Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia

BACKGROUND AND STUDY AIMS

The most permanent method of treating achalasia is a surgical myotomy. Because of the requirement for a mucosal incision and the risk of perforation, this procedure has not generally been approached endoscopically. We hypothesized that we could perform a safe and robust myotomy by working in the submucosal space, accessed from the esophageal lumen.

MATERIALS AND METHODS

Four pigs were used for this experiment. Baseline lower esophageal sphincter (LES) pressures were recorded and the pigs underwent upper endoscopy using a standard endoscope. A submucosal saline lift was created approximately 5 cm above the LES and a small nick was made in the mucosa in order to facilitate the introduction of a dilating balloon. After dilation, the scope was introduced over the balloon into the submucosal space and advanced toward the now visible fibers of the LES. The circular layer of muscle was then cleanly incised using an electrocautery knife in a distal-to-proximal fashion, without complications. The scope was then withdrawn back into the lumen and the mucosal defect was closed with endoscopically applied clips. The entire procedure took less than 15 minutes. Manometry was repeated on day 5 after the procedure and the animals were euthanized on day 7.

RESULTS

LES pressures fell significantly from an average of 16.4 mm Hg to an average of 6.7 mm Hg after the myotomy. The necropsy examinations revealed no evidence of mediastinitis or peritonitis.

CONCLUSIONS

Endoscopic submucosal esophageal myotomy is feasible, safe, and effective in the short term. It has the potential for being useful in patients with achalasia. The submucosal space is a novel and potentially important field of operation for endoscopic procedures.

Dietary Lutein/Zeaxanthin Partially Reduces Photoaging and Photocarcinogenesis in Chronically UVB-Irradiated Skh-1 Hairless Mice

Lutein and zeaxanthin are xanthophyll carotenoids with potent antioxidant properties protecting the skin from acute photodamage. This study extended the investigation to chronic photodamage and photocarcinogenesis. Mice received either a lutein/zeaxanthin-supplemented diet or a standard nonsupplemented diet. Dorsal skin of female Skh-1 hairless mice was exposed to UVB radiation with a cumulative dose of 16,000 mJ/cm(2) for photoaging and 30,200 mJ/cm(2) for photocarcinogenesis. Clinical evaluations were performed weekly, and the animals were sacrificed 24 h after the last UVB exposure. For photoaging experiments, skin fold thickness, suprapapillary plate thickness, mast cell counts and dermal desmosine content were evaluated. For photocarcinogenesis, samples of tumors larger than 2 mm were analyzed for histological characterization, hyperproliferation index, tumor multiplicity, total tumor volume and tumor-free survival time. Results of the photoaging experiment revealed that skin fold thickness and number of infiltrating mast cells following UVB irradiation were significantly less in lutein/zeaxanthin-treated mice when compared to irradiated animals fed the standard diet. The results of the photocarcinogenesis experiment were increased tumor-free survival time, reduced tumor multiplicity and total tumor volume in lutein/zeaxanthin-treated mice in comparison with control irradiated animals fed the standard diet. These data demonstrate that dietary lutein/zeaxanthin supplementation protects the skin against UVB-induced photoaging and photocarcinogenesis.

The effects of individual- and community-level knowledge, beliefs, and fear on stigmatization of people living with HIV/AIDS in China

This paper assesses the effects of individual- and community-level knowledge of HIV transmission, beliefs and fear of infection on individual attitudes toward and willingness to interact with people living with HIV/AIDS in China. Data are from a sample survey of 12,270 men and women age 15-49 from seven provinces/municipalities. The survey was conducted by the Population and Family Planning Commission in December 2003. Multilevel regression analyses show that stigmatization of people living with HIV/AIDS is strongly associated with community-level HIV knowledge and fear, even after taking into account HIV knowledge and fear at the individual level. The findings suggest that individual attitudes are partially shaped through social learning and social influence. Public-health interventions aimed at eliminating stigmatization of people living with HIV/AIDS will need to pay special attention to social and community influences while continuously working to enhance HIV knowledge and reduce inaccurate beliefs and fear.

