Phase 3 study of docosahexaenoic acid-paclitaxel versus dacarbazine in patients with metastatic malignant melanoma

BACKGROUND

Docosahexaenoic acid-paclitaxel (DHA-paclitaxel, Taxoprexin(®)) is made by covalently conjugating the essential fatty acid DHA to the paclitaxel molecule. Preclinical studies of DHA-paclitaxel have demonstrated increased activity relative to paclitaxel and the potential for an improved therapeutic ratio. In the present study, the efficacy and toxicity profiles of DHA-paclitaxel were compared with those of dacarbazine.

METHODS

In this study, 393 chemonaive patients with metastatic melanoma were randomly assigned to receive either DHA-paclitaxel at a starting dose of 900 mg/m(2) IV on day 1 every 3 weeks or dacarbazine at a starting dose of 1000 mg/m(2) IV on day 1 every 3 weeks. The primary end point of the study was the comparison of overall survival (OS).

RESULTS

No significant difference in OS was noted between patients in the DHA-paclitaxel and dacarbazine arms. Similarly, there were no significant differences in response rate, duration of response, time to progression, and time to treatment failure between the two drugs. Safety results of the two drugs were as predicted from prior studies. Myelosuppression was more common with DHA-paclitaxel.

CONCLUSIONS

DHA-paclitaxel was not superior to dacarbazine. We conclude that further studies with the drug on an every 3-week schedule in melanoma are not warranted.

Loss of heterozygosity on chromosome 11p15.5 and relapse in hepatoblastomas

BACKGROUND

IGF2 is a tumor suppressor gene at locus 11p15. Many hepatoblastomas have loss of heterozygosity (LOH) at this locus. Earlier studies have not demonstrated any association between LOH and prognosis. Aim of the study was to evaluate the prognostic significance of LOH at 11p15.5 in hepatoblastomas.

METHODS

DNA was isolated from normal liver and tumor tissue in 20 patients with hepatoblastoma. PCR was performed and cases were classified as LOH present, absent or non-informative. Patients' follow-up data was analyzed using Fischer's exact test and Kaplan-Meier survival analysis for relapse-free survival (RFS) in relation to LOH. Ethical clearance was obtained from the institutional ethics board.

RESULTS

All cases were informative for at least one microsatellite marker used. 4 of the 20 cases (20%) had LOH at 11p15.5. One patient died in the immediate postoperative period. 5 of 19 patients relapsed (26%). Of 4 patients who had LOH, 3 (75%) relapsed, the time to relapse being 7, 7 and 9 months, respectively. Of the 15 cases without LOH, 2 (13.3%) relapsed. 4 patients had mixed epithelial and mesenchymal histology; 3 of them had LOH. The 2 groups with and without LOH were well matched. The RFS for patients with LOH (n=4) was 13% (mean survival time [MST]: 8.7 months; 95CI 6.7-10.7), while the RFS for cases without LOH (n=15) was 75% (MST: 100.7 months; 95CI 74.5-126.8).

CONCLUSION

Mixed epithelial and mesenchymal histology is more frequently associated with LOH on chromosome 11p15.5 than pure epithelial histology. LOH on chromosome 11p15.5 is associated with a significantly increased incidence of relapse and a significantly shorter relapse-free survival in patients with hepatoblastoma. The risk of relapse is higher and the RFS lower both in standard-risk and high-risk patients with hepatoblastoma if they demonstrate the presence of LOH at 11p15.5.

Mesophase ordering of TiO2 film with high surface area and strong light harvesting for dye-sensitized solar cell

Mesophase ordering and structuring are carried out to attain optimized pore morphology, high crystallinity, stable porous framework, and crack-free mesoporous titanium dioxide (TiO(2)) films. The pore structure (quasi-hexagonal and lamellar) can be controlled via the concentration of copolymer, resulting in two different types of micellar packing. The calcination temperature is also controlled to ensure a well-crystalline and stable porous framework. Finally, the synthesized mesoporous TiO(2) film is modified by adding P25 nanoparticles, which act as scattering centers and function as active binders to prevent formation of microcracks. Adding P25 nanoparticles into mesoporous structure helps to provide strong light-harvesting capability and large surface area for high -efficiency dye-sensitized solar cells (DSSC). The short-circuit photocurrent density (J(sc)) of the cell made from mixture of mesoporous TiO(2) and P25 nanoparticles displays a higher efficiency of approximately 6.5% compared to the other homogeneous films. A combination of factors such as increased surface area, introduction of light-scattering particles, and high crystallinity of the mesoporous films leads to enhanced cell performance.

