Survival outcome of metastatic adenocarcinoma patients after patient-tailored outpatient chemotherapy guided by fusion imaging

13145

Background: We treated 173 patients with metastatic Stage IV adenocarcinoma, including 65 patients with metastatic colorectal cancer (MCRC), 22 patients with metastatic pancreas cancer (MPC), and 86 patients with metastatic breast cancer (MBC) in an outpatient setting. The metastatic sites included liver (49% of patients), bone (39%), lung (36%), brain (16%), peritoneum (16%), lymph node (14%) and chest wall (8%). Methods: MCRC patients received multiple cycles of Xeloda-based empirical chemotherapy regimens: alone or in combination with Irinotecan, Oxaliplatin or Mitomycin. MPC patients were given cycles of Gemcitabine-based empirical chemotherapy regimens: alone or with Cisplatin, 5-FU or Xeloda. MBC patients received cycles of Taxol-based chemotherapy: alone or with Adriamycin, Carboplatin or Gemcitabine; Xeloda plus Taxotere or Vinorelbine; Gemcitabine plus Taxotere or Vinorelbine; and Adriamycin plus Taxotere. Anatomic imaging/fusion technology with combined anatomic and functional imaging (CT/MRI fused with whole body PET scans) plus serial cancer marker level measurements monitored response to therapy and in patients showing evidence of progression on a given regimen were switched to a different treatment regimen. Results: Kaplan Meier calculated median survival time for all 173 metastatic adenocarcinoma patients was 17 mo (95% CI 13–19 mo); for subgroups medians were 12 mo (9–16 mo), 16 (8–22 mo) and 22 mo (18–42 mo) for MCRC, MPC and MBC patients respectively. The probability of living at 1 yr after initiation of therapy was 61 ± 6% for all patients, 47 ± 6% for MCRC, 59 ± 10% for MPC and 72 ± 5% for MBC patients. Our results indicate that a significant portion of previously treated patients with MCRC, MPC and MBC with liver, lung, and/or brain metastases can achieve objective responses and long-term progression-free survival with an excellent quality of life on patient tailored outpatient treatments guided by fusion imaging. Conclusions: Fusion technology provides a powerful diagnostic tool for timely termination or modification of ineffective treatments. Empirical patient-tailored chemotherapy should be offered to metastatic adenocarcinoma patients as an alternative to the clinical trial and hospice options.

No significant financial relationships to disclose.

Clonal origin of recurrent meningiomas

Meningiomas are common intracranial and intraspinal tumors. They are treated primarily by surgical resection. Meningioma recurrence following surgery is frequent despite advances in microneurosurgery. However, it is not clear whether recurrent meningiomas, close or distant to the primary resection site, arise from incomplete resection, dissemination of tumor fragments or from independent tumor growth. In order to address the question of clonality in recurring meningiomas, we examined a series of five patients with a total of 14 tumors for X-chromosome inactivation in the tumor tissues. Four patients with a total of 11 meningiomas were informative for polymorphisms either in the PGK or the AR genes. All recurrent meningiomas were found to be clonal with respect to the primary lesions. This finding suggests a common molecular pathogenesis of primary meningioma and subsequent recurrences (p<0.01). In a sixth patient, we analyzed the NF2 gene for mutations in the primary and 5 recurrent meningiomas. All six lesions carried the identical NF2 mutation, strongly indicating a common origin for these tumors. We conclude that recurrent meningiomas usually arise from dissemination of tumor fragments, most likely at the time of the first surgical resection. Our data should alert to the potential of meningioma cells for seeding during surgical procedures.

Emotional Self-Efficacy, Stressful Life Events, and Satisfaction with Social Support in Relation to Mood Disturbance among Women Living with Breast Cancer in Rural Communities

This study evaluated the relationships of emotional self-efficacy, stressful life events, and social support with mood disturbance among women diagnosed with breast cancer who live in rural communities. Eighty-two women completed measures of demographic characteristics, medical status, and psychosocial variables. Using multiple regression analysis, we found that greater mood disturbance was related to having less emotional self-efficacy (p < 0.001) and to having experienced more stressful life events (p = 0.02), while satisfaction with social support was not significantly related to mood disturbance (adjusted R2 = 0.39). Women living with breast cancer in rural communities who have experienced multiple stressful life events may have an increased risk for mood disturbance, whereas having greater emotional self-efficacy may provide resilience against mood disturbance.

