Toremifene increases bone mineral density in men receiving androgen deprivation therapy for prostate cancer: interim analysis of a multicenter phase 3 clinical study

PURPOSE

We evaluated the effects of toremifene on bone mineral density, a surrogate for fracture risk, in men receiving androgen deprivation therapy for prostate cancer.

MATERIALS AND METHODS

In an ongoing, multicenter, phase 3 fracture prevention study 1,392 men 50 years or older with prostate cancer receiving androgen deprivation therapy were randomized to 80 mg toremifene per day or placebo. Bone mineral density of the lumbar spine, total hip and femoral neck was assessed using dual energy x-ray absorptiometry. In this planned interim analysis of the first 197 subjects we compared bone mineral density changes from baseline to month 12 between the placebo and toremifene groups.

RESULTS

Compared with the placebo group men in the toremifene group had significant increases in bone mineral density at each evaluated skeletal site. Lumbar spine bone mineral density decreased 0.7% in the placebo group and increased 1.6% in the toremifene group (between group comparison p <0.001). Total hip bone mineral density decreased 1.3% in the placebo group and increased 0.7% in the toremifene group (p = 0.001). Femoral neck bone mineral density decreased 1.3% in the placebo group and increased 0.2% in the toremifene group (p = 0.009). Between group differences in the change in bone mineral density from baseline to month 12 were 2.3%, 2.0% and 1.5% for the lumbar spine, total hip and femoral neck, respectively.

CONCLUSIONS

Toremifene significantly increased hip and spine bone mineral density in men receiving androgen deprivation therapy for prostate cancer. The effect of toremifene on the fracture risk is being assessed in the ongoing randomized, controlled trial.

Effect of toremifene in lowering total cholesterol, LDL, and triglycerides and raising HDL in prostate cancer patients on androgen deprivation therapy

5124

Introduction: Androgen deprivation therapy (ADT) is the standard treatment for men with advanced prostate cancer. ADT has been shown to detrimentally affect lipids (average 9% increase in total cholesterol and 26% increase in triglycerides) and is associated with increased risk of coronary heart disease and myocardial infarction. Toremifene, a selective estrogen receptor modulator (SERM), improves bone mineral density and lipid profiles in women. An ongoing phase III trial will assess the safety and efficacy of toremifene in treating multiple side effects of ADT including osteoporosis, hot flashes, gynecomastia and lipid profiles. Given the emerging recognition of increased cardiovascular risk during ADT, an interim analysis was conducted to assess the effects of toremifene on lipid profiles in the ongoing phase III study. Methods: 1,392 men = 50 years old with histologically documented prostate cancer and receiving ADT were randomized to toremifene (80 mg/day) or placebo. An interim analysis evaluated changes in lipids from baseline to month 12 in the first 197 subjects to complete one-year follow up. The outcomes measured in this interim analysis were total cholesterol, LDL cholesterol, triglycerides, total cholesterol/HDL ratio, and HDL cholesterol. Results: Compared to treatment with placebo, toremifene decreased total cholesterol (7.1%; p=0.001 for between group comparison), LDL cholesterol (9.0%; p=0.003), and triglycerides (20.1%; p=0.009) levels, and the total cholesterol/HDL ratio (11.7%; p<0.001). Toremifene also significantly increased HDL levels (5.4%; p=0.018) compared to placebo. The effects of toremifene were observed in both statin users and nonusers. Conclusions: Toremifene decreases total cholesterol, LDL cholesterol, and triglycerides and increases HDL cholesterol in men receiving ADT for advanced prostate cancer compared to placebo. Conclusions regarding the clinical significance of these observations will be based on the full cohort of patients at the conclusion of the trial.

No significant financial relationships to disclose.

