Long-term survival after high-dose chemotherapy followed by peripheral stem cell rescue for high-risk, locally advanced/inflammatory, and metastatic breast cancer

Patients with high-risk locally advanced/inflammatory and oligometastatic (≤3 sites) breast cancer frequently relapse or experience early progression. High-dose chemotherapy combined with peripheral stem cell rescue may prolong progression-free survival/relapse-free survival (PFS/RFS) and overall survival (OS). In this study, patients initiated high-dose chemotherapy with STAMP-V (carboplatin, thiotepa, and cyclophosphamide), ACT (doxorubicin, paclitaxel, and cyclophosphamide), or tandem melphalan and STAMP-V. Eighty-six patients were diagnosed with locally advanced/inflammatory (17 inflammatory) breast cancer, and 12 were diagnosed with oligometastatic breast cancer. Median follow-up was 84 months (range, 6-136 months) for patients with locally advanced cancer and 40 months (range, 24-62 months) for those with metastatic cancer. In the patients with locally advanced cancer, 5-year RFS and OS were 53% (95% CI, 41%-63%) and 71% (95% CI, 60%-80%), respectively, hormone receptors were positive in 74%, and HER2 overexpression was seen in 23%. In multivariate analysis, hormone receptor-positive disease and lower stage were associated with better 5-year RFS (60% for ER [estrogen receptor]/PR [progesterone receptor]-positive versus 30% for ER/PR-negative; P < .01) and OS (83% for ER/PR-positive versus 38% for ER/PR-negative; P < .001). In the patients with metastatic cancer, 3-year PFS and OS were 49% (95% CI, 19%-73%) and 73% (95% CI, 38%-91%), respectively. The favorable long-term RFS/PFS and OS for high-dose chemotherapy with peripheral stem cell rescue in this selected patient population reflect the relative safety of the procedure and warrant validation in defined subgroups through prospective, randomized, multi-institutional trials.

A phase I study of bortezomib and temozolomide in patients with advanced solid tumors

PURPOSE

The primary objective was to determine the maximum tolerated doses (MTDs) of the combination of bortezomib and temozolomide in patients with solid tumors. The secondary objective was to evaluate the pharmacokinetics (PK) of bortezomib with and without concurrent hepatic enzyme-inducing anticonvulsants (HEIAs).

METHODS

Bortezomib was administered on days 2, 5, 9, and 12; temozolomide on days 1-5 of a 28-day cycle. Dose escalation proceeded using a standard 3+3 design. Patients with primary or metastatic brain tumors were eligible and were stratified based on whether they were taking HEIAs or not.

RESULTS

Of the 25 patients enrolled, 22 were not taking HEIAs. MTDs were only given to patients not receiving HEIAs. Dose-limiting toxicities (DLTs) consisted of grade-3 constipation, hyponatremia, fatigue, elevated hepatic enzymes, and grade-4 neutropenia, thrombocytopenia, constipation, and abdominal pain. Stable disease (>8 weeks) was observed in 5 patients. Bortezomib systemic clearance (CL(sys)) on day 9 was 51% of the CL(sys) on day 2 (P < 0.01) Similarly, the normalized area under the concentration-time curve (norm AUC) on day 9 was 1.9 times the norm AUC on day 2 (P < 0.01). The median bortezomib CL(sys) on days 2 and 9 was significantly higher (P < 0.04) in patients taking HEIAs, and the median norm AUC was correspondingly lower (P < 0.04).

CONCLUSIONS

The MTDs for the combination of bortezomib and temozolomide in patients not taking HEIAs are 1.3 and 200 mg/m(2), respectively. The rate of bortezomib elimination in patients taking HEIAs was increased twofold. Additional trials are needed to better define the optimal dosing in such patients.

Detection of middle ear cholesteatoma by diffusion-weighted MR imaging: multishot echo-planar imaging compared with single-shot echo-planar imaging

BACKGROUND AND PURPOSE

Previous reports have shown that DWI is useful in detecting cholesteatoma. SS-EPI is the most widely used DWI technique. However, SS-EPI may have susceptibility artifacts due to field inhomogeneity in the imaging of the temporal bone region. Our purpose was to prospectively evaluate the advantage of MS-EPI for the diagnosis of middle ear cholesteatoma by comparing it with SS-EPI.

