Duodenal obstruction by gallstone in the absence of cholecystoenteric fistula, an unusual complication of total gastrectomy: report of a case

We present a case of gallstone obstruction of the duodenum in a post total gastrectomy patient without a cholecystoenteric fistula. The patient presented with epigastric pain. On abdominal computed tomography and percutaneous transhepatic choangiography imaging, the patient was found to have duodenal obstruction. At operation, the cause of obstruction was found to be a large gallstone in the third part of the duodenum, but there was no associated cholecystoenteric fistula. This report is the first to describe duodenal obstruction by a gallstone formed within the duodenum, in a patient post total gastrectomy with Roux-en-Y reconstruction, and highlights what can be a difficult diagnosis in such patients.

167. MUTANT STEROIDOGENIC FACTOR-1 FROM PATIENTS WITH DISORDERS OF SEX DEVELOPMENT SHOW REDUCED ACTIVATION OF THE TESTIS-SPECIFIC ENHANCER OF SOX9

The orphan nuclear hormone receptor Steroidogenic Factor 1 (SF1; NR5A1) is expressed throughout hypothalamic, pituitary, gonadal and adrenal tissues. Naturally occurring human mutations combined with mouse knockout models have revealed a critical role for SF1 as a transcription factor at multiple stages during gonadal development and during development of the adrenal. Missense mutation or truncation to SF1 in XY humans cause Disorders of Sex Development (DSD) with variable phenotypes. The precise mechanisms of SF1 action that fail in human DSD are not fully determined. This work aimed to utilise naturally occurring DSD-causing mutations in SF1 to increase our understanding of the sex determining function of SF1 in the developing male gonad. Recent work by others (1) identified SOX9 as a key target gene of SF1 during testis determination. SF1 activates Sox9 through a testis-specific enhancer element, termed TES. We tested the abilities of eleven clinical SF1 mutations to activate TES in reporter assays in HEK293T cells. Eight of the eleven SF1 mutants showed considerably reduced activation of TES compared to WT SF1. Furthermore, all mutations causing moderate to severe DSD phenotypes correlated with a more severe impairment of TES activation. In addition, all eleven of the mutants showed reduced synergistic activation of TES in co-transfection with the testis-determining co-factor SRY. Overall, this biochemical analysis of the function of mutant SF1 from DSD patients suggests that a failure of SOX9 up regulation, due to reduced activation of TES during testis development, could be the primary cause of the DSD in some patients with SF1 mutations.

Global mapping of ecosystem services and conservation priorities

Global efforts to conserve biodiversity have the potential to deliver economic benefits to people (i.e., "ecosystem services"). However, regions for which conservation benefits both biodiversity and ecosystem services cannot be identified unless ecosystem services can be quantified and valued and their areas of production mapped. Here we review the theory, data, and analyses needed to produce such maps and find that data availability allows us to quantify imperfect global proxies for only four ecosystem services. Using this incomplete set as an illustration, we compare ecosystem service maps with the global distributions of conventional targets for biodiversity conservation. Our preliminary results show that regions selected to maximize biodiversity provide no more ecosystem services than regions chosen randomly. Furthermore, spatial concordance among different services, and between ecosystem services and established conservation priorities, varies widely. Despite this lack of general concordance, "win-win" areas-regions important for both ecosystem services and biodiversity-can be usefully identified, both among ecoregions and at finer scales within them. An ambitious interdisciplinary research effort is needed to move beyond these preliminary and illustrative analyses to fully assess synergies and trade-offs in conserving biodiversity and ecosystem services.

The dose–volume interaction in adult supratentorial low-grade glioma: higher radiation dose is beneficial among patients with partial resection

PURPOSE

To evaluate the hypothesis that adults with partially resected (PR<50% resection) supratentorial low-grade glioma (LGG) benefit from higher doses of radiation.

METHODS

Patients receiving post-operative radiation for WHO grade I-II LGG at the University of Western Ontario between 1979 and 2001 were studied. Patient characteristics evaluated included: age, gender, symptom duration>30 days, seizures at presentation, Karnofsky performance status (KPS)<70, astrocytoma pathology (AS), and radiation dose. A Cox proportional hazard regression model was constructed to test the influence of radiation dose.

RESULTS

One hundred and seven patients were analyzed. Patients who had PR were not significantly different from those with STR (subtotal/total resection) in terms of patient characteristics. Median survival (MST) of PR patients who received<or=50 Gy was 16.5 months while those who received>50 Gy had a MST of 109.2 months. The interaction of radiation dose and extent of resection was tested after controlling for other patient factors by Cox regression model. The interaction was highly significant for both OS and PFS (P=0.013 and P=0.003, respectively). This model remained significant after excluding six patients receiving doses<42 Gy (OS, P=0.024, and PFS, P=0.001).

