Phase III placebo-controlled double-blind randomized trial of radiotherapy for stage IIB-IVA cervical cancer with or without immunomodulator Z-100: a JGOG study

BACKGROUND

Based on the result of our previous study showing better overall survival (OS) at the lower dose (0.2 µg) of immunomodulator Z-100 than higher dose (40 µg) in patients with locally advanced cervical cancer who received radiotherapy, we conducted a placebo-controlled double-blind randomized trial.

PATIENTS AND METHODS

Patients of stages IIB-IVA squamous cell carcinoma of the uterine cervix were randomly assigned to receive Z-100 at 0.2 µg (Z) or placebo (P). The study agent was given subcutaneously twice a week during the radiotherapy, followed by maintenance therapy by administering once every 2 weeks until disease progression. Primary end point was OS, and secondary end points were recurrence-free survival, and toxicity.

RESULTS

A total of 249 patients were randomized. Death events occurred extremely slower than expected, and Independent Data Monitoring Committee recommended to analyze the survival result prematurely. The 5-year OS rate was 75.7% [95% confidence interval (CI) 66.4% to 82.8%] for Arm Z and 65.8% (95% CI 56.2% to 73.8%) for Arm P (P = 0.07); hazard ratio was 0.65 (95% CI 0.40-1.04). Survival benefit in Arm Z was observed regardless of chemoradiation or radiation alone. There was no trend in recurrence-free survival between the two arms. Side-effects were not different between two arms.

CONCLUSION

Z-100 showed a trend of improvement on OS in locally advanced cervical cancer, although the statistical power was less than anticipated because survival rates were unexpectedly higher than expected for both arms. Validation of potential survival benefit of immune modulation should be made.

TRIAL REGISTRATION

umin.ac.jp/ctr Identifier: C000000221.

Status of a compact electron cyclotron resonance ion source for National Institute of Radiological Sciences-930 cyclotron

The Kei-source is a compact electron cyclotron resonance ion source using only permanent magnets and a frequency of 10 GHz. It was developed at the National Institute of Radiological Sciences (NIRS) for producing C(4+) ions oriented for high-energy carbon therapy. It has also been used as an ion source for the NIRS-930 cyclotron. Its microwave band region for the traveling-wave-tube amplifier and maximum output power are 8-10 GHz and 350 W, respectively. Since 2006, it has provided various ion beams such as proton, deuteron, carbon, oxygen, and neon with sufficient intensity (200 μA for proton and deuteron, 50 μA for C(4+), for example) and good stability for radioisotope production, tests of radiation damage, and basic research experiments. Its horizontal and vertical emittances were measured using a screen monitor and waist-scan. The present paper reports the current status of the Kei-source.

Effects of a difference in respiratory cycle between treatment planning and irradiation for phase-controlled rescanning and carbon pencil beam scanning

OBJECTIVE

To evaluate the impact of variation in respiratory cycle between treatment planning and irradiation for pencil beam scanning and phase-controlled rescanning (PCR) on the resulting dose distribution, we conducted a simulation study based on four-dimensional CT (4DCT) data for lung cancer patients.

METHODS

4DCT data were acquired for seven patients with lung tumours. Treatment planning was designed to ensure the delivery of 95% of the prescribed dose to the clinical target volume in respective phases of the 4DCT by taking account of intrafractional beam range variations. Carbon ion pencil beam scanning dose distributions were calculated for various respiratory cycles that differed from the reference respiration (=4.4 s) but which stayed regular during irradiation. The number of rescannings was changed to 1, 4 or 8 times. PCR was correlated with the gating window in treatment planning to calculate the beam weighting map.

RESULTS

8×PCR improved dose conformation to the target for all irradiation respiratory cycles. Minimum dose (Dmin) and lowest dose encompassing 95% of the target (D95) values with 4×PCR were decreased from 94.1% and 98.1% to 88.4% and 93.5% with an altered irradiation respiratory cycle of 2.4 s. However, these values were improved with 8×PCR to over 94.9% for Dmin and 98.6% for D95 for respective irradiation respiratory cycles.

CONCLUSION

Pencil beam scanning treatment with eight or more PCRs consistently improved dose conformation for moving lung targets even when different respiratory cycles were used for treatment planning and irradiation.

ADVANCES IN KNOWLEDGE

Scanning treatment with eight or more rescannings consistently improved dose homogeneity to a moving target even though respiratory cycles varied during treatment.

