Tissue-based molecular markers for renal cell carcinoma

Since the introduction of targeted therapies in renal cell carcinoma (RCC), more individualized treatment options have become available. Molecular markers might support treatment planning due to more accurate individual risk stratification. Current molecular markers in RCC were reviewed to elucidate clinical impact and future perspectives. An English-language literature review of the Medline database (1990 to September 2010) of published data on tissue-based molecular markers and RCC was undertaken. Histological types, clinical and oncological behaviour are variable in renal masses. Molecular markers offer potential for additional information in tumour detection and diagnosis, prognostic and predictive values, as well as determination of therapeutic targets. Investigations on molecular biomarkers in RCC include hypoxia inducible factor (HIF-α), vascular endothelial growth factor (VEGF), carbonic anhydrase IX (CAIX), mammalian target of rapamycin (mTOR), survivin, B7-H1, p53, matrix metalloproteinases (MMP), Insulin-like growth factor II mRNA-binding protein 3 (IMP3), Ki-67, C-reactive protein (CRP), Vimentin, Fascin, platelet count, hemoglobin level and combinations of these factors. Although some markers offer promising results, utilization in daily practice is compromised due to limited specificity, predictive accuracy and tumour histology variablity. There is an imminent need for novel molecular markers that allow accurate histologic and biologic classification of RCC to improve upon current outcomes. It is very likely that a panel of molecular markers will be used to achieve a sufficient degree of certainty in order to guide clinical decisions. A large concerted effort is required to advance the field of RCC molecular marker through systematic discovery, verification, and validation.

Predictors of hepatitis B screening among patients with cancer

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Background: Patients with hepatitis B virus (HBV) infection are at risk of reactivation after chemotherapy. It is unclear whether all patients or only those with certain risk factors should be screened for HBV before chemotherapy. The purpose of our study was to determine the clinical predictors of HBV screening in a single institution.

Methods: In this retrospective, cross-sectional study, we evaluated new patients who received chemotherapy between 1/1/04 and 9/30/07. We collected data on patients' demographics, types of cancer and chemotherapy, and HBV risk factors such as a previous ICD-9 code for hepatitis C or other liver conditions. We searched for HBV screening as defined by an HBsAg or anti-HBc test ordered prior to chemotherapy. In univariate analyses, we examined the association between each of the patient-related variables and HBV screening. We then determined predictors of HBV screening in a multivariable logistic regression model.

Results: We found 10,729 patients who had chemotherapy during the study period. Overall, 16.7% had HBV screening. All of the following predictors in the univariate analysis were significant for HBV screening at the p<0.01 level: age, gender, ethnicity, U.S. residence, cancer type, chemotherapy type, and having a HBV risk factor. In multivariable logistic regression examining predictors for screening using HBsAg, we found that Asian ethnicity (OR 1.75; 1.16-2.66), hematologic malignancies (OR 22.65; 19.3-26.31), and the receipt of rituxamab (OR 3.71; 3.03-4.48) were significant predictors at the p<0.01 level. Women were less likely to be screened than men (OR 0.68; 0.59-0.78). We repeated the analyses using the anti-HBc screening test, and the results were similar. Overall, 1.5% of the screened patients had a positive HBV test.

Conclusions: We found that ethnicity, cancer types, and chemotherapy drugs predict physician-driven HBV screening. Future research is needed to study the predictors of a positive HBV screening test and reactivation of HBV after chemotherapy.

[Table: see text]

[Urethral reconstruction after failed primary surgery]

There are numerous procedures available for surgical management of a urethral stricture. Establishing the correct indication for performing a specific surgical method requires a great deal of experience. Nonetheless, postoperative complications are never avoidable. Secondary intervention after an unsuccessful primary operation poses particular challenges to the surgeon. This article provides an overview of the open surgical techniques currently employed. It also highlights factors that should be considered to minimize postoperative complications. The concluding discussion describes the individual surgical procedures suitable for revision surgery depending on the previous approach.

