Gefitinib, cisplatin, and concurrent radiotherapy for locally advanced head and neck cancer: EGFR FISH, protein expression, and mutational status are not predictive biomarkers

BACKGROUND

Gefitinib was demonstrated to be synergistic with cisplatin and radiotherapy (RT) in in vitro studies. Biomarkers predictive of response to gefitinib in squamous cell head and neck cancer is still lacking.

METHODS

Thirty-one patients with locally advanced and easily accessible primary tumor sites for biopsies were recruited. Gefitinib was started 3 weeks before the start of cisplatin/concurrent radiotherapy (CTRT) and continued during the CTRT phase and thereafter for 4 months as consolidation phase. Two baselines and a repeat tumor sample were taken after 2 weeks of gefitinib alone to study its impact on tumor gene expression. Epidermal growth factor receptor (EGFR) protein expression, FISH and mutational status, and matrix metallopeptidase 11 (MMP11) protein expression were correlated with response and survival outcome.

RESULTS

The overall response rate to gefitinib alone was 9.7%. The survival outcome is as follows: median disease free 1.3 years, median survival time 2.4 years, 3-year disease free 42.9%, and 3-year overall survival 48.4%. EGFR FISH, protein expression, and mutational status did not predict for response nor survival outcome of patients. Although MMP11 overexpression did not predict for response, it predicted significantly for a poorer survival outcome.

CONCLUSIONS

Gefitinib can be combined safely with cisplatin/RT. More studies are needed to uncover predictive biomarkers of benefit to gefitinib.

Induction of pathogenic cytotoxic T lymphocyte tolerance by dendritic cells: a novel therapeutic target

IMPORTANCE OF THE FIELD

Dendritic cells (DCs) have an important role, both direct and indirect, in controlling the expansion and function of T cells. Of the different subsets of T cells, cytotoxic T lymphocytes (CTLs/CD8(+) T cells) have been implicated in the pathogenesis and development of many diseases, including various forms of autoimmunity and transplant rejection. It may therefore be of therapeutic benefit to control the function of CTL in order to modulate disease processes and to ameliorate disease symptoms. Currently, pharmacological approaches have been employed to either directly or indirectly modulate the function of T cells. However, these treatment strategies have many limitations. Many experimental data have suggested that it is possible to alter CTL activity through manipulation of DC.

AREAS COVERED IN THIS REVIEW

Novel strategies that condition DCs to influence disease outcome through manipulation of CTL activity, both directly and indirectly. This includes the modulation of co-stimulation, negative co-stimulation, as well as manipulation of the cytokine milieu during CTL generation. Furthermore, DCs may also impact CTL activity through effects on effector and regulatory cells, along with manipulation of bioenergetic regulation, apoptotic-cell mediated tolerance and through the generation of exosomes. The implications of related interventions in the clinical arena are in turn considered.

WHAT THE READER WILL GAIN

Insight into such indirect methods of controlling CTL activity allows for an understanding of how disease-specific T cells may be regulated, while also sparing other aspects of adaptive immunity for normal physiological function. Such an approach towards the treatment of disease represents an innovative therapeutic target in the clinical arena.

TAKE HOME MESSAGE

There are numerous innovative methods for using DCs to control CTL responses. Manipulation of this interaction is thus an attractive avenue for the treatment of disease, particularly those of immune dysregulation, such as seen in autoimmunity and transplantation. With the number of studies moving into clinical stages constantly increasing, further advances and successes in this area are inevitable.

Good outcomes with mycophenolate-cyclosporine-based induction protocol in children with severe proliferative lupus nephritis