MATERIALS AND METHODS

We studied 29 patients with preoperatively suspected acquired cholesteatoma. Each patient underwent an MR imaging examination including both SS-EPI and MS-EPI by using a 1.5T MR imaging scanner. Images of the 29 patients (58 temporal bones including 30 with and 28 without cholesteatoma) were reviewed by 2 independent neuroradiologists. The confidence level for the presence of cholesteatoma was graded on a scale of 0-2 (0 = none, 1 = equivocal, 2 = definite). Interobserver agreement as well as sensitivity, specificity, and accuracy were assessed for the 2 readers.

RESULTS

Excellent interobserver agreement was shown for both MS-EPI (κ = 0.856) and SS-EPI (κ = 0.820). MS-EPI was associated with higher sensitivity (76.7%) and accuracy (87.9%) than SS-EPI (sensitivity = 50.0%, accuracy = 74.1%) (P < .05), while both methods showed 100% specificity.

CONCLUSIONS

Compared with SS-EPI, MS-EPI improves the accuracy of the diagnosis of acquired middle ear cholesteatomas.

Completion and toxicity rates of adjuvant chemotherapy in rectal cancer patients previously treated with neoadjuvant therapy and resection

609

Background: Adjuvant chemotherapy is recommended after rectal cancer surgery. Yet the success and complication rates of this adjuvant treatment are poorly studied. The purpose of this study is to determine the success rate and define the toxicity profile of adjuvant chemotherapy in rectal cancer patients previously treated with neoadjuvant chemotherapy.

Methods: Study design is a retrospective review of patients from December 2002-December 2007 from the City of Hope database. Data is available with 66 patients diagnosed with locally advanced rectal cancer treated with neoadjuvant chemo radiation and resection. Data points analyzed included demographics, chemotherapy-related toxicity and survival.

Results: Adjuvant chemotherapy was started in 35/66 (53%) of patients. In 31 cases chemotherapy was not given because of patient refusal or physician preference. 9 patients were lost to follow-up. Follow-up ranged from 9-59 months with median follow-up of 27 months. In the 26 patients with adequate follow up there were a total of 165 episodes of toxic events 3a grade 1. Most of the events were mild to moderate grade 1-2. In 10 patients (28%) 22 major toxicities 3a grade 3 episodes were observed. The median Karnofsky performance scale (KPS) showed no significant difference in patients before and after adjuvant chemotherapy (p = 0.071). The rates of 1-year, 3-year and 5-year survival were 100%, 90%, and 60%, respectively; corresponding disease-free survival was 88%, 83%, and 69% respectively.

Conclusions: These preliminary data suggest that only a fraction of rectal cancer patients previously treated with neoadjuvant CRT complete a full course of adjuvant chemotherapy. Future studies will help confirm these preliminary findings and generate an outcome comparison between patients receiving and not receiving adjuvant therapy.

No significant financial relationships to disclose.

Effect of lymph node retrieval rates on the utilization of adjuvant chemotherapy in stage II colon cancer

BACKGROUND

Failing to meet the benchmark of 12 lymph nodes in resection specimens is an indication for adjuvant chemotherapy in stage II colon cancer.

METHODS

Among consecutive eligible patients with pathologic stage II colon cancer treated at eight NCI-designated comprehensive cancer centers between September 1, 2005 and February 19, 2008, we analyzed receipt of adjuvant chemotherapy, with less than 12 versus 12+ lymph nodes removed and examined the primary explanatory variable of interest.

RESULTS

Among 258 patients, 46% received adjuvant chemotherapy. An oxaliplatin-containing regimen was used 67% of the time. Younger age (<50 years, P < 0.001), presence of lymphovascular invasion (P = 0.007), and higher T stage (P = 0.007) were independently associated with adjuvant chemotherapy use. There was significant inter-institutional variability in practice with the proportion receiving treatment ranging from 17% to 64% (P < 0.05). Notably, presence of less than 12 lymph nodes in the surgical specimen was a strong predictor of treatment (P = 0.008).