Abstract P2-14-07: Predictors of Employment Outcomes in Breast Cancer (BrCa) Patients: An Analysis from E2Z02 (ECOG's SOAPP Study)

Cancer survivors are more likely to be unemployed than healthy counterparts (de Boer et al, JAMA 2009). BrCa patients comprise roughly one-fourth of the survivor population and face challenges in their ability to work. Age and cancer therapy may increase the risk for unemployment (Hassett et al, Cancer 2009). We analyzed data from E2Z02 to examine factors affecting employment in BrCa patients.

Methods: E2Z02 prospectively enrolled patients with breast, colon, lung and prostate cancer irrespective of therapy or stage. We limited this analysis to white or black BrCa patients with age at registration ≥65 yrs (those over 65 were excluded as likely to be retired; other minorities were excluded due to small numbers). Patients and oncologists answered the MDASI-ECOG regarding symptoms; additional baseline data regarding disease and treatment were collected. Change in employment was assessed by “Has your employment status changed due to illness?’ [Answer = Yes/No]; and level of employment by “What is your current employment status?” [Answer = full-time; part-time; not in the workforce]. We developed a multivariate logistic regression model for each employment outcome (change in employment, level of employment). Explanatory variables included treatment number (TNs), age (≥45 vs 46-65 yrs), race (white vs black), stage (nonmetastatic vs metastatic), therapy status (off vs on), and ECOG PS (0 vs 1 vs 2-4). TNs were counted as 0 (no medical therapy [MT] or radiotherapy [RT]), 1 (either) or 2 (both). MT encompassed both hormone and chemotherapy.

Results: E2Z02 accrued 3123 patients from 3/06 to 5/08 at academic (n=6) and community (n=32) medical oncology clinics (see demographics table); 50% of E2Z02 patients had BrCa. Patients with nonmetastatic BrCa (OR 2.16, 95% CI 1.53-3.05), off therapy (OR 1.79, 95% CI 1.31-2.44), and white race (OR 1.64, 95% CI 1.10-2.46) had a higher chance of remaining employed than their counterparts. Patients with PS 0 were more likely to remain employed compared to patients with PS 1 (OR 1.85 95%CI 1.36-2.5) or PS 2-4 (OR 2.61, 95% CI 1.25-5.44). Age and TNs were not significant. As to the level of employment, nonmetastatic patients (OR=1.60, 95% CI = 1.17-2.21) and patients with better PS (P&lt;0.0001) worked more hours in the workforce than their counterparts. Conclusions: This analysis identifies additional risk factors for employment changes in BrCa patients. Further research is needed to understand the complex relationship between race, other predictors and employment status. These findings could define a group of BrCa survivors at risk for changes in employment outcomes, and potentially allow for targeted interventions.

[Primary diffuse neurofibroma of the urinary bladder: a rare case report and review of the literature]

Diffuse neurofibromas are benign mesenchymal tumours with nerve sheath differentiation. Only a few cases have been reported in the urinary bladder. We present a well-documented case report of a 62-year-old man presenting with gross haematuria and histopathological confirmation of a diffuse neurofibroma. We further reviewed the current literature with regard to clinical features and treatment options.

Nanophotonics for quantum optics using nitrogen-vacancy centers in diamond

Optical microcavities and waveguides coupled to diamond are needed to enable efficient communication between quantum systems such as nitrogen-vacancy centers which are known already to have long electron spin coherence lifetimes. This paper describes recent progress in realizing microcavities with low loss and small mode volume in two hybrid systems: silica microdisks coupled to diamond nanoparticles, and gallium phosphide microdisks coupled to single-crystal diamond. A theoretical proposal for a gallium phosphide nanowire photonic crystal cavity coupled to diamond is also discussed. Comparing the two material systems, silica microdisks are easier to fabricate and test. However, at low temperature, nitrogen-vacancy centers in bulk diamond are spectrally more stable, and we expect that in the long term the bulk diamond approach will be better suited for on-chip integration of a photonic network.

Two-staged urethroplasty: buccal mucosa and mesh graft techniques

PURPOSE

The purpose of this study was to describe indications, the operative technique and results of the two-staged buccal mucosa (BM) and mesh graft urethroplasty for treatment of urethral strictures.

