Mouth level smoke exposure using analysis of filters from smoked cigarettes: a study of eight countries

The analysis of spent cigarette filters enables the estimation of the nicotine and tar (nicotine-free dry particulate matter) yields obtained by smokers in their everyday environment and has been shown to correlate well with biomarkers of exposure. Leading products across the range of ISO tar yields were selected from Australia, Brazil, Canada, Germany, Japan, New Zealand, South Africa and Switzerland. At least fifty demographically representative smokers were recruited per product. Subjects, ≥ 21 years of age and smoking ≥ 5 cigarettes per day, were asked to collect ≥ 15 filters from cigarettes they had smoked. The collected filters were analysed for nicotine and UV absorbance to enable the smokers' mouth level exposure to nicotine and tar to be estimated and a comparison of countries and tobacco blend styles to be made. Smoking history data were also collected. More than 80,000 filters were collected from 5703 smokers of 106 products from eight countries. Mean ± SD estimated nicotine exposures per cigarette and per day ranged from 0.93 ± 0.34 mg/cigarette (Brazil) to 1.77 ± 0.69 mg/cigarette (South Africa) and from 16.4 ± 11.1mg/day (Germany) to 31.5 ± 14.8 mg/day (South Africa), respectively. Male smokers obtained higher mean estimated tar and nicotine exposures than female smokers. These gender differences were statistically significant for six countries. Significant correlations were found between estimated nicotine exposure and ISO nicotine yield, and between estimated tar exposure and ISO tar yield (p<0.001).

Twenty-year review of quantitative transmission electron microscopy for the diagnosis of primary ciliary dyskinesia

BACKGROUND

The examination of ciliary ultrastructure in a nasal sample remains a definitive diagnostic test for primary ciliary dyskinesia (PCD).

METHODS

The quantitative assessment of ciliary ultrastructure in the diagnosis of PCD over a 20-year period was reviewed.

RESULTS

During this period, 1182 patients were referred for ciliary ultrastructural analysis, 242 (20%) of whom were confirmed as having the disease. The two main causes of PCD identified were a lack of outer dynein arms (43%) and a lack of both inner and outer dynein arms (24%). Other causes included transposition, radial spoke and inner dynein arm defects. No specific ultrastructural defects were detected in 33 patients (3%) diagnosed as having PCD on the basis of their clinical features and screening tests that included a low nasal nitric oxide concentration or slow saccharine clearance and abnormal ciliary beat frequency or pattern.

CONCLUSIONS

Electron microscopy analysis can confirm but does not always exclude a diagnosis of PCD.

Abstract P4-02-02: Epidermal Growth Factor Receptors (ErbB/HER) and the Ligand Neuregulin 1 (NRG1) Increase in Breast Tumors during Short Time Endocrine Treatment

Background: Cross-talk between estrogen receptor (ER) and growth factor signaling pathways has been suggested to play a role in development of resistance to endocrine treatment with tamoxifen or aromatase inhibitors (AIs). While HER-2/neu amplification has been associated with lack of endocrine sensitivity in ER+ breast cancer, recent data have suggestedanti-HER-2 therapy to enhance efficacy of AIs in a subset of HER-2/neu non-amplified breast cancers [1], and we found HER-2/neu upregulation in tumors responding to therapy with AIs [2]. Here, we aimed at exploring the effect of treatment with AIs on other components of the HER family, including NRG1, recently reported to be subject to silencing through promoter methylation in breast cancers [3].

Methods: Tumor biopsies were collected from 60 ER + breast cancers before and after 3 months treatment with the AIs, Anatrozole or Letrozole. Tumor biopsies after 2 weeks of treatment were available for 39 of the patients. RNA was extracted from the tumors and mRNA expression analysis of HER-1, HER-2/neu, HER-3, HER-4 and NRG1 were performed with gene-specific primers and probes by real-time PCR. Changes in mRNA expression during treatment were analyzed by Wilcoxon Sign Rank tests, and correlation between expression groups by Spearman correlation.

Results: Among HER-2/neu non-amplified tumors (n=56), we observed a significant increase in mRNA expression for HER-1 (40/50 tumors; mean increase 2.0-fold) and NRG1 (38/54 tumors; mean increase 2.9-fold) during treatment independent of treatment response (P&lt;0.001 for both). A non-significant increase in Her-2/neu was observed in 28/54 tumors (18/38 responders). Interestingly, individual alterations in tumor HER-2/neu correlated negatively to change in HER-1 (R=-0.414, p=0.001). Data on DNA methylation at the NRG1 gene will be presented. While no statistical significant increase or decrease in HER-3 or -4 were observed, individual variations in these two parameters were statistically correlated among individual tumors (R=0.621, P&lt;0.001).