Prevalence of osteoporosis and osteopenia during androgen deprivation (ADT) for prostate cancer: Baseline data from a large randomized controlled trial

5116

Background: Androgen deprivation therapy (ADT) is the standard treatment for men with advanced prostate cancer. ADT decreases bone mineral density (BMD) and increases fracture risk although there is limited information about the prevalence of osteopenia and osteoporosis during ADT. We evaluated the baseline data from a large fracture prevention study to better characterize the prevalence of ostepenia and osteoporosis in men receiving ADT for prostate cancer. Methods: In an ongoing phase 3 fracture prevention study, 1,392 men = 50 years old with histologically documented prostate cancer and receiving ADT were randomized to placebo or toremifene 80 mg, a selective estrogen receptor modulator. The phase 3 study included men at increased risk of fracture based on age = 70 years or low baseline BMD of the hip or spine as assessed by dual energy x-ray absorptiometry. Subjects with metabolic bone disease or receiving treatment for osteoporosis were excluded. In the current analyses, we report the baseline BMD and prevalence of osteopenia (T score -1.0 to -2.5 total hip, femoral neck or spine) and osteoporosis (T score = -2.5 total hip, femoral neck or spine) for the 1,139 subjects older than 70 years. The analyses were restricted to subjects =70 years because these subjects were included in the study regardless of baseline BMD. Results: Mean (± standard deviation) age was 76 ± 7 years. Mean duration on ADT was 39 ± 36 months. For men 70 years of age or older, mean T scores for the total hip, femoral neck, and spine are -1.01 ± 1.14, -1.50 ± 1.06 and 0.37 ± 1.88 respectively. A total of 73% of subjects 70 years of age or older were classified with osteopenia (55%) or osteoporosis (18%). Conclusions: In this large cross- sectional analysis, the vast majority of older men receiving ADT for prostate cancer have either osteopenia or osteoporosis. These observations provide further evidence that close attention to skeletal health is warranted during ADT for prostate cancer.

No significant financial relationships to disclose.

Interventions for pityriasis rosea

BACKGROUND

Pityriasis rosea is a scaly rash that mainly affects young adults. It can be very itchy but most people recover within 2 to 12 weeks.

OBJECTIVES

To assess the effects of interventions for pityriasis rosea.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (December 2004), the Cochrane Central Register of Controlled Clinical Trials in The Cochrane Library (Issue 4, 2004), MEDLINE (1966 to January 2005), EMBASE (1976 to January 2005), LILACS (1982 to January 2005), BIOSIS Preview (1980 to June 2002), and ongoing trials databases. We scanned bibliographies of published studies, abstracts from dermatology conference proceedings, corresponded with trialists and contacted the pharmaceutical industry.

SELECTION CRITERIA

Randomised controlled trials evaluating interventions for pityriasis rosea.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors to retrieve missing data.

MAIN RESULTS

Three trials involving 148 people were included. One poor quality trial (23 people), compared intravenous glycyrrhizin and intravenous procaine. It found no significant difference between the two interventions for treating symptoms and rash. One fair quality trial (85 people), compared the oral antihistamine dexchlorpheniramine (4 mg), the oral steroid betamethasone (500 mcg), and a combination of betamethasone (250 mcg) and dexchlorpheniramine (2 mg). It found no significant difference in itch resolution at two weeks, as rated by the participants, between dexchlorpheniramine and betamethasone, and the combination of dexchlorpheniramine and betamethasone. However, both dexchlorpheniramine and betamethasone alone seem to be better at clearing rash than the combination of dexchlorpheniramine and betamethasone. These interventions were not compared with placebo. The small good quality trial (40 people) that compared oral erythromycin and placebo found that erythromycin was more effective than placebo in terms of rash improvement, as rated by the trialists, after two weeks (RR 13.00; 95% CI 1.91 to 88.64). It was also more effective in decreasing the itch score (difference of 3.95 points, 95% CI 3.37 to 4.53). No serious adverse effects were reported for the interventions. Two out of 17 people on oral erythromycin and 1 out of 17 on placebo reported minor gastrointestinal upset.

AUTHORS' CONCLUSIONS

We found inadequate evidence for efficacy for most treatments for pityriasis rosea. Oral erythromycin may be effective in treating the rash and decreasing the itch. However, this result should be treated with caution since it comes from only one small RCT. More research is necessary to evaluate the efficacy of erythromycin and other treatments.

