Treatment of ruptured complex and large/giant ruptured cerebral aneurysms by acute coiling followed by staged flow diversion

OBJECT

Flow-diversion treatment has been shown to be associated with high rates of angiographic obliteration; however, the treatment is relatively contraindicated in the acute phase following subarachnoid hemorrhage (SAH) as these patients require periprocedural dual antiplatelet therapy. Acute coiling followed by flow diversion has emerged as an intriguing and feasible treatment option for ruptured complex and giant aneurysms. In this study the authors report outcomes and complications of patients with ruptured aneurysms undergoing coiling in the acute phase followed by planned delayed flow diversion.

METHODS

This case series includes patients from 2 institutions. All patients underwent standard endovascular coiling in the acute phase after SAH with the intention and plan to proceed with flow diversion at a later date. Outcomes studied included angiographic occlusion, procedure-related complications, and long-term clinical outcome as measured using the modified Rankin Scale.

RESULTS

A total of 31 patients underwent coiling in the acute phase with the intention to undergo flow diversion at a later date. The mean aneurysm size was 15.8 ± 7.9 mm. Of the 31 patients undergoing coiling, 4 patients could not undergo further flow-diverter therapy: 3 patients (9.7%) died of complications of subarachnoid hemorrhage and 1 patient had permanent morbidity as a result of perioperative ischemic stroke (3.1%). Twenty-seven patients underwent staged placement of flow diverters after adequate recovery. The median time to treatment was 16 weeks. There was one case of aneurysm rebleeding following coil treatment. There were no cases of permanent morbidity or mortality resulting from flow-diverter treatment. Twenty-four patients underwent imaging follow-up; 18 of these patients had aneurysms that were completely or nearly completely occluded (58.1% on an intent-to-treat basis). At last follow-up (mean 18.3 months), 25 patients had mRS scores ≤ 2 (80.6% on an intent-to-treat basis).

CONCLUSIONS

Staged treatment of ruptured complex and giant intracranial aneurysms with coiling in the acute phase and flow-diverter treatment following recovery from SAH is both safe and effective. In this series, no cases of rebleeding occurred during the interval between coiling and flow diversion. This strategy should be considered as a valid option in patients presenting with these challenging ruptured aneurysms.

Extracellular DNA traps released by acute promyelocytic leukemia cells through autophagy

Acute promyelocytic leukemia (APL) cells exhibit disrupted regulation of cell death and differentiation, and therefore the fate of these leukemic cells is unclear. Here, we provide the first evidence that a small percentage of APL cells undergo a novel cell death pathway by releasing extracellular DNA traps (ETs) in untreated patients. Both APL and NB4 cells stimulated with APL serum had nuclear budding of vesicles filled with chromatin that leaked to the extracellular space when nuclear and cell membranes ruptured. Using immunofluorescence, we found that NB4 cells undergoing ETosis extruded lattice-like structures with a DNA-histone backbone. During all-trans retinoic acid (ATRA)-induced cell differentiation, a subset of NB4 cells underwent ETosis at days 1 and 3 of treatment. The levels of tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) were significantly elevated at 3 days, and combined treatment with TNF-α and IL-6 stimulated NB4 cells to release ETs. Furthermore, inhibition of autophagy by pharmacological inhibitors or by small interfering RNA against Atg7 attenuated LC3 autophagy formation and significantly decreased ET generation. Our results identify a previously unrecognized mechanism for death in promyelocytes and suggest that ATRA may accelerate ET release through increased cytokines and autophagosome formation. Targeting this cellular death pathway in addition to conventional chemotherapy may provide new therapeutic modalities for APL.