(Pro)renin receptor is associated with angiogenic activity in proliferative diabetic retinopathy

AIMS/HYPOTHESIS

The renin-angiotensin system (RAS) potentially has a role in the development of end-organ damage, and tissue RAS activation has been suggested as a risk factor for diabetic retinopathy. We have recently shown significant involvement of (pro)renin receptor ([P]RR) in retinal inflammation in a rodent model of early diabetes. In this study we aim to elucidate the (P)RR-associated pathogenesis of fibrovascular proliferation, a late-stage angiogenic complication in human diabetic retinopathy.

METHODS

Vitreous fluids from 23 eyes of patients with proliferative diabetic retinopathy (PDR) and 16 eyes of controls with non-diabetic, idiopathic macular diseases (macular hole and epiretinal membrane) were collected. Protein levels of soluble (P)RR were measured by ELISA, and immunofluorescence was performed to assess the localisation of (P)RR and related molecules in fibrovascular tissues from PDR eyes.

RESULTS

(P)RR immunoreactivity was detected in neovascular endothelial cells, colocalised with prorenin, phosphorylated extracellular signal-regulated kinase (ERK) and vascular endothelial growth factor (VEGF). Prorenin application to human retinal microvascular endothelial cells significantly upregulated mRNA expression of VEGF, especially the VEGF165 isoform, which was abolished by (P)RR or ERK signalling blockade. Proteases known to cleave (P)RR, including furin, were positive in endothelial cells in fibrovascular tissues. Protein levels of soluble (P)RR in vitreous fluids were higher in PDR eyes than in non-diabetic control eyes, and correlated significantly with vitreous prorenin and VEGF levels and the vascular density of fibrovascular tissues.

CONCLUSIONS/INTERPRETATION

Our data using human samples provide the first evidence that (P)RR is associated with angiogenic activity in PDR.

Physics research and technology developments of electron string ion sources

The most recent experimental information on electron string phenomenon, such as two step transition to electron string state, stability of e-strings in condition of electron energy recuperation, are described. The new technology developments of electron string ion sources (ESIS) include pulse injection of gaseous species in e-string and its efficient conversion to ion beams, slow ion extraction, ion-ion cooling of heavy ions with CH(4) coolant, and a progress in the construction of the new Joint Institute for Nuclear Research ESIS with 6 T solenoid are briefly considered.

Improved transdermal delivery of prostaglandin E1 through hairless mouse skin: combined use of carboxymethyl-ethyl-β-cyclodextrin and penetration enhancers

The optimal prescription of transdermal preparations of prostaglandin E1 (PGE1) for treatment of peripheral vascular diseases has been investigated. The chemical stability of PGE1 in fatty alcohol/propylene glycol (FAPG) ointment was markedly improved by carboxymethyl-ethyl-β-cyclodextrin (CME-β-CyD). Application of a PGE1 ointment containing the penetration enhancer, 1-dodecylazacycloheptane-2-one (Azone) or 1-[2-(decylthio)ethyl]azacyclopentane-2-one (HPE-101), onto the skin of hairless mice showed the increase of blood flow in the skin due to the vasodilating action of PGE1. In particular, the ointment containing a PGE1-CME-β-CyD complex supplemented with HPE-101 showed the most prominent increase of the blood flow. Compared with other ointments, this ointment was found to show significantly greater transfer of HPE-101 into in-vitro preparations of the skin of hairless mice. Transfer of PGE1 into the skin was thought to be facilitated by this increased transfer of HPE-101. These results suggest that a combination of CME-β-CyD and HPE-101 is useful for designing PGE1 ointments for topical application with good chemical stability and percutaneous permeability.

Phase II study of nedaplatin and irinotecan with concurrent thoracic radiotherapy in patients with locally advanced non-small-cell lung cancer

Background:

Current international guidelines recommend the use of platinum-based chemotherapy with thoracic radiotherapy (TRT) for patients with locally advanced non-small-cell lung cancer (NSCLC).

Methods:

Patients with unresectable stage IIIA or IIIB NSCLC were treated with nedaplatin (NP) at 50 mg m⁻² and irinotecan (CPT) at 60 mg m⁻² on days 1 and 8 every 4 weeks for two to four cycles with concurrent TRT (2 Gy per day, total 60 Gy).

Results:

All 35 patients were able to receive a total of 60 Gy. Adverse effects and events in chemotherapy with TRT were grade 3 or 4 anaemia, neutropenia and thrombocytopenia, which occurred in 3.0%, 32.8% and 6.0% of patients, respectively. There was no grade 3 pneumonitis or oesophagitis. Adverse effects and events in chemotherapy alone were mild. There was no treatment-related death. An overall response rate was 94.3%. The median progression-free and overall survivals were 13.0 and 36.0 months, respectively. The 5-year disease-free and overall survival rates were 25.7% and 40.0%, respectively.