CONCLUSIONS

The outcome for patients with LGG is dependent on extent of tumor resection and radiation dose. Patients with PR should be considered for higher radiation dose schedules (>50 Gy). Future trials on therapeutic strategies for LGG should consider stratification of patients by extent of tumor resection. Our data suggests that one dose does not fit all.

A National Cancer Institute of Canada Clinical Trials Group Study – IND.135: Phase I/II study of irinotecan (camptosar), oxaliplatin and raltitrexed (tomudex) (COT) in patients with advanced colorectal cancer

Thirty-one patients with metastatic colorectal cancer were enrolled in this phase I/II trial of a triple combination of camptosar (C), oxaliplatin (O) and tomudex (T), all given on day one of a convenient three-week schedule. Patients received 257 cycles (1-18) in five cohorts. Toxicity was manageable and haematological toxicity was mild to moderate. Diarrhoea was the main dose-limiting toxicity; nausea and vomiting were common. Fatigue was frequent, moderate in severity and a reason for discontinuation in some patients. The recommended phase II doses were (C) 220 mg/m(2), (O) 100mg/m(2), (T) 2.75 mg/m(2). A 50% response rate in 30 evaluable patients was confirmed by an independent radiology review board; progression-free survival and overall median survival were 7.3 months and 16.6 months, respectively. Of the 16 patients treated at the recommended dose, 9 (56.3%) experienced partial response. Further evaluation in a randomized study compared to sequential doublets is warranted. Triple combinations could be relevant in curative settings for high-risk patients.

Helical tomotherapy for craniospinal radiation

Helical tomotherapy (HT) plans for craniospinal radiation were generated for the case of a 4-year-old boy with disseminated ependymoma. The HT plans demonstrated excellent target coverage, homogeneity and organ sparing compared with a conventional linear accelerator based craniospinal radiation plan. On the basis of this case study, further evaluation of HT for craniospinal radiotherapy seems justified.

Randomized phase II study of two doses of gefitinib in hormone-refractory prostate cancer: a trial of the National Cancer Institute of Canada-Clinical Trials Group

PURPOSE

Overexpression of the epidermal growth factor receptor has been demonstrated in advanced prostate cancer and is associated with a poor outcome. A multi-institutional, randomized, phase II study was undertaken by the National Cancer Institute of Canada-Clinical Trials Group to evaluate the efficacy and toxicity of two doses of oral gefitinib in patients with minimally symptomatic, hormone-refractory prostate cancer (HRPC).

PATIENTS AND METHODS

Between July and November 2001, 40 patients with HRPC and increasing prostate-specific antigen (PSA) or progression in measurable disease who had not received prior chemotherapy were randomly assigned to 250 mg (n = 19) or 500 mg (n = 21) oral gefitinib daily continuously. The primary end points were PSA response rate and objective measurable response. Functional Assessment of Cancer Therapy Prostate Cancer Subscale (FACT-P) quality-of-life questionnaires were completed at baseline and during treatment.

RESULTS

None of the patients demonstrated a PSA or objective measurable response. Five (14.3%) of 35 assessable patients had stable PSA (one patient at 250 mg and four patients at 500 mg), and five patients (14.3%) had a best response of stable disease (duration, 2.5 to 16.8 months). No significant effect on the rate of increase in PSA was seen. The most common drug-related nonhematologic toxicities observed were grade 1 to 2 diarrhea (250 mg, 65%; 500 mg, 56%), fatigue (250 mg, 29%; 500 mg, 33%), and grade 1 to 2 skin rash (250 mg, 24%; 500 mg, 39%). FACT-P scores decreased during treatment, indicating worsening of symptoms compared with baseline.

CONCLUSION

Gefitinib did not result in any responses in PSA or objective measurable disease at either dose level. Gefitinib has minimal single-agent activity in HRPC.

A phase 1 study of OSI-211 given as an intravenous infusion days 1, 2, and 3 every three weeks in patients with solid cancers

PURPOSE

To define the maximum tolerated dose (MTD), recommended phase II dose (RD) and dose limiting toxicity (DLT) of liposomal lurtotecan, OSI-211 (formerly known as NX211), given as a short intravenous infusion on days 1, 2, and 3 every three weeks.

EXPERIMENTAL DESIGN

Thirty-seven patients were enrolled and treated in a dose escalation study from a starting dose of 0.15 mg/m(2) daily x 3 to 2.1 mg/m(2) daily x 3. Detailed pharmacokinetic analyses of blood were done on both days 1 and 3 of the first cycle and toxicity was monitored.

