was 7.3 days in the Preop arm and 23.5 days in the Postop arm (to allow for incisional healing time).

CONCLUSION

In one of the early initiated randomized prospective cohorts of Preop vs Postop SRT, we demonstrated logistical feasibility with an efficient clinical trial workflow for study treatment. Differences in Preop vs Postop logistics reflect clinical practice differences in time-to-treatment. Therapy with various modalities reflected real-world practice and possibly provider preferences in technique when addressing the nature of delineating cavities and changes in cavity volume with regard to fractionation. Independent of the primary outcomes, our data provides insights in the practical management of patients receiving these two modalities of therapy, and further data at the completion of trial will address relevant primary outcomes.

Advances in the management of spinal metastases: what the radiologist needs to know

Spine is the most frequently involved site of osseous metastases. With improved disease-specific survival in patients with Stage IV cancer, durability of local disease control has become an important goal for treatment of spinal metastases. Herein, we review the multidisciplinary management of spine metastases, including conventional external beam radiation therapy, spine stereotactic radiosurgery, and minimally invasive and open surgical treatment options. We also present a simplified framework for management of spinal metastases used at The University of Texas MD Anderson Cancer Center, focusing on the important decision points where the radiologist can contribute.

Use of the Toxicity Index in Evaluating Adverse Events in Anal Cancer Trials: Analysis of RTOG 9811 and RTOG 0529

Novel toxicity metrics that account for all adverse event (AE) grades and the frequency of may enhance toxicity reporting in clinical trials. The Toxicity Index (TI) accounts for all AE grades and frequencies for categories of interest. We evaluate the feasibility of using the TI methodology in 2 prospective anal cancer trials and to evaluate whether more conformal radiation (using Intensity Modulated Radiation Therapy) results in improved toxicity as measured by the TI. Patients enrolled on NRG/RTOG 0529 or nonconformal RT enrolled on the 5-Fluorouracil/Mitomycin arm of NRG/RTOG 9811 were compared using the TI. Patients treated on NRG/RTOG 0529 had lower median TI compared with patients treated with nonconformal RT on NRG/RTOG 9811 for combined GI/GU/Heme/Derm events (3.935 vs 3.996, P=0.014). The TI methodology is a feasible method to assess all AEs of interest and may be useful as a composite metric for future efforts aimed at treatment de-escalation or escalation.

Multidisciplinary management of spinal metastases: what the radiologist needs to know

The modern management of spinal metastases requires a multidisciplinary approach that includes radiation oncologists, surgeons, medical oncologists, and diagnostic and interventional radiologists. The diagnostic radiologist can play an important role in the multidisciplinary team and help guide assessment of disease and selection of appropriate therapy. The assessment of spine metastases is best performed on MRI, but imaging from other modalities is often needed. We provide a review of the clinical and imaging features that are needed by the multidisciplinary team caring for patients with spine metastases and stress the importance of the spine radiologist taking responsibility for synthesizing imaging features across multiple modalities to provide a report that advances patient care.

An interdisciplinary consensus on the management of brain metastases in patients with renal cell carcinoma

Brain metastases are a challenging manifestation of renal cell carcinoma. We have a limited understanding of brain metastasis tumor and immune biology, drivers of resistance to systemic treatment, and their overall poor prognosis. Current data support a multimodal treatment strategy with radiation treatment and/or surgery. Nonetheless, the optimal approach for the management of brain metastases from renal cell carcinoma remains unclear. To improve patient care, the authors sought to standardize practical management strategies. They performed an unstructured literature review and elaborated on the current management strategies through an international group of experts from different disciplines assembled via the network of the International Kidney Cancer Coalition. Experts from different disciplines were administered a survey to answer questions related to current challenges and unmet patient needs. On the basis of the integrated approach of literature review and survey study results, the authors built algorithms for the management of single and multiple brain metastases in patients with renal cell carcinoma. The literature review, consensus statements, and algorithms presented in this report can serve as a framework guiding treatment decisions for patients. CA Cancer J Clin. 2022;72:454-489.

Comparing Costs of Radical Versus Partial Cystectomy for Patients Diagnosed With Localized Muscle-Invasive Bladder Cancer: Understanding the Value of Surgical Care

OBJECTIVE

To compare costs associated with radical versus partial cystectomy. Prior studies noted substantial costs associated with radical cystectomy, however, they lack surgical comparison to partial cystectomy.

METHODS

A total of 2305 patients aged 66-85 years diagnosed with clinical stage T2-4a muscle-invasive bladder cancer from January 1, 2002 to December 31, 2011 were included. Total Medicare costs within 1 year of diagnosis following radical versus partial cystectomy were compared using inverse probability of treatment-weighted propensity score models. Cox regression and competing risks analysis were used to determine overall and cancer-specific survival, respectively.

RESULTS

Median total costs were not significantly different for radical than partial cystectomy in 90 days ($73,907 vs $65,721; median difference $16,796, 95% CI $10,038-$23,558), 180 days ($113,288 vs $82,840; median difference $36,369, 95% CI $25,744-$47,392), and 365 days ($143,831 vs $107,359; median difference $34,628, 95% CI $17,819-$53,558), respectively. Hospitalization, surgery, pathology/laboratory, pharmacy, and skilled nursing facility costs contributed largely to costs associated with either treatment. Patients who underwent partial cystectomy had similar overall survival but had worse cancer-specific survival (Hazard Ratio 1.45, 95% Confidence Interval, 1.34-1.58, P < .001) than patients who underwent radical cystectomy.

CONCLUSION

While treatments for bladder cancer are associated with substantial costs, we showed radical cystectomy had comparable total costs when compared to partial cystectomy among patients with muscle-invasive bladder cancer. However, partial cystectomy resulted in worse cancer-specific survival further supporting radical cystectomy as a high-value surgical procedure for muscle-invasive bladder cancer.

Long-Term Institutional Experience With Telemedicine Services for Radiation Oncology: A Potential Model for Long-Term Utilization

Purpose

With the development of the coronavirus disease 2019 (COVID-19) pandemic, health care practices and radiation oncology departments have begun to incorporate telemedicine services to practice social distancing and minimize the chances of disease spread. Given the severity of this pandemic, it will likely fundamentally affect the use of these services for years to come. Our institution and radiation oncology department have used telemedicine services for many years; we would like to report on our departmental experience to guide other radiation oncology practices on its long-term use for clinical evaluation and patient care.