Conclusions: Estrogen suppression with use of AIs significantly increased intratumor expression levels of HER-1 and NRG1 in HER-2/neu non-amplified tumors, while HER-2/neu increased in a subset of tumors. These findings suggest extensive cross-talks between estrogen stimulation and the HER system, indicating potential mechanisms of therapy resistance. The increase in NRG1 during treatment with AIs may represent a cellular response that leads to changes in its tumor suppressor activity. These findings merits further explorations.

1. Johnston, S., et al., Lapatinib combined with letrozole versus letrozole and placebo as first-line therapy for postmenopausal hormone receptor-positive metastatic breast cancer. J Clin Oncol, 2009. 27(33): p. 5538-46.

2. Flageng, M.H., et al., Nuclear receptor co-activators and HER-2/neu are upregulated in breast cancer patients during neo-adjuvant treatment with aromatase inhibitors. Br J Cancer, 2009. 101(8): p. 1253-60.

3. Chua, Y.L., et al., The NRG1 gene is frequently silenced by methylation in breast cancers and is a strong candidate for the 8p tumour suppressor gene. Oncogene, 2009. 28(46): p. 4041-52.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-02-02.

Abstract P4-05-05: Stromal Response to 14-Day Preoperative Therapy in Postmenopausal Oestrogen Receptor Positive Breast Cancer

Background: Stromal-epithelial interaction is a key factor in tumour progression. Cancer-associated fibroblasts (CAFs) and macrophage infiltration have been associated with early relapse in breast cancer. Bisphosphonates are effective inhibitors of osteoclast activation in metastatic breast cancer but also have a general inhibitory effect on breast cancer progression. In order to monitor a potential tumour stromal response in breast cancer during treatment with an aromatase inhibitor and a bisphosphonate we analysed pre-and post-treatment samples from a neoadjuvant window study and focused on the presence of macrophages and CAFs.

Materials and methods: Tissue microarrays (TMAs) from surgical samples and pre-operative core biopsies were immunohistochemically stained for aSMA (CAF marker), CD68 (macrophages) and epithelial proliferation (Ki67). In order to validate if the presence of macrophages and aSMA could be monitored by the TMA approach, we initially analysed a screening cohort of 144 breast cancer samples. We then studied pre-and post-treatment samples from 110 postmenopausal ER-positive invasive breast cancer patients randomised to receive 14 days of preoperative treatment (placebo, Letrozole, or Letrozole plus Zoledronate). Results: In the screening cohort, we observed significant links between aSMA positive fibroblasts and disease recurrence as well as between CD68 positive macrophages and tumour size, grade, lymph node positivity and recurrence. This validated the use of TMAs for stromal analyses and furthersupported a link with key tumour biological events. In both treatment arms, there was a significant drop in absolute Ki67 value compared to placebo (-9.3% Letrozole and -13.1% combination reduction versus 1% increase, P&lt;0.001). Post-treatment CD68 (median 35, range 3 to 117) was significantly linked to a Ki67 drop (p=0.045). Interestingly, this effect was mainly observed in the combination treatment group (p=0.002). aSMA expression was unaffected during treatment in 52%, increased in 35% and decreased in 13% of cases. Patients with aSMA reduction post treatment had a larger Ki67 fall compared to patients with increase or no change in aSMA (p=0.007).

Conclusion: Short term treatment response in the epithelial component of cancers was paralleled by specific responses in the tumour stromal component. These novel findings suggest that bisphosphonates and aromatase inhibitors have major effects on tumour stroma in vivo which might augment their inhibitory effect on tumour progression.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-05-05.

Use of a long-chain triglyceride-restricted/medium-chain triglyceride-supplemented diet in a case of malonyl-CoA decarboxylase deficiency with cardiomyopathy

Malonyl coenzyme A (CoA) decarboxylase (EC 4.1.1.9, MCD) deficiency, or malonic aciduria, is a rare inborn error of metabolism characterised by a variable phenotype of developmental delay, seizures, cardiomyopathy and acidosis. There is no consensus for dietary treatment in this condition. This case describes the effect of a long-chain triglyceride (LCT)-restricted/medium-chain triglyceride (MCT)-supplemented diet upon the progress of an affected child. A full-term Asian girl of birth weight 3590 g was screened for malonic aciduria after birth due to a positive family history. She had elevated urine malonic and methylmalonic acids and was presumably homozygous for a deleterious mutation in the MLYCD gene. Her echocardiography showed mild cardiomyopathy at 0.5 months of age, but heart function was good. She was treated with carnitine 100 mg/kg per day and continued a high-energy formula feed, as her growth was slow. At 3 months of age, echocardiography showed deteriorating cardiac function with a fractional shortening of 18%. She started an angiotensin-converting enzyme (ACE) inhibitor (Captopril). Over the next few months, her diet was altered to comprise 1.9% energy from LCT, 25% from MCT and the remainder carbohydrate. Cardiac function improved and was optimal at 23 months of age, with a fractional shortening of 28% and good systolic function. During a period of low MCT intake, her cardiac function was noted to deteriorate. This reversed and stabilised following reinstatement of the diet. This case of malonic aciduria with cardiomyopathy demonstrates improvement in cardiac function attributable to LCT-restricted/MCT-supplemented diet.