Nuclear insulin receptor substrate-1 activates promoters of cell cycle progression genes

The insulin receptor substrate-1 (IRS-1) is a docking protein of the insulin-like growth factor-1 (IGF-1) receptor and of the insulin receptor. IRS-1 sends a strong mitogenic, anti-apoptotic signal and plays an important role in cell transformation and cancer. IRS-1 translocates to nuclei of cells, where it increases the activity of the rDNA, c-myc and cyclin D1 promoters. We show, by chromatin immunoprecipitation, occupancy by IRS-1 of the same promoters. Both promoter activation and promoter occupancy are IGF-1-dependent. In cells that respond to IGF-1 but in which IRS-1 does not translocate to nuclei, promoter occupancy is absent and promoter activation is absent or much reduced. Transcriptional activation of c-myc and cyclin D1 promoters by nuclear IRS-1 does not occur with a mutant, inactive IRS-1 protein (deletion of the phosphotyrosine-binding domain, PTB) and does not require PI3-kinase activity. Taken together, these results indicate a novel mechanism by which nuclear IRS-1 activates cell cycle genes.

Nested-PCR Detection and Sequence Confirmation of 'Candidatus Liberibacter asiaticus' from Murraya paniculata in Guangdong, China

Murraya paniculata (orange jasmine) is a popular ornamental rutaceaous plant and is known to be a preferred host for the Asian citrus psyllid, Diaphorina citri (Kuwayana), the primary vector of 'Candidatus Liberibacter spp.' that causes citrus Huanglongbing (HLB). HLB is a highly destructive citrus disease worldwide. However, the presence of 'Ca. Liberibacter spp.' in M. paniculata remains uncertain (2). Clarification of M. paniculata as a host of 'Ca. Liberibacter spp.' has direct impact on HLB control programs. During June of 2006, we identified three M. paniculata trees near a mandarin orchard affected by HLB in Luoding City and two trees from Guangzhou City, Guangdong Province, People's Republic of China. All trees had leaves showing yellowing and mottling symptoms characteristic of HLB. Both symptomatic and asymptomatic leaves were collected. DNA was extracted using the CTAB (cetyltrimethylammoniumbromide) method and assayed by nested-PCR. The general bacterial 16S rDNA primer set fDl/rD1 (3) was used for the first round of amplification. Amplification was conducted as previously described (1), and 2 μl of PCR reaction product were used for a second round of amplification using the same procedure but with 35 PCR cycles with primer set OI1/OI2c (3,4). After agarose gel electrophoresis and staining with ethidium bromide, a 1.1-kb DNA band was unambiguously associated with symptomatic but not asymptomatic leaf samples. Nonnested-PCR using primer set OI1/OI2c alone did not yield a target DNA band or yielded a very weak DNA band. XbaI digestion of the nested-PCR DNA product yielded two fragments, 520 and 640 bp long, characteristic of 'Ca. L. asiaticus'. PCR amplicons were sequenced and were 1,095 bp long. This sequence shared >98% similarity to sequences of 'Ca. L. asiaticus' in the GenBank database. We observed that nested-PCR is necessary for consistent amplification of DNA from 'Ca. L. asiaticus' from M. paniculata. We excluded the possible nonspecific amplification associated with nested-PCR by XbaI restriction enzyme digestion and by nucleotide sequence analysis. Our data indicate that M. paniculata is a host of 'Ca. L. asiaticus' but the bacterial titer might be low. References: (1) X. Deng et al. Online publication. doi:10.1094/PHP-2007-0419-01-BR. Plant Health Progress, 2007. (2) M. Garnier and J. Bove. Huanglongbing (Greening). Page 46 in: Compendium of Citrus Diseases. 2nd ed. L. W. Timmer et al., eds. The American Phytopathological Society, St. Paul, MN, 2000. (3) S. Jagoueix et al. Int. J. Syst. Bacteriol. 44:379, 1994. (4) S. Jagoueix et al. Mol. Cell. Probes 10:43, 1996.

Effects of neferine on cytosolic free calcium concentration in corpus cavernosum smooth muscle cells of rabbits

To study the relaxation mechanisms of neferine (Nef) on the corpus cavernosum smooth muscle (CCSM), the CCSM cells from New Zealand White rabbits were cultured in vitro. [Ca(2+)](i) was measured by fluorescence ion digital imaging system (FIDIS), using Fluo-2/AM as a Ca(2+)-sensitive fluorescent indicator. Nef (0.1, 1 and 10 micromol l(-1)) had no effect on the resting [Ca(2+)](i) (P > 0.05). In the presence of extracellular Ca(2+) (2.5 mmol l(-1)), Nef (0.1, 1 and 10 micromol l(-1)) inhibited [Ca(2+)](i) elevation induced by high K(+) and phenylephrine (PE) in a concentration-dependent manner (P < 0.05). In calcium free solution containing egtaic acid (EGTA), Nef (0.1 micromol l(-1)) had no inhibitory effects on [Ca(2+)](i) elevation induced by PE (P > 0.05). However, Nef (1 and 10 micromol l(-1)) inhibited [Ca(2+)](i) elevation induced by PE (P < 0.05). These data suggest that Nef inhibited [Ca(2+)](i) in CCSM cells via blocking voltage-dependent Ca(2+) channel, alpha(1)-adrenoceptor-operated Ca(2+) channel and Ca(2+) release from intracellular Ca(2+) pool. This inhibitory action on [Ca(2+)](i) might be one of the relaxation mechanisms of Nef on the CCSM.