The use of alendronate in the treatment of avascular necrosis of the femoral head

The use of bisphosphonates in the treatment of avascular necrosis of the femoral head is an encouraging but relatively new option with most published data being derived from small trials with limited follow-up. We present a clinicoradiological analysis of 395 hips with avascular necrosis which were treated with oral alendronate for three years with a mean follow-up of four years (1 to 8).

Our results show an improvement in the clinical function, a reduction in the rate of collapse and a decrease in the requirement for total hip replacement, compared with the findings of other studies in which no treatment was given. This improvement is particularly marked if the treatment is begun in the pre-collapse stages of the disease. Even in Ficat stage-III hips some benefit was obtained from treatment with alendronate by at least a delay in the need for total hip replacement.

Staple versus locking compression plate fixation after lateral closing wedge high tibial osteotomy

PURPOSE

To compare the results of staple versus locking compression plate fixation after closing wedge high tibial osteotomy.

METHODS

A group of 23 patients (24 knees) who underwent box high tibial osteotomy and staple fixation was compared with another group of 19 patients (22 knees) who underwent a similar procedure but with locking compression plate fixation. Both groups were followed up for 3 years. The range of movement, Hospital for Special Surgery (HSS) Knee Score, time to full weight bearing, incidence of delayed union, femorotibial angle, and stage of osteoarthritis were compared.

RESULTS

At 6 months after the operation, the median HSS score and the proportion of patients with excellent or good scores were significantly higher in the locking compression plate than the staple fixation group (76 vs 62, p=0.003; 75% vs 42%, p=0.0354), but not at one and 3 years. The range of movement was significantly greater in the locking compression plate fixation group in the short term (6 weeks, 3 and 6 months), but not after one year. The median time to full weight bearing was significantly shorter in the locking compression plate fixation group (86 vs 116 days, p<0.001). There were fewer delayed unions in the locking compression plate fixation group but not significantly (1 vs 5, p=0.198), possibly because of the small numbers involved. There was no difference, within the limits of measurement error, in the femorotibial angle or correction loss between the 2 groups.

CONCLUSION

Locking compression plate fixation obviates the use of plaster casts, enables early mobilisation and bone union, and reduces the numbers with delayed union and the time to full weight bearing. Longer-term studies are needed to evaluate its effect on revarisation and arthropathy.

Effect of rifampin on steady-state pharmacokinetics of atazanavir with ritonavir in healthy volunteers

Mycobacterium tuberculosis is a concern in patients with human immunodeficiency virus (HIV) infection. Rifampin (RIF), an agent used against M. tuberculosis, is contraindicated with most HIV protease inhibitors. Atazanavir (ATV) has clinical efficacy comparable to a standard of care regimen in naive patients and, when dosed with low-dose ritonavir (RTV), also in treatment-experienced patients. We evaluated here the safety and pharmacokinetics of ATV, resulting from three regimens of ATV, RTV, and RIF in 71 healthy subjects. The pharmacokinetics for ATV and RTV were assessed after 6 and 10 days of dosing with ATV 400 mg (n = 53) and with ATV-RTV at 300 and 100 mg (ATV/RTV 300/100; n = 52), respectively. Steady-state pharmacokinetics for ATV, RTV, RIF, and desacetyl-rifampin (des-RIF) were measured after 10 days of dosing of ATV/RTV/RIF 300/100/600 (n = 17), ATV/RTV/RIF 300/200/600 (n = 17), or ATV/RTV/RIF 400/200/600 (n = 14). An RIF 600-alone arm was enrolled as a control group (n = 18). With ATV/RTV/RIF 400/200/600, ATV area under the concentration-time curve values were comparable, but the C(min) values were lower relative to ATV 400 alone. ATV exposures were substantially reduced for the other RIF-containing regimens relative to ATV 400 alone and for all regimens relative to ATV/RTV 300/100 alone. RIF and des-RIF exposures were 1.6- to 2.5-fold higher than with RIF 600 alone. The incidence of grade 3/4 alanine aminotransferase/aspartate aminotransferase values was limited to 1 subject each in both the ATV/RTV/RIF 300/200/600 and the ATV/RTV/RIF 400/200/600 treatments. Coadministration of ATV with RIF was safe and generally well tolerated. Since ATV exposures were reduced in all regimens, ATV and RIF should not be coadministered at the dosing regimens studied.