Lanthanum chloride enhances cisplatin-induced apoptosis in ovarian cancer cells

Ovarian cancer begins in an ovary. It is the leading cause of mortality from gynecologic cancer. Cisplatin is an anti-ovarian tumor drug. However, repeated use of cisplatin causes serious resistance. Recently, Lanthanum chloride (LaCl3) was found to inhibit the proliferation and promote the apoptosis in some cancer cells. In this study, we investigated the influence of LaCl3 on cisplatin-induced apoptosis in the ovarian cell line (COC1). Cell-based assays and analysis of cellular ultra structure were used. Result showed that LaCl3 enhanced cisplatin-induced apoptosis in COC1. Furthermore, the application of Cisplatin also altered the expression level of tumor related proteins, such as ERCC1, Ki67, and CDK6. Overall, we determined the inhibitory effect of LaCl3 on the COC1 growth when treated with Cisplatin, which may serve as a basis for the clinical application of LaCl3 in the treatment of ovarian cancer.

Measurement and comparison of individual external doses of high-school students living in Japan, France, Poland and Belarus-the 'D-shuttle' project

Twelve high schools in Japan (of which six are in Fukushima Prefecture), four in France, eight in Poland and two in Belarus cooperated in the measurement and comparison of individual external doses in 2014. In total 216 high-school students and teachers participated in the study. Each participant wore an electronic personal dosimeter 'D-shuttle' for two weeks, and kept a journal of his/her whereabouts and activities. The distributions of annual external doses estimated for each region overlap with each other, demonstrating that the personal external individual doses in locations where residence is currently allowed in Fukushima Prefecture and in Belarus are well within the range of estimated annual doses due to the terrestrial background radiation level of other regions/countries.

BCR/ABL oncogene-induced PI3K signaling pathway leads to chronic myeloid leukemia pathogenesis by impairing immuno-modulatory function of hemangioblasts

An increasing number of studies indicate that during development, endothelial and hematopoietic cells derive from common progenitors named hemangioblasts that have important roles in the pathogenesis. This is particularly true in chronic myeloid leukemia (CML). Here, we isolated fetal liver kinase-1-positive (Flk1(+)) cells from CML patients and found they expressed BCR/ABL-specific CML oncogene. We examined their biological characteristics as well as immunological functions and further detected the possible molecular mechanism involved in the leukemia genesis. We showed that CML patient-derived Flk1(+)CD31(-)CD34(-) mesenchymal stem cells (MSCs) had normal morphology, phenotype and karyotype but appeared impaired immuno-modulatory function. The capacity of Flk1(+)CD31(-)CD34(-) MSCs from CML patients to inhibit T lymphocyte activation and proliferation was impaired in vitro. CML patient-derived MSCs have dampening immuno-modulatory functions, suggesting that the dysregulation of hematopoiesis and immune response might originate from MSCs rather than hematopoietic stem cells (HSCs). These Ph(+) putative CML hemangioblast upregulated TGF-β1 and resultantly activated matrix metalloproteinase-9 (MMP-9) to enhance s-KitL and s-ICAM-1 secretion, which activated c-kit(+) HSCs from the quiescent state to the proliferative state. Further studies showed that phosphatidylinositol-3 kinase (PI3K)/Akt/nuclear factor (NF)-κB signaling pathway was involved in CML pathogenesis. Flk1(+)CD31(-)CD34(-) MSCs that express BCR/ABL leukemia oncogene are hemangioblasts and they have a critical role in the progression of CML through PI3K/Akt/NF-κB signaling pathway.

Endovascular treatment of anterior communicating artery aneurysms: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

Endovascular therapy has become an acceptable alternative to traditional clipping for the management of intracranial aneurysms. However, a limited number of studies have examined outcomes and complications specific to embolization of anterior communicating artery aneurysms.

MATERIALS AND METHODS

A systematic review of the literature was conducted with the use of multiple data bases to identify reports on endovascular treatment of anterior communicating artery aneurysms between 1994 and 2012. Angiographic results, clinical outcomes, and complication rates were pooled across studies by using random-effects meta-analysis with subgroup analysis of outcomes by rupture status and time trend stratification.