Complex dynamics of correlated electrons in molecular double ionization by an ultrashort intense laser pulse

With a semiclassical quasistatic model we achieve insight into the complex dynamics of two correlated electrons under the combined influence of a two-center Coulomb potential and an intense laser field. The model calculation is able to reproduce experimental data of nitrogen molecules for a wide range of laser intensities from the tunneling to the over-the-barrier regime, and predicts a significant alignment effect on the ratio of double over single ion yield. The classical trajectory analysis allows us to unveil subcycle molecular double ionization dynamics.

Discovery of antiandrogen activity of nonsteroidal scaffolds of marketed drugs

Finding good drug leads de novo from large chemical libraries, real or virtual, is not an easy task. High-throughput screening is often plagued by low hit rates and many leads that are toxic or exhibit poor bioavailability. Exploiting the secondary activity of marketed drugs, on the other hand, may help in generating drug leads that can be optimized for the observed side-effect target, while maintaining acceptable bioavailability and toxicity profiles. Here, we describe an efficient computational methodology to discover leads to a protein target from safe marketed drugs. We applied an in silico "drug repurposing" procedure for identification of nonsteroidal antagonists against the human androgen receptor (AR), using multiple predicted models of an antagonist-bound receptor. The library of marketed oral drugs was then docked into the best-performing models, and the 11 selected compounds with the highest docking score were tested in vitro for AR binding and antagonism of dihydrotestosterone-induced AR transactivation. The phenothiazine derivatives acetophenazine, fluphenazine, and periciazine, used clinically as antipsychotic drugs, were identified as weak AR antagonists. This in vitro biological activity correlated well with endocrine side effects observed in individuals taking these medications. Further computational optimization of phenothiazines, combined with in vitro screening, led to the identification of a nonsteroidal antiandrogen with improved AR antagonism and marked reduction in affinity for dopaminergic and serotonergic receptors that are the primary target of phenothiazine antipsychotics.

Prognostic significance of positive lymph nodes in carcinoma of the cervix following radical hysterectomy

5538

Background: Lymph node (LN) metastases portend a poor outcome in women with carcinoma of the uterine cervix, but little data quantitatively evaluate nodal metastasis in relation to prognosis. We queried a large population database to analyze the number of positive LN in relation to survival following radical hysterectomy and lymphadenectomy. Methods: Data were collected from the Surveillance, Epidemiology, and End Results (SEER) Program on women who had primary surgery for the years 1988–2003 (n = 4,559). Analyses using the chi-square test and Cox proportional hazards regression were performed. Exploratory analysis revealed equivalent statistical outcomes in each group for 0 (n = 3,715), 1–2 (n = 552), 3–9 (n = 261), and ≥10 (n = 31) positive LNs, respectively. Results: The median number of LNs removed per patient has significantly declined in recent years (median = 21 for 1988–1998, median = 18 1998–2003, p=.003). The 5-year rates of cause specific (CSS) and overall survival (OS) were 94% and 91%, 76% and 69%, 62% and 58%, and 41% and 35% for 0, 1–2, 3–9 and ≥10 positive LNs, respectively. Favorable stage and grade predicted for survival on multivariate analysis. Adenocarcinoma histology predicted significantly inferior CSS (p=.007) and OS (p=.01) compared to squamous histology in women with positive LNs, but predicted improved OS (p=.004) in women with LN negative disease. An increasing number of LNs removed significantly benefited OS (p=.001). The strongest predictors for both CSS and OS were ≥10 positive LN (HR 1.8 CI 1.2–2.7, p<.0001) a positive LN ratio >25% (HR 1.8 CI 1.5–2.2, p<.0001) and paraaortic LN metastasis (HR 2.1 CI 1.6–2.8, p<.0001). Conclusions: The extent of lympadenectomy has declined since 1988 within the SEER. LN positive disease in carcinoma of the cervix portends a prognosis that is inversely proportional to the number of involved nodes. Adenocarcinoma histology predicted for a more aggressive or benign phenotype depending on LN status. A positive LN ratio >25% demonstrated diminished survival suggesting that the quantitative LN burden is predictive of prognosis. Nodal involvement of the paraaortic region remains a strong indicator of mortality.

