Pediatric urolithiasis: developing nation perspectives

PURPOSE

We evaluated epidemiology, etiology, dietary and urinary risk factors, and the composition of calculi in pediatric stone formers in Pakistan.

MATERIALS AND METHODS

This retrospective study includes 1,440 children treated between 1987 and 2000. Case records were reviewed for demographics, etiology and clinical symptoms. Dietary and urinary risk factors were analyzed prospectively in idiopathic stone formers. Stone composition was analyzed by infrared spectroscopy.

RESULTS

There were 1,075 males and 365 females for a male-to-female ratio of 3:1. The peak age for renal and bladder stones was 6 to 10 and 1 to 5 years, respectively. Overall 795 stones (55%) were renal, 198 (14%) were ureteral and 447 (31%) were vesical. Bladder stones were present in 60% of cases in the mid 1980s but decreased to 15% in the mid 1990s. The clinical symptoms were abdominal pain in 511 patients (51%) and fever in 193 (19.5%). There were anatomical abnormalities in 96 patients (12%), metabolic abnormalities in 206 (25%), infection stones in 60 (7%) and idiopathic stones in 444 (55%). Urinary analysis in idiopathic stone formers revealed hypercalciuria in 17 (11%), hyperoxaluria in 62 (40%), hyperuricosuria in 41 (27%) and hypocitruria in 97 (63%). Diet involved a low intake of protein in 60 cases (44%), calcium in 45 (33%), potassium in 105 (77%) and high oxalate in 75 (55%). The composition was calcium oxalate in 362 stones (47%), ammonium hydrogen urate in 210 (27%) and struvite in 49 (6.4%). Stones recurred in 30 patients (2%).

CONCLUSIONS

The pattern of calculous disease changed from a predominantly lower tract site in the mid 1980s to the upper tract in the mid 1990s. Stone composition, urinary risk factors and dietary analysis suggest that diet, dehydration and poor nutrition are the main causative factors of stone disease.

Pediatric urolithiasis: developing nation perspectives

PURPOSE

We evaluated epidemiology, etiology, dietary and urinary risk factors, and the composition of calculi in pediatric stone formers in Pakistan.

MATERIALS AND METHODS

This retrospective study includes 1,440 children treated between 1987 and 2000. Case records were reviewed for demographics, etiology and clinical symptoms. Dietary and urinary risk factors were analyzed prospectively in idiopathic stone formers. Stone composition was analyzed by infrared spectroscopy.

RESULTS

There were 1,075 males and 365 females for a male-to-female ratio of 3:1. The peak age for renal and bladder stones was 6 to 10 and 1 to 5 years, respectively. Overall 795 stones (55%) were renal, 198 (14%) were ureteral and 447 (31%) were vesical. Bladder stones were present in 60% of cases in the mid 1980s but decreased to 15% in the mid 1990s. The clinical symptoms were abdominal pain in 511 patients (51%) and fever in 193 (19.5%). There were anatomical abnormalities in 96 patients (12%), metabolic abnormalities in 206 (25%), infection stones in 60 (7%) and idiopathic stones in 444 (55%). Urinary analysis in idiopathic stone formers revealed hypercalciuria in 17 (11%), hyperoxaluria in 62 (40%), hyperuricosuria in 41 (27%) and hypocitruria in 97 (63%). Diet involved a low intake of protein in 60 cases (44%), calcium in 45 (33%), potassium in 105 (77%) and high oxalate in 75 (55%). The composition was calcium oxalate in 362 stones (47%), ammonium hydrogen urate in 210 (27%) and struvite in 49 (6.4%). Stones recurred in 30 patients (2%).

CONCLUSIONS

The pattern of calculous disease changed from a predominantly lower tract site in the mid 1980s to the upper tract in the mid 1990s. Stone composition, urinary risk factors and dietary analysis suggest that diet, dehydration and poor nutrition are the main causative factors of stone disease.

