Real-time epidural anesthesia guidance using optical coherence tomography needle probe

Epidural anesthesia is one of the most widely used anesthesia methods. Due to lack of visual feedback to guide needle navigation, failure rate of epidural anesthesia is up to 20%, and the complication rate of peripheral nerve block approaches 10%, with the potential of permanent nerve damage. To address these difficulties, needle insertion under ultrasound guidance and fluoroscopy has been introduced. However, they do not provide adequate resolution and contrast to distinguish the tissue layers that the needle travels through or to specifically identify the epidural space. To improve the accuracy of epidural space identification, we developed a small hand-held optical coherence tomography (OCT) forward-imaging needle device for real-time epidural anesthesia surgery guidance and demonstrated its feasibility through ex vivo and in vivo animal experiments. With tissue structures visualized and differentiated at the needle tip, OCT needle imaging device will enhance clinical outcomes with regards to complication rates, induced pain, and procedure failure when compared to standard practice. Furthermore, this technology could be used in combination with ultrasound/fluoroscopy to enhance outcomes.

Chest modeling and personalized surgical planning for pectus excavatum

Pectus excavatum is among the most common major congenital anomalies of the chest wall whose correction can be performed via minimally invasive Nuss technique that places a pectus bar to elevate the sternum anteriorly. However, the size and bending of the pectus bar are manually modeled intraoperatively by trial-and-error. The procedure requires intense pain management in the months following surgery. In response, we are developing a novel distraction device for incremental and personalized PE correction with minimal risk and pain, akin to orthodontic treatment using dental braces. To design the device, we propose in this study a personalized surgical planning framework for PE correction from clinical noncontrast CT. First, we segment the ribs and sternum via kernel graph cuts. Then costal cartilages, which have very low contrast in noncontrast CT, are modeled as 3D anatomical curves using the cosine series representation and estimated using a statistical shape model. The size and shape of the correction device are estimated through model fitting. Finally, the corrected/post-surgical chest is simulated in relation to the estimated shape of correction device. The root mean square mesh distance between the estimated cartilages and ground truth on 30 noncontrast CT scans was 1.28 +/- 0.81 mm. Our method found that the average deformation of the sterna and cartilages with the simulation of PE correction was 49.71 +/- 10.11 mm.

Whole-exome sequencing identifies homozygous AFG3L2 mutations in a spastic ataxia-neuropathy syndrome linked to mitochondrial m-AAA proteases

We report an early onset spastic ataxia-neuropathy syndrome in two brothers of a consanguineous family characterized clinically by lower extremity spasticity, peripheral neuropathy, ptosis, oculomotor apraxia, dystonia, cerebellar atrophy, and progressive myoclonic epilepsy. Whole-exome sequencing identified a homozygous missense mutation (c.1847G>A; p.Y616C) in AFG3L2, encoding a subunit of an m-AAA protease. m-AAA proteases reside in the mitochondrial inner membrane and are responsible for removal of damaged or misfolded proteins and proteolytic activation of essential mitochondrial proteins. AFG3L2 forms either a homo-oligomeric isoenzyme or a hetero-oligomeric complex with paraplegin, a homologous protein mutated in hereditary spastic paraplegia type 7 (SPG7). Heterozygous loss-of-function mutations in AFG3L2 cause autosomal-dominant spinocerebellar ataxia type 28 (SCA28), a disorder whose phenotype is strikingly different from that of our patients. As defined in yeast complementation assays, the AFG3L2(Y616C) gene product is a hypomorphic variant that exhibited oligomerization defects in yeast as well as in patient fibroblasts. Specifically, the formation of AFG3L2(Y616C) complexes was impaired, both with itself and to a greater extent with paraplegin. This produced an early-onset clinical syndrome that combines the severe phenotypes of SPG7 and SCA28, in additional to other "mitochondrial" features such as oculomotor apraxia, extrapyramidal dysfunction, and myoclonic epilepsy. These findings expand the phenotype associated with AFG3L2 mutations and suggest that AFG3L2-related disease should be considered in the differential diagnosis of spastic ataxias.

Cold plasma selectivity and the possibility of a paradigm shift in cancer therapy

Background:

Plasma is an ionised gas that is typically generated in high-temperature laboratory conditions. However, recent progress in atmospheric plasmas has led to the creation of cold plasmas with ion temperature close to room temperature.

