Design of a randomized, placebo-controlled study evaluating efficacy and safety of a cancer preventative vaccine in dogs

Preventative anti-cancer vaccination strategies have long been hampered by the challenge of targeting the diverse array of potential tumor antigens, with successes to date limited to cancers with viral etiologies. Identification and vaccination against frameshift neoantigens conserved across multiple species and tumor histologies is a potential cancer preventative strategy currently being investigated. Companion dogs spontaneously develop cancers at a similar incidence to those in people and are a complementary comparative patient population for the development of novel anti-cancer therapeutics. In addition to an intact immune system with tumors that arise in an autochthonous tumor microenvironment, dogs also have a shorter lifespan and temporally compressed tumor natural history as compared to humans, which allows for more rapid evaluation of safety, immunogenicity, and efficacy of cancer vaccination strategies. Here we describe the study protocol for the Vaccination Against Canine Cancer Study (VACCS), the largest interventional cancer clinical trial conducted in companion dogs to date. In addition to safety and immunogenicity, the primary endpoint of VACCS is the cumulative incidence (CI) of dogs developing malignant neoplasia of any type at the end of the study period. Secondary endpoints include changes in incidence of specific tumor types, survival times following neoplasia diagnosis, and all-cause mortality.

Efficient generation of lower induced motor neurons by coupling Ngn2 expression with developmental cues

Human pluripotent stem cells (hPSCs) are a powerful tool for disease modeling of hard-to-access tissues (such as the brain). Current protocols either direct neuronal differentiation with small molecules or use transcription-factor-mediated programming. In this study, we couple overexpression of transcription factor Neurogenin2 (Ngn2) with small molecule patterning to differentiate hPSCs into lower induced motor neurons (liMoNes/liMNs). This approach induces canonical MN markers including MN-specific Hb9/MNX1 in more than 95% of cells. liMNs resemble bona fide hPSC-derived MN, exhibit spontaneous electrical activity, express synaptic markers, and can contact muscle cells in vitro. Pooled, multiplexed single-cell RNA sequencing on 50 hPSC lines reveals reproducible populations of distinct subtypes of cervical and brachial MNs that resemble their in vivo, embryonic counterparts. Combining small molecule patterning with Ngn2 overexpression facilitates high-yield, reproducible production of disease-relevant MN subtypes, which is fundamental in propelling our knowledge of MN biology and its disruption in disease.

Abstract 3269: Dual targeting of FLT3 and LSD1 disrupts the MYC super-enhancer complex in acute myeloid leukemia

Clinical responses to kinase inhibitor therapy in acute myeloid leukemia (AML) are limited by development of resistance. A major contributor of resistance is epigenetic adaptation to kinase inhibitor therapy. We present evidence that inhibition of the epigenetic regulator lysine-specific demethylase 1 (LSD1) augments the response to inhibitors of FMS-like tyrosine kinase 3 (FLT3) in FLT3-mutant AML. We demonstrate that combined FLT3 and LSD1 inhibition results in synergistic cell death of FLT3-mutant AML cell lines and primary patient samples. High-resolution epigenetic sequencing revealed that the combination therapy synergistically suppresses pro-proliferative MYC-bound promoters and activates pro-differentiative PU.1-bound enhancers. Regulon enrichment analysis in primary AML samples nominated STAT5 (a downstream target of activated FLT3 signaling) as a putative regulator of MYC gene expression. STAT5 is highly bound to the MYC blood super-enhancer and FLT3 inhibition results in a loss of both STAT5 binding and MYC blood super-enhancer chromatin accessibility. In contrast, LSD1 inhibition suppresses MYC target genes by accumulation of repressive H3K9me1 marks. We validated these findings in 72 primary AML samples, including 19 FLT3-ITD positive AML samples. The combination improved responses in the vast majority of patient samples, and high MYC regulon activity was a predictor of response. Gene expression profiling in treated primary AML samples confirmed that dual FLT3 and LSD1 inhibition activates PU.1 target genes and suppresses MYC target genes. Finally, single cell ATAC-seq on primary AML blasts treated ex vivo with combined FLT3 and LSD1 shifted cells from a MYC super-enhancer high to MYC super-enhancer low state. Collectively, these data provide preclinical rationale for the investigation of dual FLT3 and LSD1 inhibition in clinical trial.