Occult neurovesical dysfunction with anorectal malformations

OBJECTIVE

To evaluate for the occurrence of occult NVD in children with anorectal malformations (ARM) using urodynamic evaluation.

METHODS

This prospective study was carried out on children with ARM prior to and following definitive procedure. Urodynamic studies were performed on the Phoenix Griffon machine (Albyn Medical) using Phoenix plus software.

RESULT

Nineteen children in the age range of 3 months to 156 months (mean = 19.2) were included in this study. Among these 19 children 13 underwent re-evaluation after definitive surgery for ARM. There were 11(57.9%) males and 8(42.1%) females. Of the 19 children 14 (73.7%) were cases of high anorectal malformation (HARM) and 5 (26.3%) were cases of low anorectal malformation (LARM). Baseline evaluation done in 19 children revealed seven urodynamic patterns: Normal capacity, compliant without uninhibited contractions (UIC) (21.1%); Normal capacity, compliant with UIC (5.3%); Normal capacity, poorly compliant without UIC (5.3%); Normal capacity, poorly compliant with UIC (10.5%); small capacity, compliant with UIC (5.3%); Small capacity, poorly compliant with UIC (26.3%) and large capacity, complaint with UIC (26.3%). Thirteen patients were evaluated post operatively also and in only 23% (3 of 13) no change in urodynamic pattern were observed. In the remaining 76.9% (10 of 13) some changes in urodynamics pattern were observed. The deleterious changes observed were appearance of UIC in 30.8% (4 of 13), decrease in the bladder capacity in 23% (3 of 13) and decrease in bladder compliance in 15.4% (2 of 13).

CONCLUSION

Only 9 of of the 19 patients had normal urodynamics pre-operatively and post-operatively 3 more patients worsened. Incidence of occult NVD is high in patients with ARM even in the absence of clinical and radiological evidence of vertebral or lower urinary tract abnormalities. Though there seems to be a high incidence of changes in the neurovesical functions of these patients following definitive corrective surgery for ARM only time will show whether this has any deleterious effect on the upper tracts.

Phase II study of combretastatin A4 phosphate (CA4P) in patients with advanced anaplastic thyroid carcinoma (ATC)

5580

Background: CA4P is the first tubulin-binding vascular disrupting agent tested in the clinic. Phase I studies were devoid of significant myelosuppression, DLT included cardiovascular side effects, and there was demonstrable activity in ATC (Cancer Res 2002; 62:3408; Clin Cancer Res 2004; 10:96). Methods: Patients with metastatic ATC, good performance status, normal ECG and cardiac function, and no prior therapy for disseminated disease were eligible for study. CA4P at a dose of 45 mg/m2 was administered as 10-minute IV infusion on days 1, 8 and 15 every 28 days (1 cycle) until progression of disease. Results: A total of 18 patients (pts) (11M/7F), median age 62 (range 40–71 yrs), received a total of 55.67 cycles of treatment. Therapy was well tolerated with mild to moderate nausea, vomiting, headache, and tumor pain (3 pts with grade 3) all of which essentially resolved within first 24 hrs. There was no clinically meaningful myelosuppression or cardiac toxicity. No objective responses were seen; 6 pts with stable disease and 12 pts progressed. Median progression free survival (PFS) was 7.4 wks (range 2–84+ wks); with 28% of pts progression free > 3.0 mos. (12.0+, 14.3, 15.3, 25.6 and 84.0+ wks). Pts without bulky disease tended to do better. Fourteen pts have died; 4 are alive; and 2 are alive and on-study at 12.0+ and 84.0+ wks. Median survival is on the order of approximately 20 wks. Conclusions: Approximately a quarter of patients treated with single-agent CA4P experience greater than 3 mos. freedom from progression. Combined modality strategies with CA4P and either chemotherapy and other targeted agents or with radiation are warranted. [Supported in part by a clinical grant from OXiGENE, Inc., Waltham, MA and NIH grant nos. M01 RR-00080].