Methods:

Both in-vitro and in-vivo studies revealed that cold plasmas selectively kill cancer cells.

Results:

We show that: (a) cold plasma application selectively eradicates cancer cells in vitro without damaging normal cells; and (b) significantly reduces tumour size in vivo. It is shown that reactive oxygen species metabolism and oxidative stress responsive genes are deregulated.

Conclusion:

The development of cold plasma tumour ablation has the potential of shifting the current paradigm of cancer treatment and enabling the transformation of cancer treatment technologies by utilisation of another state of matter.

Vascular injury following accidental intra-arterial injection of clindamycin: adverse drug reaction report

Clindamycin in a commonly used antibiotic, considered safe for oral, intravenous and intra-arterial use. We present a case of a patient that received an inadvertent injection clindamycin 600 mg in 4 mL through a radial arterial line. The patient presented signs and symptoms of vascular occlusion and despite aggressive pharmacological and medical treatment developed massive and severe tissue injury.

Outcome after reduced chemotherapy for intermediate-risk neuroblastoma

BACKGROUND

The survival rate among patients with intermediate-risk neuroblastoma who receive dose-intensive chemotherapy is excellent, but the survival rate among patients who receive reduced doses of chemotherapy for shorter periods of time is not known.

METHODS

We conducted a prospective, phase 3, nonrandomized trial to determine whether a 3-year estimated overall survival of more than 90% could be maintained with reductions in the duration of therapy and drug doses, using a tumor biology-based therapy assignment. Eligible patients had newly diagnosed, intermediate-risk neuroblastoma without MYCN amplification; these patients included infants (<365 days of age) who had stage 3 or 4 disease, children (≥365 days of age) who had stage 3 tumors with favorable histopathological features, and infants who had stage 4S disease with a diploid DNA index or unfavorable histopathological features. Patients who had disease with favorable histopathological features and hyperdiploidy were assigned to four cycles of chemotherapy, and those with an incomplete response or either unfavorable feature were assigned to eight cycles.

RESULTS

Between 1997 and 2005, a total of 479 eligible patients were enrolled in this trial (270 patients with stage 3 disease, 178 with stage 4 disease, and 31 with stage 4S disease). A total of 323 patients had tumors with favorable biologic features, and 141 had tumors with unfavorable biologic features. Ploidy, but not histopathological features, was significantly predictive of the outcome. Severe adverse events without disease progression occurred in 10 patients (2.1%), including secondary leukemia (in 3 patients), death from infection (in 3 patients), and death at surgery (in 4 patients). The 3-year estimate (±SE) of overall survival for the entire group was 96±1%, with an overall survival rate of 98±1% among patients who had tumors with favorable biologic features and 93±2% among patients who had tumors with unfavorable biologic features.

CONCLUSIONS

A very high rate of survival among patients with intermediate-risk neuroblastoma was achieved with a biologically based treatment assignment involving a substantially reduced duration of chemotherapy and reduced doses of chemotherapeutic agents as compared with the regimens used in earlier trials. These data provide support for further reduction in chemotherapy with more refined risk stratification. (Funded by the National Cancer Institute; ClinicalTrials.gov number, NCT00003093.)

Abstract LB-255: A phenotypic and molecular characterization of murine neuroblastoma stem-like cells

Reports suggest the existence of cancer stem cells in solid tumors and it appears that tumor cells responsible for failure after successful initial therapy exhibit stem cell-like properties. However, tumor cells that undergo transition between epithelial and mesenchymal states may also acquire stem-like traits and are thought to be activated during cancer invasion and metastasis. It is unclear whether such cells are true stem cells or simply gain stem-like properties.

We used mouse neuroblastoma to develop a model where stem-like cells were generated and studied in the context of tumorigenicity, proliferation, response to radiation and chemotherapy. Next, we generated complete protein profiles of neuroblastoma stem-like (tumorspheres) and non stem-like (committed) cells comparing them to normal murine subventricular zone (SVZ) stem cells attempting to further characterize the “stem-ness” of these tumor cells. Murine neuroblastoma and the Neuro2A cell line were harvested and cultured in regular media with FBS or NeuroCult complete media specific for enrichment of neural stem cells. Adult mouse SVZ was dissected, and neural stem cells isolated and cultured in NeuroCult complete media.

