Congestive heart failure in Indians: how do we improve diagnosis & management?

Heart failure is a common cardiovascular disease with high morbidity and mortality. Unlike western countries where heart failure is predominantly a disease of the elderly, in India it affects younger age group. Important risk factors include coronary artery disease, hypertension, diabetes mellitus, valvular heart disease and cardiomyopathies. Plasma brain natriuretic peptide levels are helpful in the diagnosis of heart failure. Echocardiography is the primary imaging modality of choice, through recently cardiac magnetic resonance imaging (MRI) has been found to play an increasing role. Aim of management is to improve symptoms & enhance survival. Diuretics are important in relieving symptoms. Beta-blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers and adosterone antagonists improve survival in patients with impaired systolic function. Device therapy including cardiac resynchronization therapy and implantable cardiac defibrillators, though expensive are useful in selected patients. Unlike in patients with systolic heart failure where several therapies have been shown to improve survival, clinical trial results in diastolic heart failure have been disappointing and therapy in these patients is restricted to symptom improvement and risk factor control. Therapies like stem cell therapy are being evaluated in clinical trials and appear promising. Early diagnosis and appropriate therapy helps in reversing the process of remodelling and clinical improvement in most of the patients.

A novel multifunctional oligonucleotide microarray for Toxoplasma gondii

BACKGROUND

Microarrays are invaluable tools for genome interrogation, SNP detection, and expression analysis, among other applications. Such broad capabilities would be of value to many pathogen research communities, although the development and use of genome-scale microarrays is often a costly undertaking. Therefore, effective methods for reducing unnecessary probes while maintaining or expanding functionality would be relevant to many investigators.

RESULTS

Taking advantage of available genome sequences and annotation for Toxoplasma gondii (a pathogenic parasite responsible for illness in immunocompromised individuals) and Plasmodium falciparum (a related parasite responsible for severe human malaria), we designed a single oligonucleotide microarray capable of supporting a wide range of applications at relatively low cost, including genome-wide expression profiling for Toxoplasma, and single-nucleotide polymorphism (SNP)-based genotyping of both T. gondii and P. falciparum. Expression profiling of the three clonotypic lineages dominating T. gondii populations in North America and Europe provides a first comprehensive view of the parasite transcriptome, revealing that ~49% of all annotated genes are expressed in parasite tachyzoites (the acutely lytic stage responsible for pathogenesis) and 26% of genes are differentially expressed among strains. A novel design utilizing few probes provided high confidence genotyping, used here to resolve recombination points in the clonal progeny of sexual crosses. Recent sequencing of additional T. gondii isolates identifies >620 K new SNPs, including ~11 K that intersect with expression profiling probes, yielding additional markers for genotyping studies, and further validating the utility of a combined expression profiling/genotyping array design. Additional applications facilitating SNP and transcript discovery, alternative statistical methods for quantifying gene expression, etc. are also pursued at pilot scale to inform future array designs.

CONCLUSIONS

In addition to providing an initial global view of the T. gondii transcriptome across major lineages and permitting detailed resolution of recombination points in a historical sexual cross, the multifunctional nature of this array also allowed opportunities to exploit probes for purposes beyond their intended use, enhancing analyses. This array is in widespread use by the T. gondii research community, and several aspects of the design strategy are likely to be useful for other pathogens.

Evaluation of proper above-the-diaphragm central venous catheter placement: the saline flush test

hest radiographs are routinely obtained after the insertion of above-the-diaphragm central venous catheters to confirm placement and detect mechanical complications. At times, performing the radiograph can be time-consuming and findings may be inaccurate. We present a case of a patient with difficult access who required emergent resuscitation. A central venous catheter was inserted under ultrasound guidance into the patient's right internal jugular vein. After the procedure, a 2-dimensional bedside ultrasound of the heart was performed with simultaneous flush of saline through the catheter. Ultrasound detected an immediate echogenic turbulent pattern from the flush in the right atrium and then the right ventricle. This correlated to the proper placement of the catheter tip in the superior vena cava. A bedside ultrasound of the ipsilateral lung evaluated and ruled out iatrogenic pneumothorax. Other investigators have demonstrated different methods to confirm central venous catheter placement by bedside ultrasound, utilizing multiple views, Doppler technology, or microbubble contrast. This novel technique, as described here, is most simple. Further research is needed to demonstrate accuracy and utility.