Thalomid (Thalidomide) capsules: a review of the first 18 months of spontaneous postmarketing adverse event surveillance, including off-label prescribing

The sedative/hypnotic thalidomide was withdrawn from the worldwide market nearly 40 years ago, because of its teratogenic and neurotoxic effects. Thalidomide was later found to very effectively suppress erythema nodosum leprosum (ENL). The US Food and Drug Administration (FDA) has approved Thalomid (thalidomide) capsules for the acute treatment of the cutaneous manifestations of moderate to severe ENL. Thalidomide is currently under investigation for the treatment of a wide variety of diseases, including conditions thought to have an inflammatory or immune basis, malignancies and complications of infection with HIV. Interest in the potential anti-inflammatory, immunomodulatory and anti- angiogenic effects of thalidomide has resulted in off-label use of prescription thalidomide. During the first 18 months of spontaneous postmarketing adverse event surveillance for Thalomid, 1210 spontaneous postmarketing adverse event reports were received for patients treated with prescription thalidomide for all therapeutic indications, including off-label use. The most common adverse events spontaneously reported would have been expected on the basis of the current Thalomid labelling/product information. The current labelling/product information reflects what was known about the risks associated with thalidomide therapy in limited patient populations at the time of the approval of Thalomid. With the postmarketing use of thalidomide in populations other than patients with ENL, it becomes increasingly important to identify patient groups that may be particularly susceptible to specific adverse drug effects and to identify conditions under which specific adverse events may be more likely to occur. Oncology patients may represent a patient population with increased susceptibility to thalidomide-associated adverse effects, including thromboembolic events. Consideration of the spontaneous postmarketing safety surveillance data may help to identify and characterise factors associated with increased risk in this and other patient groups. Serious unexpected adverse events reported with sufficient frequency to signal previously undetected product-event associations for which there may potentially be plausible evidence to suggest a causal relationship have included seizures and Stevens-Johnson syndrome. The potential effects of thalidomide on wound healing are also being closely monitored. Premarketing human clinical trials of drug products are inherently limited in their ability to detect adverse events. Broader postmarketing experience with thalidomide in more varied patient populations and more experience in the setting of long term thalidomide use will increase our ability to detect rare adverse events and to identify signals that may need to be evaluated in more controlled settings.

Predictors of family members' satisfaction with hospice

This large, long-term study of families served by hospice found that nearly 95 percent said hospice had been helpful. Still, about 30 percent of family members said there was something they wish hospice had done differently. Those who had some complaint were more likely than those who had no complaints to be women, to report the patient had needed a great deal of care, to have a history of depression and greater levels of distress before and after the patient's death, and to be dissatisfied with the support they received from family members and friends.

Down-regulation of dendritic spine and glutamic acid decarboxylase 67 expressions in the reelin haploinsufficient heterozygous reeler mouse

Heterozygous reeler mice (HRM) haploinsufficient for reelin express approximately 50% of the brain reelin content of wild-type mice, but are phenotypically different from both wild-type mice and homozygous reeler mice. They exhibit, (i) a down-regulation of glutamic acid decarboxylase 67 (GAD(67))-positive neurons in some but not every cortical layer of frontoparietal cortex (FPC), (ii) an increase of neuronal packing density and a decrease of cortical thickness because of neuropil hypoplasia, (iii) a decrease of dendritic spine expression density on basal and apical dendritic branches of motor FPC layer III pyramidal neurons, and (iv) a similar decrease in dendritic spines expressed on the basal dendrite branches of CA1 pyramidal neurons of the hippocampus. To establish whether the defect of GAD(67) down-regulation observed in HRM is responsible for neuropil hypoplasia and decreased dendritic spine density, we studied heterozygous GAD(67) knockout mice (HG(67)M). These mice exhibited a down-regulation of GAD(67) mRNA expression in FPC (about 50%), but they expressed normal amounts of reelin and had no neuropil hypoplasia or down-regulation of dendritic spine expression. These findings, coupled with electron-microscopic observations that reelin colocalizes with integrin receptors on dendritic spines, suggest that reelin may be a factor in the dynamic expression of cortical dendritic spines perhaps by promoting integrin receptor clustering. These findings are interesting because the brain neurochemical and neuroanatomical phenotypic traits exhibited by the HRM are in several ways similar to those found in postmortem brains of psychotic patients.

Intracellular parasitism by the human granulocytic ehrlichiosis bacterium through the P-selectin ligand, PSGL-1

Human granulocytic ehrlichiosis (HGE) is a febrile tick-borne illness caused by a recently discovered intracellular bacterium remarkable for its tropism for professionally phagocytic neutrophils. Monoclonal antibodies against the P-selectin binding domain of the leukocyte P-selectin glycoprotein ligand, PSGL-1, prevented HGE cell binding and infection, as did enzymatic digestion of PSGL-1. Furthermore, simultaneous neoexpression in nonsusceptible cells of complementary DNAs for both PSGL-1 and its modifying alpha-(1,3) fucosyltransferase, Fuc-TVII, allowed binding and infection by HGE. Thus, the HGE bacterium specifically bound to fucosylated leukocyte PSGL-1. Selectin mimicry is likely central to the organism's unique ability to target and infect neutrophils.