Experience with sentinel node localisation in a district general hospital breast unit

Intraoperative lymphatic mapping with identification of the first draining lymph node (sentinel node) is under investigation as a possible sole axillary staging procedure in breast cancer patients. The role of sentinel node biopsy in the district general hospital breast unit is currently unclear. We report a series of 122 patients undergoing sentinel node biopsy, using a blue dye technique. The sentinel node was identified in 113 patients, and accurately predicted the status of the axilla in 108 patients (96%). Of 39 patients who were node positive, the sentinel node was the only positive node in 11 cases (26%). There were five false negatives in patients who had a node-positive axilla. We therefore suggest that sentinel node biopsy may be a feasible alternative to formal axillary dissection in certain patients, and that lack of access to radioisotope facilities in a district general hospital need not preclude such an approach.

Correlation of fine needle aspiration cytology and its histopathology in diagnosis of breast lumps

This study was carried out to evaluate the accuracy of FNAC and the role of FNAC in palpable breast lumps for the early surgical management in out patient and inpatient basis. The study was carried out in Dhaka Medical College during the period of January-December, 2000. FNAC was performed on 310 patients presented with palpable breast lumps. Histopathology was available for 122 cases. Of them, cytologically diagnosed benign cases were 106, histologically 105 cases were proved so. There was false negative diagnosis in one case. All 14 cases diagnosed as malignant cytologically proved as such histologically. Two cases reported as suspicious for malignancy one of which were proved malignant histologically. False positive diagnosis was made in one case. FNAC of breast lump was found to be associated with increased diagnostic yields. It can be carried out safely as a preoperative diagnostic method in-patients with breast lumps mostly in out-patient department.

Need and duration of antibiotic therapy in clean and clean contaminated operations

OBJECTIVE

To define the need and duration of prophylactic antibiotic administration in clean and clean contaminated surgery in the prevailing operating theatre environment in Karachi.

SETTING

Surgical Department of Hamdard University Hospital and three other private hospitals in Karachi.

METHODS

One hundred consecutive patients undergoing elective clean and clean contaminated surgery were recruited from October 2000 to October 2001. Patients were admitted either a day prior to surgery or on the day of surgery, depending on the nature of procedure. Prophylaxis was provided by single dose of antibiotic at induction. The rest of the pre-operative preparation was done in standard way. Patients were discharged home as dictated by the nature of the operation and social circumstances. Wounds were examined for Surgical Site Infection (SSI) on day 4 and day 11. Patients who had post-operative pyrexia or signs of SSI were given extended antibiotic treatment for 5 days or until resolution of infection.

RESULTS

Four out of 8 patients who developed SSI required extended antibiotic treatment.

CONCLUSION

Single dose prophylactic antibiotic therapy is satisfactory in our surgical environment. This practice would be efficient, cost effective and prevent the emergence of nosocomial infections in a developing country such as Pakistan with extremely limited health care resources.

Effects of the PKA inhibitor H-89 on excitation-contraction coupling in skinned and intact skeletal muscle fibres

This study investigated the effects of the protein kinase A (PKA) inhibitor, H-89, in mechanically-skinned muscle fibres and intact muscle fibres, in order to determine whether PKA phosphorylation is essential for normal excitation-contraction (E-C) coupling. In skinned EDL fibres of the rat, force responses to depolarization (by ion substitution) were inhibited only slightly by 10 microM H-89, a concentration more than sufficient to fully inhibit PKA. Staurosporine (1 microM), a potent non-specific kinase inhibitor, also had little if any effect on depolarization-induced responses. At 1-2 microM, H-89 significantly slowed the repriming rate in rat skinned fibres, most likely due to it deleteriously affecting the T-system potential. With 100 microM H-89, the force response to depolarization by ion substitution was completely abolished. This inhibitory effect was reversed by washout of H-89 and was not due to block of the Ca2+ release channel in the sarcoplasmic reticulum (SR). In intact single fibres of the flexor digitorum longus (FDB) muscle of the mouse, 1-3 microM H-89 had no noticeable effect on action-potential-mediated Ca2+ transients. Higher concentrations (4-10 microM) caused Ca2+ transient failure in fibres stimulated at 20 Hz in a manner indicative of action-potential failure. At 10-100 microM, H-89 also inhibited net Ca2+ uptake by the SR and affected the Ca2+-sensitivity of the contractile apparatus in rat skinned fibres. All such effects were proportionately greater in toad muscle fibres. These results do not support the hypothesis that phosphorylation is essential for the Ca2+ release channel to open in response to voltage-sensor activation in skeletal muscle fibres.