Methods and Materials

Our institution’s telemedicine program provides clinical services for a number of remote locations and represents the largest telehealth network in the world, with over 300 sites and 60,000 patient encounters a year.

Results

Specifically for our radiation oncology department, over 200 patient encounters occur via telemedicine a year. Patients report great appreciation and satisfaction with these encounters, as they eliminate the time and energy needed for travel from long distances. It has resulted in improved efficiency and cost-effectiveness as well.

Conclusions

Based on our institutional experience, our long-term vision for telemedicine (after COVID-19 pandemic has hopefully subsided) is as an excellent and cost-efficient tool to provide long-term follow-up for patients, especially for those who live far away in rural or underserved areas.

Comparing Survival Outcomes and Costs Associated With Radical Cystectomy and Trimodal Therapy for Older Adults With Muscle-Invasive Bladder Cancer

Importance

Radical cystectomy is the guidelines-recommended treatment of muscle-invasive bladder cancer, but a resurgence of trimodal therapy has occurred. Limited comparative data are available on outcomes and costs attributable to these 2 treatments.

Objective

To compare the survival outcomes and costs between trimodal therapy and radical cystectomy in older adults with muscle-invasive bladder cancer.

Design, Setting, and Participants

This population-based cohort study used data from the Surveillance, Epidemiology, and End Results-Medicare linked database. A total of 3200 older adults (aged ≥66 years) with clinical stage T2 to T4a bladder cancer diagnosed from January 1, 2002, to December 31, 2011, and with claims data available through December 31, 2013, were included in the analysis. Patients who received radical cystectomy underwent either only surgery or surgery in combination with radiotherapy or chemotherapy. Patients who received trimodal therapy underwent transurethral resection of the bladder followed by radiotherapy and chemotherapy. Propensity score matching by sociodemographic and clinical characteristics was used. Data analysis was performed from August 1, 2017, to March 11, 2018.

Main Outcomes and Measures

Overall survival and cancer-specific survival were evaluated using the Cox proportional hazards regression model and the Fine and Gray competing risk model. All Medicare health care costs for inpatient, outpatient, and physician services within 30, 90, and 180 days of treatment were compared. The total amount spent nationwide was estimated, using 180-day medical costs between treatments, by the total number of new cases of muscle-invasive bladder cancer in the United States in 2011.

Results

Of the 3200 patients who met the inclusion criteria, 2048 (64.0%) were men and 1152 (36.0%) were women, with a mean (SD) age of 75.8 (6.0) years. After propensity score matching, 687 patients (21.5%) underwent trimodal therapy and 687 patients (21.5%) underwent radical cystectomy. Patients who underwent trimodal therapy had significantly decreased overall survival (hazard ratio [HR], 1.49; 95% CI, 1.31-1.69) and cancer-specific survival (HR, 1.55; 95% CI, 1.32-1.83). No differences in costs at 30 days were observed between trimodal therapy ($15 233 in 2002 vs $18 743 in 2011) and radical cystectomy ($17 990 in 2002 vs $21 738 in 2011). However, median total costs were significantly higher with trimodal therapy than with radical cystectomy at 90 days ($80 174 vs $69 181; median difference, $8964; Hodges-Lehmann 95% CI, $3848-$14 079) and at 180 days ($179 891 vs $107 017; median difference, $63 771; Hodges-Lehmann 95% CI, $55 512-$72 029). Extrapolating these figures to the total US population revealed $335 million in excess spending for trimodal therapy compared with the less costly radical cystectomy ($492 million) for patients who received a muscle-invasive bladder cancer diagnosis in 2011.

Conclusions and Relevance

Trimodal therapy was associated with significantly decreased overall survival and cancer-specific survival as well as $335 million in excess spending in 2011. These findings have important health policy implications regarding the appropriate use of high value-based care among older adults with invasive bladder cancer who are candidates for either radical cystectomy or trimodal therapy.

Comparison of Costs of Radical Cystectomy vs Trimodal Therapy for Patients With Localized Muscle-Invasive Bladder Cancer

Importance

Earlier studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days.

Objective

To compare the 1-year costs associated with trimodal therapy vs radical cystectomy, accounting for survival and intensity effects on total costs.

Design, Setting, and Participants

This population-based cohort study used the US Surveillance, Epidemiology, and End Results-Medicare database and included 2963 patients aged 66 to 85 years who had received a diagnosis of clinical stage T2 to T4a muscle-invasive bladder cancer from January 1, 2002, through December 31, 2011. The data analysis was performed from March 5, 2018, through December 4, 2018.

Main Outcomes and Measures

Total Medicare costs within 1 year of diagnosis following radical cystectomy vs trimodal therapy were compared using inverse probability of treatment-weighted propensity score models that included a 2-part estimator to account for intrinsic selection bias.

Results

Of 2963 participants, 1030 (34.8%) were women, 2591 (87.4%) were white, 129 (4.4%) were African American, and 98 (3.3%) were Hispanic. Median costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83 754 vs $68 692; median difference, $11 805; 95% CI, $7745-$15 864), 180 days ($187 162 vs $109 078; median difference, $62 370; 95% CI, $55 581-$69 160), and 365 days ($289 142 vs $148 757; median difference, $109 027; 95% CI, $98 692-$119 363), respectively. Outpatient care, radiology, medication expenses, and pathology/laboratory costs contributed largely to the higher costs associated with trimodal therapy. On inverse probability of treatment-weighted adjusted analyses, patients undergoing trimodal therapy had $136 935 (95% CI, $122 131-$152 115) higher mean costs compared with radical cystectomy 1 year after diagnosis.

Conclusions and Relevance

Compared with radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. The differences in costs were largely attributed to medication and radiology expenses associated with trimodal therapy. Extrapolating cost figures resulted in a nationwide excess spending of $468 million for trimodal therapy compared with radical cystectomy for patients who received a diagnosis of bladder cancer in 2017.

