Sanctuary site leptomeningeal metastases in HER-2 positive breast cancer: A review in the era of trastuzumab

The development of trastuzumab and other targeted systemic therapies has transformed the management of HER-2 positive breast cancers. However, as patients live longer and systemic therapies may not cross the blood brain barrier a rising number of patients are developing leptomeningeal metastases and brain metastases as a sanctuary site of disease. Intrathecal trastuzumab has been reported to treat these. We describe a breast cancer patient with HER-2 positive leptomeningeal disease in the spinal cord successfully treated with intrathecal trastuzumab and methotrexate, alongside systemic anti-HER-2 therapy and radiotherapy. We also review the literature to date on the efficacy and safety of intrathecal trastuzumab, and recent evidence suggesting that intrathecal trastuzumab passes via the blood brain barrier into the serum to achieve intravenous concentrations similar to that seen with systemic therapy alone. Overall, intrathecal trastuzumab appears to be a safe and often effective treatment for leptomeningeal metastases in HER-2 positive breast cancer. Ongoing phase I and II studies are required to determine optimum dosing schedules, validate CSF and CSF-to-serum pharmacokinetics, determine efficacy, and to assess the added benefits or disadvantages of prior radiotherapy and concomitant systemic therapy.

Image Quality of 256-Slice Computed Tomography for Coronary Angiography

PURPOSE

To assess the image quality of 256-slice computed tomographic angiography (CTA) and to identify possible impact factors associated with image quality.

METHODS

From November 2009 to January 2010, 506 patients underwent 256-slice CTA at our institute. A total of 451 patients were enrolled in our study, after 55 patients were excluded because of prior bypass surgery and stenting. CTA image quality was graded by two observers using a 4-point scale: excellent (score 1), good (score 2), moderate (score 3), poor and non-diagnostic (score 4). The coronary arteries were divided into 15 segments. Image quality was correlated to the subjects' age, gender, body mass index, heart rate, and calcium scores.

RESULTS

We evaluated 6650 coronary segments from CTA images of our enrolled 451 patients. The mean image quality score of all coronary segments was 1.14. Most coronary segments (99.7%) were assessable, and only 21 segments (0.3%) were non-diagnostic. A total of 5824 coronary segments were classified as having excellent image quality. Forty-two patients (9.3%) required control of heart rate with beta-blockers before CTA could be performed. Male patients had better image quality than female patients. Heart rate and severity of calcification were impact factors associated with image quality.

CONCLUSIONS

Examination with 256-slice CTA provides good image quality and can effectively evaluate most coronary segments.

KEY WORDS

Coronary angiography; Heart rate; Image quality; Multi-slice computed tomography.

Diagnostic Performance of 64- versus 256-Slice Computed Tomography Coronary Angiography Compared with Conventional Coronary Angiography in Patients with Suspected Coronary Artery Disease

PUPOSE

The newer 256-slice computed tomography coronary angiography (CTCA) has the capability of improving diagnostic performance in the detection of obstructive coronary artery disease (CAD) compared to 64-slice CTCA. The aim of this study was to compare the diagnostic performance of 64- versus 256-slice CTCA in two similar populations.

METHODS

Our study included 120 consecutive patients who were referred for CTCA and subsequently underwent conventional coronary angiography (CCA). Sixty patients were studied by 64-slice CTCA, with the other 60 by 256-slice CTCA. We compared the technical characteristics and diagnostic performance of 64- and 256-slice CTCA for the detection of ≥ 50% stenosis of the coronary arteries on CCA.

RESULTS

The 256-slice CTCA had a shorter scanning time (4.4 ± 0.6 sec vs. 5.0 ± 0.7 sec, p < 0.001) compared to 64-slice CTCA. The diagnostic accuracy rates of 256-slice CTCA based on patient analysis (97% vs. 83%, p < 0.05), vessel analysis (95% vs. 85%, p < 0.05), and segment analysis (94% vs. 88%, p < 0.05) were significantly superior to those of 64-slice CTCA. The diagnostic accuracy rates of 64- and 256-slice CTCA were affected by the presence of stent (65% vs. 75%, respectively, p > 0.05) and severe calcifications (75% vs. 82%, respectively, p > 0.05).