Living-related pediatric renal transplants: a single-center experience from a developing country

We retrospectively analyzed the results of 75 living-related pediatric renal transplants performed at our center between January 1986 and December 1999. The major causes of end-stage renal disease (ESRD) were glomerulonephritis (26%) and nephrolithiasis (16%), while the etiology was unknown in 50%. The mean age of the recipients was 12 yr (range 6-17 yr) and that of the donors was 39 yr (range 20-65 yr). The majority (73%) of donors were parents. Eighty five per cent of donors were one-haplotype matched and the rest identical. Immunosuppression was based on a triple drug regimen. Thirty per cent of recipients were rapid metabolizers of cyclosporin A (CsA) (area under the curve [AUC]: < 6,000 ng/mL/h), while 16% were slow metabolizers (AUC: > 8,000 ng/mL/h). Forty three (57%) children encountered 59 rejection episodes, the majority of which (59%) were recorded in the first month post-transplant. Seventy-four per cent of the rejection episodes were steroid sensitive and the rest, except two, were resolved by therapy with antithymocyte globulin (ATG) or orthoclone thymocyte 3 (OKT3). After a mean follow-up of 37 months, 17 (22%) grafts had chronic rejection and 76% of these recipients had previously experienced acute rejection episodes. The overall infection rate was high, necessitating two hospital admissions/patient/year. The majority (53%) of the infections were bacterial. Urinary tract infections (UTIs) were seen in 17 (23%) recipients. Twelve of these had ESRD as a result of stone disease and eight grafts were lost because of UTIs. Eight per cent of recipients developed tuberculosis (TB), and extra-pulmonary lesions were seen in 50%. Surgical complications were encountered in eight patients. Free medication to all recipients and parental support ensured a compliance rate of 93%. Baseline growth deficit was seen in children of the two groups studied (the 6-12 yr and 13-17 yr age-groups), with Z-scores of - 2.39 and - 2.12, respectively. No growth catch-up was observed at 12 and 24 months in either group. Post-donation complications were seen most commonly in donors > 50 yr of age and included: proteinuria (> 300 mg/24 h, four patients), hypertension (three patients), and diabetes (one patient). Twenty-four grafts were lost, 54% as a result of immunological and the rest as a result of non-immunological causes, and 17 recipients died during the follow-up period. Infections were the main cause of patient and graft loss. Overall 1- and 5-yr graft and patient survival rates were 88% and 65%, and 90% and 75%, respectively.

Association of a Monopartite Begomovirus Producing Subgenomic DNA and a Distinct DNA Beta on Croton bonplandianus Showing Yellow Vein Symptoms in Pakistan