Thyroid disease: a review for primary care

Manifestations of thyroid disease include hyperthyroidism and hypothyroidism. In the past, the diagnosis of thyroid disease has been perplexing due to the multisystemic effects of thyroid hormone and the lack of specificity in laboratory tests. New methods of measuring thyroid function have made screening and diagnosis of thyroid dysfunction both more accurate and cost-effective. Testing for thyroid stimulating hormone (TSH) is now a first-line diagnostic procedure and, in some cases, may be the only test indicated. The general pathophysiology of thyroid, the diagnosis and management of thyroid disease, and current screening recommendations are reviewed here.

Peripheral administration of a serine protease inhibitor blocks kindling

An inhibitor of tissue plasminogen activator (tPA) was tested for its effects on the rapid kindling induced by a series of afterdischarges (ADs) triggered in hippocampus over a 3-h period. Rats injected with vehicle prior to the session had prolonged ADs in tests carried out 10 days later. This was not the case for animals treated with the inhibitor. These findings support the hypothesis that activity-driven proteolysis contributes importantly to the production of long-lasting physiological changes.

Isolation of Neisseria gonorrhoeae mutants that show enhanced trafficking across polarized T84 epithelial monolayers

Initiation of a gonococcal infection involves attachment of Neisseria gonorrhoeae to the plasma membrane of an epithelial cell in the mucosal epithelium and its internalization, transepithelial trafficking, and exocytosis from the basal membrane. Piliation and expression of certain Opa proteins and the immunoglobulin A1 protease influence the transcytosis process. We are interested in identifying other genetic determinants of N. gonorrhoeae that play a role in transcellular trafficking. Using polarized T84 monolayers as a model epithelial barrier, we have assayed an N. gonorrhoeae FA1090 minitransposon (mTn) mutant bank for isolates that traverse the monolayer more quickly than the isogenic wild-type (WT) strain. From an initial screen, we isolated four mutants, defining three genetic loci, that traverse monolayers significantly more quickly than their WT parent strain. These mutants adhere to and invade cells normally and do not affect the integrity of the monolayer barrier. Backcrosses of the mutations into the WT FA1090 strain yielded mutants with a similar fast-trafficking phenotype. In two mutants, the mTns had inserted 370 bp apart into the same locus, which we have named fit, for fast intracellular trafficker. Backcrosses of one of these mutants into the MS11A genetic background also yielded a fast-trafficking mutant. The fit locus contains two overlapping open reading frames, fitA and fitB, whose deduced amino acid sequences have predicted molecular weights of 8.6 and 15.3, respectively. Neither protein contains a signal sequence. FitA has a potential helix-turn-helix motif, while the deduced sequence of FitB offers no clues to its function. fitA or fitB homologues are present in the genomes of Pseudomonas syringae and Rhizobium meliloti, but not Neisseria meningitidis. Replication of the MS11A fitA mutant in A431 and T84 cells is significantly accelerated compared to that of the isogenic WT strain. In contrast, growth of this mutant in liquid media is normal. Taken together, these results strongly suggest that traversal of N. gonorrhoeae across an epithelial barrier is linked to intracellular bacterial growth.

Explaining the gender difference in depressive symptoms

It was hypothesized that women are more vulnerable to depressive symptoms than men because they are more likely to experience chronic negative circumstances (or strain), to have a low sense of mastery, and to engage in ruminative coping. The hypotheses were tested in a 2-wave study of approximately 1,100 community-based adults who were 25 to 75 years old. Chronic strain, low mastery, and rumination were each more common in women than in men and mediated the gender difference in depressive symptoms. Rumination amplified the effects of mastery and, to some extent, chronic strain on depressive symptoms. In addition, chronic strain and rumination had reciprocal effects on each other over time, and low mastery also contributed to more rumination. Finally, depressive symptoms contributed to more rumination and less mastery over time.

Explaining the gender difference in depressive symptoms

It was hypothesized that women are more vulnerable to depressive symptoms than men because they are more likely to experience chronic negative circumstances (or strain), to have a low sense of mastery, and to engage in ruminative coping. The hypotheses were tested in a 2-wave study of approximately 1,100 community-based adults who were 25 to 75 years old. Chronic strain, low mastery, and rumination were each more common in women than in men and mediated the gender difference in depressive symptoms. Rumination amplified the effects of mastery and, to some extent, chronic strain on depressive symptoms. In addition, chronic strain and rumination had reciprocal effects on each other over time, and low mastery also contributed to more rumination. Finally, depressive symptoms contributed to more rumination and less mastery over time.

