High-dose chemotherapy with autologous hematopoietic progenitor cell support for metastatic and high-risk primary breast cancer

High-dose chemotherapy (HDCT) is being evaluated in the treatment of metastatic and high-risk primary breast cancer. The actuarial 2-year disease-free survival rate for patients with stage IV breast cancer is approximately 15% to 20%. A single metastatic site and achievement of a complete response to induction chemotherapy may be favorable prognostic indicators for disease-free survival after HDCT. Phase II studies in patients with primary breast cancer and > or = 10 and four to nine involved axillary nodes are encouraging. Prospective randomized trials are ongoing in these patient groups. Various strategies are being investigated to reduce the incidence of relapse after HDCT.

Intraoperative radio-lympho-scintigraphy improves sentinel lymph node identification for patients with melanoma

BACKGROUND

The sentinel lymph node (SLN), the first node draining the primary tumor site, has been shown to reflect the histologic features of the remainder of the lymphatic basin in patients with melanoma. Intraoperative localization of the SLN, first proposed by Morton and colleagues, has been accomplished with the use of a vital blue dye mapping technique. Technical difficulties resulting in unsuccessful explorations have occurred in up to 20% of the dissections.

OBJECTIVES

The authors aimed to define the SLN using gamma detection probe mapping and to determine whether intraoperative radiolymphoscintigraphy using technetium sulfur colloid and a hand-held gamma-detecting probe could be used to improve detection of all SLNs for patients with melanoma.

METHODS

To ensure that all initial nodes draining the primary site were removed at the time of selective lymphadenectomy, the authors used intraoperative radiolymphoscintigraphy to confirm the location of the SLN, which was determined initially with the preoperative lymphoscintigram and the intraoperative vital blue dye injection.

PATIENT POPULATION

The patient population consisted of 106 consecutive patients who presented with cutaneous melanomas larger than 0.75 mm in all primary site locations.

RESULTS

The preoperative lymphoscintigram revealed that 22 patients had more than one lymphatic basin sampled. Two hundred SLNs and 142 neighboring non-SLNs were harvested from 129 basins in 106 patients. After the skin incision was made, the mean ratio of hot spot to background activity was 8.5:1. The mean ratio of ex vivo SLN-to-non-SLN activity for 72 patients who had SLNs harvested was 135.6:1. When correlated with the vital blue dye mapping, 139 of 200 (69.5%) SLNs demonstrated blue dye staining, whereas 167 of 200 (83.5%) SLNs were hot according to radioisotope localization. With the use of both intraoperative mapping techniques, identification of the SLN was possible for 124 of the 129 (96%) basins sampled. Micrometastases were identified in SLNs of 16 of the 106 (15%) patients by routine histologic analysis.

CONCLUSION

The use of intraoperative radiolymphoscintigraphy can improve the identification of all SLNs during selective lymphadenectomy.

Translocation between chromosomes 6 and 15 (45,XX,t(6;15)(q25;q11.2)) with further evidence for lack of imprinting of the insulin-like growth factor II/mannose-6-phosphate receptor in humans

We report a 24 year old female with growth retardation, microcephaly, and congenital abnormalities who has an unbalanced de novo translocation between chromosomes 16 and 6: 45,XX,t(6;15)(q25;q11.2). FISH analysis confirmed that the deletion on chromosome 15 is proximal to the Prader-Willi locus. Several genes have been assigned to the 6q25-qter region including the insulin-like growth factor II/mannose-6-phosphate (IGF-II/M6P) receptor. DNA analysis from our patient documented the loss of one IGF2R gene copy. These data confirm the localisation of the IGF2R receptor to distal 6q25. We also showed reduced expression of the soluble and membrane bound IGF-II receptor, a gene dosage effect incompatible with imprinting. The IGF2R gene has been shown to be imprinted in the mouse but not in humans. Our data provide further evidence for lack of imprinting of this gene in humans.

A comparison of the psychosocial aspects of AIDS and cancer-related bereavement

OBJECTIVE

This study compares the psychological symptoms and bereavement distress of individuals bereaved by AIDS with a group bereaved by a cancer death, and addresses the question of whether an AIDS death is associated with a higher rate of adverse psychosocial factors that may increase risk of psychological morbidity in the bereaved individuals.

METHOD

AIDS (n = 28) and cancer (n = 30) bereaved individuals (all within 3 months of the bereavement) completed measures of psychological morbidity and measures addressing a range of other adverse factors, e.g., number of losses, levels of social support and stigma.