Citation Format: William M. Yashar, Brittany M. Smith, Jake VanCampen, Garth L. Kong, Jommel Macaraeg, Daniel J. Coleman, Brian J. Druker, Julia E. Maxson, Theodore P. Braun. Dual targeting of FLT3 and LSD1 disrupts the MYC super-enhancer complex in acute myeloid leukemia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3269.

Navigating Challenges in Monitoring Chronic Myeloid Leukemia with Multiple BCR-ABL1 Transcripts

Quantitative PCR-based strategies are typically effective for monitoring BCR-ABL1 transcript levels in chronic myeloid leukemia (CML). Additionally, some patients treated with tyrosine kinase inhibitors can experience long-term treatment-free remission after discontinuation of the inhibitor. However, this outcome hinges on effectively monitoring the patient's response to therapy. We present a patient with CML and multiple BCR-ABL1 transcripts, including a rare isoform that lacks qPCR standardization. We describe unexpected discrepancies in transcript quantification, further having an impact on clinical decision-making regarding duration of treatment. To better inform clinical practice, we suggest monitoring patients at the same testing facility to better track transcript trend.

Abstract 1133: Combined inhibition of cKIT and Lysine-Specific Demethylase 1 as a therapeutic strategy in acute myeloid leukemia

Responses to kinase inhibitors in AML are short-lived with the inevitable development of resistance. Combination therapy with agents from distinct functional classes is one strategy to overcome this resistance. Using AML cell lines and primary patient samples harboring oncogenic cKIT mutations we demonstrate that inhibition of the epigenetic regulator Lysine-Specific Demethylase 1 (LSD1) markedly augments the cytotoxic effect of the KIT inhibitor avapritinib. Transcriptomic and epigenetic profiling revealed synergistic suppression of Myc activity accompanied by a global loss of acetylation and decreased expression of key leukemia cell cycle genes. This epigenetic reorganization results from disruption of key transcription factor networks responsible for maintaining leukemia cell self-renewal and survival. These findings demonstrate that combined KIT and LSD1 inhibition is an exciting new therapeutic avenue for KIT mutant AML.

Previously, we have shown targeting the leukemic epigenome as a possible mechanism to augment the efficacy of kinase inhibitors. Thus, we hypothesize that targeting both the cKIT and CBF mutations with combination therapy will result in a deeper molecular response. Kasumi-1 cells harbor mutant cKIT, making an ideal model to study this combination. We observed a synergistic response to a clinically available KIT inhibitor, avapritinib, and two different LSD1 inhibitors, ORY-1001 and GSK-LSD1. Colony formation of healthy CD34+ cells and cell growth of cKIT WT cells were not significantly altered by the combination, thus showing the specificity of this combination by targeting mutant KIT. Bulk RNA-seq and master regulator analysis revealed greater suppression of Myc target genes with dual inhibition of KIT and LSD1. Using Cleavage Under Targets and Tagmentation (CUT&Tag), we observed synergistic loss of H3K27Ac at the promoters of genes necessary for cell proliferation. Additionally, we used Cleavage Under Targets and Release Using Nuclease (CUT&RUN) to interrogate Myc localization, and found a greater loss of Myc binding with dual inhibition, overlapping with the loss of acetylation at these loci. This study demonstrates the synergistic efficacy of combination therapy and identifies key biomarkers for drug activity, namely loss of histone acetylation and Myc binding. Collectively, combined KIT and LSD1 inhibition may be an effective therapeutic approach for cKIT mutant AML.

Citation Format: Brittany M. Smith, Daniel J. Coleman, Lauren Maloney, Cody Coblentz, Zachary Schonrock, Joseph Estabrook, Theresa Lusardi, Brian J. Druker, Julia E. Maxson, Theodore P. Braun. Combined inhibition of cKIT and Lysine-Specific Demethylase 1 as a therapeutic strategy in acute myeloid leukemia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1133.

Prevalence and predictors of airflow obstruction in an HIV tertiary care clinic in Montreal, Canada: a cross-sectional study

Objectives

The reported prevalence of chronic obstructive pulmonary disease (COPD) in people living with HIV (PLWHIV) varies widely. Our objective was to estimate the prevalence of airflow obstruction and COPD in unselected PLWHIV and identify characteristics that increase the risk of nonreversible airflow obstruction in order to guide case finding strategies for COPD.