The recent discovery that monopartite begomoviruses on ageratum and cotton essentially require a DNA satellite called DNA β (2,4) is leading to identification of several other hosts that have similar disease complexes. A weed species (Croton bonplandianus) belonging to the family Euphorbiaceae is one such example. C. bonplandianus is widely distributed on wastelands throughout the Punjab Province in Pakistan. It very often shows yellow vein symptoms indicating infection by a begomovirus. To detect a begomovirus, both symptomatic and asymptomatic plants were collected from several widely separated locations in the Punjab Province. Total DNA was isolated from these samples by the cetyltrimethylammoniumbromide (CTAB) method, resolved in an agarose gel, and blotted on a nylon membrane (2). A full-length clone of DNA A of Cotton leaf curl virus (CLCuV) labeled with ³²PdCTP was used as a probe in Southern hybridization (2). The probe detected hybridizing bands only in symptomatic plants, confirming the presence of a begomovirus. In addition to hybridizing bands of the expected sizes, smaller bands were also detected, suggesting the presence of subgenomic molecules derived from DNA A. Universal polymerase chain reaction (PCR) primers for dicot-infecting geminiviruses (1) were used in PCR for amplification of DNA A of the begomovirus associated with the disease. The use of these primers in PCR was expected to result in amplification of full-length DNA A. In addition to a product of the expected size (2.7 to 2.8 kb), another product of approximately 1.4 kb was amplified. The presence of subgenomic DNAs that are derived from DNA A is an indicator of the monopartite nature of begomoviruses, because in bipartite begomoviruses subgenomic DNAs are derived solely from DNA B. The presence of a DNA β, a DNA satellite associated with certain monopartite begomoviruses, was suspected because of symptoms and the possible monopartite nature of the virus. Universal primers for amplification of DNA β (3) were used in PCR for amplification of a putative DNA β. The PCR reaction yielded a product of expected size (≈1.4 kb). A probe from the amplified product was made by the oligolabeling method. The probe detected hybridizing bands in all symptomatic samples collected from three locations, confirming the association of a DNA β with the disease. A duplicate blot when hybridized with a DNA β associated with ageratum yellow vein disease did not hybridize to these samples. These results confirm that yellow vein disease on this weed is associated with a monopartite begomovirus and a distinct DNA β. References: (1) R. W. Briddon et al. Mol. Biotechnol. 1:202, 1994. (2) R. W. Briddon et al. Virology 285:234, 2001. (3) R. W. Briddon et al. Mol. Biotechnol. In press. (4) K. Saunders et al. Proc. Natl. Acad. Sci. U S A 97:6890, 2000.

Daphwazirin, biscoumarin glycopyranoside from Daphne oleoides

Daphwazirin, a new biscoumarin glycoside (1), along with four known compounds (2), (3), (4) and (5) has been isolated from the roots of Daphne oleoides. Its chemical structure is established as 7-hydroxy-8-[2-oxo-2H-1-benzopyran-7'-(O-alpha-L-rhamnosyl)-6'-yl]-2H-1-benzopyran-2-one through spectroscopic techniques and chemical analysis.

Correlation of ultrasonographic findings with ultrasound guided fine needle aspiration of liver lesion

Ultrasonographic findings of liver were correlated with cytological findings in a series of 50 patients. Multiple lesions described by ultrasonography and suggested as HCC/TB were proved to be metastatic in 60% cases and hepatocellular carcinoma in 40% cases by cytological examination. Multiple lesions suggested as metastatic lesions in ultrasonography was proved as such by cytology in 83% cases. Solitary lesion suggested as neoplastic in ultrasonography was proved as such in cytology in 90% cases. Of the 2 patients suggested as diffuse parenchymal lesion revealed cytological findings of cirrhosis in one case and that of TB in other. Serum alpha-feto protein and Carcinoembryogenic antigen (CEA) was done in all the cases. Serum alpha-feto protein was higher in hepatocellular carcinoma and CEA was higher in metastatic lesions. Ultrasound guided fine needle aspiration of liver can play more role in diagnosis and classification of liver disease than ultrasonographic comment alone, as it requires greater degree of precision to reach diagnostic accuracy.

Identification and characterization of a novel 38.5-kilodalton cell surface protein of Staphylococcus aureus with extended-spectrum binding activity for extracellular matrix and plasma proteins