Population-based outcomes comparing radical cystectomy with trimodal therapy for patients diagnosed with localized muscle-invasive bladder cancer

e16029

Background: Radical cystectomy is the guideline-recommended treatment for muscle-invasive bladder cancer; however, use of trimodal therapy, which utilizes a combination of surgery, radiation, and chemotherapy, has increased in recent years with conflicting survival outcomes. Methods: Utilizing data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, a total of 2,963 patients aged 66 years or older diagnosed with clinical stage T2-4a bladder cancer from January 1, 2002 to December 31, 2011 were analyzed. Conventional regression, propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were used to compare radical cystectomy and trimodal therapy for overall and cancer-specific survival, and cost. Results: Patients who underwent TMT had significantly decreased overall (conventional regression: Hazard Ratio (HR) 1.54, 95% Confidence Interval (CI), 1.39-1.71; PSM: HR 1.49, 95% CI 1.31-1.69; IPTW: HR 1.54, 95% CI 1.39-1.71) and cancer-specific (conventional regression: HR 1.51, 95% CI 1.40-1.63; PSM: HR 1.55, 95% CI 1.32-1.83; IPTW: HR 1.51, 95% CI 1.40-1.63) survival. Median total costs were significantly higher with trimodal therapy than with radical cystectomy at 6-month ($171,401 vs. $99,890, p < 0.001). Conclusions: Using population-based data and different analytic methods to control for imbalance between study groups, we found that trimodal therapy was associated with decreased overall and cancer-specific survival at increased costs compared to radical cystectomy.

Comparing costs of radical cystectomy versus trimodal therapy for patients diagnosed with localized muscle-invasive bladder cancer

e16021

Background: Earlier studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days. The objective of this study is to compare the one-year costs associated with trimodal therapy versus radical cystectomy, accounting for survival and intensity effects on total costs. Methods: This cohort study used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Data analysis was performed from March 5, 2018 through December 4, 2018. A total of 2,963 patients aged 66-85 years diagnosed with clinical stage T2-4a muscle-invasive bladder cancer from January 1, 2002 through December 31, 2011. Total Medicare costs within one year of diagnosis following radical cystectomy versus trimodal therapy were compared using inverse probability of treatment-weighted (IPTW) propensity score models, which included a two-part estimator to account for intrinsic selection bias. Results: Median costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83,754 vs. $68,692; median difference $11,805, 95% CI $7,745 to $15,864), 180 days ($187,162 vs. $109,078; median difference $62,370, 95% CI $55,581 to $69,160), and 365 days ($289,142 vs. $148,757; median difference $109,027, 95% CI $98,692 to $119,363), respectively. Outpatient care, radiology, medication expenses and pathology/laboratory costs contributed largely to the higher costs associated with trimodal therapy. On IPTW-adjusted analyses, patients undergoing trimodal therapy had $129,854 (95% CI $115,793-$145,299) higher costs compared with radical cystectomy one year after diagnosis. Conclusions: Compared to radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. Extrapolating cost figures resulted in nationwide excess spending of $444 million for trimodal therapy compared with radical cystectomy for patients diagnosed in 2017.

Comparing costs of radical cystectomy versus trimodal therapy for patients diagnosed with localized muscle-invasive bladder cancer

372

Background: Studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days. This study aimed to compare the one-year costs of trimodal therapy versus radical cystectomy, accounting for survival and intensity effects on total costs. Methods: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data, we included a total of 2,963 patients aged ≥66 years diagnosed with clinical stage T2-4a bladder cancer between 2002 and 2011. We compared total Medicare costs within one year of diagnosis among patients following radical cystectomy or trimodal therapy using inverse probability of treatment weighted (IPTW) propensity score models, which included a two-part estimator to account for intrinsic selection bias. Results: Median total costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83,754 vs. $68,692; median difference $11,805, 95% CI $7,745 to $15,864), 180 days ($187,162 vs. $109,078; median difference $62,370, 95% CI $55,581 to $69,160), and 365 days ($289,142 vs. $148,757; median difference $109,027, 95% CI $98,692 to $119,363), respectively. Outpatient, radiology, pharmacy and pathology/laboratory costs contributed largely to the significantly higher costs associated with trimodal therapy. On IPTW-adjusted analyses, patients undergoing trimodal therapy had $142,337 (95% CI $117,423-$175,300) higher costs compared with radical cystectomy one year after treatment (Table). Conclusions: Compared to radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. Extrapolating cost figures to the total US population resulted in excess spending of $853 million for trimodal therapy compared with radical cystectomy for patients diagnosed in 2018. [Table: see text]

Comparing radical cystectomy with trimodal therapy for patients diagnosed with bladder cancer: Critical assessment of statistical methodology and interpretation of observational data

373

Background: Treatment guidelines for muscle-invasive bladder cancer recommend radical cystectomy. However, use of trimodal therapy has increased in recent years with conflicting survival outcomes. The aim of this study was to compare radical cystectomy and trimodal therapy in terms of survival outcomes and cost of treatment according to varying statistical methodology in order to interpret findings using observational data. Methods: Patients aged 66 years or older diagnosed with clinical stage T2-4a bladder cancer from January 1, 2002-December 31, 2011 were included from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Outcomes included cancer-specific survival, overall survival, and 6-month costs. Cox proportional hazards regression, propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were used to control for baseline differences between patients undergoing radical cystectomy vs. trimodal therapy, and to determine predictors for overall and cancer-specific survival. Results: A total of 2,963 patients were included: 728 (24.6%) who underwent trimodal therapy were compared to 2,235 (75.4%) who underwent radical cystectomy. In all adjusted analyses, patients who underwent trimodal therapy had significantly decreased cancer-specific survival (Cox regression: Hazard Ratio (HR) 1.51, 95% Confidence Interval (CI) 1.40-1.63; PSM: HR 1.55, 95% CI 1.32-1.83; IPTW: HR 1.51, 95% CI 1.40-1.63) and overall survival (Cox regression: HR 1.54, 95% CI 1.39-1.71; PSM: HR 1.49, 95% CI 1.31-1.69; IPTW: HR 1.54, 95% CI 1.39-1.71). However, median total costs over six months were significantly higher with trimodal therapy than radical cystectomy ($171,401 vs. $99,890, p<0.001). Conclusions: Trimodal therapy was associated with decreased cancer-specific and overall survival at increased costs compared to radical cystectomy. In the absence of data from randomized controlled trials, this observational study provides further evidence to suggest the superiority of radical cystectomy over trimodal therapy in patients with muscle-invasive bladder cancer.

The Use of "QUAD Shot" in Anal Canal Squamous Cell Carcinoma: A Case Study With Review of the Literature

CONTEXT

Patients with locoregional anal carcinoma who do not qualify for standard definitive chemoradiation are candidates for a short course of palliative hypofractionated radiotherapy such as QUAD Shot.

METHODS

A 57-year-old man with massive locoregional squamous cell carcinoma of the anal canal was treated with QUAD Shot (14.8 Gy in four fractions over two consecutive days) repeated every four weeks for a total of two courses.