No significant financial relationships to disclose.

Urethral duplication in association with anorectal malformation

Urethral duplication is an uncommon congenital anomaly, not often reported, which may be partial or complete. Anorectal malformations are not as uncommon and they may be associated with a host of associated anomalies. However, the association of urethral duplication with anorectal malformation is rare; this report describes two such cases. In one case the intervening septum could be incised endoscopically and in the other case the duplicated urethra was excised.

Right Atrial Trans-Septal Approach for Left Atrial Myxomas—Nine-Year Experience

OBJECTIVE

In this single-center study we reviewed our experience with left atrial myxomas occurring over the past 9 years.

METHODS

Sixty-three patients underwent excision of cardiac myxomas between 1995 and 2004. Of these, 56 patients (32 females and 24 males) had left atrial (LA) myxoma. The mean age was 37.80+12.97 years (range 3.5-67 years). Echocardiography was the only diagnostic evaluation done. The preferred approach for resection was right atrial trans-septal. Annual echocardiographic evaluation was undertaken following surgery. Follow-up is current and available in all the survivors (range 4 months-9 years).

RESULTS

Clinically 75% of the LA myxomas simulated mitral stenosis. The symptoms were present for 2-6 months before operation. Most (86%) LA myxomas were attached to the fossa ovalis. Few (14%) originated from the LA wall, mitral valve annulus and anterior mitral leaflet. One patient succumbed to low cardiac output and another died of massive embolic stroke following surgery. There were no late deaths. Two patients (3.7%) developed left hemiparesis after operation but recovered completely. There was one (1.9%) recurrence 3 years after surgery. Atrial fibrillation occurred in one patient. Mitral insufficiency which was seen in two (3.7%) patients prior to surgery subsided following excision of the tumor. Postoperatively 94% patients remained without symptoms.

CONCLUSION

Owing to the risk of valvular obstruction or embolization early surgery is indicated. Right atrial trans-septal approach is safe and easy. Most patients are asymptomatic following surgery. A yearly follow-up is essential.

Anorectal malformations and their impact on survival

OBJECTIVE

To evaluate the incidence, types and the effect on outcome of associated anomalies in neonates with anorectal malformations (ARM).

METHODS

This retrospective study was carried out on all neonates with ARM admitted to the neonatal surgical intensive care unit (NSICU) from 1998 through 2003.

RESULTS

Of the 754 neonates admitted to the NSICU during the study period of 6 years, there were 124 (16.4%) neonates with anorectal malformations. Of these 110 were included in the study. 73 % were male and 27% female. 86% of these were high ARM (HARM) while only 14% were low ARM (LARM). Associated anomalies were seen in 68% of patients. The incidence was 72% for HARM and 50% for LARM. The major associated anomalies consisted of esophageal (13%), gastrointestinal (GIT) (11%), genitourinary (GUT) (32%), skeletal (26%), cardiac (33%) and miscellaneous 26%. The overall survival rate was 84% (82% for HARM and 94% for LARM). The survival among those with associated esophageal anomalies was 43%, GIT 67%, GUT 80%, cardiac 61%, skeletal 76% and miscellaneous 79% respectively. This difference in survival was significant only for those with esophageal (p=0.004) and cardiac anomalies (p=0.0026). The survival rates among those with one, two or more than two organ systems involved with associated anomalies were 88%, 82% and 58% respectively. This difference was significant only for more than two organ systems involvement (p=0.003).

CONCLUSION

Associated anomalies are common in neonates with ARM, the incidence being similar for HARM and LARM. The survival depends upon the number and severity of associated anomalies both in patients with LARM and HARM. Neonates with more number of organ systems involved have a poorer survival specially when associated with esophageal and cardiac anomalies. All neonates with ARM merit a meticulous search for associated anomalies so that the management can be tailored for each baby.