Patient-based strategy for systemic treatment of metastatic renal cell carcinoma

There were only a few options 3 years ago to treat metastatic renal cell carcinoma (mRCC), a disease with a very poor prognosis. With the approval of targeted therapies for mRCC since December 2005, this situation has changed dramatically. Currently, oncologists can choose between several promising options to improve the longevity and quality of their patients' lives. A widely accepted treatment scheme for targeted therapies in mRCC does not yet exist. Based on a selective literature search, drawing on studies with six targeted therapies for mRCC, and including data from the latest American Society of Clinical Oncology (ASCO) and European Society for Medical Oncology (ESMO) Annual Meetings, this review introduces the available therapies, evaluates patient-specific criteria for their application and suggests an algorithm for a patient-based treatment scheme. Clinical experiences with sequential therapies are summarized and potential combination therapies discussed. In conclusion, the crucial criteria of the treatment scheme we propose are the tumor burden and the disease pace, as well as the quality of life of a patient. These define whether tumor control or tumor remission should be the primary therapeutic goal. This scheme suggests which kind of therapeutic sequence to pursue to optimize patient care in mRCC.

Reirradiation for progressive brain metastases

Brain metastases constitute one of the most common distant metastases of cancer and are increasingly being detected with better diagnostic tools. The standard of care for solitary brain metastases with the primary disease under control is surgery followed by radiotherapy. Radiotherapy is also the primary modality for the treatment of multiple brain metastases, and improves both the quality of life and survival of patient. Unfortunately, more than half of these treated patients eventually progress leading to a therapeutic dilemma. Another course of radiotherapy is a viable but underutilized option. Reirradiation resolves distressing symptoms and has shown to improve survival with minimal late neurotoxicity. Reirradiation has conventionally been done with whole brain radiotherapy, but now studies with stereotactic radiosurgery have also shown promising results. In this review, we focus on reirradiation as a treatment modality in such patients. We performed a literature search in MEDLINE (www.pubmed.org) with key words brain metastases, reirradiation, whole brain radiotherapy, stereotactic radiosurgery, interstial brachytherapy, and brain. The search was limited to the English literature and human subjects.

Fibronectin confers survival against chemotherapeutic agents but not against radiotherapy in DU145 prostate cancer cells: involvement of the insulin like growth factor-1 receptor

BACKGROUND

Tumor growth is influenced by an increase in cell proliferation and a reduction in apoptosis; both of which are affected by alterations in extracellular matrix (ECM). Our aim was to assess if the susceptibility of prostate cancer cells to apoptosis induced by either chemotherapeutics or radiotherapy was altered by changes in the ECM.

METHODS

Prostate cancer cell lines LNCaP and DU145 (androgen independent) cells were treated with chemotherapeutics (ceramide and docetaxel) or radiotherapy in the presence or absence of fibronectin, laminin, or vitronectin. Cell death was assessed using Trypan blue cell counting and apoptosis was confirmed by measuring PARP cleavage by Western immunoblotting (WIB). To identify a mechanism of action, changes in the abundance (WIB) or association (immunoprecipitation followed by WIB) of key proteins was also assessed.

RESULTS

We found that fibronectin, but not laminin or vitronectin activated a survival pathway that protected DU145 but not LNCaP prostate cancer cells against ceramide and docetaxel-induced apoptosis but not that induced by radiotherapy. This survival effect involved the insulin-like growth factor (IGF-I) and beta1 integrin receptors and was associated with an increase in the recruitment of the beta1 integrin to a complex containing the IGF-IR and protein receptor for activated C kinase (RACK-1) and an increase in the abundance of a MAPK-phosphatase-1 (MKP-1).

CONCLUSIONS

Changes in the ECM associated with disease progression may contribute to resistance to chemotherapeutic drugs but not to radiation therapy. The susceptibility to chemotherapy may be improved by targeting either the IGF-I or beta1 integrin receptors.

Radiation therapy in paediatric gliomas: our institutional experience

BACKGROUND AND PURPOSE

The aim of our retrospective study was to analyze the clinical outcome of paediatric glioma patients treated with radiation therapy (RT) in our institution.