Methods

All adults attending the Chronic Viral Illness Service were invited to participate in the study, regardless of smoking status or history of known COPD/asthma. Individuals underwent spirometric testing both before and after use of a salbutamol bronchodilator. Airflow obstruction was defined as forced expiratory volume in 1 s (FEV₁)/forced vital capacity (FVC) < 0.7 post‐bronchodilation, whereas COPD was defined as FEV₁/FVC < 0.7 post‐bronchodilation and Medical Research Council (MRC) score > 2. Multivariate logistic regression was used to evaluate risk factors associated with airflow obstruction, reported as adjusted odds ratios (aORs).

Results

Five hundred and three participants successfully completed spirometry testing. The median (Q1; Q3) age was 52 (44; 58) years. The median (Q1; Q3) CD4 count was 598 (438; 784) cells/μL and the median (Q1; Q3) nadir CD4 count was 224 (121; 351) cells/μL. There were 119 (24%) current smokers and 145 (29%) former smokers. Among those screened, 54 (11%) had airflow obstruction whereas three (1%) of the participants had COPD. Factors that were associated with airflow obstruction included a history of smoking [aOR 2.2; 95% confidence interval (CI) 1.1; 4.7], older age (aOR 1.6; 95% CI 1.2; 2.2), and lower CD4 count (aOR 0.8; 95% CI 0.7; 1.0).

Conclusions

Airflow obstruction was relatively uncommon. Our findings suggest that PLWHIV who are ≥50 years old, smokers and those with nadir CD4 counts ≤ 200 cells/μL could be targeted to undergo spirometry to diagnose chronic airflow obstruction.

Implementing a declination form programme to improve influenza vaccine uptake by staff in Department of Veterans Affairs spinal cord injury centres: a pilot study

BACKGROUND

Individuals with spinal cord injuries and disorders are at high risk for respiratory and influenza-related complications after developing influenza. These individuals often have frequent contact with the healthcare system. Vaccination rates in healthcare workers at Department of Veterans Affairs (VA) spinal cord injury (SCI) centres have been approximately 50% for several years. Efforts are needed to increase vaccination uptake among SCI HCWs. Declination form programmes (DFPs) in combination with other strategies have resulted in significant increases in influenza vaccination uptake in HCWs.

AIM

Use of external and internal facilitation including local teams and consensus processes to pilot a DFP in two VA SCI centres and evaluate factors influencing implementation.

METHODS

Implementation meetings and a consensus-building process with leadership and implementation team members were conducted, along with semi-structured post-implementation interviews with members of each implementation team (N = 7).

FINDINGS

The DFP was well accepted and easy to use. Leadership was a key facilitator for DFP implementation. Barriers included difficulty communicating with HCWs working during early/late shifts. Participation was 100% at Site 1 and 48% at Site 2.

CONCLUSION

Use of local teams and consensus to identify strategies to implement a DFP is feasible and effective for achieving moderate-to-high levels of participation in the programme.

Effect of HPMC on the quality of wheat-free bread made from carob germ flour-starch mixtures

Carob germ proteins have been shown to have functional properties similar to wheat gluten enabling formulation and production of yeast leavened gluten-free baked goods from a true dough rather than a stiff batter. The purpose of this research was to optimize the production of wheat-free bread containing carob germ flour, corn starch, NaCl, sucrose, hydroxypropyl methylcellulose (HPMC), and H₂O. A key criterion was to formulate viscoelastic dough similar to wheat dough. To that end, response surface methodology (RSM) was used to determine optimal levels of carob germ flour, H₂O, and HPMC. Components varied as follows: 4.94%-15.05% for carob germ flour, 0.05%-3.75% HPMC, and 65.25%-83.75% H₂O (percents are on a flour basis, where carob germ flour in combination with maize starch equals 100%). Sucrose, NaCl, and yeast were held constant at 2%. Bread parameters evaluated were specific volume and crumb hardness, where the largest specific volume and the lowest value for crumb hardness were considered most desirable. The optimum formula as determined by RSM consisted of 7% carob germ flour, 93% maize starch, 2% HPMC, and 80% H₂O with predicted crumb hardness of ~200 g of force and a specific volume of ~3.5 cm³/g. When proof time was optimized, a specific volume of ~5.6 ml/g and crumb hardness value of ~156 g of force was observed. Carob germ flour may be used as an alternative to wheat flour in formulating viscoelastic dough and high quality gluten-free bread.