The ability to attach to host ligands is a well-established pathogenic factor in invasive Staphylococcus aureus disease. In addition to the family of adhesive proteins bound to the cell wall via the sortase A (srtA) mechanism, secreted proteins such as the fibrinogen-binding protein Efb, the extracellular adhesion protein Eap, or coagulase have been found to interact with various extracellular host molecules. Here we describe a novel protein, the extracellular matrix protein-binding protein (Emp) initially identified in Western ligand blots as a 40-kDa protein due to its broad-spectrum recognition of fibronectin, fibrinogen, collagen, and vitronectin. Emp is expressed in the stationary growth phase and is closely associated with the cell surface and yet is extractable by sodium dodecyl sulfate. The conferring gene emp (1,023 nucleotides) encodes a signal peptide of 26 amino acids and a mature protein of a calculated molecular mass of 35.5 kDa. Using PCR, emp was demonstrated in all 240 S. aureus isolates of a defined clinical strain collection as well as in 6 S. aureus laboratory strains, whereas it is lacking in all 10 S. epidermidis strains tested. Construction of an allelic replacement mutant (mEmp50) revealed the absence of Emp in mEmp50, a significantly decreased adhesion of mEmp50 to immobilized fibronectin and fibrinogen, and restoration of these characteristics upon complementation of mEmp50. Emp expression was also demonstrable upon heterologous complementation of S. carnosus. rEmp expressed in Escherichia coli interacted with fibronectin, fibrinogen, and vitronectin in surface plasmon resonance experiments at a K(d) of 21 nM, 91 nM, and 122 pM, respectively. In conclusion, the biologic characterization of Emp suggests that it is a member of the group of secreted S. aureus molecules that interact with an extended spectrum of host ligands and thereby contribute to S. aureus pathogenicity.

Teichoic acid enhances adhesion of Staphylococcus epidermidis to immobilized fibronectin

Adhesion is a prerequisite for coagulase-negative staphylococci to cause invasive disease and may be mediated by adhesive host molecules adsorbed on implanted polymers. In this study, we can confirm previous observations demonstrating binding of Staphylococcus epidermidis to fibronectin (FN) adsorbed polymer surfaces. So far, the nature of FN-recognizing adhesin(s) in S. epidermidis remains elusive. Since teichoic acids (TA) have been shown to exert binding functions for extracellular matrix molecules in several Gram-positive species, we have purified wall TA of S. epidermidis laboratory strains KH11 and RP62A, as well as clinical isolate AB9. Using a polymethylmethacrylate (PMMA) coverslip adhesion assay, a microtitre plate assay and a particle agglutination assay, we found that purified TA significantly enhanced adhesion of S. epidermidis KH11 and RP62A to FN coated surfaces. Enhanced adhesion was dose-dependent and saturable. Preincubation, either of microorganisms or of FN coated surfaces, with TA promoted adhesion, while adhesion to TA-adsorbed PMMA was comparably low. This observation may suggest a potential role of cell wall carbohydrates as bridging molecules between microorganisms and immobilized FN in early steps of S. epidermidis pathogenesis.

Analogs of Eap protein are conserved and prevalent in clinical Staphylococcus aureus isolates

Map and Eap are secreted Staphylococcus aureus proteins that interact with various extracellular matrix molecules. PCR analysis using map primers yielded positive reactions in 97.9% of S. aureus isolates but not in Staphylococcus epidermidis isolates. Cloning and sequencing of the conferring genes revealed a high degree of overall homology combined with size variability of the gene product due to various repeat numbers and early translation termination in a poly(A) region. Thus, Map and Eap may provide a potential novel tool for S. aureus identification and typing.

Survey of knowledge about tuberculosis amongst family physicians

OBJECTIVE

To investigate the knowledge, attitudes and practices pertaining to tuberculosis (TB) amongst family physicians.

METHOD

A questionnaire-based study in which 150 family physicians were interviewed.

RESULTS

Of the family physicians 21.3% considered that TB is not a serious problem; 29% did not advise BCG vaccination as they considered that BCG vaccination has adverse side effects and limited usefulness. Only 38% depended on sputum analysis for diagnosis and 39% were prescribing four drug regimen for newly diagnosed TB patients. Majority of family physicians were prescribing the drugs that are classified currently as non-recommendable. Only 7.3% were able to write down the correct contents and quantity of tablets of what they were prescribing.

CONCLUSION

There are many misunderstandings about the transmission of tuberculosis and BCG vaccinations. Method of diagnosis, treatment and monitoring of treatment by and large is not satisfactory.