The outcomes of children with severe proliferative lupus nephritis (LN) were examined using a new mycophenolate and cyclosporine-based (MMF-CSA) induction protocol. Sixteen children with LN (WHO class III and IV), 31.3% of whom required dialysis at induction, were retrospectively studied. Median MMF dose was 942 mg/m( 2)/day. Thirteen patients (81%) with persistent proteinuria received CSA. Clinical and laboratory parameters were compared at pre-induction, 6 and 12 months. Treatment outcome was defined by Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), renal function, haematuria, proteinuria and serological markers (complements C3, C4 and anti-dsDNA). Comparing these parameters at induction, 6 months and 12 months, respectively, SLEDAI (25.4 +/- 8.7 versus 3.2 +/- 2.9 versus 2.9 +/- 2.8), serum C3 (47 +/- 21 versus 107 +/- 27 versus 111 +/- 38 mg/dl), C4 (12 +/- 14 versus 23 +/- 14 versus 22 +/- 11 mg/dl) and urine protein (6.97 +/- 7.09 versus 0.98 +/- 1.56 versus 0.21 +/- 0.13 g/ day/1. 73 m(2)) improved significantly (p < 0.05). Anti-dsDNA titres decreased in 73% by 6 and 12 months (p < 0.05). Complete renal remission was achieved in 7/16 (43.8%) at 6 months and 12/16 (75%) at 12 months, the rest achieving partial remission with no treatment failures. In conclusion, a combination MMF-CSA protocol is an effective therapeutic alternative for induction of children with severe proliferative LN, resulting in significant clinical and serological improvement with minimal adverse effects.

Manipulation of indoleamine 2,3 dioxygenase; a novel therapeutic target for treatment of diseases

BACKGROUND

The discovery of indoleamine 2,3-dioxygenase (IDO) as a modulator for the maintenance of fetomaternal immuno-privileged state has been heralded as a significant step in further defining the role of IDO in immunobiology. IDO is an IFN-inducible, intracellular enzyme that catalyzes the initial and rate-limiting step in the degradation of the essential amino acid, tryptophan. It has been suggested that IDO has the capacity to regulate the immune system via two discrete mechanisms; firstly the deprivation of tryptophan, which is essential for T cell proliferation and via the cytotoxic effects of tryptophan metabolites on T(H)1 cell survival.

METHODS

The sources of information used to prepare the paper are published work on Pubmed/Medline. In this review, we examine the therapeutic role of modulating IDO activity a variety of disease states including tumour tolerance, chronic infection, transplant rejection, autoimmunity and asthma. We propose that IDO represents a novel therapeutic target for the treatment of these diseases. We also explore the diverse strategies which are being employed, either to augment or to inhibit IDO activity in order to modify various disease processes. The limitations associated with these strategies are also scrutinized.

LARG at chromosome 11q23 has functional characteristics of a tumor suppressor in human breast and colorectal cancer

Deletion of 11q23-q24 is frequent in a diverse variety of malignancies, including breast and colorectal carcinoma, implicating the presence of a tumor suppressor gene at that chromosomal region. We examined a 6-Mb region on 11q23 by high-resolution deletion mapping, using both loss of heterozygosity analysis and customized microarray comparative genomic hybridization. LARG (leukemia-associated Rho guanine-nucleotide exchange factor) (also called ARHGEF12), identified from the analysed region, is frequently underexpressed in breast and colorectal carcinomas with a reduced expression observed in all breast cancer cell lines (n=11), in 12 of 38 (32%) primary breast cancers, 5 of 10 (50%) colorectal cell lines and in 20 of 37 (54%) primary colorectal cancers. Underexpression of the LARG transcript was significantly associated with genomic loss (P=0.00334). Hypermethylation of the LARG promoter was not detected in either breast or colorectal cancer, and treatment of four breast and four colorectal cancer cell lines with 5-aza-2'-deoxycytidine and/or trichostatin A did not result in a reactivation of LARG. Enforced expression of LARG in breast and colorectal cancer cells by stable transfection resulted in reduced cell proliferation and colony formation, as well as in a markedly slower cell migration rate in colorectal cancer cells, providing functional evidence for LARG as a candidate tumor suppressor gene.

Manipulation of indoleamine 2,3-dioxygenase (IDO) for clinical transplantation: promises and challenges

BACKGROUND

Since the discovery that indoleamine 2,3-dioxygenase (IDO) is a modulator for maintenance of fetomaternal immuno-privilege state, it has been implicated in tumour tolerance, autoimmune diseases and asthma. IDO is an IFN-gamma-inducible, intracellular enzyme that catalyzes the initial and rate-limiting step in the degradation of tryptophan. It has been suggested that IDO can regulate the immune system either through deprivation of tryptophan that is essential for T cell proliferation or via cytotoxic effects of kynurenine pathway metabolites on T cell survival.

METHODS

The sources of information used were obtained through Pubmed/Medline.

