[Dose intensified adjuvant chemotherapy in high risk breast carcinoma with 4-9 positive lymph nodes]

OBJECTIVE

Taxanes and anthracyclines represent the two most active groups of agents for the treatment of breast cancer. We evaluated this combination in patients with more than 3 positive lymph nodes in an adjuvant, dose-intensive, sequential therapy in comparison with the standard chemotherapy regimen epirubicin/cyclophosphamide in relation to toxicities.

MATERIAL AND METHODS

Since 9/96 127 patients with 4-9/over 9 positive lymph nodes have been recruited from 21 participating centers in an ongoing trial. 67 patients were prospectively randomised for first-line chemotherapy to treatment group A (epirubicin 90 mg/m2-paclitaxel 175 mg/m2; 4 cycles bi-weekly, supported by G-CSF 5 micrograms/kg day 5-13 and 3 sequential cycles of CMF 600/40/600 mg/m2 at 2-weeks interval) and 60 patients to treatment group B (epirubicin 90 mg/m2-cyclophosphamide 600 mg/m2, 4 cycles tri-weekly, and 3 sequential cycles of CMF 600/40/600 mg/m2 at 3-weeks interval).

RESULTS

Preliminary safety and toxicity data are evaluable for 679 cycles. Data about response rate and disease-free-survival and overall survival will be delivered later. For the hematological toxicity the main grade 3 and 4 adverse events for A vs. B were: leucopenia 9.8% vs. 8.4%, febrile neutropenia 1.6% vs. 0.8%--anemia (< 5.9 mmol/l), 0.4% vs. 0.2%--thrombopenia 0% vs. 0%. Non-hematological toxicity occurred more frequently in group A (grade 2, 3, 4):--neuropathy 4.4% vs. 0%,--nausea/emesis 27.8% vs. 19.3%,--fatigue 14.6% vs. 3.4% and mucositis 2.8% vs. 0.3%.

Reduction of electromagnetic interference from a commercially available MR-compatible flow simulator

Electromagnetic interference (EMI) associated with the electronics of a commercially available computer controlled flow simulator substantially decreases the quality of the MR image. The effect of a custom-built radiofrequency shield on its spectral emission, and the corresponding signal-to-noise ratio measured for the image of a standard phantom, were determined. The results demonstrate the elimination of EMI and a significant improvement in image quality.

Expression of TRAIL and its receptors in human brain tumors

Recently, TRAIL has been demonstrated to selectively induce apoptosis in transformed cell lines, and subsequently four receptors (TRAIL-R1-TRAIL-R4) have been identified. The ability to transduce death signals is restricted to TRAIL-R1/TRAIL-R2. In contrast, TRAIL-R3/TRAIL-R4 are unable to activate apoptotic pathways and have therefore been suggested to act as "decoys" protecting normal tissues from cell death. However, the biological role of the TRAIL system remains incompletely understood. We analyzed the expression of TRAIL and its receptors in a panel of human brain tumors (n = 34) and in four glioma cell lines in comparison to normal brain tissue. Constant co-expression of TRAIL and of receptors TRAIL-R1, TRAIL-R2, and TRAIL-R3 in different tumor entities as well as in normal brain indicates that additional mechanisms might modulate the previously proposed "decoy" model. Furthermore, in contrast to previous reports, we demonstrate TRAIL and TRAIL-R2 to be present on a transcriptional level in normal brain tissue. Exceptional expression of TRAIL-R4 transcripts does not suggest a significant regulatory role of this receptor in the human brain and its tumors.

Design of highly specific cytotoxins by using trans-splicing ribozymes

We have designed ribozymes based on a self-splicing group I intron that can trans-splice exon sequences into a chosen RNA target to create a functional chimeric mRNA and provide a highly specific trigger for gene expression. We have targeted ribozymes against the coat protein mRNA of a widespread plant pathogen, cucumber mosaic virus. The ribozymes were designed to trans-splice the coding sequence of the diphtheria toxin A chain in frame with the viral initiation codon of the target sequence. Diphtheria toxin A chain catalyzes the ADP ribosylation of elongation factor 2 and can cause the cessation of protein translation. In a Saccharomyces cerevisiae model system, ribozyme expression was shown to specifically inhibit the growth of cells expressing the virus mRNA. A point mutation at the target splice site alleviated this ribozyme-mediated toxicity. Increasing the extent of base pairing between the ribozyme and target dramatically increased specific expression of the cytotoxin and reduced illegitimate toxicity in vivo. Trans-splicing ribozymes may provide a new class of agents for engineering virus resistance and therapeutic cytotoxins.