Alterations in synaptic transmission and long-term potentiation in hippocampal slices from young and aged PDAPP mice

Synaptic transmission and plasticity were studied in the CA1 field of hippocampal slices from young and aged transgenic mice over-expressing a mutant form of the human amyloid precursor protein (PDAPP mice). The transgenic mice at 4-5 months of age, prior to the formation of amyloid-beta peptide deposits in these animals, differed from non-transgenic control mice in three respects: (1) paired-pulse facilitation (PPF) was enhanced; (2) responses to high frequency stimulation bursts were distorted; (3) long-term potentiation (LTP) decayed more rapidly. More striking was the profound reduction in the size of synaptic responses and frequent loss of field potentials that were found in the transgenic mice at 27-29 months, an age at which they exhibit numerous amyloid plaques, neuritic dystrophy, and gliosis. Control mice at these ages did not show such dramatic effects. PPF was reduced in aged transgenic mice, compared to aged controls; however, LTP was still in evidence, although direct comparisons of its induction conditions in aged transgenic and control mice were compromised by the profound differences in field potentials between the two groups. These results point to two conclusions: (1) altered synaptic communication appears in PDAPP mice in advance of amyloid plaque formation and probably involves changes in presynaptic calcium kinetics; (2) the disturbances in synaptic transmission that appear when abundant plaques and Alzheimer's-like neuropathology are present in the transgenic mice are not necessarily accompanied by a disproportionate loss of long-term synaptic plasticity.

Mapping the pro-region of carboxypeptidase B by protein engineering. Cloning, overexpression, and mutagenesis of the porcine proenzyme

The proteolytic processing of pancreatic procarboxypeptidase B to a mature and functional enzyme is much faster than that of procarboxypeptidase A1. This different behavior has been proposed to depend on specific conformational features at the region that connects the globular domain of the pro-segment to the enzyme and at the contacting surfaces on both moieties. A cDNA coding for porcine procarboxypeptidase B was cloned, sequenced, and expressed at high yield (250 mg/liter) in the methylotrophic yeast Pichia pastoris. To test the previous hypothesis, different mutants of the pro-segment at the putative tryptic targets in its connecting region and at some of the residues contacting the active enzyme were obtained. Moreover, the complete connecting region was replaced by the homologous sequence in procarboxypeptidase A1. The detailed study of the tryptic processing of the mutants shows that limited proteolysis of procarboxypeptidase B is a very specific process, as Arg-95 is the only residue accessible to tryptic attack in the proenzyme. A fast destabilization of the connecting region after the first tryptic cut allows subsequent proteolytic processing and the expression of carboxypeptidase B activity. Although all pancreatic procarboxypeptidases have a preformed active site, only the A forms show intrinsic activity. Mutational substitution of Asp-41 in the globular activation domain, located at the interface with the enzyme moiety, as well as removal of the adjacent 310 helix allow the appearance of residual activity in the mutated procarboxypeptidase B, indicating that the interaction of both structural elements with the enzyme moiety prevents the binding of substrates and promotes enzyme inhibition. In addition, the poor heterologous expression of such mutants indicates that the mutated region is important for the folding of the whole proenzyme.

Activation of muscarinic M3-like receptors and beta-adrenoceptors, but not M2-like muscarinic receptors or alpha-adrenoceptors, directly modulates corticostriatal neurotransmission in vitro

The aim of this study was to characterize the modulation of synaptic transmission in the glutamatergic corticostriatal pathway by cholinergic and adrenergic receptors. In coronal slices of mouse brain, negative-going field potentials were recorded in the dorsal striatum in response to stimulation of the overlying white matter, and their susceptibility to various pharmacological manipulations was studied. The responses were mediated by alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA)-type glutamate receptors, since they were augmented by aniracetam (0.5-1.5 mM), a positive modulator of AMPA-type glutamate receptors, and blocked by 6-cyano-7-nitroquinoxaline-2,3-dione (> or = 10 microM), a selective antagonist of AMPA receptors. Carbachol (10 microM), a muscarinic agonist, reduced the size of responses and abolished paired-pulse depression; these effects being consistent with previous studies indicating that muscarinic activation inhibits release of glutamate in the corticostriatal pathway. Muscarinic antagonists could block the effect of carbachol. Their rank order was: 10 microM scopolamine (a non-selective muscarinic antagonist) > or = 1 microM 4-diphenylacetoxy-N-methyl-piperidine (M3/M1 antagonist)>1 microM pirenzepine (M1 antagonist)>10 microM methoctramine (M2 antagonist). McN-A-343 (1-10 microM), an M1 muscarinic agonist, was ineffective in this preparation. In contrast, isoproterenol (10-30 microM), a beta-adrenergic agonist, slightly increased the synaptic responses, but it did not affect paired-pulse depression. None of alpha-adrenergic agents (30 nM-1.0 microM dexmedetomidine, an alpha2-adrenergic agonist, 0.3 microM atipamezole, an alpha2-adrenergic antagonist or 30 microM phenylephrine, an alpha1-adrenergic agonist) influenced the size of the responses; neither did these drugs alter paired-pulse depression. These results indicate that the activation of striatal M3-like muscarinic receptors and beta-adrenoceptors, but not M2-like muscarinic receptors and alpha-adrenoceptors, modulates directly corticostriatal glutamatergic neurotransmission.