RESULTS/CONCLUSION

While IDO emerges as a regulator of immunity, its role in controlling allo-response is unfolding. IDO can control T cell responses to allo-antigens and induce generation of allo-specific regulatory T cells. Exploiting IDO as a modulator of transplant rejection, many groups have manipulated its activity to prolong allograft survival in transplantation models. Despite the initial promise, its application to clinical transplantation may be limited. We therefore examine the potentials and limitations associated with clinical translation of IDO into a therapeutic.

Interaction of current cancer treatments and the immune system: implications for breast cancer therapeutics

Early diagnosis and treatment of breast cancer may account for the current improvement in the mortality of breast cancer. However, achieving a complete 'cure' is the holy grail of cancer medicine and, in many cases, cancer patients still succumb to their ultimate fate. There is therefore a need to devise innovative therapies to overcome this problem. To this end, many emerging therapies utilizing the immune system to eradicate the residues of disease have been described in the preclinical and clinical arenas. However, there is very little work examining the impact of immunotherapy on the existing natural immunity. The relationship between antitumor immunity, in the form of immunotherapy (either passive or active), and current strategies of treatment also needs to be explored. If we are to improve the success of cancer treatment, we must understand how current therapies interact with the immune system and with the emerging immunotherapies. For breast-cancer treatment to be successful, therapeutics should be tailored towards antitumor immunity; they should also avoid tumor-specific tolerance. The sources of information used to prepare this paper were obtained through published work on Pubmed/Medline and materials published on the US/UK governmental agencies' websites.

The role of immunohistochemistry in the differential diagnosis of papillary lesions of the breast

Papillary lesions of the breast represent a heterogeneous group with differing biological behaviour. Correct diagnosis is crucial but may be difficult, as many benign and malignant papillary lesions have similar appearances. Immunohistochemistry plays a useful role in their differentiation. Myoepithelial markers can help in differentiating papilloma from papillary carcinoma, as the former usually shows a continuous layer of myoepithelial cells. In intracystic papillary carcinoma, there is controversy as to the presence of a complete myoepithelial cell layer around these lesions. p63 is the marker of choice as the staining is nuclear, cross-reactivity is minimal, and sensitivity is high. Papilloma may frequently be complicated by superimposed different types of epithelial hyperplasia, which range from usual to atypical or even ductal carcinoma in situ, and they many be morphologically similar. Basal cytokeratins (CKs) are useful to differentiate these entities; as usual hyperplasia is positive for basal CKs with a mosaic staining pattern. CK5/6 is probably the best marker. Neuroendocrine markers (chromogranin A and synaptophysin) may be positive in papillary carcinoma, particularly in the solid type, and there may be some overlap with the ductal carcinoma in situ with spindle cells or endocrine ductal carcinoma in situ. A panel of CK5/6, p63 and neuroendocrine markers can be useful in the diagnostic investigation of problematic papillary lesions of the breast. As the experience with these markers remains rather limited, it is too early to recommend basing treatment choices on these marker studies alone. Complete removal of lesion is probably still the treatment of choice.

Adenoid cystic carcinoma of the breast

Adenoid cystic carcinoma of the breast is a rare neoplasm that constitutes less than one percent of all mammary carcinomas. To date, there have been about 140 cases reported in the literature. It is a rare variant of adenocarcinoma that usually occurs in the salivary glands. In contrast to the aggressive nature of adenoid cystic carcinoma that occurs in the head and neck region, adenoid cystic carcinoma of the breast has a very favourable prognosis. Little has been published to date on its radiological features. We describe a 63-year-old woman with adenoid cystic carcinoma detected on mammography in our national breast screening programme, the radiological findings at presentation, the surgical management and a review of the literature.

Imaging of painful solitary lesions of the sacrum

In patients with sacral pain, the painful symptoms may be caused by a variety of bony and soft tissue lesions. Benign lesions include giant cell tumour, neurogenic tumour, insufficiency fracture, infection and giant bone island. Malignant lesions include primary bone tumours, Ewing sarcoma, plasmacytoma, lymphoma and chordoma. Soft tissue tumours adjacent to or involving the sacrum may cause painful symptoms. A multimodality approach to imaging is required for full assessment of these lesions. This pictorial essay describes a range of common solitary sacral lesions that may cause pain, with emphasis on imaging features.