How government policy decisions affect seniors' quality of life: findings from a participatory policy study carried out in Toronto, Canada

Toronto seniors explored how government policy decisions were influencing their health and well-being. In this participatory policy study, emphasis was upon the lay and critical knowledge of highly informed seniors. Focus groups and interviews revealed that all three levels of governments were seen as not listening to seniors' voices. In nine key policy areas identified as influencing seniors' quality of life--hearing seniors' voices, housing, acute illness care, long-term care, income supports, transportation and mobility, promoting healthy lifestyles, access to information, and hearing voices from cultural communities--many concerns were raised. The gap between government rhetoric and government action on seniors' issues merits public health attention.

Association of a Disease Complex Involving a Begomovirus, DNA 1 and a Distinct DNA Beta with Leaf Curl Disease of Okra in Pakistan

Okra leaf curl disease (OLCD), characterized by either upward or downward leaf curl and stunted plant growth, is one of the major diseases of okra (Hibiscus esculentis L.) in Pakistan. OLCD is transmitted by the whitefly Bemisia tabaci and is suspected of being associated with a whitefly-transmitted geminivirus (Genus Begomovirus). Total DNAs isolated from both symptomatic and healthy okra plants collected from several locations in Pakistan were resolved on agarose gels and blotted to nylon membranes. A full-length DNA A clone of Cotton leaf curl virus (CLCuV) from Pakistan (2) was labeled with 32PdCTP and used as a probe at medium stringency. The probe detected the presence of characteristic geminivirus DNA forms in infected plants, while no hybridization was observed to healthy plant extracts, confirming the association of a begomovirus with OLCD. Degenerate oligonucleotide primers based on conserved sequences of DNA B components of begomoviruses were used in PCR for the detection of a potential DNA B (3). No amplification was observed with these primers from okra plants, while amplification of a product of expected size was obtained from plants infected with African cassava mosaic virus, suggesting the lack of a genomic component equivalent to DNA B. We have reported previously that monopartite begomoviruses on cotton and Ageratum conyzoides in Pakistan are associated with a disease complex involving a DNA component termed DNA 1, which shows homology to components of nanoviruses that encode the replication-associated protein (2). Recently, another molecule, DNA beta, has been identified, associated with Ageratum yellow vein disease from Singapore (4) and with cotton leaf curl disease (CLCuD) from Pakistan (1). These molecules are DNAs satellite and are essential for the development of typical disease symptoms in their respective hosts. Duplicate blots were probed for the presence of DNAs homologous to DNA 1 and DNA beta (using full-length clones of these molecules isolated from CLCuD originating from Pakistan [1,2]) and washed at medium stringency. The probes detected bands hybridizing to DNA 1 in extracts from infected okra plants but not DNA beta. No hybridizing bands were detected for either probe in extracts from healthy okra. A pair of primers, designed to conserved sequences in DNA beta molecules (4), were used in PCR for the amplification of DNA beta from symptomatic plants. The use of these primers amplified a product of the expected size (approximately 1.35 kb) from extracts of infected okra plants. The amplified DNA was cloned in TA cloning vector and labeled with 32PdCTP. The use of this as a probe detected the presence of a hybridizing band in infected okra plants, while no signal was observed in extracts from cotton plants showing symptoms of CLCuD. These results show that OLCD in Pakistan is associated with a DNA beta molecule that is distinct from that reported on cotton and Ageratum. In particular, the DNA beta of CLCuD and OLCD originating from Pakistan are sufficiently diverse not to cross-hybridize under the conditions used here, and are most likely different disease complexes. To our knowledge this is the first report of the association of a whitefly-transmitted begomovirus/DNA 1/DNA beta complex with okra leaf curl disease. References: (1) R. W. Briddon et al. Virology, 2001 (In press). (2) S. Mansoor et al. Virology 259:190, 1999. (3) M R. Rojas et al. Plant Dis. 77: 340, 1993. (4) K. Saunders et al. PNAS 97:6890, 2000.

