Ecteinascidin-743 (ET-743) for chemotherapy-naive patients with advanced soft tissue sarcomas: multicenter phase II and pharmacokinetic study

PURPOSE

To evaluate the response rate, toxicity profile, and pharmacokinetics of ecteinascidin-743 (ET-743) as first-line therapy in patients with unresectable advanced soft tissue sarcoma (STS).

PATIENTS AND METHODS

Thirty-six patients with STS were enrolled onto the study between September 1999 and August 2000. Patients were treated with 1.5 mg/m2 of ET-743 given as a 24-hour continuous intravenous (IV) infusion every 21 days. Pharmacokinetic sampling was performed in 23 patients.

RESULTS

One complete and five partial responses were achieved in 35 assessable patients for an overall response rate of 17.1% (95% CI, 6.6% to 33.6%). In addition, one patient had a minor response, leading to an overall clinical benefit of 20%. Neutropenia and transaminitis were the main grade 3 to 4 toxicities, which occurred in 33% and 36% of the patients. The estimated 1-year progression-free and overall survival rates were 21% (95% CI, 11% to 41%) and 72% (95% CI, 59% to 88%), respectively. Total body clearance (L/h) was not significantly correlated with body-surface area (r = -0.28; P = .21). Mild hepatic impairment or the extent of prior cytotoxic therapy does not seem to contribute significantly to the high interpatient variability (49%) in the clearance of this drug. Severity of treatment-related toxicity was not correlated with pharmacokinetic variables.

CONCLUSION

ET-743 demonstrates clinical activity as first-line therapy against STS with acceptable toxicity. Additional studies to establish empirical dosing guidelines may be necessary to improve the safety of the drug in patients with varying degrees of hepatic dysfunction and definitively establish the role of ET-743 for patients with these malignancies.

Aortic Root Infection in a Prosthetic Valve Demonstrated by Gallium-67 Citrate SPECT

A 70-year-old man presented with 6 weeks of worsening low back pain, fever, sweating, and weight loss with known severe lumbosacral osteoarthritis. His history included CABG in 1992, porcine aortic valve replacement, and permanent pacemaker implantation in 2002. CT of the chest, abdomen, and pelvis did not demonstrate a cause for the symptoms. Blood cultures grew penicillin-sensitive enterococcus and he was referred for evaluation of possible osteodiskitis or epidural abscess. Gallium planar imaging demonstrated increased activity in the lumbar spine, suspicious for the presence of infection, and activity was noted in the mid mediastinum as well. SPECT clearly showed increased Ga-67 activity in the region of the aortic root, suspicious for infection. A perivalvular aortic root abscess was subsequently demonstrated by transesophageal echo. This case illustrates the value of Ga-67 chest SPECT in patients with prosthetic valves for detection of endocarditis.

Medical imaging in neurological disorders

Functional imaging is clinically useful in evaluating cerebrovascular disease, dementia, and presurgical localization of epileptic foci. Both PET and SPECT are complex technologies that must be performed carefully to yield interpretable images. SPECT and PET images can be very useful in detecting the changes in blood flow or glucose metabolism of epileptogenic tissues, although image interpretation in infants and young children must consider the differing types and levels of activity in the developing brain. PET and SPECT are being used to evaluate a new generation of antiparkinsonian medications aimed at slowing the course of the disease, rather than simply symptom abatement.

99m Tc anti-CD 15 monoclonal antibody (LeuTech) imaging improves diagnostic accuracy and clinical management in patients with equivocal presentation of appendicitis

BACKGROUND

Appendicitis frequently presents in an atypical fashion leading to misdiagnosis or a delay in diagnosis. This is particularly true in early cases where the patient may be erroneously discharged from an emergency department and will invariably return with perforated appendicitis. The standard of care is hospital admission for observation or early operation. Adjunctive imaging tests have been used with mixed results in this equivocal patient population. The authors studied a promising new monoclonal antibody, 99mTc-labeled anti-CD 15 (LeuTech; Palatin Technologies, Inc., Princeton, NJ), which specifically targets neutrophils and may be used for imaging appendicitis. This prospective, multicenter, open-label study evaluated the diagnostic efficacy and clinical impact of LeuTech scintigraphy for detecting appendicitis in patients with an equivocal presentation.

METHODS

A total of 200 patients (121 females, 79 males; age range 5-86 years; mean age 30.5 +/- 16.5 years) completed the study. Management plan was formulated before and reassessed following LeuTech imaging to determine impact on management. Following intravenous injection of LeuTech, the abdomen was imaged with a standard gamma camera for 30 to 90 minutes.