Trans-splicing ribozymes for targeted gene delivery

Ribozymes are potential tools for genetic manipulation, and various naturally occurring catalytic RNAs have been dissected and used as the basis for the design of new endoribonuclease activities. While such cleaving ribozymes may work well in vitro, they have not proved to be routinely effective in depleting living cells of the chosen target RNA. Recently, trans-splicing ribozymes have been employed to repair mutant mRNAs in vivo. We have designed modified trans-splicing ribozymes with improved biological activity. These allow accurate splicing of a new 3' exon sequence into a chosen site within a target RNA, and in frame fusion of the exon can result in expression of a new gene product. These trans-splicing ribozymes contain catalytic sequences derived from a self-splicing group I intron, which have been adapted to a chosen target mRNA by fusion of a region of extended complementarity to the target RNA and precise alteration of the guide sequences required for substrate recognition. Both modifications are required for improved biological activity of the ribozymes. Whereas cleaving ribozymes must efficiently deplete a chosen mRNA species to be effective in vivo, even inefficient trans-splicing can allow the useful expression of a new gene activity, dependent on the presence of a chosen RNA. We have targeted trans-splicing ribozymes against mRNAs of chloramphenicol acetyltransferase, human immunodeficiency virus, and cucumber mosaic virus, and demonstrated trans-splicing and delivery of a marker gene in Escherichia coli cells. The improved trans-splicing ribozymes may be tailored for virtually any target RNA, and provide a new tool for triggering gene expression in specific cell types.

Cardiovascular effects of mibefradil in hypertensive patients with obstructive sleep apnea

OBJECTIVE

Hypertension is often seen in obstructive sleep apnea (OSA) and is characterized by increased sympathetic activity, depressed baroreflex and accentuated vascular responsiveness. The objective of this study was to investigate the effects of the new T-selective calcium channel blocker mibefradil on invasively measured blood pressure (BP) and heart rate in hypertensive patients with OSA.

METHODS

The present study was a double-blind, randomized and placebo-controlled before and after trial in two parallel groups. Fifty-three men aged 23 69 years with systemic hypertension and OSA were recruited from the Outpatient Department of the Marburg University Sleep Laboratory and hospitalized for 10 days. Mibefradil (50 mg) or placebo were given orally in the morning for 8 days. The main outcome measure was the mean arterial (radial) BP monitored continuously during nocturnal sleep and during standardized daytime physical and psychological performance testing.

RESULTS

Mibefradil lowered mean arterial BP and heart rate with (SD) during the entire measurement period compared with placebo: -7.25 (9.59) vs -2.11 (8.43) mmHg (P=0.039) and -4.83 (5.94) vs -1.34 (4.13) bpm (P=0.022), respectively. Both effects were observed during nocturnal sleep and performance testing, including graded exercise. Adverse events did not differ compared with placebo.

CONCLUSION

Mibefradil is an effective but well-tolerated antihypertensive that also lowers heart rate over 24 h in OSA, in conditions known to increase BP.

A 2-week pretreatment with 13-cis-retinoic acid + interferon-alpha-2a prior to definitive radiation improves tumor tissue oxygenation in cervical cancers

BACKGROUND

We have evaluated the tumor tissue pO2 in cervical cancers in patients treated with 13-cis-retinoic acid and interferon-alpha-2a prior to and during radiotherapy.

PATIENTS AND METHODS

From June 1995 through April 1997, 22 patients with squamous cell carcinoma FIGO IIB/III of the cervix who were scheduled for definitive radiotherapy with curative intent received additional treatment with 13-cis-retinoic acid (cRA, isotretinoin) plus interferon-alpha-2a (IFN-alpha-2a) as part of a phase-II protocol. cRA/IFN-alpha-2a started 14 days prior to radiotherapy (1 mg per kilogramme body weight cRA orally daily plus 6 x 10(6) IU IFN-alpha-2a subcutaneously daily). After this induction period, standard radiotherapy was administered (external irradiation with 50.4 Gy in 28 fractions of 1.8 Gy plus HDR-brachytherapy). During radiotherapy, cRA/IFN-alpha-2a treatment was continued with 50% of the daily doses. Tumor tissue pO2-measurements were performed prior to and after the cRA/IFN-induction period as well as at 20 Gy and at the end of radiotherapy with an Eppendorf-pO2-histograph.