We describe a subset of mouse neuroblasoma cells harvested from established tumors and cell lines with characteristics of neural stem cells. This subset shows features of self-renewal, grows in tumorspheres in serum free media and can be stimulated to undergo multi-lineage differentiation. Moreover, stem-like cells showed higher resistance to radiation, doxorubicin and Sutent treatment compared to committed cells. Committed cells showed a higher rate of proliferation both in vitro and in vivo. Using clonogenic assays, there was cross over between stem-like and non-stem like cells whereby tumorspheres reseeded into full-serum media exhibited a fully-differentiated, epithelial-like phenotype. Likewise, fully-differentiated non-stem like cells, if reseeded into stem cell media, resulted in round, undifferentiated, non-adherent cells resembling tumorspheres.

Stringent proteomic filtration identified 1,168 proteins. The greatest proteomic similarity was between stem-like and non stem-like cells with little overlap between SVZ stem cells (n=45 or n=51 respectively). Ninety two proteins were uniquely expressed by SVZ cells, including Nestin, defining a differential proteomic profile for neural stem cells compared to tumor stemlike cells. Several mesenchymal proteins were differentially up-regulated in the stem-like tumorspheres suggesting a mesenchymal transition.

Our data show that neuroblastoma tumor cells can transition between the epithelial and mesenchymal state and such cells are not true stem cells. The mesenchymal cells have stem-like qualities, but on proteomic analysis differ significantly from neural stem cells. Characterization of the proteome, not only validated the phenotypes, but may also identify targets for selective killing of resistant tumor-specific mesenchymal cells.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr LB-255.

A sense of urgency: Evaluating the link between clinical trial development time and the accrual performance of CTEP-sponsored studies

CRA6509

Background: Post-activation barriers to oncology clinical trial accruals are well documented; however, potential barriers prior to trial opening are not. We investigate one such barrier: trial development time. Methods: National Cancer Institute Cancer Therapy Evaluation Program (NCI-CTEP) sponsored trials for all therapeutic, non-pediatric phase I,I/II, II, and III studies activated in an eight year period (2000–2007) were investigated (n=553). Successful trials were those achieving 100% of minimum accrual goal. Time to open a study was the calendar time from initial CTEP submission to trialactivation. Multivariable logistic regression analysis was used tocalculate unadjusted and adjusted odds ratios, controlling for study phase and size of expected accruals. Results: 40.0 percent (n=221) of CTEP-approved oncology trials failed to achieve minimum accrual goals, with 49.2 percent (n=30) of phase III trials failing to achieve at least 25 percent of accrual goals. A total of 8,723 patients (17.0% of accruals) accrued to those studies that were unable to achieve the projected minimum accrual goal. Trials requiring 9–12 months development were significantly more likely to achieve accrual goals (odds ratio, 1.94; 95% CI, 1.06 to 3.52, P=0.031) than trials requiring the median time (15–18 months); trials that exceeded 27 months of development time were significantly less likely of achieving accrual goals (odds ratio, 0.14; 95% CI, 0.04 to 0.54, P=0.004). Conclusions: A large percentage of oncology clinical trials do not achieve minimum projected accruals. Trial development time appears to be one important predictor of the likelihood of successfully achieving the minimum accrual goals.

[Table: see text]

No significant financial relationships to disclose.

Urine PGE-M to assess prostaglandin E2 (PGE2) levels in non-small cell lung cancer (NSCLC)