CONCLUSIONS

Adjuvant chemotherapy use after resection of stage II colon cancer is common, but by no means standard practice at National Comprehensive Cancer Network (NCCN) institutions. More attention to achieving the recommended benchmark for lymph node dissection has the potential to decrease exposure to the toxicity of adjuvant treatment.

Radiochemical study on the mechanism of target fragmentation of Cu, Nb, Pr and Au targets induced by 12C and 40Ar projectiles

A thick-target thick-catcher experiment was performed to measure the formation cross sections and recoil momenta of products from target fragmentation of Cu, Nb, Pr, and Au by using gamma-ray spectrometry. Bombardments of C ions (180, 290, and 400 MeV/u) and Ar ions (290 and 650 MeV/u) were performed at the HIMAC facility in Japan. The results were discussed in comparison with systematics of fragmentation and used to deduce the prefragments in fragmentation process of the measured systems.

Photofission of209Bi at intermediate energies

The reaction yields of 63 radionuclides with the mass numberA= 56 − 135 produced in the photofission of209Bi by bremsstrahlung of end-point energies (E0) from 450 to 1100 MeV have been measured using a catcher foil technique with the aid of intensive chemical separation. The charge distribution was well reproduced by a Gaussian function with the most probable charge (Zp) expressed by a linear function ofA,i.e.,Zp=RA+S, and with theA-independent full width at half maximum (FWHMCD). The charge distribution parametersR,Sand FWHMCDwere independent ofE0above 600 MeV, reflecting the resonance nature in photonuclear reactions at intermediate energies. The weighted mean values atE0≥ 600 MeV wereR= 0.421 ± 0.001,S= 0.6 ± 0.1 and FWHMCD= 2.1 ± 0.1 charge unit (c.u.). The numbers of pre- and post-fission neutrons were deduced to be νpre= 12 ± 1 and νpost= 1.4 ± 0.3, respectively, assuming the Unchanged Charge Distribution (UCD). Based on the charge distribution parameters, the symmetric mass yield distributions with the most probable massApof 96 ± 1 mass unit (m.u.) and the width FWHMMDof 33 ± 1 m.u. were also obtained. The characteristics of the charge and mass yield distributions are discussed by referring to those for197Au based on the results of calculations using the Photon-induced Intranuclear Cascade Analysis code combined with the Generalized Evaporation Model (PICA3/GEM).

Target-dependence of light fragment production in photonuclear reactions at intermediate energies

Yields of7Be,10Be,22Na,24Na and28Mg produced fromnatB,natC,natO,23Na,27Al,natSi,natS,natCl,natK,natCa,natV,55Mn,natFe,59Co,natNi,natCu,89Y,natAg,natIn,141Pr,159Tb,165Ho and197Au in irradiations with bremsstrahlung having maximum end-point energies up to 1200 MeV were measured by γ-ray spectrometry (7Be,22Na,24Na and28Mg) and accelerator mass spectrometry (10Be). The yields of heavier fragments,39Cl,43, 44m, 44g, 46, 47, 48Sc,59Fe, and56, 57, 58, 60Co, were also measured by γ-ray spectrometry in order to survey the relative contribution of fragmentation to spallation and/or fission in the mass yield curves. A distinct difference of the target mass-dependence of these yields has made it possible to disentangle the contributions of photospallation and photofragmentation processes. It was found that the neutron-to-proton ratios of targets strongly affect the formation of the nuclei by fragmentation as revealed in the yields of the isotopic pairs as well as of the single isotopes. The photon results were compared with those of proton-induced reactions, and no clear effect due to the difference of the initial interactions of photons and protons with nuclei was found in the fragment yields.