MATERIAL AND METHODS

Between 3/1993 and 12/1999, urethral reconstructions were performed in 267 consecutive patients (group I), including 68 mesh graft urethroplasties (25 %) and 30 BM urethroplasties (12 %). Between 1/2000 and 8/2004, additional 249 urethroplasties were performed: Of those, 12% were mesh graft and 50% BM urethroplasties (group II).

RESULTS

In patient group I, stricture recurrence was found to be the main complication of both procedures (BM 17 %, mesh 16 %). However, erectile dysfunction and curvature only occurred in the mesh graft group with 4% and 9 %, respectively. Patient satisfaction was high in both groups (BM 96.7%, mesh 83.3%). Between 1/2000 and 8/2004 (group II) the number of BM urethroplasties increased to 50%, whereas the number of mesh graft urethroplasty decreased (12%). More than 80% of the patients were satisfied with the results.

CONCLUSIONS

Long strictures with severe spongiofibrosis represent an indication for two staged urethro-plasty (BM and mesh graft). Excellent results can be achieved with both techniques with a similar rate of complications. The mesh graft technique remains the last option for a complex patient group.

Survey of disease and treatment-related symptoms in outpatients with invasive cancer of the breast, prostate, lung, or colon/rectum (E2Z02, the SOAPP study)

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Background: The full spectrum and impact of symptoms experienced by ambulatory patients (pts) in medical oncology clinics throughout their care trajectory is poorly understood. Methods: This large prospective study by the Eastern Cooperative Oncology Group (ECOG) enrolled pts with invasive cancer of the breast, prostate, colon/rectum or lung regardless of phase of care or stage of disease. The study was conducted between 3/06 and 5/08 at multiple academic (n=7) and community (n=32) medical oncology clinics. Pre-defined sampling algorithms were used to reduce selection bias. At baseline and again 4 weeks later, pts completed a 25-item measure of symptoms and functional interference (M.D. Anderson Symptom Inventory-ECOG). Patients’ providers simultaneously prioritized their symptoms. Results: 3124 patients were enrolled (90% from community clinics) and 3077 were analyzable with 1524 breast (50%), 715 colorectal (23%), 518 lung (17%), and 320 prostate (10%) pts. The most prevalent moderate-to-severe symptoms of the full cohort at baseline (B) and follow-up (F) were: fatigue (B34% to F32%), disturbed sleep (B27% to F21%), drowsiness (B22% to F21%), hair loss (B20% to F19%), pain (B19% to F18%), dry mouth (B19% to F15%), and numbness/tingling (B19% to F17%). At baseline, 40% of the cohort had at least 3 moderate-to-severe symptoms and 36% had this attribute at follow-up. Clinician perception of symptoms was strongly correlated with patient symptom survey results regardless of disease site, race, or ethnicity. Of the 849 pts receiving anti-cancer treatment for metastatic disease, half had 2 or more metastatic sites with 75% receiving cytotoxic chemotherapy. Clinicians judged lung cancer patients’ symptoms to be the most difficult to manage (p<0.01). Conclusions: Non-pain symptoms, particularly fatigue and sleep disturbance, are a major source of symptom distress in ambulatory medical oncology practice. Overall, symptom burden remains substantial and difficult to resolve. These data will help guide future interventional studies.

No significant financial relationships to disclose.

Evaluation of brain natriuretic peptide (BNP), troponin levels, and left ventricular ejection fraction (LVEF) in older adults with diffuse large B cell lymphoma (DLBCL)