RESULTS

Fifty-nine patients had a histopathologic diagnosis of acute appendicitis. LeuTech identified 53 of 59 patients with appendicitis (90% sensitivity) and was negative in 122 of 141 patients without appendicitis (87% specificity). Accuracy, positive predictive value, and negative predictive value were 88%, 74%, and 95%, respectively. Diagnostic efficacy was unchanged in a subgroup of 48 pediatric patients (5-17 years). Diagnostic images for appendicitis were achieved within 8 minutes postinjection in 50% of patients and within 47 minutes in 90% of patients. Significant shifts in patient management decisions were evident following LeuTech results. LeuTech was well tolerated with no serious adverse events reported.

CONCLUSION

LeuTech is a convenient, safe, rapid, and sensitive imaging test for diagnosis of appendicitis and favorably impacts patient management in adult and pediatric patients with equivocal signs and symptoms.

Public-private health partnerships: a strategy for WHO

Following early success with a number of high-profile partnerships, WHO is increasingly working with the private for-profit sector. In so doing, the organization finds itself in the maelstrom of a vibrant debate on the roles of public, civic, and commercial entities in society and on the appropriate modes of interaction among them. This paper examines WHO's involvement with the commercial sector, particularly in partnerships. WHO's approach to this sector is outlined and the criticisms levelled at public-private partnerships are reviewed. An indication is given of the steps recently taken by WHO to confront the concerns that have been expressed. The paper argues that partnership between WHO and the commercial sector is inevitable and that it presents considerable opportunities, but also significant risks, for the organization and for public health. A strategy is proposed for directing the debate on issues critical to WHO and its role in the promotion and protection of public health.

ASCCP Practice Guidelines Management Guidelines for the Follow-up of Atypical Squamous Cells of Undetermined Significance (ASCUS)

: Editor's Note: This guideline was first published in The Colposcopist in January 1996 and reflected the peer-reviewed literature available on the management of ASCUS at that time. The decision to republish this guideline in The Journal of Lower Genital Tract Disease, to accompany guidelines on the management of low-grade squamous intraepithelial lesion (LGSIL) and benign cellular changes (BCC) was made to complete the set of guidelines in the Journal pertaining to management of the cytology screening system. (See also previous guidelines on Management Issues Related to the Quality of the Smear, Management of Atypical Glandular Cells of Undetermined Significance (AGUS), and the Abnormal Pap Follow-up System.) Our original intention was to update the ASCUS guideline for this publication in the expectation that the data from the enrollment phase of the National Cancer Institute's ASCUS LGSIL Triage Study (ALTS) would be available to provide relevant evidence-based recommendations. The unavailability of this data at this time has ensured a later update of the ASCUS guideline. However, an accumulating body of new literature, particularly on the clinical utility of HPV testing with Hybrid Capture II (Digene Corp., Gaithersburg, MD), will be incorporated within the next year with the enrollment ALTS data in a new ASCUS guideline. Until that time, the guideline presented here remains the recommendation of the ASCCP, based on the review of the literature at that time, and on the collective experience and knowledge of the ASCCP Practice Committee and the Board of Directors.The cost analysis in this guideline is based upon a set of cost assumptions which will vary from setting to setting. This analysis is intended to serve as a reference for average costs in a fee-for-service setting. The individual practitioner will need to analyze cost differentials for his/her own setting.This guideline reflects emerging clinical and scientific advances as of February 1996, and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Fat intolerance depends on rapid gastric emptying

Patients with fat intolerance complain of early satiety, bloating, nausea, and vomiting. Since these symptoms are similar to those of patients with postgastrectomy dumping syndrome, we hypothesized that fat intolerance may be associated with early, rapid gastric emptying. Using a three-meal gastric emptying study, we compared gastric emptying in nine patients with a history of fat intolerance and nine normal volunteers. On three separate days, 500-ml radiolabeled test meals containing 0, 15, or 60 g of fat were studied. The percentages of the test meal emptied at 15 and 60 min were analyzed by repeated measures two-way ANOVA. At 15 min (p < 0.05) but not 60 min, gastric emptying was faster in patients than normals. Gastric emptying at 15 min (p < 0.001) and 60 min (p < 0.001) depended on the dose of fat. We conclude that fat intolerance is associated with early, rapid gastric emptying.