RESULTS

He reported symptomatic relief following each course of radiation. In regard to his first QUAD Shot, his pain was 10/10 in severity at the time of admission and 4/10 at the time of discharge. In regard to his second QUAD Shot, his pain was 8/10 at the time of admission and 0/10 at the time of discharge. He did not experience any treatment-related toxicity. He passed away 15 weeks after the first course.

CONCLUSION

QUAD Shot is both efficacious and safe for palliation in patients with anal carcinoma.

Survival outcomes and costs of trimodal therapy compared with radical cystectomy among patients diagnosed with localized muscle-invasive bladder cancer

421

Background: Radical cystectomy is the guideline-recommended treatment for muscle-invasive bladder cancer. Recently there has been a resurgence in trimodal therapy with limited data on comparative outcomes, and especially attributable costs. Methods: A total of 3,200 patients aged 66 years or older diagnosed with clinical stage T2-4a bladder cancer from January 1, 2002- December 31, 2011 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare data were analyzed. Cox regression analysis and propensity score matching methods were used to determine predictors for overall and cancer-specific survival. Results: A total of 3,200 patients met inclusion criteria. After propensity score matching, 687 patients underwent trimodal therapy and 687 patients underwent radical cystectomy. Patients who underwent trimodal therapy had significantly decreased overall (Hazard Ratio (HR) 1.49, 95% Confidence Interval (CI), 1.31-1.69, p < 0.001) and cancer-specific (HR 1.55, 95% CI 1.32-1.83, p < 0.001) survival, respectively. While there was no difference in costs at 30 days, median total costs were significantly higher with trimodal therapy than radical cystectomy at 90-d ($63,355 vs. $73,420, p < 0.001) and 180-d ($98,005 vs. $164,720, p < 0.001), respectively. Extrapolating these figures to the total US population results in excess spending of $179 million for trimodal therapy compared to less costly radical cystectomy for patients diagnosed in 2011. Conclusions: Trimodal therapy was associated with significantly decreased overall and cancer-specific survival resulting in excess national spending of $179 million in 2011 compared with radical cystectomy. These findings have important health policy implications regarding appropriate use of high-value based care among patients who are candidates for either treatment.

Effect of incorporation of preoperative CT scan on bladder doses and irradiated volume in postprostatectomy radiation therapy (pPRT)

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Background: pPRT increases local control, biochemical progression free survival, and even overall survival in patients with adverse features undergoing prostatectomy. The Radiation Therapy Oncology Group (RTOG) consensus definition of the clinical target volume (CTV) in 2010 was based on patterns of failure and anatomy without consideration of pre-operative imaging. This results in large volumes of bladder in the treatment field. Our study evaluates whether incorporation of pre-operative prostate volume can reduce the post-operative CTV and minimize dose to adjacent normal tissue. Methods: We reviewed records of all patients with available pre-operative pelvic CT scans treated at our institution with pPRT. The pre-operative CT scan was fused to the simulation CT. Post-operative CTV (CTV1) was delineated based on RTOG guidelines. A separate CTV (CTV2) was constructed, based on the intact prostate and proximal seminal vesicles. Plans were constructed for each CTV and doses to rectum, bladder, and penile bulb calculated, as well as concordance between the two CTVs and planning target volumes (PTVs). Paired student’s t-test was used to calculate difference between doses in the two different plans. Results: 10 patients’ plans were analyzed. Dosimetric parameters are shown in table 1. Volume of the bladder receiving 65 Gy or higher (V65) was significantly higher in CTV1. As would be expected, there were no significant differences in dose to either the rectum or penile bulb. Additionally, there was on average only 39% overlap between the CTVs and 60% between the PTVs in the two plans. Conclusions: Utilization of the pre-operative pelvic CT scan can aid in more accurate delineation of the CTV/PTV in prostate bed radiation therapy and decrease the bladder dose. As many patients at risk for pPRT have had this imaging performed preoperatively, in accordance with guidelines, incorporation of this data appears prudent. These findings need to be validated in a larger cohort. [Table: see text]

Accelerated partial breast irradiation: Past, present, and future

Accelerated partial breast irradiation (APBI) focuses higher doses of radiation during a shorter interval to the lumpectomy cavity, in the setting of breast conserving therapy for early stage breast cancer. The utilization of APBI has increased in the past decade because of the shorter treatment schedule and a growing body of outcome data showing positive cosmetic outcomes and high local control rates in selected patients undergoing breast conserving therapy. Technological advances in various APBI modalities, including intracavitary and interstitial brachytherapy, intraoperative radiation therapy, and external beam radiation therapy, have made APBI more accessible in the community. Results of early APBI trials served as the basis for the current consensus guidelines, and multiple prospective randomized clinical trials are currently ongoing. The pending long term results of these trials will help us identify optimal candidates that can benefit from ABPI. Here we provide an overview of the clinical and cosmetic outcomes of various APBI techniques and review the current guidelines for selecting suitable breast cancer patients. We also discuss the impact of APBI on the economics of cancer care and patient reported quality of life.

Impact of radiation and surgery for intraductal papillary neoplasm of the bile duct: A population-based analysis

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Background: Intraductal Papillary Neoplasm of the Bile Duct (IPNB), either in-situ or invasive, is a histological variant with better prognosis then the more common adenocarcinoma. This study’s purpose is to use the Surveillance Epidemiology and End Results (SEER) database to evaluate prognostic factors: histology, stage, location, extent of surgery and the use of radiation therapy (RT). Methods: Cases from 1973-2011 were acquired. Inclusion criteria included intrahepatic (IHD), extrahepatic bile duct (EHD) or ampulla of vater (AoV) locations, first primary, extent of surgery and RT history. Kaplan-Meier and Log-Rank methods measured overall survival (OS) and disease specific survival (DSS) in months (m) and their medians (MOS, MDSS). Cox multivariate regression computed hazard ratios (HR) controlling for stage, treatment, surgical extent and histology. Results: . For non-invasive cases, 14% were IPNB (n = 31). Survival was similar for EHD & AoV cases. Surgery was associated with prolonged MOS of 120m compared to 8m without surgery or RT. A trend suggested better survival with lesser extent of surgery for EHD & AoV cases (p < 0.16, n = 8 at both sites). For invasive cases, 5% were IPNB (n = 1309). For cases not receiving surgery, RT was associated with prolonged OS & DSS from 3 to 7m (p = 0.026) and 4 to 8m (p = 0.074). In T1N0M0 EHD cases, surgery with and without RT had similar OS & DSS. Cox analysis observed similar OS & DSS for surgery with and without RT for EHD and AoV cases. Mucin-producing IPNB was less likely local stage disease (10% vs 39%, p < 0.01), with shorter OS 5m vs 23 m (p < 0.01) and DSS 6m vs 28m (p < 0.01), and for EHD cases, with HR = 2.0 (p < 0.01) compared to papillary type IPNB. Conclusions: For non-invasive IPNB, surgery with less extensive resections was associated with better prognosis. For invasive IPNB cases not amenable to surgery, RT improved short term survival. If high-risk factors such as suboptimal surgical margins, which are not recorded in SEER, correlated with the use of RT, then the outcomes in EHD & AoV locations could be explained by an imparted benefit. As well, mucin-associated IPNB, was associated with worse survival than papillary type. Further work is necessary to validate these findings.