RESULTS

The cancer and AIDS bereaved were essentially similar on all psychological symptom measures. The AIDS group reported lower levels of social support in response to the bereavement than cancer bereaved individuals; a greater number of bereavements, were more likely to conceal the cause of death from significant others including their own family and perceived, in some instances, a greater level of rejection from others. The AIDS group reported higher levels of social support from friends than from family.

CONCLUSIONS

At three months following bereavement, AIDS and cancer bereaved were similar in levels of distress. While this may change with the progress of grief over time, it suggests essentially similar early bereavement responses. Those bereaved by AIDS reported a range of other adverse factors such as a greater number of losses, lower social support, stigma, and less open disclosure of the cause of death.

A gene (SRPX) encoding a sushi-repeat-containing protein is deleted in patients with X-linked retinitis pigmentosa

X-linked retinitis pigmentosa (XLRP) is characterized by retinal degeneration with night blindness and progressive reduction of the visual fields. By linkage and deletion analysis a gene locus (RP3) has been mapped to the short arm of the X chromosome between the genes CYBB and OTC. Analysis of transcript in this region has revealed a gene which is abundantly expressed in human retina and encodes a putative membrane protein with significant homologies to short consensus repeat (SCR/sushi) domains known from selections and complement proteins. The gene termed SRPX (sushi-repeat-containing protein, x chromosome) is deleted in an RP patient who also suffers from chronic granulomatous disease and McLeod syndrome. A 75 kb deletion removing exon 1 of the gene was also found in two brothers of a second XLRP family. However, no further functionally significant mutations were detected by SSCP screening of all 10 exons in 34 unrelated XLRP patients nor by full length RT-PCR sequencing in two RP3 families. The role of this highly conserved retinal gene in the pathogenesis of RP therefore remains to be determined.

Stem cell isolation

High-dose chemotherapy with autologous hematopoietic progenitor cell support is increasingly used to treat a variety of malignant diseases. A drawback of this technique is the potential for infusing clonogenic tumor cells with the autograft, producing relapse of the disease in the patient. The use of positive selection techniques to isolate stem cells and thus reduce or eliminate tumor cell contamination has been extensively studied over the past few years. Preliminary clinical results have demonstrated that these procedures deplete 2 to 7 logs of tumor cells and do not impair engraftment. It is too early to assess the ultimate clinical benefit of this strategy. Additional applications of CD34-selection include ex vivo expansion of and gene transfer into hematopoietic progenitor cells and T-cell depletion of allogeneic grafts to reduce the incidence of graft-versus-host disease.

Effects of granulocyte-macrophage colony stimulating factor produced in Chinese hamster ovary cells (regramostim), Escherichia coli (molgramostim) and yeast (sargramostim) on priming peripheral blood progenitor cells for use with autologous bone marrow after high-dose chemotherapy

Peripheral blood progenitor cells (PBPCs) were collected without prior association with chemotherapy but after the administration of granulocyte-macrophage colony-stimulating factor (GM-CSF) produced in Chinese hamster ovary cells (CHO-GM, regramostim), Escherichia coli (E. coli-GM, molgramostim), or yeast (Yeast-GM, sargramostim) and used in conjunction with autologous bone marrow after high-dose chemotherapy in 69 patients with breast cancer or melanoma. The mean peripheral white blood cell (WBC) counts increased by 2.2 to 2.7-fold after regramostim, 4.5 to 7.3-fold after molgramostim and 4.3-fold after sargramostim. All patients underwent three leukaphereses. The mean (+/- standard error) total nucleated pheresed cells per kg x 10(8) were 4.15 +/- 0.56, 15.10 +/- 1.77 and 7.24 +/- 1.00 for patients receiving regramostim, molgramostim or sargramostim respectively. The mean (+/- standard error) granulocyte-macrophage colony-forming units per kg x 10(4) mobilized into the PB were 8.75 +/- 3.63, 71.03 +/- 17.85, and 65.11 +/- 18.74 for patients receiving regramostim, molgramostim, or sargramostim respectively. The total mean (+/- standard error) CD34+ cells per kg x 10(7) collected by three leukaphereses were 3.28 +/- 1.62, 1.34 +/- 0.51 and 2.57 +/- 1.93, for patients receiving regramostim, molgramostim or sargramostim respectively. The use of either molgramostim- or sargramostim-primed PBPCs led to complete elimination of absolute leukopenia with a WBC count under 100/mm3 in 64% and 77% of patients treated, respectively. Patients receiving molgramostim-primed PBPCs required fewer red blood cells transfusions than patients receiving regramostim-primed PBPCs (p = 0.0062). Our data indicate that PBPCs collected without prior association with chemotherapy but after either molgramostim or sargramostim with autologous bone marrow support and GM-CSF shorten the hematopoietic recovery after myeloablative chemotherapy in patients with breast cancer or melanoma.