Activation of NMDA receptors stimulates extracellular proteolysis of cell adhesion molecules in hippocampus

Recent work indicates that treatments which block adhesion receptors prevent the stabilization of long term potentiation (LTP). The experiments reported here show that brief stimulation of hippocampal NMDA receptors, a triggering event for LTP induction, results in the extracellular proteolysis of two or more members of the Cell Adhesion Molecule (CAM) family. This effect is rapid, occurs at a consensus serine protease site, and is selective to NMDA receptors. It is also found in vivo after kainic acid induced seizures. Cleavage of adhesive connections could be an early step in the formation of new synaptic configurations.

Making sense of loss and benefiting from the experience: two construals of meaning

Theoretical models of the adjustment process following loss and trauma have emphasized the critical role that finding meaning plays. Yet evidence in support of these models is meager, and definitions of meaning have been too broad to facilitate a clear understanding of the psychological process involved. Using a prospective and longitudinal study of people coping with the loss of a family member, we differentiate 2 construals of meaning--making sense of the event and finding benefit in the experience--and demonstrate that both independently play roles in the adjustment process following the loss. Results indicate that making sense of the loss is associated with less distress, but only in the 1st year postloss, whereas reports of benefit finding are most strongly associated with adjustment at interviews 13 and 18 months postloss.

Central nervous system tuberculoma: a case report

Pediatric cerebral tuberculoma is a disease rarely encountered in the United States. We report a case of central nervous system tuberculoma in a 6-month-old infant who presented to the emergency department with isolated right upper extremity paralysis. The discussion includes a brief review of central nervous system tuberculomas.

Making sense of loss and benefiting from the experience: two construals of meaning

Theoretical models of the adjustment process following loss and trauma have emphasized the critical role that finding meaning plays. Yet evidence in support of these models is meager, and definitions of meaning have been too broad to facilitate a clear understanding of the psychological process involved. Using a prospective and longitudinal study of people coping with the loss of a family member, we differentiate 2 construals of meaning--making sense of the event and finding benefit in the experience--and demonstrate that both independently play roles in the adjustment process following the loss. Results indicate that making sense of the loss is associated with less distress, but only in the 1st year postloss, whereas reports of benefit finding are most strongly associated with adjustment at interviews 13 and 18 months postloss.

Preserved induction of long-term potentiation in the stratum radiatum in the CA1 field of hippocampal slices from transgenic mice overexpressing ornithine decarboxylase and overproducing putrescine

The role of putrescine in synaptic neurotransmission and plasticity was studied using transgenic mice overexpressing ornithine decarboxylase (ODC), a polyamine-synthesizing enzyme. Transgenic mice were produced using the standard microinjection technique leading to elevated levels of putrescine in the periphery and in the brain. The experiments investigated whether or not ODC mice with elevated levels of putrescine show alterations in synaptic transmission and induction of long-term potentiation in the CA1 field of the hippocampus in vitro. Our results indicated that (1) putrescine levels in brain slices of the transgenic mice were more than ten times higher than those in fresh slices of control mice, although the absolute levels of putrescine and spermine decreased (by 15 and 40%, respectively) after 3-6 h incubation in vitro, while the levels of spermidine slightly increased (by 10%), (2) the excitatory synaptic response waveforms were wider (an increased half-width), and paired-pulse facilitation was somewhat reduced in ODC mice as compared to controls, and (3) potentiation of excitatory synaptic responses (measured 30-45 min after theta burst stimulation) did not differ between ODC and control mice. These results indicate that synaptic transmission is affected, but synaptic plasticity in the field CA1 assessed in vitro is not changed by elevated levels of intracellular putrescine.