The impact of managed behavorial healthcare on the costs of psychiatric and chemical dependency treatment

As Congress debates the Health Security Act, a key issue centers on whether and how to include mental health and substance abuse benefits and how to contain costs if and when these benefits are paid at parity with general healthcare. Previous studies estimating the average annual cost of providing behavioral healthcare services have shown considerable divergence, depending on the nature of the defined population and the inclusion of various benefit categories, out-of-pocket expense and administrative costs. Experience from 14 members of the American Managed Behavioral Healthcare Association (AMBHA) is used to define the key features of managed behavioral healthcare, and to demonstrate that a properly managed behavioral healthcare benefit can be significantly less costly than the current reform debate would admit. AMBHA companies (which have many years of experience and presently manage the cost and quality of care for over 65 million people in the United States) [See Table 3, page 28], have shown that a specialty managed care approach can achieve not only significant savings to healthcare providers, payers and society, but also improve quality and access to care. Traditional attempts at reducing mental illness benefit coverage costs have entailed limitations on the availability or access to care. These approaches, however, ignored the larger implications to society of untreated mental illness and chemical dependency. When traditional coverages have offered more extensive benefits, they have primarily favored inpatient treatment, thus increasing costs by overemphasizing care of patients at expensive inpatient settings. AMBHA's proposed principles of healthcare reform and recommended benefit packages for behavioral healthcare can be found on page 80 of this magazine.

Serial thallium-201 scintigraphy in osteosarcoma. Correlation with tumor necrosis after preoperative chemotherapy

In 27 patients with extremity lesions (24 osteosarcoma, three malignant fibrous histiocytoma), a notable decrease in thallium-201 uptake was correlated with a good response to preoperative chemotherapy of the primary tumor. A good response is indicated by a greater than 95% tumor necrosis. Serial quantitative thallium-201 uptake of malignant bone tumors in patients receiving preoperative chemotherapy therefore can accurately predict a good histologic response and prognosis. Serial thallium scintigraphy can furthermore identify poor responses within two weeks after the initiation of treatment, or can prompt an early change in preoperative chemotherapy and facilitate limb salvage surgery.

Thallium-201 scintigraphy in differentiated thyroid cancer: comparison with radioiodine scintigraphy and serum thyroglobulin determinations

The role of thallium-201 (201TI) scintigraphy in the follow-up evaluation of differentiated thyroid carcinoma (DTC) is controversial. Desirable characteristics of 201TI scintigraphy including the potential for no thyroid hormone withdrawal, immediate imaging postinjection, and low radiation burden relative to iodine-131 (131I) suggests it is logistically superior to 131I scintigraphy. Fifty-two patients with DTC were evaluated with 201TI and 131I neck and chest images, and serum thyroglobulin measurements. In post-thyroidectomy and pre-131I ablation therapy patients, very little 201TI accumulation was noted within the thyroid bed, with discordantly increased 131I activity and normal serum thyroglobulin measurements. Twenty-nine percent of patients evaluated after 131I ablative therapy had elevated serum thyroglobulin levels and localized neck and chest abnormalities on 201TI scan that were not seen on 131I studies. Our data suggest that 201TI is more sensitive than 131I diagnostic (5 mCi) studies for detection of DTC, while 131I is more sensitive in detecting normal residual thyroid tissue postoperatively.

Thallium-201 scintigraphy in bone sarcoma: comparison with gallium-67 and technetium-MDP in the evaluation of chemotherapeutic response

This study attempts to characterize thallium-201 (201TI) uptake in patients with bone and soft-tissue sarcoma and to compare these findings with gallium-67 (67Ga) and bone scintigraphy with emphasis on evaluating tumor viability before and after chemotherapy. Thirty-eight patients with surgically-proven sarcomas were evaluated. All patients had gallium and thallium studies. Nineteen patients underwent pre- and post-chemotherapy thallium and evaluation. Seven patients also had technetium-99m-MDP (99mTc-MDP) bone scintigraphy comparisons. Pathologic changes pre- and postchemotherapy were graded on the basis of %tumor necrosis as defined histologically. Scintigraphic comparisons demonstrated a high degree of correlation with 201TI and poor correlation with 99mTc-MDP. Thallium-201 was superior to 99mTc-MDP and 67Ga in predicting tumor response to chemotherapy as determined by %tumor necrosis determined histologically. Gallium was superior to Tc-MDP in predicting response to chemotherapy. However, both 67Ga and 99mTc-MDP appear to be affected by factors other than tumor activity.