Photoluminescence spectroscopy of carbon nanotube bundles: evidence for exciton energy transfer

We investigate photoluminescence of nanotube bundles. Their spectra are explained by exciton energy transfer between adjacent tubes, whereby excitation of large gap tubes induces emission from smaller gap ones. The consequent relaxation rate is faster than nonradiative recombination, leading to enhanced photoluminescence of acceptor tubes.

Mucinous breast lesions: diagnostic challenges

Breast lesions with mucin represent a broad spectrum of entities, ranging from benign fibrocystic changes with luminal mucin to mucocele-like lesions (MLL), which can be associated with banal epithelial alterations, atypical ductal hyperplasia or ductal carcinoma in situ. Occasionally invasive mucinous carcinoma can be identified in contiguity with MLL. Diagnostic challenges are enumerated, histological differentials are discussed, and a practical approach towards resolving some of these issues is provided. In addition to these lesions with abundant extracellular mucin, there are also conditions that feature stromal mucinous or myxoid material, as well as rare entities that demonstrate both epithelial extracellular and stromal mucin.

Changing viral tropism using immunoliposomes alters the stability of gene expression: implications for viral vector design

Many strategies for redirecting the tropism of murine Moloney leukemia virus (MMLV) have been described. Preformed virion-liposome complexes, termed virosomes, have been reported to be relatively stable. Virosomes mediate envelope-independent transduction that allows efficient superinfection of resistant cell lines; however, virosome-mediated transduction behaves in a non-target-specific manner. We developed a novel method using antibodies to direct MMLV to vascular endothelium. We have given the term immunovirosomes to the complexes formed between viruses, liposomes, and antibodies. These immunovirosomes improve the transduction efficiency of the viruses and alter their tropism. We have shown improved transduction when immunovirosomes were targeted at the endocytic receptors CD71 and CD62E/P and rather less good delivery when targeted at CD106. The enhancement of the transduction efficiency was transient, however, suggesting that rerouting the entry pathway of viruses alters the expression properties of the viruses.

Changing viral tropism using immunoliposomes alters the stability of gene expression: implications for viral vector design

Many strategies for redirecting the tropism of murine Moloney leukemia virus (MMLV) have been described. Preformed virion-liposome complexes, termed virosomes, have been reported to be relatively stable. Virosomes mediate envelope-independent transduction that allows efficient superinfection of resistant cell lines; however, virosome-mediated transduction behaves in a non-target-specific manner. We developed a novel method using antibodies to direct MMLV to vascular endothelium. We have given the term immunovirosomes to the complexes formed between viruses, liposomes, and antibodies. These immunovirosomes improve the transduction efficiency of the viruses and alter their tropism. We have shown improved transduction when immunovirosomes were targeted at the endocytic receptors CD71 and CD62E/P and rather less good delivery when targeted at CD106. The enhancement of the transduction efficiency was transient, however, suggesting that rerouting the entry pathway of viruses alters the expression properties of the viruses.

Gene delivery to vascular endothelium using chemical vectors: implications for cardiovascular gene therapy

The vascular endothelium is an attractive target for gene therapy because of its accessibility and its importance in the pathophysiology of a wide range of cardiovascular conditions. In general, viral methods have been shown to be very effective at delivering genes to endothelium. The immunogenicity and pathogenicity associated with viral vectors have led increased efforts to seek alternative means of 'ferrying' therapeutic genes to endothelium or to decrease the short-comings of viral vectors. This paper reviews developments in non-viral technology. In addition, discussion also covers the mechanisms whereby existing chemical vectors deliver DNA to cells. Understanding the pathways of vector internalisation and intracellular traffic is important in developing strategies to improve vector technology. The authors propose that the chemical vector may represent a robust and versatile technology to 'ferry' therapeutic genes to vascular endothelium in order to modify the endothelial dysfunction associated with many cardiovascular diseases.

Prevention of postoperative nausea and vomiting after intrathecal morphine for Cesarean section: a randomized comparison of dexamethasone, droperidol, and a combination

BACKGROUND

Intrathecal morphine provides good analgesia after cesarean delivery but the side effects include nausea and vomiting. Low-dose droperidol (0.625 mg) combined with dexamethasone 4 mg is postulated to have an additive antiemetic effect with less side effects. We therefore compared single doses of dexamethasone and droperidol alone with a low-dose combination of the two, to prevent spinal morphine-induced nausea and vomiting after cesarean section.