PRACTICAL APPLICATION

Celiac disease affects approximately 1% of the world's population. Sufferers of the disease must consume a gluten-free diet. Currently, gluten-free baked products are made from batters and lack the ability to be made from dough based systems which limits the overall processability and product variety. This research is aimed at the utilization of carob germ protein and its ability to form dough to produce an optimal gluten-free bread formulation. This will help to alleviate problems in processability and product variety associated with gluten-free baked goods.

Standardization of the immunocytochemical detection of cancer cells in BM and blood: I. establishment of objective criteria for the evaluation of immunostained cells

BACKGROUND

Detection of isolated tumor cells (TC) in BM from carcinoma patients can predict future relapse. Various molecular and immunocytochemical (ICC) methods have been used to detect these cells, which are present at extremely low frequencies of 10(-5) - 10(-6). The specificity and sensitivity of these techniques may vary widely. In 1996, a European ISHAGE Working Group was founded to standardize and optimize procedures used for the detection of minimal residual disease. We have attempted to develop objective criteria for the evaluation of immunocytochemically identifiable cancer cells.

METHODS

An interlaboratory ring experiment was performed, to compare the screening and detection of micrometastasis-positive events between different laboratories. The discrepant results induced us to establish a common consensus on morphological criteria applicable to the identification of immunostained micrometastatic TC.

RESULTS

Bared on this consensus evaluation, we propose a classification of stained elements into three groups: (1) 'TC's show pathognomonic signs of epithelial TC-nature, as defined by a clearly enlarged nucleus or clusters of > or = 2 immunopositive cells. (2) 'Probable TC's represent morphological overlap between hematopoietic cells (HC) and TC which lack pathognomonic signs of TC-nature, but do not exhibit clear morphological features of HC. These cells are considered as TC if control staining with an isotype-specific, unrelated Ab is negative. (3) 'TC-negative' cells are defined as 'false positive' HC, skin squamous epithelial cells and artefacts.

DISCUSSION

The proposed classification of immunostained events is a first step towards the development of standardized immunocytochemical assays for the detection of occult micrometastatic TC in BM or blood.

Interspecialty fellowships in oncoplastic surgery and breast reconstruction – the innovative training scheme in the United Kingdom

Abstract #4141

Improved survival rates for breast cancer have evolved with specialist multidisciplinary care and adjuvant treatment regimes. Surgical options for breast cancer are increasingly complex comprising adequate oncological resection with improved aesthetic outcome, quality of life and psychosexual function for cancer survivors. Such surgery requires oncoplastic skills and innovative techniques and is an integral part of delivering a modern surgical breast service.&#x2028; In 2002, an innovative interspecialty training program was established for senior trainees in breast and plastic surgery, initiated by senior breast specialist surgeons and funded by the Department of Health. Nine breast centres in the UK were selected for their high volume high quality specialist care in breast disease with dual training in breast and plastic surgery. Competitive application to the training program selected the highest quality trainees for a year of interspecialty Fellowship training. The demand for these posts has required a highly competitive curriculum vitae and a higher academic degree.&#x2028; Since 2004, detailed prospective data has been collected on the qualitative and quantitative experience of the Fellowship scheme. This has been questionnaire based using logbook data for quantitative technical experience and comparative qualitative data for Fellowship satisfaction and outcome in specialty training.&#x2028; 53 fellows have to 2008 completed interspecialty training. 43 have been in their penultimate or last year in higher surgical training, the majority (42) are breast trainees in general surgery, 11 are trainees in plastic and reconstructive surgery. The Fellowship maximises exposure to operative planning and surgical techniques. 62% of oncology surgery (including breast reconing procedures), 49% of (immediate and delayed) reconstructive procedures, and 49% of breast symmetrization and aesthetic surgery is performed by the trainee under direct supervision. Overall expectations and quality of the Fellowships scored 'high' to 'excellent' and this was reflected in the confidence of fellows to take up NHS Consultant posts and continue to use the skills acquired within a multidisciplinary specialised breast team.&#x2028; The interspecialty training program has been successful for both breast and plastics trainees. It has given senior surgical trainees the opportunity to focus and direct their own training requirements into an intense clinical year of surgical oncology and breast reconstruction. Key components to the success of this year include working in high volume, specialist breast and plastic reconstructive units with direct supervision from dedicated trainers, supernumerary training status and an elective surgical practice. It succeeds as a pioneering program designed to increase the number of trained surgeons offering seamless oncoplastic surgery for the benefit of the patients.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4141.