Cost analysis of adjuvant management strategies in early stage (stage I) testicular seminoma

BACKGROUND

Acceptable post-orchiectomy adjuvant therapy strategies for stage I seminoma patients include surveillance, para-aortic radiation therapy (RT), dog-leg RT, and a single cycle of carboplatin. The required follow-up recommendations were amended by the National Comprehensive Cancer Network (NCCN) in 2012. Given a cause-specific survival of nearly 100%, a closer analysis of the reimbursement for each treatment strategy is warranted.

METHODS

NCCN guidelines were used to design treatment plans for each acceptable adjuvant treatment strategy. Follow-up charges were generated for 10 years based on 2012 (version 1.2012; unchanged in current version 1.2013) and 2011 NCCN (version 2.2011) surveillance recommendations. The 2012 Medicare reimbursement rates were used to calculate each treatment strategy and incremental cost-effectiveness ratios to compare the treatment options.

RESULTS

Under the current NCCN follow-up recommendations, the total reimbursements generated over 10 years of surveillance, para-aortic RT, dog-leg RT, and carboplatin were $10,643, $11,678, $9,662, and $10,405, respectively. This is compared with the reimbursements as per the 2011 NCCN recommendations: $20,986, $11,517, $9,394, and $20,365 respectively. Factoring the rates of relapse into a salvage model, observation was found to be more costly and less effective ($-1,831, $-7,318, $-7,010) in the adjuvant management of stage I seminoma patients.

CONCLUSION

Based on incremental cost-effectiveness ratios, para-aortic RT, dog-leg RT, and carboplatin are cost-effective options for the treatment of stage I seminoma when compared with observation; however, surveillance could potentially spare as many as 80%-85% of men diagnosed with stage I seminoma from additional therapy after radical inguinal orchiectomy. Such cost and reimbursement analyses are becoming increasingly relevant, but are not meant to usurp sound clinical judgment. Further studies are required to validate these findings.

Cost analysis of adjuvant management strategies in early-stage testicular seminoma

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Background: Acceptable post-orchiectomy management strategies for stage I seminoma include surveillance (SV), para-aortic (PA-RT) radiation therapy, dog-leg (DL-RT) or a single cycle of carboplatin (Carbo). The follow-up recommendations for each option were recently amended by the National Comprehensive Cancer Network (NCCN) in 2012. As such, surveillance imaging after treatment, a contributor to costs, was significantly scaled back. This was driven, in part, by the maturation of data from the MRC TE 19/EORTC 30982 study along with an effort to decrease exposure to frequent CT scans. Methods: NCCN guidelines were used to design treatment plans for each of the acceptable adjuvant treatments strategies: SV, Carbo (AUC=7), PA-RT (20 Gy), DL-RT (20 Gy) and salvage chemotherapy (bleomycin, etoposide, and cisplatin x 3 cycles). NCCN guidelines for growth factor support and anti-emetic use were incorporated into the treatments. Follow-up charges, including weighted costs for salvage for each modality, were generated for 10 years based on both the 2012 and the 2011 NCCN guidelines. According to published literature, the anticipated failure rate for SV, either DL-RT or PA-RT, or Carbo was 18%, 4%, and 5% respectively. 2012 Medicare reimbursement rates (both facility and professional charges) were used to determine the actual reimbursement for each treatment course over a 10-year period. Results: Under the current 2012 NCCN recommendations, the total Medicare reimbursement for SV, PA- RT, DL-RT, and Carbo, when factoring in the cost of salvage, were $10,643, $11,678, $9,662, and $7,870 respectively. This is compared to the reimbursement under the 2011 NCCN guidelines for SV, PA- RT, DL-RT, and Carbo of $20,986, $11,517, $9,394, and $20,365. Conclusions: Reduced imaging during SV or after adjuvant therapy has significantly narrowed the difference in reimbursement between adjuvant management options. This is driven primarily by the integration of results from the MRCTE19/EORTC 30982 outcomes and patterns of failures. We are currently in the process of using Treeage models to fine-tune treatment costs and patient variables to better assess cost-effectiveness between adjuvant treatment modalities.

Multimodality treatment of locally advanced penile cancer: A contemporary dosimetric comparison and case presentation

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Background: There is a paucity of data on the optimal therapy for locally advanced penile cancer (PC). However, advances in other HPV associated neoplasms utilizing combined modality therapy (CMT) have been encouraging. We describe the management of advanced PC with such an approach.

Methods: The patient presented following partial penectomy and inguinal dissection with T2N3 disease and extra-capsular extension (ECE). In a multi-disciplinary setting, it was decided to treat him post-operatively with concurrent chemoradiation. CT data sets were used for dosimetric comparison of critical structures (small bowel, rectum, bladder, scrotum, testes, bone marrow, skin, bowel, and femoral heads) and plans were generated using conventional penile fields (3D), Intensity Modulated Radiation Therapy (IMRT), and Volumetric Modulated Arc Therapy (VMAT), minimizing dose to organs at risk while optimizing treatment dose.

Results: The patient was treated with IMRT (45 Gy to penile stump, pelvic and inguinal nodes (INs) with a 9 Gy boost to left INs and 15 Gy boost to right INs, due to ECE) and weekly Cisplatin (20 mg/m2). IMRT gave similar coverage and avoidance of normal structures compared to VMAT but with lower mean scrotal dose ( IMRT 27.0 Gy , VMAT 29.9 Gy, 3D 45.6 Gy). There was no >grade II toxicities, with grade II scrotal edema and moist desquamation of bilateral inguinal folds, not requiring treatment breaks. Acute RT toxicities had near resolution at 1 month. The IMRT and VMAT plans vs. the 3D plan had lower mean doses to the normal structures. 3D planning had unacceptable max doses to femoral head (62 Gy) and scrotum (55 Gy). Small bowel, V15Gy ≤ 150 cc was achieved by all plans. Dose homogeneity was improved for IMRT/VMAT vs. 3D planning (max dose 119%).