METHODS

In a double-blind study, 120 women undergoing elective cesarean section under spinal anesthesia (using 0.5% bupivacaine 10 mg and morphine 0.2 mg) were allocated randomly to receive dexamethasone 8 mg, droperidol 1.25 mg, dexamethasone 4 mg and droperidol 0.625 mg, or placebo, before the end of surgery. The incidences of nausea and vomiting, sedative score, pain score, and side effects were recorded.

RESULTS

The incidence of nausea and vomiting within 6 h postoperatively was lower and incidence of no nausea and vomiting for 24 h postoperatively was significantly higher for the combination group compared to the placebo group and the dexamethasone only group. Sedation scores within 3 h postoperatively and incidence of restlessness for the combination group were significantly lower than in the droperidol only group.

CONCLUSION

An additive antiemetic effect and no significant side effects were shown for the combination of dexamethasone 4 mg and droperidol 0.625 mg. This combination was more effective than either dexamethasone 8 mg or droperidol 1.25 mg alone in preventing nausea and vomiting after spinal anesthesia using 0.5% bupivacaine and morphine 0.2 mg.

Preoperative and intraoperative diagnosis of low-grade adenosquamous carcinoma of the breast: potential diagnostic pitfalls

AIMS

Low-grade adenosquamous carcinoma (LGAC), a rare variant of metaplastic breast cancer, may mimic benign or other low-grade malignant lesions histologically. Diagnostic difficulty may be encountered when evaluating breast cytology, core needle biopsy or intraoperative frozen section specimens.

METHODS AND RESULTS

Pathology reports, cytology aspirates and histological slides of LGAC diagnosed at the Department of Pathology, Singapore General Hospital, were reviewed. Four cases of LGAC were analysed. Cytology from the first case showed atypical cells and the subsequent surgical excision specimen showed a complex sclerosing lesion with LGAC. The second and third cases were investigated by core needle biopsies: the preoperative histological features were suggestive of but not diagnostic of LGAC, until further excision biopsies were performed. The fourth case entailed a frozen section specimen, for which definitive diagnosis was deferred to paraffins. The patients remained well with no evidence of recurrent disease to date.

CONCLUSIONS

When limited material, in the form of needle aspirates, core biopsy specimens or frozen sections, is submitted for histology, making a diagnosis of LGAC is not only challenging, but may be impossible. In difficult cases, careful pathological assessment, clinicopathological correlation and follow-up or complete excision biopsy may prove invaluable in establishing a definitive diagnosis.

The Transplantation Society--new key opinion leaders of tomorrow 2006

One of the new initiatives taken by the immediate past president of The Transplantation Society, KJ Wood, is to introduce a new series of meetings named 'New Key Opinion Leaders of Tomorrow'. The Transplantation Society invites the leading young investigators in the field of transplantation to participate in this meeting together with the present leaders of the field. The key objective of this meeting is to identify the potential key opinion leaders of tomorrow. Each presentation during the meeting was jointly given by the senior and junior investigators. The meeting in Buenos Aires covered six main topics on clinical, translational and basic transplantation. These included: innate immunity and inflammation; transplant infectious diseases; tumour and transplantation; medical and ethical aspects of transplantation; dendritic cells (stimulating and manipulating the immune response to a transplant); and ABO incompatible donor recipient pairs. This report focuses on the emerging biological therapeutics and their ramifications on clinical transplantation.

Cytology is useful in breast screening: results and long-term follow-up of the Singapore Breast Screening Pilot Project

OBJECTIVE

The Singapore Breast Screening Pilot Project (SBSPP) was embarked upon (1994-1997) to determine if mammography was useful in early breast cancer detection among Asian women.

PATIENTS AND MEASUREMENTS

Of 28 231 women screened, fine needle aspiration cytology (FNAC) was performed in 232 individuals as part of the triple assessment.