RESULTS

Fourteen studies, consisting of 1552 treated anterior communicating artery aneurysms, were included in this meta-analysis. The rate of immediate and long-term complete and near-complete angiographic occlusion was 88% (95% CI = 81-93%) and 85% (95% CI = 78-90%), respectively. Intraprocedural rupture rate was 4% (95% CI = 3-6%). The re-bleeding rate was 2% (95% CI = 1-4%) and the retreatment rate was 7% (95% CI = 5-12%). Morbidity or mortality caused by perioperative stroke occurred at a 3% (95% CI = 2-6%) rate. Overall procedure-related morbidity and mortality were 6% (95% CI = 4-8%) and 3% (95% CI = 2-4%), respectively. Outcomes did not differ between ruptured and unruptured aneurysms, nor did outcomes change over time, though these latter subanalyses were relatively underpowered.

CONCLUSIONS

Endovascular therapy for anterior communicating artery aneurysms is associated with a high rate of complete angiographic occlusion. However, the procedure-related permanent morbidity and mortality are not negligible for aneurysms in this location.

Paraclinoid aneurysms: is there a new endovascular standard?

OBJECTIVES

Paraclinoid aneurysms are challenging lesions to treat with traditional surgical and conventional endovascular techniques despite modern improvements in technique and technology. Flow diversion emerged recently as a promising new therapy that overcomes limitations related to the wide-neck and fusiform morphology, and importantly addresses the underlying diseased parent artery from which the aneurysm arises.

METHODS

We reviewed the current literature regarding the safety and efficacy of flow diversion therapy for treatment of paraclinoid aneurysms.

RESULTS

Early results suggest excellent ability for flow diversion to remodel the diseased parent artery and achieve durable complete angiographic occlusion of the aneurysm with acceptable rates of peri-procedural risk.

DISCUSSION

Flow diversion therapy can achieve durable and high rates of obliteration that surpass traditional methods of management for paraclinoid aneurysms. However, caution is warranted when considering this treatment modality due to several concerning and often-unpredictable complications associated with this technology.

Abstract P3-11-01: Prospective study of cognitive function in women with early stage breast cancer: Predictors of cognitive decline and relationship to cognitive complaints

Background: Cognitive complaints are common among women receiving adjuvant therapy (Rx) for early stage breast cancer (ESBC). Longitudinal prospective data is needed to understand cognitive complaints and decline. We conducted a prospective trial to evaluate the effects of chemotherapy (CTX) and hormone therapy (HRx) on brain and cognitive function in patients with ESBC using objective & subjective tests as well as MRI/PET imaging.

Methods: Eligibility included female patients planning to receive adjuvant Rx for ESBC. Patients were enrolled in 3 treatment groups: CTX, CTX and HRx, and HRx, with a 4th no disease age and education matched control group. Patients underwent a battery of objective and subjective cognitive tests before start of Rx, 1 month after CTX or 5 months after start of HRx (FU1), then 9 months (FU2) and 18 months (FU3) after Rx. Brain MRI, PET & serum estradiol (E) were performed at baseline, FU1 & FU3.

Results: 81 patients were enrolled as follows: 14 CTX, 33 CTX & HRx, 22 HRx, and 12 control. 90% completed FU1, 72% FU2, & 62% FU3, with 29 patients waiting to complete testing. Demographics were similar between groups: median age 54, 78% Caucasian. At each FU, approximately 25% of patients showed cognitive decline using a reliable change index; 51% showed decline at ≥ 1 time point, primarily in tests of executive function & verbal memory. 62 - 77% of patients who declined later stabilized or improved. Compared to controls, receipt of HRx (OR 4.94, p = .004) but not serum E, menopausal status, CTX, demographic factors, depression, or fatigue, were significant predictors of decline at any time point. Rx group did not predict cognitive complaints (FACT-Cog). At FUP1, depression, fatigue, and decline in letter fluency predicted overall cognitive complaints, but HRx did not. Cognitive complaints were predicted by domain-specific cognitive decline: memory decline predicted memory complaints, and verbal fluency decline predicted verbal fluency complaints, even after controlling for depression and fatigue. Additional analyses will be presented as more patients complete follow-up testing.