MATERIAL AND METHODS

We retrieved the case records of all children with gliomas (age < 18 years) who received RT in our department between 2004 and 2007. We analyzed the information regarding patients' demography, clinical details, treatment given, RT details, and survival. The event-free survival (EFS), the period from the date of completion of RT to the date of the event, i.e. death/recurrence, was calculated with respect to age, sex, location of tumour (brainstem vs. non-brainstem), histopathology (low grade vs. high grade), extent of surgical resection, dose and duration of RT, and use of chemotherapy.

RESULTS

A total of 70 children with glioma received RT during the above-mentioned period. The 3-year EFS rate for all patients was 44% and the median EFS period was 18 months. The 3-year EFS in patients who underwent surgical decompression and no surgery was 58% and 25%, respectively (p < 0.05). Patients with brainstem lesions had statistically significantly lower 3-year EFS to non-brainstem gliomas (28% vs. 56%, p < 0.01). Chemotherapy use showed no statistically significant trend towards better survival.

CONCLUSIONS

RT is an effective modality of treatment in paediatric glioma patients in our setup. Early use of RT in incompletely resected low-grade gliomas is worth revisit-ing. Results of chemotherapy in high-grade glioma and brainstem gliomas are encouraging.

Clear cell meningioma of the fourth ventricle in a child: a case report and literature review

Clear cell meningiomas are rare meningioma variants and are recognized as World Health Organization grade II tumours. They may be difficult to manage given their propensity to recur early especially if present in surgically challenging locations. We describe a rare case of a fourth ventricular clear cell meningioma without dural attachment in a 14-year-old boy with an unusual presentation of failure to thrive. The case is presented in detail and a review of the recent literature is discussed.

Time Dependent Improvement in Survival for Women with Multiple Brain Metastases from HER2 Positive Breast Cancer: The Influence of Systemic Therapy

Background: Women with multiple breast cancer brain metastases (BM) ineligible for neurosurgery or radiosurgery have a poor prognosis and the role of systemic therapy is ill defined.Method: The outcomes for 120 women treated for multiple (≥2) BM between 2002-2008 at this regional cancer centre have been analysed according to time of BM diagnosis (Cohorts (A) 2002-5 & (B) 2006-8) and HER2 status of the primary tumour (+ or -). We have previously shown that A+ patients experienced longer survival than A-, the advantage apparently restricted to a subgroup of A+ who continued trastuzumab after BM diagnosis (Church et al, Am J Clin Oncol 2008, 31(3) 250-4).Results: There was no difference in survival between B- and A- cohorts (B- patients (n=25) survival median 119 days; A- patients (n=53) median survival 118 days; p=0.57). In contrast there was a time dependent improvement in survival favouring B+ patients (n=19, median 520 days,) over A+ patients (n=23, median 148 days, p &lt;0.02). B+ and A+ cohorts differed significantly in the consistency of their exposure to both trastuzumab (T) and chemotherapy (CT) post BM (p&lt;0.02). Subsequently, patients in the B+ cohort was more frequently treated with additional lines of CT and 5 patients in the B+ cohort (versus none in A+) went on to receive second line anti-HER2 therapy (lapatinib).CohortT + CTLines of CT≥ 2LapatinibMedian survival12 month survivalA+ (n=23)39% (9pts)22% (5)0% (o)148 days30%B+ (n=19)79% (15pts)58% (11)26% (5)520 days80% p&lt;0.02p&lt;0.03p&lt;0.02p&lt;0.02 A+ and B+ were not significantly different with regard to presence of systemic metastases (SM) or time from SM to BM (median A+ 304 days; B+ 334, p=0.3)Conclusion: Following our earlier observation on the A+ cohort, the improvement in survival for B+ may reflect increased optimism of patients and physicians regarding the role of systemic therapy. Although no randomised trial has been performed, it is increasingly apparent from these and other data that HER2+ patients with multiple BM benefit from continued incorporation of systemic therapy into clinical management strategies and, at variance with historic experience, survival &gt; 1 year can now be expected. Randomised trials, specifically to identify the best agents to accompany anti-HER2 therapy, will be required to further extend this benefit.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5092.

Interstitial brachytherapy guided intensity modulated radiation therapy (IBGIMRT) in cervical cancer: a dosimetric study

PURPOSE

Interstitial brachytherapy (IBT) is used as an alternative to intracavitary radiotherapy in the management of cervical carcinoma. We have devised a new technique called interstitial brachytherapy guided intensity modulated radiotherapy (IBGIMRT) which can potentially reduce doses to organs at risk (OaRs). It utilizes IMRT planning on the target volume (TV) defined by implantation of IBT needles. This study compares the dosimetry of IBT and IBGIMRT.