First Report of Hiemalis begonias Wilt Disease Caused by Fusarium foetens in Canada

Hiemalis begonias Fotsch (Begonia × hiemalis), a member of the family Begoniaceae, is a commercially important potted flowering plant in Europe and North America. In the spring of 2010, stunted growth and dull green leaves of H. begonias were observed in a commercial greenhouse in southern Ontario, Canada. Symptoms began with dull green foliage, followed by wilted leaves, then the stem base became water soaked with vascular discoloration, and finally, large macroconidial masses of a fungus developed on the collapsed stems and veins. A fungus was consistently isolated from the leaves, stems, and roots of symptomatic plants. Single conidia were isolated from sporodochia and cultured on potato dextrose agar (PDA) and oatmeal agar (OA) for 7 days. Isolates exhibited strong pungent odors on PDA and OA and a brownish orange colony on OA and a light orange colony on PDA. Masses of light orange and hemispherical-shaped conidia and stromata formed on OA. Conidiophores formed from aerial mycelium producing ellipsoidal microconidia without septation. Sporodochia formed on agar surface producing three-septate, slightly curved macroconidia. The cultural and conidial characteristics of the isolates were similar to those of Fusarium foetens Schroers (4). Partial translation elongation factor 1-α (TEF) gene was amplified and sequenced with primers ef1 and ef2. A comparison of a partial sequence has been deposited in GenBank (Accession No. HM748968) and showed a 100% match with F. foetens (2). Inoculations with F. foetens isolates were performed by injecting a 100-μl suspension of 1 × 10⁶ conidia/ml into stems of five healthy plants near the ground or soaking the soil of five healthy 6-week-old H. begonias cv. Golden Edith with 50 ml of suspension. Control plants were similarly injected with sterile water or sown in sterile soil. After 4 weeks, all inoculated plants developed dark, wilting leaves and collapsed stems and veins similar to those observed in the commercial greenhouse. F. foetens was reisolated from diseased plants, and identification was reconfirmed by conidial characteristics and TEF 1-α sequence. Control plants were healthy and symptom free. F. foetens has recently been described in association with a new disease of H. begonias in Europe (3) and the United States (1). F. foetens can cause major economic losses to farmers and marketers of H. begonias in Europe and the United States. To our knowledge, this is the first report of F. foetens causing wilt disease of H. begonias in Canada. References: (1) W.-H. Elmer et al. Plant Dis. 88:1287, 2004. (2) D.-M. Geiser et al. Eur. J. Plant Pathol. 110:473, 2004. (3) R. Schrage. Phytomed. Ges. 33:68, 2003. (4) H.-J. Schroers et al. Mycologia 96:393, 2004.

Randomised Placebo Controlled Trial Studying Short Term Biological Effects of the Combination of Letrozole and Zoledronic Acid on Invasive Breast Cancer

To determine whether the addition of Zoledronic Acid to endocrine therapy increases apoptosis or decreases proliferation in early invasive breast cancer, a placebo controlled randomised trial comparing 14 days treatment with Letrozole or Letrozole and Zoledronic Acid pre-operatively was performed.PatientsIn total 109 postmenopausal women with early invasive hormone receptor positive breast cancer were randomised (1:1:1) to either placebo, Letrozole 2.5mg/day or Letrozole with Zoledronic Acid 4mg single dose intravenously 2-4 days before definitive surgical excision. Epithelial proliferation and apoptosis were measured on paired baseline and surgical biopsy specimens (after 14 days of treatment) using Ki67 and Activated Caspase 3 immunohistochemistry. Alterations in angiogenic markers (VCAM/VEGF and CD31) were also studied. The primary endpoint was fall in Ki67 between diagnosis and surgical excision.ResultsOverall 109 women were enrolled but paired biopsies were only available for 101 patients. PlaceboLetrozoleLet + Zoln323435Absolute Ki67 change (median,range)-0.8 (-12,12)8.6 (-14,37)12.9 (-12,29)    Caspase 3 change (median,range)0.1 (-3.8, 9.3)0.4 (-2.7, -4.1)0.2 (-10.9, -14.4)    Absolute change (Cell turnover index)-0.3 (-142, -59)18.9 (-201, 192)17.7 (-14, 379) Statistically significant reductions in Ki67 and Cell Turnover Index were seen with Letrozole and Let & Zol (p ≤ 0.001) but there was no significant different between Letrozole and Letrozole plus Zoledronic Acid groups (p = 0.26). Apoptosis did not change between the three groups.ConclusionLetrozole reduces proliferation by 70% when used for 14 days prior to surgery. Zoledronic Acid administration prior to surgery is safe but when administered as a single dose at a median of 3 days before surgery did not significantly increase apoptosis or decrease proliferation compared to Letrozole alone.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2009.