"Upward creep" of the heart: a frequent source of false-positive reversible defects during thallium-201 stress-redistribution SPECT

A new cause of artifactual 201Tl defects on single photon emission computed tomography (SPECT) termed "upward creep" of the heart is described. In 102 consecutive patients undergoing 201Tl SPECT, 30 (29%) demonstrated upward creep defined by an upward movement of the heart of greater than or equal to 2 pixels during acquisition. In 45 consecutive patients with a less than 5% likelihood of coronary artery disease, 17 (38%) had upward creep. Of these nine had reversible 201Tl defects localized to the inferior and basal inferoseptal walls, while none of the 28 without upward creep had defects. The 17 low likelihood patients with upward creep had longer exercise duration and higher peak heart rate than those without upward creep. In five additional low likelihood patients with upward creep in whom imaging was immediately repeated, the upward creep pattern disappeared on the repeated images. After we changed our test protocol to begin imaging 15 min postexercise, only five (14%) of 36 low likelihood patients tested demonstrated upward creep. Upward creep is probably related to a transient increase in mean total lung volume early following exhaustive exercise, resulting in a mean lower position of the diaphragm (and thus the heart) at the beginning of imaging. The frequency of this source of false-positive 201Tl studies can be reduced by delaying SPECT acquisition until 15 min postexercise.

Responses of left and right ventricular ejection fractions to aerobic and anaerobic phases of upright and supine exercise in normal subjects

The effects of aerobic and anaerobic exercise on ventricular performance were studied in 13 normal subjects who underwent simultaneous pulmonary gas exchange evaluation and exercise radionuclide ventriculography in the supine and upright postures. Right and left ventricular ejection fraction was measured serially at 2-minute intervals during exercise. The anaerobic threshold occurred at 74% and 80% of maximum heart rate, respectively, during upright and supine exercise. Left and right ventricular ejection fractions rose from rest to the anaerobic threshold (p less than 0.01, p less than 0.01, respectively) and there was a further increase between the anaerobic threshold and maximum exercise (p less than 0.01, p less than 0.01, respectively). The rate of rise of ejection fraction beyond the anaerobic threshold was slightly blunted compared with the rise prior to attaining the anaerobic threshold. There was no significant difference in ventricular performance between supine and upright exercise. The data demonstrate that ventricular performance increases steadily during exercise and is not limited by the conversion of aerobic to anaerobic metabolism.

Patient motion in thallium-201 myocardial SPECT imaging. An easily identified frequent source of artifactual defect

Because Tl-201 SPECT requires that patients remain in an awkward position for a prolonged time, patient motion is a potentially serious source of artifactual defects on tomographic reconstructions. Thus, a simple method was developed for detection and correction of motion from SPECT images using a Co-57 point source placed on the lower anterior chest, an area remaining in the camera's field of view throughout imaging. In the absence of motion, this point source inscribes a straight line on planar summation of the 32 projections over 180 degrees. Movement is detected by deviation from this line. The number of pixels of motion is used to shift images so that the resultant images of the point source are linear. The method of motion detection and correction was tested in 48 consecutive patients undergoing Tl-201 SPECT. The corrected and uncorrected images were reconstructed and long and short axis tomographic cuts were quantitatively analyzed using circumferential profiles of maximal counts with comparison to the lower limits of normal. Motion was detected in eight of 48 patients (17%). The amount of motion was 2 pixels in three patients and 1 pixel in five patients. Quantitative defect extent was less after correction in seven of eight patients, with a mean decrease of 71% in patients with 2 pixel motion and 44% in patients with 1 pixel motion. This corresponded with a definite reduction in the size of the tomographic defect by visual analysis, and closer resemblance to quantitatively analyzed planar images performed either before or after tomography in the same patient.(ABSTRACT TRUNCATED AT 250 WORDS)

The distribution of microtubule-associated protein 2 changes when dendritic growth is induced in rat sympathetic neurons in vitro

We have examined the distribution of microtubule-associated protein 2 in embryonic rat sympathetic neurons grown under culture conditions that alter morphological development. Cultures were established in serum-free medium. After 8 days some were transferred to a serum-containing medium, which promotes dendritic development. Sister cultures were maintained in serum-free medium, which inhibits dendritic growth but permits normal axonal development. After growth for 2-6 weeks in serum-containing medium, sympathetic neurons were multipolar, with short, tapering dendrites and long, thin axons. Intense immunoreactivity for microtubule-associated protein 2 was observed in the somata and dendrites of all neurons, but there was little or no staining of the network of axonal processes that ran between cell somata. When the morphology of individual cells was assessed by injection of fluorescent dye before immunostaining, we found that staining for microtubule-associated protein 2 extended to the distal tips of the dendrites while the axon was essentially unstained, even in its proximal portion. Neurons from sister cultures that were not exposed to serum were usually unipolar, having only an axon. Under these conditions microtubule-associated protein 2 was also expressed, but its distribution was altered: intense immunostaining for microtubule-associated protein 2 was present in axons as well as somata. Staining in axons could sometimes be traced for several millimeters, but, since unstained segments of axons were also common, microtubule-associated protein 2 probably was not present throughout the entire axonal arborization. These results show that the expression of microtubule-associated protein 2 is not of itself sufficient to induce the formation of dendrites. Despite the association of microtubule-associated protein 2 with the axonal cytoskeleton, the light microscopic morphology of the axons was not obviously altered.