e19026

Background: COX-2 is often overexpressed in NSCLC leading to high systemic PGE2 levels that in turn play a role in NSCLC pathogenesis. Changes in urine PGE-M (the major PGE2 metabolite) reflect changes in systemic & intratumoral PGE2 [Csiki et al. Clin Cancer Res 11:6634, 2005]. A ≥70% decline in PGE-M in NSCLC patients (pts) treated with celecoxib (C) (400 mg bid) + docetaxel (D) was associated with an apparent survival benefit [Ibid]. To effect maximum COX-2 inhibition we tested a higher C dose in a subsequent phase II trial. Methods: Eligibility: previously treated NSCLC, PS 0–2, evaluable/measurable disease, adequate marrow, renal & hepatic function, no current NSAID or sulfa allergy. Urine PGE-M measured prior to & 5–10 days after C 600 mg PO bid. Pts with ≥70% decline in PGE-M continued on C + D 75 mg/m2 or pemetrexed 500 mg/m2 q3wk x 4 cycles followed by maintenance C 400 mg PO bid until PD or drug intolerance. Results: 21 pts enrolled; F=7, M=14; 2 ineligible (1 carcinoid; 1 elevated LFT); 2 stopped C early (1 ARF; 1 pruritus). Mean PGE-M levels decreased from 38.9 to 7.8 ng/mg Cr pre- & post-C (mean change = 80%; P=0.002). The mean decline was greater in current & former smokers (81%; P=0.002) compared to never smokers (46%; P=0.19). Males had higher pre- treatment PGE-M (44 vs. 28.8 ng/mg Cr; P=0.21). Males had a significant decrease in mean PGE-M levels after C (78%; P=0.011); a similar albeit not significant change occurred in females (P=0.12). 12 screened pts (57%) had a ≥70% decline in PGE-M & received treatment with C + chemotherapy; 8 pts are evaluable for response; SD = 6; PD = 2. Treatment was well tolerated with no cardiac toxicities noted. Conclusions: These preliminary data indicate C 600 mg bid effectively inhibits intratumoral COX-2 in >50% NSCLC pts, a higher percentage than our previous trial using C 400 mg bid. The effect is greatest in former & current smokers & males compared to never smokers & females. Toxicities are acceptable. Accrual is ongoing. [Funding: VICC Lung Cancer SPORE CA90949].

No significant financial relationships to disclose.

Enrollment of lung cancer patients on clinical trials at an NCI comprehensive cancer center

6633

Background: Enrollment of cancer patients (pt) in clinical trials is considered essential in order to improve cancer care. However, cancer clinical trials participation remains low. Understanding barriers to pt enrollment is necessary to overcome this problem. Previous reports have identified pt age, race, and ethnicity, disease stage, performance status (PS) and relationship with their health care provider as factors that can influence the enrollment of pts in clinical trials. Methods: We conducted a retrospective review of the charts of all lung cancer pts seen in the Thoracic Oncology Clinic at Vanderbilt Ingram Cancer Center between November 2005 and November 2008. A total of 1075 lung cancer pts were seen. Results: 577 charts (of a planned 1075) have been audited to date. Pt demographics: median age = 64 yrs; male = 54%; Caucasian = 92%, African American = 4%, and Asian = 1%; NSCLC = 80%, SCLC = 17%. Male pts were more likely than females to be eligible for a clinical trial (p = 0.056). A study protocol was available for 57% of pts; 52% of pts proved eligible; 36% were entered into a study (11% total population). Significantly more protocols were available for NSCLC pts compared to pts with SCLC (p ≤ 0.001); there was also a non-significant trend towards higher enrollment of eligible NSCLC pts. There was no difference in eligibility between ethnicity; the percentage of eligible pts enrolling on trials was similar between Caucasian & African American pts (46% and 43%); no Asian pts were enrolled. The most common reasons for not enrolling included a preference for treatment closer to home (29%), patient refusal (19%), PS (19%), and co-morbidities (17%). The distance pts traveled was inversely correlated with likelihood of study participation. Conclusions: A total of 11% of lung cancer pt evaluated in our Thoracic Oncology Clinic were enrolled in clinical trials. Our data suggest additional strategies are needed to attract minority groups, increase enrollment of women and pts with comorbidities and poor PS. Travel distances influence pt willingness to participate in clinical trials. Strategies are needed to overcome this factor.

No significant financial relationships to disclose.

A sense of urgency: Evaluating the link between clinical trial development time and the accrual performance of CTEP-sponsored studies

CRA6509

The full, final text of this abstract will be available in Part II of the 2009 ASCO Annual Meeting Proceedings, distributed onsite at the Meeting on May 30, 2009, and as a supplement to the June 20, 2009, issue of the Journal of Clinical Oncology.

No significant financial relationships to disclose.