Review of specialist dietitian services in patients with inherited metabolic disease in the United Kingdom

INTRODUCTION

Dietary management forms the mainstay of treatment for many inherited metabolic diseases (IMDs) and specialist dietitians play a crucial role in the multi-disciplinary core team for these patients. Professional concerns have been expressed that the current clinical workforce is inadequate for meeting current and future service demands. The aim of this work was to describe the provision of specialist dietetics to patients with IMD as part of a national needs assessment and review.

MATERIALS AND METHODS

The 24 main specialist providers and 27 specialist dietitians were surveyed by a questionnaire. A focus group of three specialist dietitians was also held to explore the roles of specialist dietitians in greater depth.

RESULTS

Responses were received from all 24 specialist service providers and 63% of 27 specialist dietitians. The majority of service providers (92%) have specialist dietitians, but only eight services had more than one whole time equivalent (33%). Key roles were management of complex dietary regimens, prevention and management of metabolic crises, education, co-ordination of care, clinical audit and research. Although highly qualified, there is currently no clear formal career structure or training pathway for dietitians in IMDs.

CONCLUSION

Specialist dietitians have important clinical and leadership roles in managing IMD but specialist services are thinly spread. There is a need for access to formal education, training and support programmes. The clinical workforce needs expansion to provide more comprehensive and equitable services.

A review of current practices in breast conservation surgery in the UK

INTRODUCTION

The aim of this study was to assess whether surgeons in the UK were practising wide excision consistent with current guidelines and current evidence.

PATIENTS AND METHODS

Questionnaires were sent to 200 breast surgeons throughout the UK to determine current practices in breast conserving surgery.

RESULTS

When performing a wide excision for invasive cancer, 61% of respondents always remove full thickness of breast tissue and 37% usually do. Of surgeons, 60% rarely use specimen X-ray for palpable lesions. However, 91% always take specimen X-rays in impalpable lesions, but 9% do not always take specimen X-rays for impalpable lesions. In 93% of units, the pathologist always reports the distance to the nearest margin. For both invasive and in situ cancer, there is a wide variation in what is considered an adequate radial margin. There is wide variation in the practice of re-excision. Of surgeons, 50% indicated that they wish wider margins in the presence of an extensive in situ component and 39% wish wider margins in younger women.

CONCLUSIONS

The results show a large variation in practice with many surgeons not treating patients in accordance with current guidelines and evidence.

Guideline for the diagnosis and management of glutaryl-CoA dehydrogenase deficiency (glutaric aciduria type I)

Glutaryl-CoA dehydrogenase (GCDH) deficiency is an autosomal recessive disease with an estimated overall prevalence of 1 in 100 000 newborns. Biochemically, the disease is characterized by accumulation of glutaric acid, 3-hydroxyglutaric acid, glutaconic acid, and glutarylcarnitine, which can be detected by gas chromatography-mass spectrometry of organic acids or tandem mass spectrometry of acylcarnitines. Clinically, the disease course is usually determined by acute encephalopathic crises precipitated by infectious diseases, immunizations, and surgery during infancy or childhood. The characteristic neurological sequel is acute striatal injury and, subsequently, dystonia. During the last three decades attempts have been made to establish and optimize therapy for GCDH deficiency. Maintenance treatment consisting of a diet combined with oral supplementation of L: -carnitine, and an intensified emergency treatment during acute episodes of intercurrent illness have been applied to the majority of patients. This treatment strategy has significantly reduced the frequency of acute encephalopathic crises in early-diagnosed patients. Therefore, GCDH deficiency is now considered to be a treatable condition. However, significant differences exist in the diagnostic procedure and management of affected patients so that there is a wide variation of the outcome, in particular of pre-symptomatically diagnosed patients. At this time of rapid expansion of neonatal screening for GCDH deficiency, the major aim of this guideline is to re-assess the common practice and to formulate recommendations for diagnosis and management of GCDH deficiency based on the best available evidence.