Conclusion: Decline in cognitive function is common in patients receiving adjuvant Rx for ESBC. Ongoing HRx was a risk factor for worse cognitive function, but not for perceived cognitive problems. Other Rx and patient related factors did not predict decline. Perceived cognitive problems were predicted by depression, fatigue, and letter fluency decline, with specific cognitive complaints predicted by domain-specific declines. Patients should be aware that HRx may be a risk factor for cognitive decline, while depression, fatigue, and cognitive decline predicted cognitive complaints. Intervention studies, including assessment for depression and fatigue, should be offered to patients who complain of cognitive changes and particularly to patients treated with HRx.

Funding: NIH R01 1AG025303-01A2.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-11-01.

Brain carcinoid metastases: outcomes and prognostic factors

OBJECT

Carcinoid tumors are rare and have generally been regarded as indolent neoplasms. Systemic disease is often incurable; however, patients may live years with this disease. Furthermore, metastatic brain lesions are extremely uncommon. As such, few series have examined outcomes and prognostic factors in those with brain involvement.

METHODS

The authors performed a retrospective review of patients who underwent primary treatment at Mayo Clinic in Rochester, Minnesota, for metastatic carcinoid tumors to the brain between 1986 and 2011. Progression-free survival (PFS) and overall survival (OS) were analyzed using Kaplan-Meier statistics. Cox proportional hazards were used to determine predictors of survival.

RESULTS

Fifteen patients underwent primary treatment for metastatic carcinoid tumors to the brain between 1986 and 2011. Their mean age was 58 ± 12 years. Eighty percent (n = 12) of patients underwent surgery, whereas 2 received stereotactic radiosurgery and 1 had whole-brain radiation therapy (WBRT) as the primary treatment. The median follow-up duration was 19 months (maximum 124 months). Systemic disease progression occurred in 73% and was the leading cause of death in known cases, while intracranial disease recurred in 40%. The median PFS and OS were 21 and 19 months, respectively. The use of adjuvant WBRT correlated with improved PFS (HR 0.15, CI 0.0074-0.95, p = 0.044). Those who underwent surgery as primary modalities trended toward longer progression-free intervals (p = 0.095), although this did not reach significance.

CONCLUSIONS

Metastatic carcinoid disease to the brain appears to have a worse prognosis than that of other extracranial metastases. Although there was a trend toward a survival advantage in patients who underwent surgery and WBRT, further study is needed to establish definitive treatment recommendations.

Endometrial carcinoma tumorigenesis and pharmacotherapy research

Endometrial carcinoma is the common malignant tumor of the female genital tract, and its incidence is increasing. Two different clinicopathological subtypes are recognized based on epidemiology, genetic carcinogenesis and clinical behavior. Understanding and identifying molecular biology and genetics is essential to the development of novel therapies. This article reviews the current understanding of its risk factors, recent conceptions on its tumorigenesis and advances on its drug therapies.

Hrd1 facilitates tau degradation and promotes neuron survival

Intraneuronal accumulation of abnormal phosphorylated tau (p-tau) is a molecular pathology in many neurodegenerative tauopathies, including Alzheimer's disease (AD) and frontotemporal dementia with parkinsonism-linked to chromosome 17 (FTDP-17). However, the underlying mechanism remains unclear. Here, we showed an inverse relationship between endoplasmic reticulum membrane ubiquitin ligase (E3) Hrd1 expression and p-tau accumulation in the hippocampal neurons of AD, and proposed that Hrd1 may be a negative regulator of p-tau. This notion was further supported by in vitro study demonstrating that Hrd1 interacted with tau and promoted the degradation of total tau and p-tau as well. The degradation of tau depended on its Hrd1 E3 activity. Knockdown of endogenous Hrd1 with siRNA stabilized tau levels. In addition, inhibition of proteasome maintained tau level and increased Hrd1-mediated tau ubiquitination, suggesting the proteasome was involved in tau/p-tau degradation. Over-expression of Hrd1 significantly alleviated tau cytotoxicity and promoted cell survival. These results indicated that Hrd1 functions as an E3 targeting tau or abnormal p-tau for proteasome degradation. The study provides an important insight into the molecular mechanisms of human tauopathies.