Nephritogenic Glycoprotein X

When triglycosyl glycopeptide ( nephritogenoside ) was contaminated with glucosyl, galactosyl, mannosyl, and heteropolysaccharide glycopeptide, a mixed lesion of proliferative glomerulonephritis ( PGN ) with immunofluorescent mesangial pattern and membranous glomerulonephritis (MG) with immunofluorescent granular pattern resulted. It was concluded that PGN was caused by the presence of nephritogenoside and MG by the presence of the heteropolysaccharide glycopeptide in the crude nephritogenic glycopeptide mixtures derived from various solubilization steps used to treat the kidney extracts. Trichloroacetic acid treatment of crude nephritogenic glycopeptide mixtures precipitated the heteropolysaccharide glycopeptide of the MG-inducing factor, thus permitting the separation of nephritogenoside from the heteropolysaccharide glycopeptide by a rather simple technique. Both the heteropolysaccharide glycopeptide and Heymann's antigen (so-called tubular antigen) have a common antigenic substance, but we cannot conclude, at the present state, that both substances are chemically the same. The degree of contamination of pure nephritogenoside by this substance that is antigenically the same as Heymann's antigen (in pure nephritogenoside ) can be chemically and accurately determined, based on the evidence that pure nephritogenoside is a glycopeptide having only three glucose residues as the sugar moiety, that is, by estimating the amount of contaminated monosaccharide components such as galactose, mannose, and N-acetylglucosamine.

Nickel-63 production in copper samples exposed to the Hiroshima atomic bomb: estimation based on an excitation function obtained by neutron irradiation experiments

The upper and lower limits of the excitation function of the (63)Cu(n,p)(63)Ni reaction were experimentally determined, and the number of (63)Ni nuclei produced in copper samples exposed to atomic bomb neutrons in Hiroshima was estimated by using the experimental excitation functions and the neutron fluences given in the DS02 dosimetry system. The estimated number of (63)Ni nuclei was compared with that measured and with that calculated using the DS02 dosimetry system and the corresponding ENDF/B-VI cross section. In comparison with DS02, there is about a 60% maximum difference in (63)Ni production at the hypocenter when the experimental upper cross section values are used. The difference becomes smaller at greater distances from the hypocenter and decreases, for example, to less than 30 and 5% when using the upper and lower experimental cross sections at 1,000 m, respectively.

X chromosome inactivation in nuclear transfer ES cells

Nuclear transfer ES (ntES) cells are established from cloned blastocysts generated by somatic cell nuclear transfer and are expected to be an important resource for regenerative medicine. However, cloned mammals, generated by similar methods, show various abnormalities, which suggest disordered gene regulation. Random X chromosome inactivation (XCI) has been observed to take place in cloned female mouse embryos, but XCI does not necessarily occur according to Xce strength, a genetic element that determines the likelihood of each X chromosome to be inactivated. This observation suggests incomplete reprogramming of epigenetic marks related to XCI. Here, we investigated XCI in ntES cell lines, which were established using differentiated embryoid bodies that originated from a female mouse ES cell line. We examined Xist RNA localization, histone modifications in the Xist locus, and XCI choice. We did not find substantial differences between the ntES lines and their parental ES line. This suggests that the Xist locus and the epigenetic marks involved in XCI are reprogrammed by nuclear transfer and subsequent ntES cell establishment. In contrast to skewed XCI in cloned mice, our observations indicate that normal XCI choice takes place in ntES cells, which supports the goal of safe therapeutic cloning for clinical use.

Excitation function for 63Cu(n,p)63Ni reaction in neutron energy range up to 15 MeV

The excitation function for the (63)Cu(n,p)(63)Ni reaction has been measured by activation method using the 4.5 MV Dynamitron accelerator of the Fast Neutron Laboratory of Tohoku University. Copper plates and hollow spherical copper shells were irradiated by neutrons of various energy up to 14.9 MeV produced by the T(p,n), D(d,n), and T(d,n) reactions. The (63)Ni produced in the irradiated copper target was chemically separated. The beta-rays emitted from the extracted (63)Ni were measured by a liquid scintillation method. The cross sections obtained were compared with the evaluated data files of JENDL-3.3, ENDF/B-VI and FENDL/A-2.0. Consequently, it is found that FENDL/A-2.0 is consistent with our experimental data in the energy range studied in this work. The effect of proton shell appeared in the excitation function obtained is also discussed.