Liver herniation into the pericardium: an unusual cause of massive pericardial effusion with intrapericardial mass in a neonate

In neonates presenting with massive pericardial effusion and pericardial mass, liver herniation into the pericardium is a rare diagnosis. Echocardiogram and CT scan are useful investigations in the diagnosis of pericardial masses. Continuation of the mass with the liver with the same texture as the liver helps to make the diagnosis of intrapericardial herniation of liver. Correct diagnosis of this condition is important because the surgical approach needed for management of this condition is different from that used for other pericardial masses.

Urodynamics-based evidence for the beneficial effect of imipramine on valve bladders in children

AIMS

In an era, in which valve bladder is recognised as perhaps the single most important determinant of long-term outcome in patients with posterior urethral valves (PUV), an insight into the etiopathogenesis and management of valve bladders is warranted. The present study was designed to evaluate bladder dysfunction in PUV and to assess the response to imipramine in these patients, both subjectively and objectively, by serial urodynamic studies (UDS).

METHODS

From 1998-2001, 30 patients with PUV who had documented bladder dysfunction on UDS were studied. Patients with non-compliant or unstable bladders were treated with imipramine (1.5 - 2 mg/kg). All the patients in the present study were 5 years or older and hence old enough to be toilet trained. Assessment of continence and side effects of the drug was done after 3 months and repeat UDS were done at 3-6 months, 1 and 2 years.

RESULTS

On the basis of initial treatment, the patients were divided into 2 groups; a fulguration group (n = 10, 33.3 %) and a vesicostomy group (n = 20, 66.6 %). Symptomatic voiding dysfunction was present in 27 of the 30 patients (90 %). Two patterns of urodynamic abnormalities were noted in the present study; 1) unstable bladders with single or multiple uninhibited contractions (18/30 patients, 60 %), and 2) small capacity, hypocompliant, hypertonic bladder (12/30 patients, 40 %). Post imipramine therapy significant symptomatic improvement was noted in 16/30 patients. On serial UDS, there was a 18-20 % increase in maximum cystometric capacity (MCC) and 30-35 % increase in pressure specific bladder volume (PSBV) following one year of imipramine therapy in 16/30 patients and 11/30 patients, respectively. 4 patients failed to show any improvement in MCC and PSBV with imipramine, they had been initially diverted with vesicostomy and later required augmentation cystoplasty.

CONCLUSION

Unstable bladders and those with marginal bladder capacity and compliance showed the best response to imipramine therapy. Fibrotic, small capacity, hypertonic bladders are less responsive to imipramine. However, a trial of imipramine therapy is still warranted in these patients, as only 4/12 (33.3 %) patients with fibrotic hypertonic bladders failed to show any response and ultimately required augmentation cystoplasty. Imipramine qualifies as an effective and cheap drug for valve bladders.

Diagnosis of ectopic gastric mucosa using 99Tcm-pertechnetate: spectrum of scintigraphic findings

We highlight the spectrum of scintigraphic findings likely to be encountered in patients with ectopic gastric mucosa with illustrative cases for each such finding. 11 children (aged 4 months to 120 months, all males) underwent (99)Tc(m)-pertechnetate scintigraphic evaluation for ectopic gastric mucosa. Functioning ectopic gastric mucosa was detected in Meckel's diverticulae in three patients, in small bowel duplications in four, in a gastric duplication in one, and in intrathoracic foregut duplication cysts in three. Ectopic functioning gastric mucosa in Meckel's diverticulum, and gastric duplication is visualized simultaneously with the stomach while in intestinal duplications tracer activity can be visualized in the dynamic sequence and even before gastric tracer visualization. In the three patients with intrathoracic duplication cysts, the functioning ectopic gastric mucosa was evident only in the delayed (99)Tc(m)-pertechnetate images, much later than the visualization of stomach activity. Therefore, acquisition of delayed images are useful when the initial images are equivocal or negative in children with intrathoracic foregut duplication cysts. In addition, we suggest a hypothesis of a possible mechanism for the uptake of pertechnetate in ectopic gastric mucosa in some patients with intrathoracic forget duplication cysts. In conclusion, a variety of scintigraphic patterns may be found in patients with ectopic gastric mucosa undergoing (99)Tc(m)-pertechnetate scintigraphy depending upon the location and size of the ectopic tissue.