Subintimal angioplasty for superficial femoral artery occlusion: poor patency in critical ischaemia

INTRODUCTION

Subintimal angioplasty has been proposed for the treatment of long segment occlusive disease and for patients with critical limb ischaemia (CLI) with significant co-morbidity. There is no consensus as to short- and long-term patency. We present our experience with this technique.

METHODS

Between 1995 and 2000, 43 consecutive patients (48 limbs) underwent subintimal angioplasty for superficial femoral artery occlusions. Outcome measures were haemodynamic and/or symptomatic patency.

RESULTS

Technical success was achieved in 14/17 limbs with CLI (82%) and 30/31 (97%) with intermittent claudication (IC). There were 7 complications (15%), 6 occurring in the claudicant group. The median occlusion length was 10 cm for CLI and 6 cm for IC. Patency at 12 and 36 months, on an intention-to-treat basis, was 69% and 58% for claudicants and 25% and 25% for patients with CLI (P = 0.0005 and P = 0.0044, respectively). Following only technically successful procedures, 12-month patency was 72% (IC) and 31% (CLI) (P = 0.009). Patients with occlusions > or = 10 cm were more likely to re-occlude than those < 10 cm (12-month patency 60% versus 25%;P = 0.037).

CONCLUSIONS

In this series, short- and long-term patency in patients with CLI is poor. Subintimal angioplasty in the treatment of CLI should be reserved for those patients not fit for surgical bypass.

Interactions between selenium and sulphur nutrition in Arabidopsis thaliana

Selenium (Se) is an essential plant micronutrient, but is toxic at high tissue concentrations. It is chemically similar to sulphur (S), an essential plant macronutrient. The interactions between Se and S nutrition were investigated in the model plant Arabidopsis thaliana (L.) Heynh. Arabidopsis plants were grown on agar containing a complete mineral complement and various concentrations of selenate and sulphate. The Se/S concentration ratio in the shoot ([Se](shoot)/[S](shoot)) showed a complex dependence on the ratio of selenate to sulphate concentration in the agar ([Se](agar)/[S](agar)). Increasing [S](agar) increased shoot fresh weight (FW) and [S](shoot), but decreased [Se](shoot). Increasing [Se](agar) increased both [Se](shoot) and [S](shoot), but reduced shoot FW. The reduction in shoot FW in the presence of Se was linearly related to the shoot Se/S concentration ratio. These data suggest (i) that Se and S enter Arabidopsis through multiple transport pathways with contrasting sulphate/selenate selectivities, whose activities vary between plants of contrasting nutritional status, (ii) that rhizosphere sulphate inhibits selenate uptake, (iii) that rhizosphere selenate promotes sulphate uptake, possibly by preventing the reduction in the abundance and/or activity of sulphate transporters by sulphate and/or its metabolites, and (iv) that Se toxicity occurs because Se and S compete for a biochemical process, such as assimilation into amino acids of essential proteins.

Primary reversed gastric tube reconstruction in long gap esophageal atresia

BACKGROUND/PURPOSE

Esophageal reconstruction in long-gap esophageal atresia (EA) poses a technical challenge with several surgical options. The purpose of this study was to review the authors' experience with the reversed gastric tube (RGT) in esophageal reconstruction.

METHODS

This series describes 7 babies with pure EA treated at 2 centers between 1989 and 2001. Data, gathered by retrospective chart review, included clinical details of the esophageal and associated malformations, technique and timing of repair, early and late complications, and long-term follow-up. Institutional review board (IRB) approval of this study has been obtained.