RESULTS

In 11 out of the 22 patients, pO2-measurements were performed prior to the cRA/IFN-induction therapy. The median pO2 of these untreated tumors was 17.7 +/- 16.3 mm Hg. The relative frequency of hypoxic readings with pO2-values below 5 mm Hg ranged from 0% to 60.6% (mean 24.3 +/- 21.0%). After the 2-week induction period with cRA/IFN, the median pO2 had increased from 17.7 +/- 16.3 mm Hg to 27.6 +/- 19.1 mm Hg (not significant). In all 5 patients with hypoxic tumors prior to cRA/IFN (median pO2 of 10 mm Hg or less), the median pO2 was above 20 mm Hg after the 2-week cRA/IFN-induction. In this subgroup of hypoxic tumors, the median pO2 increased from 6.3 +/- 2.7 mm Hg to 27.0 +/- 5.6 mm Hg (p = 0.004, t-test for paired samples). The frequency of hypoxic readings (pO2-values < 5 mm Hg) decreased from 44.7 +/- 17.1% to 2.0 +/- 2.5% (p = 0.012, t-test for paired samples). There was, however, no obvious volume reduction after 14 weeks of cRA/IFN on clinical examination. A complete clinical remission of the local tumor was observed in 19/22 patients after radiotherapy and additional cRA/IFN-alpha-2a-treatment. In primarily hypoxic tumors (with a median pO2 below 10 mm Hg prior to treatment), 4/5 achieved complete remission.

CONCLUSIONS

Pretreatment with cRA/IFN improves oxygenation of primarily hypoxic cervical cancers. The mechanisms of action remain unclear and further investigation of the combination regimen is recommended.

[Cardiac arrhythmias in sleep apnea. Increased cardiovascular risk caused by nocturnal arrhythmia?]

In sleep-disordered breathing (SDB), the greatest clinical relevance attaches to obstructive sleep apnea on account of its high prevalence and its concomitance with diseases of the cardiovascular system. The high mortality rate of untreated patients is believed to be due to the consequences of these latter diseases. Thus, for example, in addition to systemic arterial hypertension, elevated rates of such disorders as pulmonary hypertension, right heart insufficiency, coronary heart disease, myocardial infarction and stroke are also found. Up until quite recently bradycardic and tachycardic arrhythmias occurring during sleep have been held responsible of the increased mortality rate of these patients. Till the mid-eighties the prevalence of bradycardic arrhythmias was reported to be more than 30%. However, the importance of cardiac arrhythmias has been overestimated, as is supported in particular by current studies on large non-selected samples showing a much lower prevalence of apnea-related arrhythmias. In the differential diagnosis, however, consideration must be given to SDB in patients with nocturnal arrhythmias and heart rate variations.

[Therapy outcome in stage III (FIGO) ovarian carcinomas at the Leipzig University Gynecologic Clinic 1976-1982 and 1985-1991]

This retrospective study compares treatment results (median survival time, 5-year survival rate) of 153 patients diagnosed with FIGO stage III ovarian cancer treated between 1976 to 1982 (n = 73) and 1985 to 1991 (n = 80) respectively. Between 1976 to 1982, the median survival time was 12.3 months, while it increased up to 17.0 months during the period of 1985-1991. The 5-year survival rate increased from 14.0% to 28.0%. This improvement may be due to a more radical surgical approach and the use of platinum-based first-line chemotherapy. However, the difference between the two groups was not statistically significant.

Data about 154 children and adolescents reporting sexual assault

Sexual assaults on girls occur at an alarming rate representing a significant public health problem, but difficulties in correctly identifying the problem, managing the child and reporting for legal purposes have been recognized. We describe data obtained on 154 recent cases of child and adolescent sexual assault. Results indicate that those at highest risk of sexual assault are girls at age of 11-15 years having a stepfather, although the most girls at age of > 15 were assaulted by strange men with higher incidence of cross-race assault. Over a quarter of girls showed signs of physical trauma with face and neck as most common site of contact. A total of 17.5% reported threat of violence or with weapons and 9.7% had alcoholic influence. Pattern and incidence of genital injuries were described.