Temperature measurements of shock-compressed liquid hydrogen: implications for the interior of Jupiter

Shock temperatures of hydrogen up to 5200 kelvin were measured optically at pressures up to 83 gigapascals (830 kilobars). At highest pressures, the measured temperatures are substantially lower than predicted. These lower temperatures are caused by a continuous dissociative phase transition above 20 gigapascals. Because hydrogen is in thermal equilibrium in shock-compression experiments, the theory derived from the shock data can be applied to Jupiter. The planet's molecular envelope is cooler and has much less temperature variation than previously believed. The continuous dissociative phase transition suggests that there is no sharp boundary between Jupiter's molecular mantle and its metallic core. A possible convectively quiescent boundary layer might induce an additional layer in the molecular region, as has been predicted.

The influence of smoking and diet on the hypoxanthine phosphoribosyltransferase (hprt) mutant frequency in circulating T lymphocytes from a normal human population

The influence of the dietary antioxidants vitamin C, alpha- and beta-carotene, lycopene, lutein/zeaxanthin, phytofluene, beta-cryptoxanthin, retinol and alpha- and gamma-tocopherol on the hypoxanthine phosphoribosyltransferase (hprt) mutant frequency in human peripheral T lymphocytes was investigated. Twenty-five male non-smokers and 27 male smokers in the age range 50-59 years were recruited. Smokers showed a significantly higher mutant frequency compared with non-smokers (X1.5, P < 0.01). In addition, there was a significant positive relationship between hprt mutant frequency and the number of cigarettes that individuals reported smoking daily (P < 0.01). Smokers showed significantly lower levels of plasma vitamin C and the carotenoid alpha-carotene than non-smokers (P < 0.01 and P < 0.05 respectively). Both hprt mutant frequency and lymphocyte plating efficiency were weakly inversely associated with plasma vitamin C levels (P < 0.07 and P < 0.06 respectively) suggesting that vitamin C may be protective against mutation at the hprt locus. This relationship was markedly stronger in smokers (P < 0.01).

Evaluation of GM-CSF mouthwash for prevention of chemotherapy-induced mucositis: a randomized, double-blind, dose-ranging study

Uncontrolled clinical trials have shown that parenteral administration of GM-CSF reduces the frequency of chemotherapy-induced mucositis. The mechanism of this effect could be related to acceleration of haematopoiesis and/or increase in functional activation of WBC. We conducted a double-blind, placebo-controlled, dose ranging study of GM-CSF (mol-gramostim) mouthwash in patients with breast cancer during the first treatment cycle of a combination chemotherapy regimen which has historically produced dose-limiting (grade > or = 3) mucositis in approximately 39% of patients. Subjects were randomized to receive either placebo mouthwash (0.1 percent albumin) or one of four concentrations of GM-CSF mouthwash (0.01, 0.1, 1.0 or 10 mcg/ml). The primary endpoint was to evaluate the relationship between dose of GM-CSF mouthwash received and probability of grade > or = 3 mucositis using a logistic model. Solutions were administered four times daily starting within 24 hours of chemotherapy initiation and continuing until the end of the cycle (day 21). Mucositis was assessed on days 1-6, 10, 15 and 21. Day 6 plasma samples were assayed for GM-CSF. Forty-five patients were evaluable for response (nine per dosing group). A 42% risk (15/36) of mucositis grade > or = 3 was evident on day 15 in patients receiving GM-CSF compared to 2 of 9 patients on the placebo arm. No evidence of dose response was found by logistic regression. Five patients had a detectable plasma concentration of GM-CSF (56-209 pg/ml). A positive correlation between GM-CSF dose and leukocyte recovery was noted (P = 0.04).