RESULTS

Seven babies were included. Associated malformations were present in 4: trisomy 21 in 2 and imperforate anus in 2. After gastrostomy tube placement, patients were treated with gastrostomy tube feedings and continuous upper pouch suction. Median gap length was 5.5 vertebral segments (range, 3 to 9). RGT with a posterior mediastinal esophagogastric anastomosis was performed at median age of 62 days (range, 38 to 131). There were no anastomotic leaks. Three patients had strictures, one required resection. Exclusive oral nourishment was achieved in 5 patients by 6 months of age. At last follow-up (mean, 4.5 years), 6 patients were receiving oral nutrition exclusively, and all were maintaining growth curves.

CONCLUSIONS

In long gap EA, early esophageal reconstruction using an RGT can be performed with minimal morbidity and promising short-term results.

Oral folate reduces plasma homocyst(e)ine levels in hemodialysis patients with cardiovascular disease

INTRODUCTION

Hyperhomocyst(e)inemia (plasma homocyst(e)ine concentration >16.0 micromol/l) is an independent risk factor for atherosclerosis, and is ubiquitous in patients with end-stage renal disease (ESRD). Oral folate supplementation in the non-ESRD population has been demonstrated to reduce plasma homocyst(e)ine (Hcy) concentration, and may reduce atherosclerotic morbidity. This study was undertaken to evaluate the efficacy of folate supplementation in reducing Hcy in patients with ESRD and cardiovascular disease.

METHODS

Twenty-eight chronic hemodialysis patients with demonstrated hyperhomocyst(e)inemia (mean Hcy 35.2+/-13.3 micromol/l) were enrolled in the study. The presence of atherosclerosis was documented by history, physical examination, or ultrasonographic criteria. Hcy was determined initially and following six weeks' supplementation with 5.0mg folate and multvitamins.

RESULTS

Hcy fell a mean of 15.0+/-10.4 micromol/l (38.9+/-19.9%) following supplementation (p<0.0005, paired t-test). In patients whose Hcy 'normalized' (n=10) Hcy fell a mean of 51+/-14% compared to a reduction of 32+/-20% in 18 patients whose Hcy remained >16.0 micromol/l (p=0.02). A significant positive correlation was observed between initial Hcy and both absolute and percent reduction after folate supplementation (r=0.87, p<0.005 and 0.53, p<0.005, respectively). Seven patients with documented atherosclerosis were older (68+/-8 yr vs 51+/-5 yr, p=0.007) an tended to have lower initial and final Hcy than the 21 patients without atherosclerosis (26.8+/-9.9 vs. 38.0+/-13.3 micromol/l, p=0.051 and 16.5+/-5.0 vs. 21.3+/-6.7, p=0.06, respectively). The presence of atherosclerosis was not associated with significant alteration in the response to folate.

CONCLUSIONS

Supplementation with high-dose folate significantly reduces plasma Hcy in patients with and without atherosclerosis, and the presence of atherosclerosis does not impact on patients' response to folate and multivitamin supplementation. Hcy remained >16.0 micromol/l in the majority of patients, however, despite large absolute reductions in Hcy. Doses of folate greater than 5mg, or additional therapy may be required to further reduce Hcy in the majority of ESRD patients.

Salvage laparotomy for failure of peritoneal drainage in necrotizing enterocolitis in infants with extremely low birth weight

BACKGROUND/PURPOSE

Peritoneal drainage is a temporizing procedure for infants with extremely low birth weight (ELBW) who have perforated necrotizing enterocolitis (NEC). "Salvage" laparotomy is advocated when patients worsen after drainage. Some patients have survived with intact gastrointestinal functional after drainage alone. The purpose of this study is to determine if these salvage laparotomies are beneficial.

METHODS

The authors reviewed the records of ELBW infants treated at Stanford University with perforated NEC from 1993 through 1998. Data collected included demographic makeup, type of operation, survival rate, postoperative complications, length of stay (LOS), and cost.

RESULTS

The authors treated 26 patients, 9 with laparotomy and 17 with peritoneal drainage. The peritoneal drainage group had lower birth weight and more comorbid conditions. Survival rate was similar between laparotomy and drainage: 55.6% versus 41.2%. Four patients in the drainage group underwent salvage laparotomy for perceived clinical deterioration. All of these patients died. The clinical status of patients who had salvage laparotomy and died was similar to those who did not and lived. Seven of 13 patients treated with drainage followed only by supportive care and antibiotics survived. Cost and LOS for patients undergoing salvage laparotomy were much greater than for nonsurviving patients undergoing only peritoneal drainage: 84 +/- 20 days and $660,000 compared with 34 +/- 11 days and $306,000.