CONCLUSIONS

In two similar populations, 256-slice CTCA displayed superior diagnostic performance than 64-slice CTCA. However, the performance of 256-slide CTCA is affected in those segments that are severely calcified and/or stented.

KEY WORDS

Computed tomography coronary angiography (CTCA); Conventional coronary angiography; Diagnostic performance; 64-slice helical CTCA; 256-slice helical CTCA.

The diagnostic accuracy of 256-row computed tomographic angiography compared with invasive coronary angiography in patients with suspected coronary artery disease

AIMS

To assess the diagnostic accuracy of 256-row computed tomographic angiography (CTA) in patients with suspected coronary artery disease (CAD). Non-invasive imaging of the coronary artery by CTA has increasingly been used in recent years. The accuracy of 256-row CTA has not yet been studied. We sought to assess the accuracy of 256-row CTA compared with invasive coronary angiography (ICA) in the diagnosis and assessment of CAD.

METHODS AND RESULTS

We prospectively evaluated 104 consecutive individuals who accepted CTA and then underwent ICA. The presence of stenosis > or =50% was considered obstructive. The diagnostic accuracy of CTA for detecting obstructive stenosis was compared with that of ICA. The area under the receiver-operating-characteristic curve (AUC) was used to evaluate the diagnostic accuracy of CTA relative to ICA. A total of 86 patients had obstructive CAD. The patient-based analysis of CTA for detecting stenosis > or =50% according to ICA revealed an AUC of 0.744 [95% confidence interval (CI), 0.572-0.916], with a sensitivity of 98.8%, a specificity of 50%, a positive predictive value (PPV) of 92.4%, and a negative predictive value (NPV) of 87.5%. The segment-based analysis revealed an AUC of 0.915 (95% CI, 0.847-0.982), with a sensitivity of 93.5%, a specificity of 95%, a PPV of 77.6%, and an NPV of 98.7%. The vessel-based analysis revealed an AUC of 0.887 (95% CI, 0.808-0.966), with a sensitivity of 94.3%, a specificity of 87.3%, a PPV of 82.7%, and an NPV of 95.9%.

CONCLUSION

256-Row CTA is a highly sensitive test of CAD and has a high predictive value. 256-Row CTA may be a potential alternative to detect coronary artery stenosis and rule out CAD in suspected patients.

Differential in vitro suppressive effects of steroids on leukocyte phagocytosis in two teleosts, tilapia and common carp

The objectives of this study were to investigate the potential roles of cortisol and gonadal steroids in the phagocytic activity of peripheral blood leukocytes in two teleosts, tilapia (Oreochromis niloticus x O. aureus) and common carp (Cyprinus carpio). An in vitro microtiter plate assay, measuring incorporation of FITC-latex beads into peripheral blood leukocytes, was developed for the first time in teleosts. Peripheral blood leukocytes were cultured in AL medium with tested compounds in a microfluor black plate at 25 degrees C. FITC-latex beads were further incubated for phagocytosis and engulfed fluorescent intensity in phagocytes was detected fluorometrically. Cortisol suppressed leukocyte phagocytosis in a dose (10(-14) to 10(-4) M)- and time (0.5 to 8 h)-dependent manner in tilapia. The glucocorticoid agonist dexamethasone had a suppressive effect similar to that of cortisol, while cortisone and the mineralocorticoid aldosterone had only a weak effect in tilapia. High doses of estradiol and ethynylestradiol, but not of estrone, suppressed phagocytosis in tilapia. No suppressive effect on phagocytosis was observed with various concentrations of progesterone, testosterone, and 11-ketotestosterone. Triiodothyronine was also inactive on phagocytosis. A combination of estradiol and cortisol potentiatingly suppressed phagocytosis. Actinomycin D and cycloheximide blocked the suppressive effects of cortisol and estradiol. Cortisol had weaker suppressive effects on the phagocytosis of leukocytes in common carp than tilapia. Other steroids had no suppressive action on phagocytosis in common carp. It is concluded that the suppressive effects of cortisol and estradiol on phagocytosis in tilapia are mediated by specific glucocorticoid receptors and estrogen receptors, respectively. Cortisol would play a main and important role on the down-regulation of phagocytic activity. Sexual steroids, such as estradiol, also could interact with cortisol to further suppress immunity in tilapia. Differential responsiveness of the immune system to suppressive effects of steroids, among teleosts species, has been demonstrated.