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Background: Troponin and BNP are markers that rise acutely during myocardial injury and cardiac dysfunction, respectively. Doxorubicin (Dox) is an effective drug for treatment of DLBCL, in the regimen RCHOP (Coiffier, et.al. NEJM, 2002). Dox has risk of myocardial toxicity, which is higher in older patients (pts). Pegylated liposomal doxorubicin (D) has greater cardiac safety yet similar efficacy to Dox in breast cancer. D replaced Dox in RCHOP (DRCOP) in a phase II study in patients >60 yrs of age, with troponin and BNP levels pre and post-treatment to see if they would predict a fall in LVEF secondary to DRCOP. Methods: DRCOP is: Rituximab 375 mg/m2 IV day (d) 1; D 40 mg/m2 IV d 1; cyclophosphamide 750 mg/m2 IV d 1; vincristine 2 mg IV d 1 total dose; prednisone 100 mg/d p.o. d 1–5. Eligibility criteria: > 60 years; untreated DLBCL; Ann Arbor stage II-IV; baseline LVEF ≥ 50%. Consult at baseline by Cardiologist required, and at follow-up as indicated. The Wilcoxon rank sign test was used to compare baseline BNP with subsequent BNP. A linear mixed model was used to assess the effect of time on troponin at baseline, midpoint and endpoint. All tests were two-sided and p-values of 0.05 or less were considered statistically significant.. Statistical analysis was carried out using SAS version 9 (SAS Institute, Cary, NC). Results: 60 patients are enrolled; only one patient has developed systolic dysfunction, (LVEF to <50%). Conclusions: DLBLC older patients Older adults with DLBCL treated with DRCOP maintain preserved LVEF and troponin levels, suggesting less cardiotoxicity. There is a significant rise in BNP without clinical cardiac dysfunction. This is a new observation that merits further study.

[Table: see text]

No significant financial relationships to disclose.

[Salvage strategies after complications of hypospadias repair]

The complication rate of hypospadias repair still ranges between 20 and 30%, although operative skills and technical devices have improved. Different aspects like dressing are important for prevention of complications. Early complications are bleeding, hematoma, and infection. Late complications are fistulas, meatal stenosis, partial and complete breakdown, persisting curvature, a hairy urethra, and hypospadias cripples. Detailed preoperative diagnostics are important. There are several operative techniques that can be used for repair including the use of mesh graft or foreign material. Two or multiple stages are often needed. The surgery to correct complications after hypospadias repair is a challenge, which should only be done by an experienced surgeon.

Epidemiological survey of 214 families with bladder exstrophy-epispadias complex

PURPOSE

We sought to identify causative nongenetic and genetic risk factors for the bladder exstrophy-epispadias complex.

MATERIALS AND METHODS

A total of 237 families with the bladder exstrophy-epispadias complex were invited to participate in the study, and information was obtained from 214 families, mainly from European countries.

RESULTS

Two families showed familial occurrence. Male predominance was found among all subgroups comprising epispadias, classic bladder exstrophy and cloacal exstrophy, with male-to-female ratios of 1.4:1, 2.8:1 and 2.0:1, respectively (p = 0.001). No association with parental age, maternal reproductive history or periconceptional maternal exposure to alcohol, drugs, chemical noxae, radiation or infections was found. However, periconceptional maternal exposure to smoking was significantly more common in patients with cloacal exstrophy than in the combined group of patients with epispadias/classic bladder exstrophy (p = 0.009). Only 16.8% of mothers followed the current recommendations of periconceptional folic acid supplementation, and 17.6% had started supplementation before 10 weeks of gestation. Interestingly, in the latter group mothers of patients with cloacal exstrophy were more compliant with folic acid supplementation than were mothers of the combined group of patients with epispadias/classic bladder exstrophy (p = 0.037). Furthermore, mothers of children with cloacal exstrophy knew significantly more often prenatally that their child would have a congenital malformation than did mothers of children with epispadias/classic bladder exstrophy (p <0.0001).

CONCLUSIONS

Our study corroborates the hypothesis that epispadias, classic bladder exstrophy and cloacal exstrophy are causally related, representing a spectrum of the same developmental defect, with a small risk of recurrence within families. Embryonic exposure to maternal smoking appears to enforce the severity, whereas periconceptional folic acid supplementation does not seem to alleviate it. There is a disproportional prenatal ultrasound detection rate between severe and mild phenotypes, possibly due to the neglect of imaging of full bladders with a focus on neural tube defects.