Characterization of Anaplasma phagocytophilum major surface protein 5 and the extent of its cross-reactivity with A. marginale

Major surface protein 5 (Msp5) of Anaplasma marginale is highly conserved in the genus Anaplasma and the antigen used in a commercially available competitive enzyme-linked immunosorbent assay (cELISA) for serologic identification of cattle with anaplasmosis. This study analyzes the degrees of conservation of Msp5 among various isolates of Anaplasma phagocytophilum and the extent of serologic cross-reactivity between recombinant Msp5 (rMsp5) of Anaplasma marginale and A. phagocytophilum. The msp5 genes from various isolates of A. phagocytophilum were sequenced and compared. rMsp5 proteins of A. phagocytophilum and A. marginale were used separately in an indirect ELISA to detect cross-reactivity in serum samples from humans and dogs infected with A. phagocytophilum and cattle infected with A. marginale. Serum samples were also tested with a commercially available competitive ELISA that uses monoclonal antibody ANAF16C1. There were 100% sequence identities in the msp5 genes among all of the A. phagocytophilum isolates from the United States and a horse isolate from Sweden. Sheep isolates from Norway and dog isolates from Sweden were 99% identical to one another but differed in 17 base pairs from the United States isolates and the horse isolate. Serologic cross-reactivity was identified when serum samples from cattle infected with A. marginale were reacted with rMsp5 of A. phagocytophilum and when serum samples from humans and dogs infected with A. phagocytophilum were reacted with rMsp5 of A. marginale in an indirect-ELISA format. Serum samples from dogs or humans infected with A. phagocytophilum did not cross-react with rMsp5 of A. marginale when tested with the commercially available cELISA. These results suggest that rMsp5 of A. phagocytophilum is highly conserved among United States and European isolates and that serologic distinction between A. phagocytophilum and A. marginale infections cannot be accomplished if rMsp5 from either organism is used in an indirect ELISA.

Cytoreductive surgery and perioperative intraperitoneal chemotherapy for peritoneal carcinomatosis from colorectal carcinoma: non-mucinous tumour associated with an improved survival

AIMS

Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy has been reported as a treatment option for patients with peritoneal carcinomatosis from colorectal carcinoma.

METHODS

Thirty patients with colorectal peritoneal carcinomatosis underwent cytoreductive surgery and perioperative intraperitoneal chemotherapy. All appendiceal cancers were excluded. All patients were followed until January 2006 or death. Univariate analysis was performed to evaluate significant prognostic factors for overall survival, defined from the time of surgery.

RESULTS

There were 13 male patients. The mean age at the time of surgery was 54years. There was no hospital mortality. The mean duration of hospital stay was 27days. The overall median survival was 29months, with 1- and 2-year survival of 72% and 64%, respectively. Twenty-one patients had complete cytoreduction and their 1- and 2-year survival rates were 85% and 71%, respectively. Univariate analysis demonstrated that patients with non-mucinous colorectal adenocarcinoma, Peritoneal Cancer Index (PCI) < or =13, and complete cytoreduction were associated with an improved survival.

CONCLUSIONS

This study reported on 30 patients who underwent cytoreductive surgery and perioperative intraperitoneal chemotherapy for colorectal peritoneal carcinomatosis. Patients with mucinous tumour had relatively more extensive intraperitoneal disease. Non-mucinous colorectal adenocarcinoma, PCI < or =13, and complete cytoreduction were associated with an improved survival.

Metabolism and excretion of imrecoxib in rat

The metabolism and excretion of imrecoxib, a novel and moderately selective cyclooxygenase-II inhibitor, were investigated in rat. The structures of metabolites were identified by mass spectrometry (MSn) and nuclear magnetic resonance. Metabolic profiles of imrecoxib in urine, bile and faeces were obtained by HPLC and LC/MSn, and cumulative excretion was determined by LC/MSn. Imrecoxib was extensively metabolized in rat after intravenous administration, with less than 2% of the dose excreted as parent drug in either urine or faeces. The major metabolic pathway was that the 4'-methyl group of imrecoxib was first oxidized to the 4'-hydroxymethyl metabolite (M4), followed by additional oxidation to 4'-carboxylic acid metabolite (M2). The dihydroxylated metabolite, 4'-hydroxymethyl-5-hydroxyl imrecoxib (M3), was further oxidized to 4'-hydroxymethyl-5-carbonyl metabolite (M5), and glucuronide conjugates of M2-4 were formed. After intravenous (5 mg kg-1) administration, the majority of the dose was recovered in the faeces. The dose was primarily excreted as the carboxylic acid metabolite in addition to the 4'-hydroxymethyl metabolite. The carboxylic acid metabolite was mainly excreted in faeces, while the 4'-hydroxymethyl metabolite was mainly excreted in urine.