Conclusions: This is one of the first comparisons of contemporary radiation techniques in the multimodality setting of PC. We demonstrate that utilizing IMRT concurrently with Cisplatin is feasible and well tolerated suggesting it a reasonable strategy to obtain durable local control, without which the prognosis is uniformly dismal. Larger studies are warranted to explore this contemporary CMT approach to locally advanced PC.

TMPRSS2/ERG fusion gene expression alters chemo- and radio-responsiveness in cell culture models of androgen independent prostate cancer

PURPOSE/OBJECTIVES

The androgen regulated transmembrane serine protease (TMPRSS2) and ETS transcription factor (ERG) gene fusion is a strong prognostic factor for disease recurrence following prostatectomy. Expression of TMPRSS2/ETS-related gene (ERG) fusion gene transcripts is linked with tumor proliferation, invasion, and an aggressive phenotype. The aim of this study was to define the effect of TMPRSS2/ERG fusion gene expression on chemo- and radiosensitivity in prostate tumor cell lines.

MATERIALS/METHODS

Clonogenic survival of PC3 and DU145 cells stably expressing TMPRSS2/ERG Types III and VI fusion genes was measured after X-irradiation (0-8 Gy) and Paclitaxel. Cell cycle changes and DNA double-strand break induction and repair were assessed. Differential gene expression was measured by microarray analysis. ERG signaling pathway interactions were studied using Ariadne Pathway Studio.

RESULTS

Expression of the TMPRSS2/ERG fusions in PC3 cells increased radiation sensitivity and decreased paclitaxel sensitivity. Increased radiosensitivity was associated with persistent DNA breaks 24 hr post-irradiation, down-regulation of genes involved in DNA repair and mitosis and up-regulation of ETV, an ETS transcription factor. However, DU145 Types III and VI demonstrated a different sensitivity phenotype and gene expression changes. Pathway analysis of ERG signaling further illustrated the variation between the PC3 and DU145 cell lines containing TMPRSS2/ERG fusions.

CONCLUSIONS

The effect of TMPRSS2/ERG gene fusions had differing effects on radiosensitivity and chemosensitivity depending on cell line and fusion type. Further work is needed with clinical samples to establish whether TMPRSS2/ERG gene fusions affect radio- and chemosensitivity in vivo.

The role of neuropeptide processing enzymes in endocrine (prostate) cancer: EC 3.4.24.15 (EP24.15)

The zinc metalloendopeptidase EC3.4.24.15 [EP24.15, thimet oligopeptidase], a neuropeptide processing enzyme, is central to the formation and degradation of many bioactive peptides in the neural proteome, and is highly expressed in normal prostate. EP24.15 actions are increased in androgen-dependent prostate cancer compared to androgen-independent; augmented by androgen treatment, and inhibited by clinical GnRH analogs. The "neural" prostate includes: neuropeptides, cognate receptors and processing enzymes regulating signaling of peptide-mediated neural inputs.

A possible association of recurrent streptococcal infections and acute onset of obsessive-compulsive disorder

Rheumatic fever is an immunologically mediated disease that follows infection by group A beta-hemolytic Streptococcus (GABHS). In rheumatic fever, antibodies generated against GABHS cross-react with the heart, joints, skin, and other sites, inducing an inflammatory, multisystem disease. Brain tissue-specific antibodies have been demonstrated in a subset of children with Sydenham chorea (a component of the Jones criteria for the diagnosis of rheumatic fever), and most Sydenham chorea patients manifest obsessive-compulsive symptoms very similar to those in traditional obsessive-compulsive disorder. The parallels drawn from the paradigm of Sydenham's chorea to Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) is an area of active controversy. Newly emerging information on the role of GABHS superantigens in the pathogenesis of rheumatic fever is of particular interest. In this article, we review the microbial characteristics of GABHS and the subsequent immune responses to GABHS as a possible etiology of PANDAS.

Novel roles of neuropeptide processing enzymes: EC3.4.24.15 in the neurome

Neuropeptide processing metalloenzymes, such as angiotensin converting enzyme, neprilysin, endothelin converting enzyme, neurolysin, and EC3.4.24.15 (EP24.15), are central to the formation and degradation of bioactive peptides. We present EP24.15 as a paradigm for novel functions ascribed to these enzymes in the neurome. Although the neurome typically encompasses proteomes of the brain and central nervous system, exciting new roles of these neuropeptidases have been demonstrated in other organ systems. We discuss the involvement of EP24.15 with clinical sequelae involving the use of gonadotropin-releasing hormone (GnRH; LHRH) analogs that act as enzyme inhibitors, in vascular physiology (blood pressure regulation), and in the hematologic system (immune surveillance). Hemodynamic forces, such as cyclic strain and shear stress, on vascular cells, induce an increase in EP24.15 transcription, suggesting that neuropeptidase-mediated hydrolysis of pressor/depressor peptides is likely regulated by changes in hemodynamic force and blood pressure. Lastly, EP24.15 regulates surface expression of major histocompatibility complex Class I proteins in vivo, suggesting that EP24.15 may play an important role in maintenance of immune privilege in sites of increased endogenous expression. In these extraneural systems, regulation of both neuropeptide and other peptide substrates by neuropeptidases indicates that the influence of these enzymes may be more global than was anticipated previously, and suggests that their attributed role as neuropeptidases underestimates their physiologic actions in the neural system.