Congenital hypothyroidism in Wales (1982-1993): demographic features, clinical presentation and effects on early neurodevelopment

OBJECTIVE

Neonatal screening for congenital hypothyroidism (CH) was introduced in Wales in 1982. The aim of the study was to evaluate the demographic features and characteristics of infants identified during the first 12 years of screening and their neurodevelopmental progress in the first 2 years of life.

DESIGN

Prospective collection of biochemical and clinical data (including results of Griffiths Mental Development Scales) obtained from questionnaires sent to paediatricians responsible for the ongoing clinical care of children with CH.

PATIENTS

In Wales, between 1982 and 1993, 136 infants with primary congenital hypothyroidism (CH) were identified by the neonatal screening programme.

RESULTS

Of all new-borns, 99.8% were screened and the prevalence of CH was 1 in 3279 (1 in 2473 girls and 1 in 4770 boys). The prevalence of CH was increased in North Wales. CH was associated with increased birth weight (48.5% of infants weighed greater than 3.5 kg) and an increased prevalence of non-thyroidal congenital abnormalities (8%) and congenital heart disease (3%). Isotope scanning demonstrated an increased prevalence of normal or enlarged thyroid glands and fewer ectopic glands compared to those reported in other studies. The mean developmental quotients (DQs) for individual subsets of intellectual and behavioural functioning in children with CH aged 1 and 2 years were all above 100 (range: 103.5-111.9). In subjects with absent thyroids, these DQs were correlated with the serum concentrations of free thyroxine before treatment.

CONCLUSIONS

The demographic features of infants with congenital hypothyroidism born in Wales are similar to those reported from other European studies although there are marked regional variations in prevalence within Wales for which there is no apparent explanation. The median age of starting therapy was 17 days and compares favourably with other screening programmes. The overall mental development of Welsh children aged 1 and 2 years with congenital hypothyroidism identified by neonatal screening is satisfactory.

Secular changes in standing height, sitting height and sexual maturation of Chinese--the Hong Kong Growth Study, 1993

In 1993 a territory-wide cross-sectional growth survey on 25,000 Chinese children from birth to 18 years was performed in Hong Kong. Compared to the last growth survey in 1963, definite secular changes were observed. There was an increase of final adult standing height of 3.6 cm in boys and 2.7 cm in girls, in which 1.8 cm and 0.5 cm respectively for boys and girls was accounted for by the sitting height. Thus most of the height increase had occurred in the leg length in girls, but in boys only half of it. The height difference was more marked during the pubertal years because secular change had brought about an earlier sexual maturation, including an advancement of median menarcheal age by 0.5 year, coupled with an earlier growth spurt. This paper also provides the first growth standards for Chinese from birth to 18 years, with percentile charts on both standing height and sexual maturation in boys and girls.

Secular trend in the sexual maturation of southern Chinese boys

A random sample of 3872 southern Chinese boys ranging from 7 to 21 years of age were selected from primary and secondary schools in Hong Kong for the assessment of sexual maturation. The median ages of onset of puberty and pubic hair development were 11.4 and 12.7 years, respectively. The advancement of sexual maturation coincides with the secular increase in height and weight for Chinese children in Hong Kong.

Oral calcium treatment in vitamin D-dependent rickets type II

Vitamin D-dependent rickets type II is a rare hereditary disease that results from target organ resistance to the action of 1,25-dihydroxyvitamin D3. There is a great heterogeneity in the clinical presentation of this condition. The affected patients usually present early in childhood with clinical and biochemical evidence of rickets. Physiological replacement dosage of 1,25-dihydroxyvitamin D3 has no therapeutic effect. Responses to pharmacological doses of vitamin D metabolites or long-term calcium infusion have been variable. A case is reported here of an 8 year old girl, of consanguineous parents with vitamin D-dependent rickets, type II, in whom treatment with high dose oral calcium resulted in marked biochemical and radiological improvement. It is concluded that high dose oral calcium treatment is an effective treatment option for patients with vitamin D-dependent rickets type II.