Toremifene citrate increases bone mineral density in men receiving androgen deprivation therapy for prostate cancer

4553

Background: In men with prostate cancer, androgen deprivation therapy by either surgical orchiectomy or treatment with a gonadotropin releasing hormone agonist decreases bone mineral density (BMD) and increases clinical fracture risk. In postmenopausal women, selective estrogen receptor modulators (SERMs) increase BMD and decrease fracture incidence. We conducted a multicenter randomized controlled trial to evaluate the efficacy of the SERM toremifene citrate in men with prostate cancer. Methods: In a 24-month prospective study, 1392 men with prostate cancer who have been treated with ADT for at least 6 months and are at increased risk of fracture based on either being older than 70 years of age or having evidence of osteopenia by baseline dual energy X-ray absorptiometry (DEXA) scan were assigned randomly (1:1) to receive either toremifene citrate 80mg or placebo (by mouth daily). The primary study endpoint is proportion of men with one or more fracture at 24 months. Secondary endpoints include changes in BMD of the hip and spine. Here we report the results of a planned interim analysis of 12-month changes in BMD for the first 200 subjects. Results: As summarized in the table below, toremifene citrate significantly increased BMD of the lumbar spine, total hip, and femoral neck compared to placebo. Conclusions: In men receiving ADT for prostate cancer, toremifene citrate significantly increased BMD of the hip and spine. In randomized controlled trials of SERMs in postmenopausal women, similar BMD improvements translated into statistically and clinically significant decreases in fractures risk. These interim results of BMD effects suggest toremifene citrate has the potential to provide a fracture reduction benefit in men with prostate cancer, the hypothesis being tested in the ongoing study.

[Table: see text]

[Table: see text]

Single centre experience of liver resection for hepatocellular carcinoma in patients outside transplant criteria

INTRODUCTION

To report analysis of our results of liver resection for HCC outside the transplant criteria with preserved liver function.

METHODS

Between January 1990 and March 2005, 279 patients with HCC were seen at our institution and entered into a prospective database. There were 51 patients who did not fulfill the transplant criteria and underwent partial hepatectomy. Survival was determined by Kaplan-Meier analysis.

RESULTS

The median tumour size was 10.0 cm with a range of 3-20 cm. Twenty-nine patients had solitary tumours and 21 patients had two or more liver tumours, with four patients whose tumours were less than 5 cm in maximal diameter. Ten patients had bilobar disease. The 30-day mortality was 8%. The 1-, 3- and 5-year overall survival was 63, 40 and 33%, respectively, and the median survival was 16.6 months. Fifteen potential variables were analysed as potential predictors of adverse outcome. Multivariate analysis showed Child-Pugh classification, presence of cirrhosis, rupture on presentation and tumour histology to be independent prognostic factors on survival.

CONCLUSION

Partial hepatectomy in patients with advanced HCC who are ineligible for transplantation can be performed safely and can achieve a 5-year survival of 33%.

The role of histone acetylation versus DNA damage in drug-induced senescence and apoptosis

The present study was undertaken to determine the significance of histone acetylation versus DNA damage in drug-induced irreversible growth arrest (senescence) and apoptosis. Cellular treatment with the DNA-damaging drugs doxorubicin and cisplatin or with the histone deacetylase inhibitor trichostatin A, led to the finding that all the three drugs induced senescence at concentrations significantly lower than those required for apoptosis. However, only doxorubicin and cisplatin induced activation of H2AX, a marker for double-strand break formation. Interestingly, this occurred mainly at apoptosis and not senescence-inducing drug concentrations, suggesting that non-DNA-damage pathways may be implicated in induction of senescence by these drugs. In agreement with this, chromatin immunoprecipitation experiments indicated that doxorubicin was able to induce acetylation of histone H3 at the promoter of p21/WAF1 only at senescence-inducing concentrations. Collectively, these findings suggest that alteration of chromatin structure by cytotoxic drugs may represent a key mediator of senescence.