Tolerability of endocrine treatment for advanced breast cancer: results of an international survey

In contrast with cytotoxic therapy, the impact of hormonal therapy for advanced breast cancer in postmenopausal women is poorly documented. Two recent surveys of the impact of hormonal therapy in this patient group found that side-effects had an adverse impact on patients' quality of life which needed to be taken into account when discussing treatment options. Patients were perceived to be more comfortable discussing treatment-related problems with nurses rather than doctors, who tended to underestimate the distress caused to patients by the side-effects of treatment. A need was identified for better lines of communication between patients and medical professionals, and for a simple, more widely applicable tool for assessment of side-effects. As a result of these findings, a simple checklist, Checklist for Patients on Endocrine Therapy (C-PET), has been developed to be completed by patients before a physician appointment, to form a basis for discussion. A pilot study has indicated that C-PET is easy and quick for patients to complete and aids communication between patients and healthcare professionals. C-PET has now been formally launched to nurses, oncologists, and other cancer physicians.

Influence of sleep apnea on 24-hour blood pressure

OBJECTIVE

To study the influence of obstructive sleep apnea (OSA) on 24-h BP.

SETTING

Sleep laboratory of the Medical Department, Neukölln Hospital, Berlin, Germany.

METHODS

In 93 subjects, noninvasive 24-h BP monitoring was performed with BP recordings made at 15-min intervals. Apnea severity was evaluated by means of a portable device that allows calculation of an oxygen desaturation index (ODI). A normal 24-h BP profile (dipping) was defined by a night/day BP ratio of 0.9.

RESULTS

ODI was related to systolic and diastolic daytime (p<0.001) and nighttime BP (p<0.001) as well as systolic and diastolic BP night/day ratios (p<0.001). Multiple regression analysis showed that age and ODI were independently related to daytime BP. When subjects were grouped according to apnea severity, daytime BP increased as ODI increased: 127/80+/-10/11 mm Hg in habitual snorers (ODI 0 to 5), 135/87+/-15/9 mm Hg in mild OSA (ODI 6 to 30), and 140/90+/-13/10 mm Hg in severe OSA (ODI >30) (p values <0.05 for comparisons of OSA groups with habitual snorers). Compared to subjects with mild OSA or habitual snorers, BP night/day ratios were greater in patients with severe OSA (p values <0.05). Accordingly, hypertension and nondipping increased as ODI increased.

CONCLUSION

OSA is associated with hypertension independent of the confounding factors of age and obesity. Nondipping is related to apnea severity. These alterations might contribute to the increased mortality in patients with severe OSA.

Weekly paclitaxel with epirubicin as second-line therapy of metastatic breast cancer: results of a clinical phase II study

Phase I/II trials have shown that combination of an anthracycline with paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) represents a high-potency therapy for treatment of patients with metastatic breast cancer, with response rates exceeding 90%. This phase II trial was conducted to test the tolerability and efficacy of weekly epirubicin plus paclitaxel as second-line therapy for patients with pretreated metastatic breast cancer. In this study, 35 patients with previous hormone therapy and/or chemotherapy were treated at a weekly dose of paclitaxel 80 mg/m2 with epirubicin 35 mg/m2 (10 patients, 123 cycles) or paclitaxel 80 mg/m2 with epirubicin 25 mg/m2 (25 patients, 218 cycles). The dose reduction of anthracyclines became necessary due to severe hemotoxicity (neutropenia World Health Organization grade 3 to 4 in 30.2% of cycles). The therapy schema included a 2-week therapy interval after each treatment period of 6 weeks, with treatment continued until response or disease progression. Overall, 18 patents (51.4%) presented with responses (complete response or partial response) to therapy, with seven (20%) achieving a complete response after six to 18 cycles. In three cases (8.6%), tumor state was unchanged for a median interval of 11 weeks (range, 5 to 20 weeks). Progressive disease was observed in seven cases (20%), and seven patients (20%) were not evaluable. Following epirubicin dose reduction, neutropenia World Health Organization grade 3 to 4 occurred in only 18.1% of cycles. Referring to nonhematologic toxicity, alopecia exceeded World Health Organization grade 2. Other nonhematologic toxicities exceeding grade 2 were observed in only a few courses and were not statistically relevant. No clinically relevant deterioration of cardiac function was observed at a median cumulative dose of epirubicin 285 mg/m2 (maximum cumulative dose, 630 mg/m2). This study has substantiated that the schedule used is highly efficient and well tolerated as second-line chemotherapy for patients with metastatic breast cancer.