A case for synchronous reduction of testicular androgen, adrenal androgen and prolactin for the treatment of advanced carcinoma of the prostate

The present study was undertaken mainly to investigate whether prolactin manipulation combined with maximal androgen blockage improves the effectiveness of treatment in advanced prostatic cancer. The efficacy of oral hydrocortisone as an alternative to commercial anti-androgens in reducing the adrenal androgens, and of bromocriptine in reducing the prolactin level were also examined. A consecutive series of 30 patients with untreated and advanced prostatic cancer were entered into a three-arm prospective randomised trial. 10 patients received subcapsular orchiectomy alone (arm 1), another 10 had subcapsular orchiectomy plus flutamide (arm 2), and the remaining 10 had subcapsular orchiectomy plus oral hydrocortisone and bromocriptine (arm 3). Clinical and biochemical parameters, including trans-rectal ultrasound-determined prostatic volumes, hormonal profiles and radionuclide bone scan were evaluated at regular intervals. At 12 months, serum testosterone was reduced by more than 90% in all arms, however, maximum suppression of androstenedione, prolactin, and reduction of prostatic volumes were only observed in arm 3; this was reflected by the significant improvement in clinical response in arm 3 compared with other arms. This study suggests that a combined maximal suppression of androgens and prolactin offers a significant improvement in response over conventional treatments without prolactin suppression in the treatment of advanced prostatic cancer. Importantly, a better clinical outcome in arm 3 was still apparent at the end of 36 months.

Effects of granulocyte-macrophage colony stimulating factor produced in Chinese hamster ovary cells (regramostim), Escherichia coli (molgramostim) and yeast (sargramostim) on priming peripheral blood progenitor cells for use with autologous bone marrow after high-dose chemotherapy

Peripheral blood progenitor cells (PBPCs) were collected without prior association with chemotherapy but after the administration of granulocyte-macrophage colony-stimulating factor (GM-CSF) produced in Chinese hamster ovary cells (CHO-GM, regramostim), Escherichia coli (E. coli-GM, molgramostim), or yeast (Yeast-GM, sargramostim) and used in conjunction with autologous bone marrow after high-dose chemotherapy in 69 patients with breast cancer or melanoma. The mean peripheral white blood cell (WBC) counts increased by 2.2 to 2.7-fold after regramostim, 4.5 to 7.3-fold after molgramostim and 4.3-fold after sargramostim. All patients underwent three leukaphereses. The mean (+/- standard error) total nucleated pheresed cells per kg x 10(8) were 4.15 +/- 0.56, 15.10 +/- 1.77 and 7.24 +/- 1.00 for patients receiving regramostim, molgramostim or sargramostim respectively. The mean (+/- standard error) granulocyte-macrophage colony-forming units per kg x 10(4) mobilized into the PB were 8.75 +/- 3.63, 71.03 +/- 17.85, and 65.11 +/- 18.74 for patients receiving regramostim, molgramostim, or sargramostim respectively. The total mean (+/- standard error) CD34+ cells per kg x 10(7) collected by three leukaphereses were 3.28 +/- 1.62, 1.34 +/- 0.51 and 2.57 +/- 1.93, for patients receiving regramostim, molgramostim or sargramostim respectively. The use of either molgramostim- or sargramostim-primed PBPCs led to complete elimination of absolute leukopenia with a WBC count under 100/mm3 in 64% and 77% of patients treated, respectively. Patients receiving molgramostim-primed PBPCs required fewer red blood cells transfusions than patients receiving regramostim-primed PBPCs (p = 0.0062). Our data indicate that PBPCs collected without prior association with chemotherapy but after either molgramostim or sargramostim with autologous bone marrow support and GM-CSF shorten the hematopoietic recovery after myeloablative chemotherapy in patients with breast cancer or melanoma.

Interleukin-1 production in tumor cells of human melanoma surgical specimens

To determine whether IL-1 alpha and/or IL-1 beta protein is expressed by human melanoma tumor in vivo, we first analyzed nine human melanoma cell lines and optimized the in situ detection of these proteins. Three of the melanoma cell lines stained positively for both IL-1 alpha and IL-1 beta using immunohistochemistry (IHC). THe specificity of IHC was confirmed by the ability of purified recombinant IL-1 alpha and IL-1 beta protein to abolish the staining after being adsorbed by their respective antibodies before use in IHC. The three positively staining cell lines were also the only lines to demonstrate IL-1 production by western blot analysis as well as IL-1 secretion by ELISA. Next we examined 29 surgically obtained melanoma tumor specimens (6 primary and 23 metastases) that had been formalin fixed and paraffin embedded. Using the same anti-IL-1 antibodies, 5 of 23 metastatic tumors stained positively. None of the 6 primary lesions stained for either IL-1 alpha or IL-1 beta. Comparison of staining pattern performed on serially sectioned tissue using preimmune serum and antibodies against S-100 protein, melanoma-associated antigen (HMB-45), and CD68 (kappa P1), which recognizes monocyte-macrophage cell lineage, demonstrates for the first time that IL-1 protein is produced by human melanoma tumor cells in vivo. These findings provide the basis for examination of what may be a previously unrecognized biologically distinct subset of patients.