Regulation of cell-surface major histocompatibility complex class I expression by the endopeptidase EC3.4.24.15 (thimet oligopeptidase)

Endopeptidase EP24.15 (EC 3.4.24.15; thimet oligopeptidase), traditionally classified as a neuropeptide-processing enzyme, degrades well-known MHC I (major histocompatibility complex class I) peptides in cell extracts. In the present study, we determine the contribution of EP24.15 in vivo to the surface expression of MHC I on intact cells. CTLs (cytotoxic T-lymphocytes) recognize a vast array of peptides presented in the context of MHC I cell-surface molecules. Stable retroviral overexpression of EP24.15 induces a dramatic, long-term inhibition of surface MHC I. In contrast, overexpression of a mutant EP24.15, which is expressed, but is enzymically inactive, does not affect the surface MHC I expression level. We observed no difference in the effect of EP24.15 on the expression of different classes of MHC I. IFN-gamma (interferon-gamma) treatment re-established MHC I expression on these EP24.15-overexpressing cells, and also induced EP24.15 cytosolic protein expression and enzyme activity. To our knowledge, this is the first demonstration of cytokine-induced EP24.15 expression and activity. Conversely, stable retroviral silencing of endogenous EP24.15 by RNA interference induced a striking, long-term increase in surface MHC I. Subcellular fractionation and enzyme-activity experiments localized the vast majority of EP24.15 protein expression and function to the cytosol. Therefore we introduce a novel function of the cytosolic form of EP24.15. EP24.15 activity in the extracellular space is significant for neuropeptide processing, and in the present paper, we demonstrate that EP24.15 activity in the cytosol may be significant for regulation of MHC I cell-surface expression.

WISP genes are members of the connective tissue growth factor family that are up-regulated in wnt-1-transformed cells and aberrantly expressed in human colon tumors

Wnt family members are critical to many developmental processes, and components of the Wnt signaling pathway have been linked to tumorigenesis in familial and sporadic colon carcinomas. Here we report the identification of two genes, WISP-1 and WISP-2, that are up-regulated in the mouse mammary epithelial cell line C57MG transformed by Wnt-1, but not by Wnt-4. Together with a third related gene, WISP-3, these proteins define a subfamily of the connective tissue growth factor family. Two distinct systems demonstrated WISP induction to be associated with the expression of Wnt-1. These included (i) C57MG cells infected with a Wnt-1 retroviral vector or expressing Wnt-1 under the control of a tetracyline repressible promoter, and (ii) Wnt-1 transgenic mice. The WISP-1 gene was localized to human chromosome 8q24.1-8q24.3. WISP-1 genomic DNA was amplified in colon cancer cell lines and in human colon tumors and its RNA overexpressed (2- to >30-fold) in 84% of the tumors examined compared with patient-matched normal mucosa. WISP-3 mapped to chromosome 6q22-6q23 and also was overexpressed (4- to >40-fold) in 63% of the colon tumors analyzed. In contrast, WISP-2 mapped to human chromosome 20q12-20q13 and its DNA was amplified, but RNA expression was reduced (2- to >30-fold) in 79% of the tumors. These results suggest that the WISP genes may be downstream of Wnt-1 signaling and that aberrant levels of WISP expression in colon cancer may play a role in colon tumorigenesis.

In vivo effects of cardiotrophin-1

Cardiotrophin-1 (CT-1) is a recently discovered cytokine that was isolated based on its ability to induce cardiac myocyte hypertrophy in vitro. In this study, the effects of chronic administration of CT-1 to mice (0.5 or 2 microg by intraperitoneal injection, twice a day for 14 days) were determined. A dose-dependent increase in both the heart weight and ventricular weight to body ratios was observed in the treated groups. The body weights of the animals were unaffected. These results indicate that CT-1 can induce cardiac hypertrophy in vivo. CT-1 was not specific for the heart, however. It stimulated the growth of the liver, kidney, and spleen, and caused atrophy of the thymus. CT-1 administration also increased the platelet counts by 70%, with no change in mean platelet volume. Red blood cell counts were increased in the treated animals, and there was a concomitant increase in haemoglobin concentration. Thus, CT-1 has a broad spectrum of biological activities in vivo. This observation is consistent with previous in-vitro findings showing that the mRNA for CT-1 is expressed in several tissues, and that CT-1 can function through binding to the leukaemia inhibitory factor (LIF) receptor and signalling through the gp130 pathway.

The tumour-suppressor gene patched encodes a candidate receptor for Sonic hedgehog

The protein Sonic hedgehog (Shh) controls patterning and growth during vertebrate development. Here we demonstrate that it binds Patched (vPtc), which has been identified as a tumour-suppressor protein in basal cell carcinoma, with high affinity. We show that Ptc can form a physical complex with a newly cloned vertebrate homologue of the Drosophila protein Smoothened (vSmo), and that vSmo is coexpressed with vPtc in many tissues but does not bind Shh directly. These findings, combined with available genetic evidence from Drosophila, support the hypothesis that Ptc is a receptor for Shh, and that vSmo could be a signalling component that is linked to Ptc.

Cardiotrophin-1, a cytokine present in embryonic muscle, supports long-term survival of spinal motoneurons

The muscle-derived factors required for survival of embryonic motoneurons are not clearly identified. Cardiotrophin-1 (CT-1), a cytokine related to ciliary neurotrophic factor (CNTF), is expressed at high levels in embryonic limb bud and is secreted by differentiated myotubes. In vitro, CT-1 kept 43% of purified E14 rat motoneurons alive for 2 weeks (EC50 = 20 pM). In vivo, CT-1 protected neonatal sciatic motoneurons against the effects of axotomy. CT-1 action on motoneurons was inhibited by phosphatidylinositol-specific phospholipase C (PIPLC), suggesting that CT-1 may act through a GPI-linked component. Since no binding of CT-1 to CNTFR alpha was detected, CT-1 may use a novel cytokine receptor alpha subunit. CT-1 may be important in normal motoneuron development and as a potential tool for slowing motoneuron degeneration in human diseases.

Human cardiotrophin-1: protein and gene structure, biological and binding activities, and chromosomal localization

Cardiotrophin-1 (CT-1) is a new member of the interleukin-6 cytokine family that was identified from a mouse embryoid body cDNA library by expression cloning. Mouse CT-1 induces features of hypertrophy in neonatal rat cardiac myocytes and binds to and activates the leukaemia inhibitory factor/gp130 receptor complex. In this work we report the isolation and characterization of cDNA and genomic clones encoding human CT-1. These clones encode a 201 amino acid protein that is 80% identical to the mouse protein. Human CT-1 produced by transfection of the cDNA clones into mammalian cells induces the hypertrophy of neonatal rat cardiac myocytes. Human and mouse CT-1 bind to the leukaemia inhibitory factor receptor on both human and mouse cell lines indicating a lack of species specificity. No binding to the human oncostatin M specific receptor was detected. A 1.7 kb CT-1 mRNA is expressed in adult human heart, skeletal muscle, ovary, colon, prostate and testis and in fetal kidney and lung. The coding region of CT-1 is contained on three exons and is located on human chromosome 16p11.1-16p11.2.