CONCLUSIONS

Both primary peritoneal drainage and laparotomy should be considered primary therapy for perforated NEC. Patients undergoing peritoneal drainage typically experience clinical deterioration after operation. In this limited experience, salvage laparotomy did not appear beneficial.

Response of circulating tumor cells to systemic therapy in patients with metastatic breast cancer: comparison of quantitative polymerase chain reaction and immunocytochemical techniques

PURPOSE

We previously developed a quantitative system for the detection of cytokeratin 19 (CK-19) transcripts using reverse transcriptase polymerase chain reaction (PCR) to detect breast carcinoma cells in blood and bone marrow. The aim of this study was to determine the value of this system in monitoring patients with metastatic disease and to compare it with an established immunocytochemical method.

PATIENTS AND METHODS

Patients with progressive, locally advanced, and metastatic breast cancer (all stage IV) who were due to start systemic treatment were recruited. Blood samples were analyzed for CK-19 transcripts using quantitative PCR (QPCR) and immunocytochemistry (ICC) throughout their course of treatment.

RESULTS

One hundred forty-five blood samples were obtained from 22 patients over 13 months. Seventy-two (49.6%) of these samples were positive by QPCR, and 56 (42%) of 133 were positive by ICC. Of the 133 specimens analyzed by both techniques, 95 (71.4%) had the same results for each, and of the 71 samples that were positive, 40 (56%) were positive by both methods. The relationship between the number of cells detected and the QPCR values was statistically significant (P <.0001). Of the 25 courses of assessable treatment, 17 (68%) of 25 treatment outcomes (either response or disease progression) were reflected by QPCR measurements, and 12 (57%) of 21 were reflected by ICC. During the course of the study, five patients showed a response, and of these, ICC was in agreement in four cases (80%) and QPCR in three cases (60%). Eighteen courses of treatment resulted in progression of the disease; however, only 15 of these were assessable by ICC. ICC was in agreement in eight (53%) of 15 of these cases, and QPCR in 15 (83%) of 18 cases.

CONCLUSION

Circulating carcinoma cells are frequently found in patients with metastatic breast cancer. In the majority of patients, cancer cell numbers as evaluated by QPCR or ICC reflected the outcome of systemic treatment.

Microsatellite alterations plasma DNA of primary breast cancer patients

The aim of this study was to analyze plasma DNA from primary and metastatic breast cancer cases for tumor-specific alterations and to compare these findings with immunocytochemistry and estimation of cytokeratin 19 (CK19) mRNA for detection of micrometastases. DNA was extracted from plasma, lymphocytes, and microdissected tumor tissue sections obtained from 71 patients with breast cancer and 9 controls. DNA samples were analyzed for loss of heterozygosity (LOH) and/or microsatellite instability (MI) by PCR with two polymorphic markers (DM-1 and D16S400). Reverse transcription-quantitative PCR (QPCR) and immunocytochemistry were used for detection of CK19 mRNA and protein. Breast cancer plasma DNA displayed frequent LOH (31.3%) and MI (11.6%) supported by the same alteration in microdissected tumor DNA. Most notably, 10 of the 39 patients with primary breast cancer showed LOH (n = 6) or MI (n = 4). We compared plasma tumor DNA, plasma and bone marrow QPCR, and blood and bone marrow immunocytochemistry in 32 of the patients with primary cancer. Of these, only one patient had immunocytochemically detectable carcinoma cells in the blood, and three showed abnormally high levels of plasma CK19 mRNA. All four of these patients had plasma DNA alterations. We then compared bone marrow findings: of the 10 primary breast cancers that showed LOH or MI, 6 had elevated CK19 mRNA and 5 had immunocytochemically positive cells. Tumor DNA is readily detectable in plasma of primary and metastatic breast cancer patients, and plasma DNA alterations (LOH and MI) reflect those seen in the tumor. The application of microsatellite analyses to plasma DNA may be useful in assessing tumor burden in breast cancer patients, particularly when combined with QPCR, and is preferable for patients with breast cancer, for whom sequential bone marrow aspiration is undesirable.