Identification of a prostate inhibitory substance in a pollen extract

Recently, much attention has focused on the treatment of BPH with the pollen extract, Cernilton. The present investigation was designed to identify the active component in this agent which might be responsible for the symptomatic relief of BPH as previously reported. Sequential purification of the active component present in the pollen extract was carried out by a combination of dialysis, gel filtration, and reverse phase chromatography. To monitor the biological activity of each of the purified fractions, a biological assay employing the human prostate cancer cell line DU145 was undertaken. While we have identified a number of constituent components in the pollen extract, only one fraction designated V-7 (FV-7) maintained a strong inhibitory effect on the growth of DU145 cells. The inhibition was time- and dose-dependent, and the concentrations of FV-7 required to reduce the cell numbers by 50% (IC50) after 2 days of exposure was 5 micrograms/ml. FV-7 was also inhibitory towards the primary culture of prostate stroma and epithelial cells, with the stroma/fibroblast showing greater sensitivity towards the HPLC-purified component. However, it should be noted that this inhibitory activity measured in the primary culture cells was only achieved at higher concentrations of FV-7. Preliminary characterization of the active ingredient identified FV-7 as DIBOA which is a cyclic hydroxamic acid. FV-7 and DIBOA induce similar inhibitory effects on the growth of DU145 cells.

Isolation and characterization of a cyclic hydroxamic acid from a pollen extract, which inhibits cancerous cell growth in vitro

One fraction, designated FV-7, in the water soluble ingredient of the pollen extract Cernilton was found to be inhibitory to the growth of a prostate cancer cell line. Characterization of FV-7 by high-resolution mass spectrometry and nuclear magnetic resonance identified the fraction as hydroxamic acid, 2,4-dihydroxy-2H-1,4-benzoxazin-3(4H)-one (DIBOA). To confirm this further, we synthesized an authentic sample of DIBOA and found subsequently that the synthetic DIBOA was structurally indistinguishable from FV-7. Furthermore, in a separate experiment we compared the in vitro effects of FV-7 and DIBOA on the growth of a prostate cancer cell line and found that in both cases the effect was inhibitory and that the inhibition curves obtained for both compounds were virtually identical.

Determinations of dangerousness in forensic patients: an archival study

The involvement of mental health professionals in determinations of dangerousness is both common and controversial. Among the various contexts for these evaluations, the release of potentially violent forensic patients from maximum security facilities evokes justified concern from involved experts and apprehension to outrage from the immediate community. We sought to examine how conclusions are reached on dangerousness at two sequential stages: clinical recommendations and Manifest Dangerousness Hearings decisions. In an archival study of 245 patients, we found that lack of progress in the institution and physical assaultiveness were the strongest correlates with dangerousness. In contrast, experts and review boards appeared to be relatively less influenced by diagnosis, types of treatment, and sociodemographic variables.

Comparison of simultaneous renal clearances of true endogenous creatinine and subcutaneously administered iothalamate in man

125I-iothalamate and true endogenous creatinine clearances, measured over two short collections periods of 1 and 2 h, were compared simultaneously in 70 patients with a variety of renal diseases and a wide range of renal function. Reproducibility of the iothalamate clearance was 18.5% and that of the creatinine clearance 12.2%. The slope of the regression was not significantly different from 1 (95% confidence interval, CI, 0.964-1.155) for the whole group, nor in any subgroup chosen. The intercept at 12.6 ml/min (CI = 5.0-20.2) indicates that there is some creatinine secretion, but this was constant at all levels of GFR. It is concluded that although the clearance of true creatinine obtained during short collection periods consistently overestimates GFR by a constant proportion, it is a reproducible and accurate measure of GFR suitable for use in the clinical setting.

Violence content in nursing curricula: strategic issues and implementation

Many nurse educators today are sensitized to the importance of including content on violence and victim/survivor care in various nursing education programmes. While a survey of Ontario's schools of nursing in Canada revealed a considerable number of hours devoted to this topic, the approach is largely incidental, depending heavily on individual faculty interests. National and international initiatives to stem the tide of violence against women and children, plus the strategic role of nurses in primary care, call for curricula in which this content is addressed systematically. To achieve this goal and avoid pitfalls such as an 'add-on' approach to curriculum revision, nurse educators' needs in Ontario were addressed in a series of workshops involving collaboration between faculty, clinical preceptors and community-based experts in victim/survivor care.