Cardiotrophin-1. Biological activities and binding to the leukemia inhibitory factor receptor/gp130 signaling complex

Cardiotrophin-1 (CT-1) is a newly isolated cytokine that was identified based on its ability to induce cardiac myocyte hypertrophy. It is a member of the family of cytokines that includes interleukins-6 and -11, leukemia inhibitory factor (LIF), ciliary neurotrophic factor, and oncostatin M. These cytokines induce a pleiotropic set of growth and differentiation activities via receptors that use a common signaling subunit, gp130. In this work we determine the activity of CT-1 in six in vitro biological assays and examine the composition of its cell surface receptor. We find that CT-1 is inactive in stimulating the growth of the hybridoma cell line, B9 and inhibits the growth of the mouse myeloid leukemia cell line, M1. CT-1 induces a phenotypic switch in rat sympathetic neurons and promotes the survival of rat dopaminergic and chick ciliary neurons. CT-1 also inhibits the differentiation of mouse embryonic stem cells. CT-1 and LIF cross-compete for binding to M1 cells, Kd [CT-1] approximately 0.7 nM, and this binding is inhibited by an anti-gp130 monoclonal antibody. Both ligands can be specifically cross-linked to a protein on M1 cells with the mobility of the LIF receptor (approximately 200 kDa). In addition, CT-1 binds directly to a purified, soluble form of the LIF receptor in solution (Kd approximately 2 nM). These data show that CT-1 has a wide range of hematopoietic, neuronal, and developmental activities and that it can act via the LIF receptor and the gp130 signaling subunit.

Tumor reactive cis-aconitylated monoclonal antibodies coupled to daunorubicin through a peptide spacer are unable to kill tumor cells

Antibody-drug conjugates containing a linkage susceptible to lysosomal hydrolases were constructed by coupling peptide-daunorubicin (DNR) derivatives to MAb. Using a modification in the method of Trouet et al, peptide derivatives of DNR containing the sequences Ala-Leu and Ala-Leu-Ala-Leu linked to drug via their carboxy terminus were prepared. Cleavage of these derivatives by lysosomal enzymes resulting in the release of free DNR was demonstrated. Human antitumor MAb were derivatized with either succinic anhydride or cis-aconitic anhydride to introduce spacer arms for coupling. Binding studies showed that MAb with a decrease of 12-20 amino groups retained greater than 70% of their immunoreactivity, a level deemed acceptable for constructing conjugates. Derivatized and native MAb were conjugated to peptide-DNR via a carbodiimide mediated reaction. None of the conjugates displayed cytotoxicity toward target tumor cell lines in vitro.

Pharmaceutical continuing-education program based on a core curriculum

The use of a core curriculum concept in the establishment of a comprehensive continuing-education program is described. A departmental staff development committee was selected to develop a core curriculum of topics for professional continuing education. Six core curriculum areas of interest and importance were identified: cardiology; infectious disease; total parenteral nutrition, acid-base balance, and fluid and electrolytes; pharmacy management; critical-care medicine; and pharmacokinetics. Coordinators were selected from the staff to identify topics and speakers in each core curriculum area. The drug information center was assigned responsibility for logistical aspects of the program such as scheduling, evaluations, objectives, information support, and providing continuing-education credit. A survey of staff perceptions revealed a very positive view of the program. The staff rated the program highly as meeting their needs for continuing-education credit, as an employee benefit, and in covering topics related to their practice. The core curriculum concept has been shown to be a successful and effective approach to the establishment of a comprehensive continuing-education program.

Variability in Reproduction of Four Races of Meloidogyne incognita on Two Cultivars of Soybean

Variability in the reproduction of the four races ofMeloidogyne incognita on the soybean cuhivars Pickett 71 and Centennial was studied in growth chamber experiments. Analysis of variance in the number of eggs produced by the races 6 weeks after the plants had been inoculated with 5,000 eggs of each race revealed that the nematode race by soybean cultivar interaction was highly significant (P = 0.001). Races 1, 3, and 4 produced from about 5,000 to 15,000 eggs per root system on Pickett 71 and only from about 300 to 600 eggs per root system on Centennial. In contrast, race 2 produced about 8,000 eggs per root system on Centennial and about 1,200 eggs per root system on Pickett 71. In a second experiment, in which the plants were inoculated with 2,000 second-stage juveniles, race 1 and race 2 produced about 13,000 and 3,000 eggs per root system, respectively, on Pickett 71 and about 600 and 10,000 eggs per root system, respectively, on Centennial. The results suggest that M. incognita resistance in soybean is race-specific.

In situ preparation and fate of cis-4-hydroxycyclophosphamide and aldophosphamide: 1H and 31P NMR evidence for equilibration of cis- and trans-4-hydroxycyclophosphamide with aldophosphamide and its hydrate in aqueous solution

cis-4-Hydroxycyclophosphamide (2) and aldophosphamide (4) were generated in aqueous phosphate or cacodylate buffer by dimethyl sulfide reduction of cis-4-hydroperoxycyclophosphamide (8) and by sodium periodate cleavage of 3,4-dihydroxybutyl N,N-bis(2-chloroethyl)phosphorodiamidate (9), respectively; the reactions of 2 and 4 were examined by 1H and 31P NMR. Within 30-60 min (pH or pD 7.0, 25 degrees C) the same pseudoequilibrium mixture was established in both reactions, with cis- and trans-4-hydroxycyclophosphamide (2 and 3), aldophosphamide (4), and its hydrate (5) present in the approximate ratio of 4:2:0.3:1. Structures of the intermediates were assigned unambiguously based upon analysis of the chemical shifts and coupling constants in the proton spectra determined in D2O buffers, and the 31P assignments followed by correlation of component ratios at equilibrium. Free energy differences of 0.4, 0.4, and 0.7 kcal/mol at 25 degrees C were estimated between 2, 3, 5, and 4, respectively, with 2 being the most stable. The aldehyde 4 reacted most rapidly with water to give hydrate 5; cyclization of 4 to 3 occurred faster than to 2, and the rate of cyclization to 2 was comparable to that for elimination to 6. Compound 5 is formed much faster than 3 from the diol cleavage, but 5 and 3 are produced at comparable rates from 2, suggesting that conversion of 2 to 3 can proceed by a mechanism other than ring opening. The rate of equilibration appears to be independent of buffer structure, indicating that bifunctional catalysis is not important in the ring-opening reaction.(ABSTRACT TRUNCATED AT 250 WORDS)