MATERIAL AND METHODS

CT scan images of 18 patients with cervical cancer, who have been already treated by HDR-BT, were used to generate two rival plans, IBT and IBGIMRT, for a prescription dose of 10 Gy. Following dosimetric factors were used for comparison: volume receiving 95% of prescription dose (V₉₅), conformity index (COIN) and external volume index (EI) for target and for OaR, dose received by volume of 1 cm³ (D_1cc), 2 cm³ (D_2cc), 5 cm³ (D_5cc) and also volume receiving 50% and 75% of prescription dose (V₅₀ and V₇₅).

RESULTS

The two plans resulted in COIN difference of 49.8% (p < 0.0001) and EI difference of 36.4% (p < 0.0028) in favor of IBGIMRT. Mean D_1cc, D_2cc and D_5cc values for bladder were 8.3 Gy, 7.6 Gy and 6.4 Gy; and 7.8 Gy, 7.3 Gy and 5.8 Gy with IBT and IBGIMRT, respectively (p > 0.05). Similar figures for rectum with IBT vs. IBGIMRT were 11.2 Gy vs. 7.02 Gy, 10.5 Gy vs. 6.4 Gy and 9.1 Gy vs. 4.8 Gy respectively (p < 0.01).

CONCLUSIONS

Our novel technique, IBGIMRT, has shown its dosimetric superiority and therefore needs to be studied in clinical set up.

Phase II study of BAY 73–4506, a multikinase inhibitor, in previously untreated patients with metastatic or unresectable renal cell cancer

5033

Background: BAY 73–4506 is an orally active, potent multikinase inhibitor targeting both tumor cell proliferation and tumor vasculature through inhibition of receptors of tyrosine kinases (VEGFR, KIT, RET, FGFR, and PDGFR) and serine/threonine kinases (RAF and p38MAPK). In tumor xenograft models, BAY 73–4506 demonstrated a broad spectrum of antitumor activity. The results of a phase I study (3 weeks on/1 week off schedule) indicated good tolerability and antitumor activity, including objective responses. Methods: Previously untreated patients with predominantly clear cell renal cell carcinoma (RCC) and measurable disease according to RECIST were enrolled in this multicenter, open-label, phase II study. Eligibility criteria included ECOG performance status 0–1, low or intermediate risk as per Motzer score, and adequate bone marrow and organ function. Treatment consisted of BAY 73–4506 160 mg once daily on a 3 weeks on/1 week off schedule. The primary end point was overall response rate. Results: 49 patients started treatment (accrual completed October 2008): 27 male, 22 female, median age 62 years (range 40–76). All patients were evaluable for safety, 33 patients are currently available for efficacy evaluation. The most common drug-related adverse events (all grades) reported in >20% of patients were hand-foot skin reaction (HFSR) (48%), fatigue (48%), hypertension (43%), mucositis (35%), dysphonia (33%), rash (30%), diarrhea (25%), and anorexia (23%). Grade 3–4 drug related toxicities (in >5% of patients) included HFSR (13%), rash (8%), fatigue (8%), and renal failure (8%). Renal failure occurred only in patients who continued taking study medication despite having inadequate fluid intake and/or diarrhea. Preliminary efficacy data of the 33 patients evaluable for response show a 27% partial response (PR) and a 42% stable disease (SD) rate. Further tumor assessments are scheduled for the patients (n = 35) remaining on study. Conclusions: Preliminary data show promising antitumor activity and good tolerability of BAY 73–4506 in patients with RCC. The observed toxicities were typical of the drug class and were manageable. Updated results will be presented at the meeting.

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Modern Chemotherapy Strategies for Management of ‘Hormone Resistant Prostate Cancer’ (HRPC)—When Should the Urologist Refer?

Before death occurs from advanced prostate cancer, all patients pass through a ‘hormone resistant’ phase of the disease (HRPC). A large proportion of patients with advanced prostate cancer on hormonal therapy are managed in the Urology Outpatient Department, albeit with multidisciplinary input into their care. Chemotherapy for HRPC has now been shown to increase survival and quality of life and many novel agents are now undergoing Phase I and Phase II trials. The timely and appropriate referral of patients for chemotherapy, however, is essential in order to optimise patients' care and use chemotherapy wisely. This article addresses many of these practical issues.