Siva-1 negatively regulates NF-kappaB activity: effect on T-cell receptor-mediated activation-induced cell death (AICD)

Ligation of TCRs on stimulated T cells leads to activation-induced cell death (AICD) resulting in the downregulation of immune responses, a process essential for T-cell homeostasis. In this study, using transformed T-cell lines such as Jurkat and Do11.10 as cellular models of TCR-mediated AICD, we have demonstrated that the proapoptotic protein Siva-1 is required for TCR-induced apoptosis. Knockdown of Siva-1 rendered T cells specifically resistant to anti-CD3 but not Fas-induced apoptosis. Further, we observed that in Siva-1 knockout Jurkat cells, TCR-mediated activation of the canonical and non-canonical limbs of the NF-kappaB pathway are significantly enhanced as reflected by elevated nuclear levels of p65 and RelB, respectively. In addition, loss of endogenous Siva-1 also resulted in the enhanced expression of NF-kappaB- responsive anti-apoptotic genes such as Bcl-xL and c-FLIP. Interestingly, the c-FLIP(short) was detected only in TCR-ligated Siva-1 knockdown Jurkat cells. These results demonstrate a significant role for endogenous Siva-1, through its inhibitory effect on NF-kappaB activity, in TCR-mediated AICD with implications in peripheral tolerance, T-cell homeostasis and cancer.

Liver resection in octogenarians

BACKGROUND

Liver resections are increasingly being performed safely in elderly patients. There are no present reports of the operative safety of liver resection in octogenarians who represents a rapidly increasing segment of the population. The purpose of this study was to analyse the results of liver resection in octogenarians over a 5 year period within a tertiary referral liver surgery unit.

METHODS

Prospective data collection and analysis of octogenarians having liver resection between 1999 and 2004. Retrospective detailed case note analysis was performed to determine peri-operative mortality and morbidity. Comparison were made to other large series of liver resection in younger patient cohorts. The primary outcome measure was 30 day mortality and secondarily a detailed analysis of post-operative complications was performed.

RESULTS

A total 15 octogenarians (median age 82) were identified from the database. There was 1 peri-operative mortality. The remaining patients were all alive at 1, 3 and 6 month follow-ups with a median follow-up of 18 months. The commonest indication for liver resection was metastatic colorectal cancer (n=1). The median operating time was 142.5 minutes and 67% of patients (n=10) had portal clamping for a median of 21.5 minutes. The median length of hospitalization was 12 days with an ICU stay of 1 day, 27% (n=4) had major surgical complications. A further 20% (n=3) had exacerbations of pre-existing comorbidities.

CONCLUSION

Liver resection can be performed safely in octogenarians within a tertiary referral unit. It has a low mortality and an acceptable level of morbidity in carefully selected octogenarians.

Recurrent acute heart failure caused by sliding hiatus hernia

The case is reported of a 75 year old woman who presented with recurrent nocturnal episodes of acute pulmonary oedema. The cause was uncertain as she had normal cardiothoracic ratio on chest radiography and normal left ventricular systolic and diastolic function by transthoracic echocardiogram. Another transthoracic echocardiogram was repeated when she was recumbent for an hour and had a full stomach. It showed a striking finding of severe left atrial compression by an external structure. Computed tomography of the thorax showed an intrathoracic mass behind the left atrium causing external compression of the left atrium suggestive of a sliding hiatus hernia. Cardiac catheterisation confirmed the diagnosis by showing a pronounced rise of pulmonary capillary wedge pressure in the recumbent position compared with the sitting up position.

Persistent shedding of viable SARS-CoV in urine and stool of SARS patients during the convalescent phase

In order to further the present knowledge of the emerging severe acute respiratory syndrome-associated coronavirus (SARS-CoV), 486 different specimens from 54 patients with a clinical diagnosis of SARS were investigated for the presence of viral RNA, and 314 plasma specimens of 73 patients were examined for IgM and IgG antibodies specific against SARS-CoV using an indirect ELISA. Viral RNA was detectable in 28 of the 54 patients tested. Cumulative data showed that 67 of the 73 SARS patients demonstrated seroconversion by week 5 of illness. In contrast, only 1 of 278 healthy subjects enrolled in the study was found to be positive for the IgG antibody. Coexistence of viral RNA in plasma and specific antibodies was simultaneously observed over three consecutive weeks in two critical cases. In three convalescent patients in particular, cultivable SARS-CoV was detected in stool or urine specimens for longer than 4 weeks (29-36 days). These findings suggest that SARS-CoV may remain viable in the excretions of convalescent patients.