No significant financial relationships to disclose.

Population-based study of the incidence, mortality and prognostic factors of small cell carcinoma of the cervix: Analysis of the Surveillance, Epidemiology and End Results database

5546

Background: Small cell carcinoma (SmC) is a rare histology of the cervix uteri that is generally associated with a poor prognosis. This is a population-based study of SmC using the Surveillance, Epidemiology and End Results (SEER). Methods: From 1977 to 2003, 290 women with SmC of the cervix uteri were identified. In addition, 27,527 patients with squamous cell carcinoma (SC) and 5231 with adenocarcinoma (AC) of the cervix were identified for comparison. The annual incidence of each histology was determined and examined for trend. The patient and disease characteristics at diagnosis were examined for each histology, and prognostic factors were evaluated for SmC. Mortality rates of SmC and other histologies were compared via log-rank tests. Results: Mean annual incidence of SmC was 0.03 per 100,000 women compared to 3.5 and 0.62 for SC and AC. A significant change in incidence was identified for SC and AC (p<0.05), but not for SmC (p=0.595). Patients with SmC were more likely to be treated with radiotherapy and to present with more advanced stage, lymph node involvement and distant metastasis than SC and AC (p<0.05). Survival rates for SmC at 2 and 5 years were 46.8% and 35.7%, which were worse compared to SC (HR 0.45; 95% CI: 0.36–0.57) and AC (HR 0.31; 95% CI: 0.25–0.39). The difference in survival is predominantly in patients with early stage, localized disease, and those treated with surgery ( Table ). Multivariate analysis of SmC, race, FIGO stage, age and hysterectomy alone significantly impacted prognosis (p<0.05), while year of diagnosis, lymph node involvement, tumor size, marital status and other treatment modality did not. Conclusions: SmC is an uncommon histologic variant of cervix cancer associated with a worse prognosis compared to SC and AC with a predilection for metastasis at diagnosis. FIGO stage, age and race are prognostic factors for survival.

[Table: see text]

No significant financial relationships to disclose.

Plasma EBV DNA and cell-free GAPDH DNA as prognostic factors of locally advanced nasopharyngeal carcinoma

6053

Background: Plasma cell-free nucleic acids have been investigated to be potential prognostic and predictive markers of treatment response, residual disease, and survival of cancer patients. However, these nucleic acids will be confounded by normal cell death, which might be caused by cancer-related inflammation, infection, or chemotherapy. Nasopharyngeal carcinoma is endemic in Taiwan, highly related to EBV infection. Plasma EBV DNA level has been suggested to be predictive of disease status and outcomes. We try to find out whether plasma EBV and cell-free glyceraldehydes-3-phosphate dehydrogenase DNA before definite treatment of locally advanced NPC predict tumor outcomes better. Methods: 144 stage IV (AJCC version 6) NPC patients received induction chemotherapy followed by concurrent chemoradiotherapy in National Taiwan University Hospital from 1998 to 1999. Pre-treatment blood samples were colleted for real-time quantitative polymerase chain reactions of EBV and GAPDH DNA. The results will be analyzed by SPSS version 13 to see if correlated with tumor extent, locoregional/distant failure, and overall survival. Results: Our patients were mainly composed of T4(97%) and N2(56%) patients. 23 % were in N3 stage. Plasma EBV and cell-free GAPDH DNA levels were not correlated with T stage. Plasma EBV DNA level was significantly correlated with N3 status(Mann-Whitney test p=0.021). After Cox regression model, only age (p=0.024) was a significant predictor of recurrence-free survival; N3 status(p=0.007) and positive plasma EBV DNA (p=0.002) predicted shorter metastasis-free survival. N3 status (p=0.031) and positive plasma EBV DNA (p=0.002) were significantly related to poor survival by log-rank test; whereas T4 lesions (p=0.524) and plasma cell-free GAPDH DNA level (p=0.182) were not. After multivariate Cox regression, positive plasma EBV DNA (hazard ratio 4.936 p=0.006) was the only significant predictor of poor survival. Conclusions: To use circulating DNA as prognostic marker, a specific one, such as EBV DNA, might be better than a non-specific one, like GAPDH DNA. This is important in the development of tumor markers for other solid tumors.