Her-2/neu overexpression in muscle-invasive urothelial carcinoma of the bladder: prognostic significance and comparative analysis in primary and metastatic tumors

PURPOSE

The prognostic significance of Her-2/neu overexpression in muscle-invasive urothelial carcinoma of the bladder is largely unknown. Accurate determination of Her-2/neu overexpression may have therapeutic importance.

EXPERIMENTAL DESIGN

Eighty consecutive cases of muscle-invasive urothelial carcinoma of the bladder treated by radical cystectomy with available follow-up were analyzed. In each case, one representative section was stained with anti-Her-2/neu. Staining was graded as 1 = faint/equivocal, 2 = moderate, and 3 = strong and was considered positive if > or =2. In those cases with a metastasis, the stain was also performed in the metastatic tumor. Results were correlated with survival.

RESULTS

Twenty-two (28%) cases were considered Her-2/neu-positive in the primary tumor, and 17 of 32 (53%) were considered Her-2/neu-positive in the lymph node metastasis. Median survival for Her-2/neu-positive primary tumors was 33 months, compared with 50 months for Her-2/neu-negative cases (P = 0.46). Similarly, Her-2/neu overexpression in the lymph node metastasis did not predict survival. Sixty metastatic urothelial carcinomas were further studied by comparing Her-2/neu expression in the primary tumor with that of the lymph node and/or distant metastasis. Forty-five percent of Her-2/neu-negative primary tumors had a Her-2/neu-positive lymph node metastasis, whereas only one case (8%) of Her-2/neu-positive primary tumors was Her-2/neu-negative in the lymph node metastasis (P = 0.009). Similarly, 67% of Her-2/neu-negative primary tumors had a Her-2/neu-positive distant metastasis, whereas no Her-2/neu-positive primary tumor was negative in the metastasis (P = 0.429).

CONCLUSIONS

Her-2/neu overexpression in primary or metastatic tumor did not predict survival in this cohort of muscle-invasive tumors. Overexpression in the primary tumors consistently predicts overexpression in a distant or regional metastasis. However, some Her-2/neu-negative primary tumors may show overexpression in their corresponding metastasis. Her-2/neu analysis in a metastasis may be necessary to accurately determine Her-2/neu status in metastatic bladder urothelial carcinoma.

Phase II evaluation of paclitaxel, alpha-interferon, and cis-retinoic acid in advanced renal cell carcinoma

BACKGROUND

Interferon and 13-cis-retinoic acid (13-CRA) therapy showed clinical response rates of 30% in advanced renal cell carcinoma (RCC). This combination also enhanced sensitivity to paclitaxel in a bcl-2 and mutant p53 expressing renal carcinoma cell line. Based on this, the authors conducted a Phase II clinical trial of the combination of interferon, 13-CRA, and weekly paclitaxel, in advanced RCC.

METHODS

The eligibility criteria consisted of unresectable or metastatic RCC, measurable disease, a Southwest Oncology Group performance status of 0-2, and adequate bone marrow, hepatic, and renal function. Prior cytotoxic or immunologic treatment including interferon was permitted. Paclitaxel was administered at a dose of 80 mg/m(2) as a 1-hour intravenous infusion on Days 1, 8, and 15 of each 28-day cycle. Interferon was administered at a dose of 3 million units subcutaneously daily and 13-CRA at 1 mg/kg/day orally in 2 divided doses for the first 21 days of each cycle.

RESULTS

Twenty-one patients were enrolled with a median age of 52 years, 16 males and 5 females, 10 patients with no prior therapy, 5 each with prior interleukin-2 or interferon therapy, and 1 patient with both. Four patients had also received prior investigational chemotherapy. A total of 61 cycles were administered with a median of 2 per patient. Grade 3 and 4 toxicities were neutropenia in three patients, anemia in four patients, and asthenia, skin rash, and hypersensitivity reaction in one case each. Of the 20 evaluable patients, one objective partial response was observed for a duration of 7+ months. Seven patients had disease stabilization. The median survival of the entire population was 9.5 months (range, 4-18+ months).

CONCLUSIONS

The combination of 13-CRA, interferon, and weekly paclitaxel was well tolerated and had minimal efficacy in advanced RCC.