Cardiovascular and renal benefits of dry bean and soybean intake

Dry beans and soybeans are nutrient-dense, fiber-rich, and are high-quality sources of protein. Protective and therapeutic effects of both dry bean and soybean intake have been documented. Studies show that dry bean intake has the potential to decrease serum cholesterol concentrations, improve many aspects of the diabetic state, and provide metabolic benefits that aid in weight control. Soybeans are a unique source of the isoflavones genistein and diadzein, which have numerous biological functions. Soybeans and soyfoods potentially have multifaceted health-promoting effects, including cholesterol reduction, improved vascular health, preserved bone mineral density, and reduction of menopausal symptoms. Soy appears to have salutary effects on renal function, although these effects are not well understood. Whereas populations consuming high intakes of soy have lower prevalences of certain cancers, definitive experimental data are insufficient to clarify a protective role of soy. The availability of legume products and resources is increasing, incorporating dry beans and soyfoods into the diet can be practical and enjoyable. With the shift toward a more plant-based diet, dry beans and soy will be potent tools in the treatment and prevention of chronic disease.

Quantitative polymerase chain reaction for the detection of micrometastases in patients with breast cancer

PURPOSE

Previous reports have indicated that reverse transcriptase polymerase chain reaction (RT-PCR) for cytokeratin 19 (CK-19) may be useful in the management of patients with breast cancer. However, the specificity of this technique is low, principally because of a high rate of false-positive results. To improve the specificity of this assay, we developed a quantitative RT-PCR methodology that enables an estimate to be made of the number of CK-19 transcripts in blood and bone marrow samples.

PATIENTS AND METHODS

We examined 45 peripheral-blood samples and 30 bone marrow samples from patients with a variety of nonneoplastic conditions using nested RT-PCR for CK-19. We also examined bone marrow and peripheral-blood samples from 23 patients with primary breast cancer and peripheral-blood samples from 37 patients with metastatic breast cancer. The number of CK-19 transcripts was estimated in positive specimens by competitive PCR and normalized to the number of ABL transcripts as an internal control for the quality and quantity of cDNA. RT-PCR results were compared with the numbers of CK-19-positive cells detected by immunocytochemistry.

RESULTS

Analysis of samples from patients without cancer enabled us to define an upper limit for the background ratio of CK-19 to ABL transcripts (1:1,000 for blood samples and 1:1,600 for bone marrow samples). Using these figures as cut-off points, elevated CK-19: ABL ratios were detected in peripheral-blood samples of 20 of 37 (54%) patients with metastatic breast cancer and in bone marrow samples of 14 of 23 (61%) patients with primary breast cancer. Only three of 23 (13%) primary breast cancer peripheral-blood samples and none of the control samples were positive by these criteria. Only two of 23 patients (9%) with primary breast cancer showed immunocytochemically detectable cells in the blood; 10 of 23 (43%) showed immunocytochemically detectable cells in the bone marrow. Of 36 patients with metastatic breast cancer, eight (22%) showed positive events.

CONCLUSION

Quantitative RT-PCR for CK-19 detects a percentage of patients with breast cancer and may enable the progression or regression of the disease to be monitored.

Effects of soy protein on renal function and proteinuria in patients with type 2 diabetes

For > 150 y, clinicians and investigators have observed that high protein intakes accelerate the progression of renal disease and that low protein intakes have beneficial effects. Some studies suggest that the effects of soy-protein intake resemble those of a low-protein diet. The Brenner hypothesis suggests that high protein intakes by diabetic individuals create hyperfiltration and glomerular hypertension eventuating in renal damage. On the basis of the available evidence, we are proposing the soy-protein hypothesis, which states that substituting soy protein for animal protein in diabetes patients results in less hyperfiltration and glomerular hypertension and, therefore, resultant protection from diabetic nephropathy. Furthermore, substituting soy protein for animal protein should have therapeutic value in diabetic nephropathy with resultant slowing of deterioration of renal function and decreasing proteinuria. The preliminary results of the study of 8 type 2 diabetes patients with obesity, hypertension, and proteinuria are reported. Under the conditions of the study, providing soy protein as half of the daily protein intake had no distinct effects on renal function or proteinuria in these subjects. Soy-protein intake was associated with a significant reduction in serum cholesterol and triacylglycerol concentrations. Further studies are required to critically examine the effects of soy-protein intake on the renal function of diabetes patients.