RESULTS

Absolute and complete sensitivities for the diagnosis of carcinoma were 46.7% and 82.2%, respectively, based on the results of FNAC. Specificity was 63.3%. The inadequate rate was 31%. Five women who were considered cancer-free on triple assessment and, in two cases open diagnostic biopsy during the SBSPP, subsequently developed breast cancer after a median follow-up of 6 years.

CONCLUSION

Although our FNAC results compared relatively well with international standards, they reflect a small cohort, and may face additional difficulties in a larger programme.

World Transplant Congress. Boston, Massachusetts, USA, 22-27 July 2006

The World Transplant Congress (WTC) is the first joint international transplant meeting co-organised by the Transplantation Society, the American Society of Transplantation (AST) and the American Society of Transplant Surgeons (ASTS). It was the first meeting of this calibre that was being held by three world-renowned authorities in the field of transplantation. Under the direction of the congress president, AB Cosimi, the attendance of this meeting is a 'must' for all working in the field of transplantation. The congress had provided an important forum for the exchange of new scientific and clinical information that is relevant to solid organ and tissue transplantation. In addition, it also created an arena for the interchange of ideas regarding the care and management of transplant recipients. There were many sessions that were engineered in order to facilitate the discussion of socioeconomic, ethical and regulatory issues related transplantation. On the whole, the meeting has set a very high standard for any future transplant congresses to match-providing the delegates with updates on transplantation with the new scientific prospectives in T cell costimulation, innate immunity (dendritic cells), anatomy of immune response and regulatory T cell biology. More importantly, it has highlighted the potentials of harnessing these new findings for future biological therapies in preventing rejection and inducing tolerance.

Aspirin-treated human DCs up-regulate ILT-3 and induce hyporesponsiveness and regulatory activity in responder T cells

Mature dendritic cells (mDCs) are potent antigen presenting cells, but immature DCs (iDCs) have been shown to have reduced antigen stimulatory capacity. Different strategies have been investigated to augment the tolerogenic capacity of dendritic cells (DCs). We demonstrate that in aspirin-treated human DCs, there is reduced expression of CD1a, HLA-DR and CD86, up-regulation of ILT-3 expression and marginal increases in PDL-1. Aspirin-treated DCs are partially resistant to phenotypic changes following maturational stimuli, such as lipopolysaccharide (LPS) or TNFalpha, IL-1alpha and PGE2. Aspirin-treated DCs demonstrate normal endocytic function, but have a reduced ability to stimulate allogeneic T cells, which is comparable to iDCs. Furthermore, they induce hyporesponsiveness and regulatory activity in responder naïve and memory T cells; for naïve T cells this is achieved more quickly and efficiently than with iDCs. We investigated the mechanism of this regulatory activity and found that both cell-cell contact and inhibitory cytokine activity are involved, although no one cytokine predominates in importance. Blocking ILT-3 or IL-12 does not diminish the capacity of these DCs to induce regulation or Foxp3 expression on the regulatory T cells. Results demonstrate that aspirin-treated DCs display tolerogenic potential, which is of interest in their therapeutic potential in reducing chronic allograft rejection.

Knockdown of mouse VCAM-1 by vector-based siRNA

Graft rejection is critically dependent on the recruitment of leukocytes via adhesion molecules on the endothelium, and inhibition of these interactions can prolong graft survival. We have therefore developed an approach using siRNA to inhibit the expression of VCAM-1 in endothelial cells. We transfected siRNA constructs into murine corneal and vascular endothelium and looked at expression of VCAM-1 and other surface molecules by flow cytometry. Adhesion assays (both static and under flow) were used to determine the effect of VCAM-1 inhibition. The activation of cellular stress responses was assessed by RT-PCR. Constructs encoding siRNA can block expression of VCAM-1 in both corneal and vascular endothelial cells (in the latter case after cytokine stimulation). Inhibition of VCAM-1 expression reduced the ability of T cells to adhere to endothelium. However, there were non-specific effects of siRNA expression, including upregulation of (Programmed Death Ligand 1) PDL1 and decreased cell growth. Analysis of stress pathways showed that the endothelial cells transfected with siRNA had upregulated molecules associated with cell stress. While these data are supportive of a potential therapeutic role for siRNA constructs in blocking the expression of adhesion molecules, they also highlight potential non-specific effects of siRNA that must be carefully considered in any application of this technology.