Conclusion:

NP and CPT treatment with concurrent TRT is effective and safe for patients with unresectable, locally advanced NSCLC.

Development of novel measurement assay for calcium in serum by the chlorophosphonazo-III vanadate method

Background

Chlorophosphonazo-III (2,7-bis[4-chloro-2-phosphonophenylazo]-1,8-dihydroxy-3,6-naphthalenedisulphonic acid, disodium salt; CPZ-III) reacts with calcium and magnesium in a sample under acidic to neutral conditions. However, the specific method of measuring calcium in serum using CPZ-III has not been established because of the difficulty of avoiding the interaction between CPZ-III and albumin.

Methods

In this study, we found that the non-specific reaction between CPZ-III and albumin could be controlled and calcium in serum could be specifically detected using CPZ-III combined with vanadate. On the basis of this finding, we evaluated a novel method of serum calcium determination using CPZ-III.

Results

This CPZ-III vanadate method gave linear results from 0 to 7.0 mmol/L. The coefficient of variation was 0.63–0.76%. There was no interference except with Omniscan. There was no change in control performance during 60 d under open-air conditions. The assay results correlated well with those of the Arsenazo-III (2,7-bis(2-arsonophenylazo)-1,8-dihydroxy-3,6-naphthalenedisulphonic acid) method (slope = 1.067; intercept = −0.120; r = 0.989; Sy/ x = 0.036 mmol/L), o-cresolphthalein complexone method (slope = 0.911; intercept = 0.186; r = 0.988; Sy/ x = 0.035 mmol/L), amylase enzymatic method (slope = 0.981; intercept = 0.072; r = 0.989; Sy/ x = 0.036 mmol/L) and inductively coupled plasma emission spectroscopy method (slope = 0.955; intercept = −0.001; r = 0.979; Sy/ x = 0.048 mmol/L).

Conclusions

These results suggested that the present method has great clinical potential for measuring calcium.

A phase II trial of dose-dense chemotherapy, followed by surgical resection and/or thoracic radiotherapy, in locally advanced thymoma: report of a Japan Clinical Oncology Group trial (JCOG 9606)

BACKGROUND

This study aimed to evaluate the safety and efficacy of dose-dense weekly chemotherapy, followed by resection and/or thoracic radiotherapy.

METHODS

Patients with histologically documented thymoma with unresectable stage III disease received 9 weeks of chemotherapy: cisplatin 25 mg m(-2) on weeks 1-9; vincristine 1 mg m(-2) on weeks 1, 2, 4, 6 and 8; and doxorubicin 40 mg m(-2) and etoposide 80 mg m(-2) on days 1-3 of weeks 1, 3, 5, 7 and 9. Patients went on to surgery and post-operative radiotherapy of 48 Gy; those with unresectable disease received 60 Gy radiotherapy.

RESULTS

total of 23 patients were entered. The main toxicities of the chemotherapy regimen were neutropenia and anaemia, and 57% of patients completed the planned 9 weeks of therapy. There were no toxic deaths. Of the 21 eligible patients, 13 (62%) achieved a partial response (95% confidence interval: 38-82%). Thirteen patients underwent a thoracotomy and nine (39%) underwent complete resection. Progression-free survival at 2 and 5 years was 80 and 43%, respectively. Overall survival at 5 and 8 years was 85 and 69%, respectively. Survival did not seem to be affected by resection.

CONCLUSION

In thymoma patients, weekly dose-dense chemotherapy has activity similar to that of conventional regimens. Although some patients could achieve complete resection, the role of surgery remains unclear.

Neurodegenerative influence of oxidative stress in the retina of a murine model of diabetes

AIMS/HYPOTHESIS

Diabetic retinopathy is a progressive neurodegenerative disease, but the underlying mechanism is still obscure. Here, we focused on oxidative stress in the retina, and analysed its influence on retinal neurodegeneration, using an antioxidant, lutein.

METHODS

C57BL/6 mice with streptozotocin-induced diabetes were constantly fed either a lutein-supplemented diet or a control diet from the onset of diabetes, and their metabolic data were recorded. In 1-month-diabetic mice, reactive oxygen species (ROS) in the retina were measured using dihydroethidium and visual function was evaluated by electroretinograms. Levels of activated extracellular signal-regulated kinase (ERK), synaptophysin and brain-derived neurotrophic factor (BDNF) were also measured by immunoblotting in the retina of 1-month-diabetic mice. In the retinal sections of 4-month-diabetic mice, histological changes, cleaved caspase-3 and TUNEL staining were analysed.