No significant financial relationships to disclose.

Imaging and therapy for Epstein-Barr virus-associated gastric cancer

4644

Background: Epstein-Barr virus (EBV) has been identified in a wide variety of malignancies, including gastric carcinomas. The virus encodes kinases that phosphorylate nucleoside analogs such as 2’-deoxy-2’-fluoro-5-iodo-1-beta-D- arabinofuranosyluracil (FIAU). We hypothesized that it might be possible to use the viral enzyme to specifically concentrate [125I]FIAU or [131I] FIAU in tumor cells harboring virus and thus deliver imaging and therapeutic radiation. Bortezomib is a potent stimulator of viral kinase expression in EBV tumor cell lines. Methods: We imaged lytic induction in vivo and evaluated the effect of [131I] FIAU on human cancer xenografts in SCID mice. These include a tumor line engineered to constitutively express the EBV thymide kinase (EBVTK), and a control engineered with a sham vector (SHAM), as well one EBV-associated human gastric tumor (KT tumor). Mice were treated with buffer, bortezomib (2μg/g), or radiolabeled FIAU or radiolabeled FIAU and bortezomib in combination. For imaging, mice, [125I]-FIAU and SPECT/CT were used. For therapy, 131I-FIAU was used and tumor dimensions were monitored with calipers. Results: SPECT/CT imaging with [125I]-FIAU of tumor-bearing SCID mice showed selective concentration of radiotracer in tumor tissue in EBVTK (3/3) and in EBV-associated KT tumors (3/3) when animals were pretreated with bortezomib. Treatment with buffer had no effect on 3 EBVTK tumors and 3 SHAM tumors all of which increased in volume. Treatment with 1.6 mCi of [131I]-FIAU alone led to tumor response in 3/3 mice with EBVTK tumors and 0/3 mice with SHAM tumors. Treatment with [131I]-FIAU alone had no effect on EBV KT tumor xenografts (0/3) and all tumors increased in volume. Treatment with bortezomib induced modest responses in all KT tumors. However, treatment with bortezomib and [131I]-FIAU led to marked tumor regression (>80%) in EBV-associated KT tumors (3/3). Conclusions: Treatment with bortezomib leads to selective concentration of radiolabeled FIAU in the EBV-associated tumor xenografts. In combination with [131I]-FIAU it leads to tumor regression.

No significant financial relationships to disclose.

Identification of sensitivity markers for BMS-536924, an inhibitor for insulin-like growth factor-1 receptor

3506

Background: Insulin-like growth factor-1 receptor (IGF-1R) signaling is an important regulator of mitogenesis, transformation to the oncogenic phenotype and anti-apoptotic effects in malignant cells. Over-expression of IGF-1R, seen in many tumors, may confer a growth advantage or drug resistance. A potent small-molecule inhibitor (BMS-536924) of IGF-1R tyrosine kinase showed anti-tumor activity in sarcoma, prostate, colon and pancreatic tumor models. One of the integral goals in the development of BMS-536924 as a cancer therapeutic is to identify molecular biomarkers predictive of response to the drug that ultimately will aid in selecting the patients who are most likely to benefit. Methods: The sensitivity (IC50) to BMS-536924 was determined for a panel of 29 pediatric sarcoma and neuroblastoma cell lines. Both microarray and LC/MS based protein profiling were utilized to analyze the baseline gene or protein expression level. Drug treatment studies were performed using two rhabdomyosarcoma cell lines, Rh41 (sensitive to BMS-536924) and Rh36 (resistant to the drug) to identify markers that are modulated by BMS-536924. Results: (1). Sixteen out of the 29 cell lines were highly sensitive to BMS-536924; candidate markers that correlated with the sensitivity to BMS-536924 were identified by gene expression and protein profiling. (2). Histological correlation was also discovered, with specific subtypes of sarcoma having a low IC50 to BMS-536924. (3). Pathway analysis noted that some major candidate markers are common key steps in the EGF-R pathway and the IGF1-R pathway. This observation of cross-talk between the two pathways led to the hypothesis of synergy with combined inhibition of both pathways. Combination studies of BMS-536924 and EGFR inhibitors were performed and synergism was observed. (4). Markers modulated by BMS-536924 in a sensitive cell line were identified. Conclusions: This work has identified candidate markers correlating to BMS-536924 sensitivity in vitro. The possible mechanism of synergistic activity of IGF1-R and EGFR inhibitors will be presented.

No significant financial relationships to disclose.