Insulin-like growth factor I regulates apoptosis in condylar cartilage

Endogenous insulin-like growth factor-I (IGF-I) is known to affect the growth and development of condylar cartilage. However, the critical effect of IGF-I on cell survival is still unknown. We hypothesized that endogenous IGF-I could regulate the survival of cells of the mandibular condylar cartilage. Mandibular condyles dissected from 12-day-old rats were cultured for 1, 3, and 5 days in medium containing antisense oligodeoxynucleotide (AS-ODN) for IGF-I. Real-time RT-PCR analysis showed that the levels of IGF-I and IGF binding protein (IGFBP)3 mRNAs in the AS-ODN group were significantly decreased. After 3 days' culture, the number of necrotic cells was observed in the undifferentiated mesenchymal cell layer. These cells were TUNEL-positive and confirmed to be apoptotic by electron microscopic observation. Immunoblotting revealed that expression of cleaved caspase3 was increased with AS-ODN. These results may suggest that the cells in the undifferentiated mesenchymal cell layer of the mandibular condyle require IGF-I for survival.

Gene expression of secretory carbonic anhydrase isozymes in striated ducts of canine salivary glands using laser microdissection system

To clarify whether striated duct cells in canine salivary glands synthesize secretory carbonic anhydrase (CA-VI), as is the case with serous acinar cells, the present study utilized laser microdissection to harvest striated duct cells from canine parotid and submandibular glands, and total RNA extracted from these cells was then amplified by reverse transcription-polymerase chain reaction to assess CA-VI gene expression. The results confirmed the local expression of CA-VI mRNA in striated duct cells. This clarified that, in canine salivary glands, CA-VI is synthesized in not only serous acinar cells, but also striated duct cells.

Meeting the 12 lymph nodes (LN) benchmark in colorectal cancer surgery: A comparison of NCCN and SEER data

4015

Background: The American College of Pathology has suggested that 12 or more LN be examined from colorectal cancer surgical specimen. Both ASCO and NCCN have considered adopting the 12 LN threshold as a quality metric. The purpose of this study was to determine whether the 12 LN benchmark is achieved at NCCN specialty centers. Methods: Patients with newly diagnosed stage I-III colon or rectal cancer, who had primary surgery at NCCN centers in 2005–6 were selected (n=345). Similarly, data from 14,019 stage I-III colorectal patients diagnosed in 2002 in a SEER region were obtained to determine the extent to which this goal was met in a population-based sample. Patient characteristics of age, gender, location, stage and number of positive nodes were compared for NCCN and SEER data in regards to number of nodes evaluated. Univariate logistic regression models were developed to identify factors associated with the 12 LN target at the NCCN. Factors evaluated were number of positive nodes, age, gender, comorbidity score, ECOG performance status, insurance, location, stage, surgery technique, and NCCN center. Results: As detailed in the Table , 89% of the 2005–6 NCCN sample and 45% of the SEER sample had at least 12 LN evaluated. For patients treated at NCCN centers, stage I compared to stage III (OR=0.20; 95% CI=0.08 to 0.48, p<0.0001) and rectal cancer (OR=0.44; 95% CI=0.22 to 0.88, p=0.02) were each less likely to achieve the 12 LN target. Conclusions: For patients operated on at NCCN centers, at least 12 LN are almost always removed and examined as part of an oncologic resection. In population based samples, this target is achieved in less than half of cases. With longer follow-up we will be able to link this potential quality metric directly to outcomes and thereby better inform whether increasing the number of nodes evaluated is an important priority for cancer control. Table 1 . Characteristics of CRC patients who did and did not have 12 or more LN evaluated at primary resection.

[Table: see text]

No significant financial relationships to disclose.