Atypia predicting prognosis for intracranial extraventricular neurocytomas

OBJECT

The literature, at present, provides limited information about extraventricular neurocytomas (EVNs) and is almost exclusively composed of case reports or small case series. Treatment for EVNs has largely been guided by results from central neurocytoma outcome studies. The authors present an analysis of all reported intracranial EVN cases to establish if tumor histopathological features can substratify EVN into groups with differing prognosis and help guide treatment decisions.

METHODS

The authors identified studies reporting histology, treatment modality, and outcomes for patients with intracranial EVN. The rates of recurrence and survival for patients were compared using Kaplan-Meier analysis. Atypical tumors, defined by MIB-1 labeling index exceeding 3% or atypical histological features, were compared with typical tumors, and patients 50 years of age or older were compared with those younger than 50 years of age.

RESULTS

Eighty-five patients met the inclusion criteria, and 27% of them had an atypical histology. Typical EVNs had a better prognosis than atypical EVNs after primary treatment, with a 5-year recurrence rate of 36% compared with 68% (p < 0.001), and a 5-year mortality rate of 4% compared with 44%, respectively (p < 0.001). Age younger 50 years was associated with a better prognosis than age equal to or greater than 50 years, with a 5-year recurrence rate of 33% and 74%, respectively (p < 0.001), and a 5-year mortality rate of 4% and 52%, respectively (p < 0.001). Multivariate analysis demonstrated that atypical EVNs carried significantly increased risk for recurrence (hazard ratio [HR] 4.91, p < 0.001) and death (HR 22.91, p < 0.01). Gross-total resection was superior to subtotal resection (STR) alone in tumor control rates for typical EVNs (95% and 68%, p < 0.05), and there was a trend for adjuvant external-beam radiotherapy to benefit STR. There was suggestion of similar trends in patients with atypical EVNs.

CONCLUSIONS

There are at least 2 distinct histological subtypes of EVN, with different prognostic significances. Atypia or MIB-1 labeling index greater than 3% is a significant predictor of poor prognosis for EVNs. Complete resection or more aggressive attempts at providing adjuvant therapy following STR appear to improve the prognosis for patients with EVNs. Although the authors' results are informative, there are limitations to their analysis. Given the relatively modest total number of cases reported, as well as the nature of the disaggregated analysis, the authors were not able to use formal meta-analytical methods to limit the impact of between center heterogeneity. Additionally, they were not able to control for individual differences in data analysis and presentation across the different studies included in their analysis.

Risk factors and incidence of thromboembolic events (TEEs) in older men and women with breast cancer

BACKGROUND

The purpose of this study is to evaluate the risk factors and the prevalence of thromboembolic events (TEEs) in breast cancer patients.

PATIENTS AND METHODS

This is a retrospective cohort study using the Surveillance, Epidemiology, and End Results-Medicare database. Breast cancer patients diagnosed from 1992 to 2005 ≥66 years old were identified. International Classification of Diseases, Ninth Revision, and Healthcare Common Procedure Coding System codes were used to identify TEEs within 1 year of the breast cancer diagnosis. Analyses were conducted using descriptive statistics and logistic regression.

RESULTS

A total of 89 841 patients were included, of them 2658 (2.96%) developed a TEE. In the multivariable analysis, males had higher risk of a TEE than women [odd ratio (OR) = 1.57; confidence interval (CI) 1.10-2.25] and blacks had higher risk than whites (OR = 1.20; CI 1.04-1.40). Compared with stage I patients, patients with stage II, III and IV had 22%, 39% and 98% increase, respectively, in risk. Placement of central catheters (OR = 2.71; CI 2.43-3.02), chemotherapy treatment (OR = 1.66; CI 1.48-1.86) or treatment with erythropoiesis-stimulating agents (ESAs) (OR = 1.33; CI 1.33-1.52) increase the risk. Other significant predictors included comorbidities, age, receptor status, marital status and year of diagnosis. Similar estimates were seen for pulmonary embolism, deep vein thromboembolism and other TEEs.

CONCLUSIONS

In total, 2.96% of patients in this cohort developed a TEE within 1 year from breast cancer diagnosis. Stage, gender, race, use of chemotherapy and ESAs, comorbidities, receptor status and catheter placement were associated with the development of TEEs.