Transient ischemic dilation of the left ventricle on stress thallium-201 scintigraphy: a marker of severe and extensive coronary artery disease

On exercise thallium-201 scintigraphy, it has been noted that the size of the left ventricle is sometimes larger on the immediate poststress image than on the 4 hour redistribution image; this phenomenon has been termed transient ischemic dilation of the left ventricle. The angiographic correlates of this finding were assessed in 89 consecutive patients who underwent both stress-redistribution thallium-201 scintigraphy and coronary arteriography. A transient dilation ratio was determined by dividing the computer-derived left ventricular area of the immediate postexercise anterior image by the area of the 4 hour redistribution image. In patients with a normal coronary arteriogram or nonsignificant coronary stenoses (less than 50%), the transient dilation ratio was 1.02 +/- 0.05 and, therefore, an abnormal transient dilation ratio was defined as greater than 1.12 (mean + 2SD). The transient dilation ratio was insignificantly elevated in patients with noncritical coronary artery disease (50 to 89% stenosis) (1.05 +/- 0.05) and in patients with critical stenosis (greater than or equal to 90%) of only one coronary artery (1.05 +/- 0.05). In contrast, in patients with critical stenoses in two or three vessels, the transient dilation ratio was significantly elevated (1.12 +/- 0.08 and 1.17 +/- 0.09, respectively; p less than 0.05 compared with all other patient groups). An abnormal transient dilation ratio had a sensitivity of 60% and a specificity of 95% for identifying patients with multivessel critical stenosis and was more specific (p less than 0.05) than were other known markers of severe and extensive coronary artery disease, such as the presence of multiple perfusion defects or washout abnormalities, or both.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in distribution of lung perfusion and ventilation at rest and during maximal exercise

A new method for evaluation of changes in the distribution of pulmonary perfusion and ventilation during exercise was applied to normal male volunteers. Ventilation and perfusion scans were done with the subjects seated on a bicycle ergometer. The resting studies utilized krypton 81 (81mKr) for ventilation and technetium 99m (99mTc) macroaggregate albumin intravenously for perfusion. Exercise studies were done when 80 percent of maximum predicted heart rate was maintained for five minutes and utilized 81mKr for ventilation and a tenfold dose of 99mTc for perfusion. Higher dose of 99mTc would minimize the effect of radioactivity left over from the resting study. This method allowed us to assess changes in ventilation and perfusion in normal subjects induced by exercise, but may also be applicable in a variety of cardiopulmonary conditions that affect pulmonary ventilation and perfusion or both.

Quantification of rotational thallium-201 myocardial tomography

A comprehensive method is described for quantification of the relative 3-dimensional distribution of Tl-201 in the myocardium, following stress and subsequent washout. The method uses maximal-count circumferential profiles of well-defined long- and short-axis tomograms to determine the 3-dimensional distribution of Tl-201; it then maps this distribution onto a 2-dimensional polar representation. Abnormal thallium distribution or washout is identified by automatic computer comparison of each patient's profile with the corresponding lower limits of normal profiles. Abnormality is expressed as a percentage of the entire myocardium by use of polar maps for extent and severity. The binary extent map expresses the degree of abnormality. Preliminary criteria for abnormality were derived from the tomographic results of 25 normals and 28 patients with documented coronary artery disease. The results were normal in 23 of the 25 normals and were abnormal in 25 of the 28 CAD patients. In addition, the computer output correctly localized the presence or absence of disease in 46 of 56 coronary circulations.

Sialadenitis following I-131 therapy for thyroid carcinoma: concise communication

During a 4-yr period, ten of 87 patients (11.5%) who received therapeutic doses of radioactive iodine (I-131) for thyroid carcinoma developed acute and/or chronic sialadenitis involving the parotid (five patients) or submandibular (four patients) glands, or both (one patient). Nine of the 10 patients had received prior I-131 therapy; the precipitating I-131 dose varied between 10 and 164 mCi. Onset of symptoms occurred between 1 day and 6 mo following therapy and the duration varied from 3 wk to 21/2 yr. This complication occurs more often than has been appreciated.