RESULTS

Two MTDs were defined; one for patients defined as minimally pretreated and one for those heavily pretreated. Dose limiting toxicity was myelosuppression: primarily thrombocytopenia although neutropenia was also noted. The MTD was 2.1 mg/m(2)/d (total dose of 6.3 mg/m(2)) in minimally pretreated patients and 1.8 mg/m(2)/d (5.4 mg/m(2) total dose) in heavily pretreated patients. Pharmacokinetics revealed that AUC and C (max) increased with dose and were significantly higher than that of free lurtotecan (AUC approx. 100 fold higher). The half life and duration of the active lactone form were also significantly longer than historical data on free drug. Two partial responses were seen, one each in a patient with breast and ovarian cancer.

CONCLUSIONS

Two Phase II recommended doses were established for OSI-211 given as a daily x 3 schedule every three weeks. The recommended phase II dose is 1.8 mg/m(2) daily x 3 for minimally pretreated patients and 1.5 mg/m(2) for those heavily pretreated. Phase II studies should be initiated in sensitive tumours.

Abbreviated Course of Radiation Therapy in Older Patients With Glioblastoma Multiforme: A Prospective Randomized Clinical Trial

Purpose

To prospectively compare standard radiation therapy (RT) with an abbreviated course of RT in older patients with glioblastoma multiforme (GBM).

Patients and Methods

One hundred patients with GBM, age 60 years or older, were randomly assigned after surgery to receive either standard RT (60 Gy in 30 fractions over 6 weeks) or a shorter course of RT (40 Gy in 15 fractions over 3 weeks). The primary end point was overall survival. The secondary end points were proportionate survival at 6 months, health-related quality of life (HRQoL), and corticosteroid requirement. HRQoL was assessed using the Karnofsky performance status (KPS) and Functional Assessment of Cancer Therapy-Brain (FACT-Br).

Results

All patients had died at the time of analysis. Overall survival times measured from randomization were similar at 5.1 months for standard RT versus 5.6 months for the shorter course (log-rank test, P = .57). The survival probabilities at 6 months were also similar at 44.7% for standard RT versus 41.7% for the shorter course (lower-bound 95% CI, −13.7). KPS scores varied markedly but were not significantly different between the two groups (Wilcoxon test, P = .63). Low completion rates of the FACT-Br (45%) precluded meaningful comparisons between the two groups. Of patients completing RT as planned, 49% of patients (standard RT) versus 23% required an increase in posttreatment corticosteroid dosage (χ2 test, P = .02).

Conclusion

There is no difference in survival between patients receiving standard RT or short-course RT. In view of the similar KPS scores, decreased increment in corticosteroid requirement, and reduced treatment time, the abbreviated course of RT seems to be a reasonable treatment option for older patients with GBM.

A phase I study of OSI-211 and cisplatin as intravenous infusions given on days 1, 2 and 3 every 3 weeks in patients with solid cancers

BACKGROUND

OSI-211 (also known as NX211) is a liposomal preparation of the topoisomerase I inhibitor, lurtotecan, which has shown antitumor activity in phase I and II clinical trials. Cisplatin is a widely used antineoplastic agent with activity in a broad range of tumor types. This phase I trial was conducted to determine the recommended doses of these agents, and their pharmacokinetic properties and toxicities in patients with advanced solid malignancies.

PATIENTS AND METHODS

Fourteen patients with advanced and/or metastatic solid malignancies were enrolled in this trial. The first planned dose level was OSI-211 0.9 mg/m(2) with cisplatin 25 mg/m(2) administered intravenously daily for the first three consecutive days of a 21-day cycle. Patients were evaluated for hematological and non-hematological toxicities, and pharmacokinetic studies were performed on both agents.

RESULTS

The recommended phase II dose was determined to be 0.7 mg/m(2) OSI-211 given with 25 mg/m(2) cisplatin. Dose-limiting neutropenia was seen in two of three patients at the starting dose level. Three of 11 patients at the second (lower) dose level experienced dose-limiting thrombocytopenia; febrile neutropenia was also seen in one patient. Non-hematological toxicities were generally manageable and included fatigue, nausea and vomiting. Considerable variability was seen in both hematological toxicities and pharmacokinetics. One complete response and three partial responses were seen.

CONCLUSIONS

The recommended phase II dose for this combination is 0.7 mg/m(2) OSI-211 with 25 mg/m(2) cisplatin given as an intravenous infusion on days 1, 2 and 3 of a 21-day cycle. The main toxicity was myelosuppression. Preliminary evidence of antitumor activity was seen.