RESULTS

Lutein did not affect the metabolic status of the diabetic mice, but it prevented ROS generation in the retina and the visual impairment induced by diabetes. ERK activation, the subsequent synaptophysin reduction, and the BDNF depletion in the diabetic retina were all prevented by lutein. Later, in 4-month-diabetic mice, a decrease in the thickness of the inner plexiform and nuclear layers, and ganglion cell number, together with increase in cleaved caspase-3- and TUNEL-positive cells, were avoided in the retina of lutein-fed mice.

CONCLUSIONS/INTERPRETATION

The results indicated that local oxidative stress that has a neurodegenerative influence in the diabetic retina is prevented by constant intake of a lutein-supplemented diet. The antioxidant, lutein may be a potential therapeutic approach to protect visual function in diabetes.

Exploring duplicated regions in natural images

Duplication of image regions is a common method for manipulating original images, using typical software like Adobe Photoshop, 3DS MAX, etc. In this study, we propose a duplication detection approach that can adopt two robust features based on discrete wavelet transform (DWT) and kernel principal component analysis (KPCA). Both schemes provide excellent representations of the image data for robust block matching. Multiresolution wavelet coefficients and KPCA-based projected vectors corresponding to image-blocks are arranged into a matrix for lexicographic sorting. Sorted blocks are used for making a list of similar point-pairs and for computing their offset frequencies. Duplicated regions are then segmented by an automatic technique that refines the list of corresponding point-pairs and eliminates the minimum offset-frequency threshold parameter in the usual detection method. A new technique that extends the basic algorithm for detecting Flip and Rotation types of forgeries is also proposed. This method uses global geometric transformation and the labeling technique to indentify the mentioned forgeries. Experiments with a good number of natural images show very promising results, when compared with the conventional PCA-based approach. A quantitative analysis indicate that the wavelet-based feature outperforms PCA- or KPCA-based features in terms of average precision and recall in the noiseless, or uncompressed domain, while KPCA-based feature obtains excellent performance in the additive noise and lossy JPEG compression environments.

A phase-II trial of dose-dense chemotherapy in patients with disseminated thymoma: report of a Japan Clinical Oncology Group trial (JCOG 9605)

BACKGROUND

To evaluate the safety and efficacy of dose-dense weekly chemotherapy in the treatment of advanced thymoma.

METHODS

Subjects comprised patients with histologically documented chemotherapy-naïve thymoma with stage-IVa or IVb disease. Thymic carcinoma, carcinoid or lymphoma cases were excluded. Patients received 9 weeks of chemotherapy: cisplatin (25 mg m(-2)) on weeks 1-9; vincristine (1 mg m(-2)) on weeks 1, 2, 4, 6 and 8; and doxorubicin (40 mg m(-2)) and etoposide (80 mg m(-2)) on days 1-3 of weeks 1, 3, 5, 7 and 9. Chemotherapy courses were supported by granulocyte colony-stimulating factor. Post-protocol local therapy was allowed.

RESULTS

From July 1997 to March 2004, 30 patients were entered. Three were ineligible due to different histology. Chemotherapy-associated toxicity was mainly haematological and was well tolerated, with no deaths due to toxicity, and 87% of patients completed the planned 9-week regimen. Overall response rate was 59%, with 16 of the 27 eligible patients achieving partial response. Median progression-fee survival (PFS) was 0.79 years (95% confidence interval: 0.52-1.40 years), and PFS at 1 and 2 years was 37 and 15%, respectively. Overall survival rates at 2 and 5 years were 89 and 65%, respectively.

CONCLUSION

In stage-IV thymoma patients, weekly dose-dense chemotherapy offers similar activity to conventional regimens.

Carbon-ion radiotherapy: clinical aspects and related dosimetry

The features of relativistic carbon-ion beams are attractive from the viewpoint of radiotherapy. They exhibit not only a superior physical dose distribution but also an increase in biological efficiency with depth, because energy loss of the beams increases as they penetrate the body. This paper reviews clinical aspects of carbon-beam radiotherapy using the experience at the National Institute of Radiological Sciences. The paper also outlines the dosimetry related to carbon-beam radiotherapy, including absolute dosimetry of the carbon beam, neutron measurements and radiation protection measurements.