Incidence of minimally invasive colorectal cancer (CRC) surgery in patients treated at NCCN institutions

6575

Background: In May 2004 the Clinical Outcomes of Surgical Therapy Study Group published the results of the North American randomized trial demonstrating that oncologic outcome is similar for laparoscopic assisted and open surgery for CRC. This and other studies have shown quicker recovery with laparoscopic CRC surgery including earlier resolution of postoperative ileus, less discomfort, and earlier discharge from the hospital. The extent to which surgeons have adopted the minimally invasive surgical (MIS) approach in CRC is unknown. Methods: Using the NCCN Colon/Rectal Cancer Outcomes Project Database, 715 patients were identified who underwent CRC resection in 2005–6. The distribution of lesions included right colon (39%), left colon (31%), and rectum (30%). The incidence of MIS for CRC and clinicopathologic features associated with this approach were analyzed by logistic regression; results are reported as odd ratio (OR) with 95% confidence intervals (CI), and significance defined at p<0.05 level. Results: A total of 167 (23%) patients underwent MIS colorectal surgery (laparoscopy in 98% and robotic in 2%). Conversion to open surgery was noted in 33 cases (20%). Surgery was performed in outside institutions in 21% of cases prior to patients presenting to NCCN institutions for further treatment. The MIS approach was more common in colon than rectal cancer (30% vs.12%, OR 2.96, CI 1.94–4.51, p<0.0001). Within the colon cancer cohort, right sided lesions were more likely to be approached with MIS techniques rather than left sided lesions (32% vs. 25%; OR 1.42, CI 1.96–2.21, p<0.0001). Stage I tumors were also more likely to be managed with the less invasive approach: Stage I-41%; II-20%; III-21%; IV-19% (Stage I vs. IV, OR=3.00, CI 1.74–5.16 p<0.0001). No differences in surgical approach were noted based on age, gender, race, Charlson comorbidity score, insurance type, or location of surgery (NCCN vs outside facility). Conclusion: The majority of CRC surgery for patients presenting to NCCN institutions is performed by open techniques. Right sided and early stage CRCs were more likely treated with MIS, possibly related to the less demanding nature of the procedure. The adoption of MIS is expected to rise as surgeons become trained in MIS techniques for CRC.

No significant financial relationships to disclose.

Radical surgery is not necessary following neoadjuvant chemotherapy in stage III-IV resectable, non-laryngeal head and neck cancer (NLHNC)

16501

Background: Traditionally, following neoadjuvant chemotherapy (NC), head and neck surgeons have insisted in performing radical surgery regardless of the response to NC. This prospective study evaluates the results of conservative surgery following NC in resectable stage III-IV non-laryngeal head and neck cancer (NLHNC). Methods: Between 1993 and 2003, 70 patients with NLHNC were treated with one of the following NC: Cisplatin and 5FU (17.1%); Cisplatin, 5FU, Leucovorin, and Taxotere (58.6%); Cisplatin, 5FU, and Taxol (24.3%). After three courses of NC, patients were reevaluated to determine the need for local therapy. Local excision or biopsy was performed for patients with near-complete pathological response (n-CPR) or patients with a complete pathological response (CPR). Radical surgery was reserved for patients with partial response (PPR). All patients received radiation to the primary and neck. Results: The median follow up was 35 months, median disease-free survival was 33.4 months and 3-year overall survival was 71.4% for the entire group. Thirty-five patients (50.0%) had a complete pathological response (CPR), 11 (15.7%) had a complete clinical response (CCR) and no pathological staging, 5 patients (7.1%) had a n-CPR, and 19 patients (27.1%) had a partial pathological response (PPR). Primary surgery is shown in the following table : At the time of the last follow up, 1/35 (2.9%) patients with CPR had a local recurrence (LR) at the primary and 5/11 (45.5%) patients with CCR and no pathological staging had a LR; in 3/6 (50%) patients with LR the primary was controlled with salvage surgery. Seven of eleven (63.6%) patients with PPR had a LR, only one achieved local control with salvage surgery. Conclusions: Complete pathological response at the primary site is a good predictor of long term local control in NLHNC. Radical surgery, is not necessary in non-laryngeal head and neck cancers following a complete pathological response at the primary site.

[Table: see text]

No significant financial relationships to disclose.