Tumor-associated proteolytic factors uPA and PAI-1 in endometrial carcinoma

The levels of plasminogen activator urokinase (uPA) and of its inhibitor (PAI-1) were measured by use of ELISA in the cytosol of tissue homogenates obtained from endometrial carcinomas and the marginal, tumor-free endometrium of postmenopausal patients (n = 64). Significantly higher median levels of uPA and PAI-1 were found in malignant endometrium (uPA 1.89 ng/mg, PAI-1 3.04 ng/mg) compared to tumor-free endometrium (uPA 0.84 ng/mg, PAI-1 1.01 ng/mg). Concerning uPA, no significant differences were found in dependence on histomorphological prognostic factors (staging, grading), but the median level of PAI-1 was significantly higher in G2/G3 carcinomas compared to G1 tumors (5.08 ng/mg vs 2.19 ng/mg). Because of the good prognosis of operated patients with endometrial carcinomas, the prognostic value of uPA and PAI-1 can only be decided by a larger number of patients and a long observation time.

Effect of angiotensin converting enzyme inhibition [Cilazapril] on blood pressure recording in hypertensive obstructive sleep apneic patients

We investigated the efficacy of an Angiotensin Converting Enzyme [ACE] inhibitor on daytime and night-time blood pressure in 55 male hypertensive patients with moderately severe to severe obstructive sleep apnea. We resolved to determine if treatment oriented towards the reduction of hypertension would be successful, despite persistent repetitive hypoxemia and sleep-disordered breathing. The study was a randomized, double-blind, single daily dose, placebo-controlled protocol, with 8 days drug intake (placebo or 2.5 mg Cilazapril) and monitoring on the final day of drug administration. Subjects underwent continuous 24-h arterial blood pressure monitoring during baseline and treatment conditions. Polysomnography was performed at night during the 24-h arterial monitoring period. Cilazapril (2.5 mg) lowered systolic, diastolic and mean blood pressure, despite persistence of repetitive obstructive apneas during sleep and the associated repetitive hypoxemia. The lowering of blood pressure occurred without a significant change in heart rate, and was noted during nocturnal sleep, performance testing and graded exercise.

[Primary dedifferentiated leiomyosarcoma of the fallopian tube]

Between 1960 and 1995 the University of Leipzig Women's Hospital encountered 44 cases of primary malignant tumors of the Fallopian tube, including four malignant Müller mixed tumors and one sarcoma. The sarcoma, a dedifferentiated leiomyosarcoma, was found incidentally in a 57-year-old woman. Treatment encompassed total abdominal hysterectomy and bilateral salpingo-oophorectomy with omentectomy and pelvic and para-aortic lymph node dissection, followed by telecobalt irradiation of the pelvis (Hd 52 Gy). One year after treatment, no evidence of disease recurrence, is found. Literature documents only 34 cases of a primary uterine tube sarcoma. Even with RO-resection, the early, high rate of local recurrence (most often within the first two years after treatment) and hematogenous metastasis to the lungs, liver and bones compose this tumor's clinical course. The prognosis is poor despite the use of radiotherapy and/or combination chemotherapy.

[Results of an individualized surgical therapy of vulvar carcinoma from 1973-1993]

From 1973 through 1993, the University of Leipzig Women's Hospital treated 285 patients with primary vulvar malignancies. Of these, 269 cases (94.3%) were squamous cell carcinomas. The patients age averaged 69 years (25-95 years). 232 women (81.4%) were older than 60 years. Only 20 women (7%) were younger than 50 years. During the given time period, 266 patients (93.3%) underwent primary surgery. Standard operative treatment, performed in 105 cases (39.5%), was radical vulvectomy and bilateral superficial inguinal lymph node dissection. Rather than en bloc resection (Butterfly method), separate incisions were used during node dissection. Only 3 patients (2.9%) experienced a relapse within the remaining skin bridge. Irradiation with a focal doses of ca. 50 Gy followed postoperative-adjuvant in those cases involving the inguinal lymph nodes. In contrast, 161 patients received largely individualized surgical treatment. Local tumor extension and patient age-dependent operability influenced the choice of treatment. Partial vulvectomy was performed in 37 cases (13.9%). Simple vulvectomy without inguinal node dissection was performed in 115 cases (43.2%) and 9 patients underwent vulvectomy with vaginal-, urethral- and partial sphincter resection, accompanied by myocutaneous flap transposition (M. gluteus maximus lobe). The cumulative (corrected) 5-year survival rate for all patients with squamous cell carcinoma was 68.6%. No significant relationship between patient age (> 60 years vs. < or = 60 years) and prognosis could be seen. Factors of importance to the prognosis, however, were primary tumor size (FIGO stage I vs. II vs. III/IV), principal tumor site (significantly poorer survival rates characterize both clitoral and multifocal carcinomas), histological staging (G1 vs. G2/G3), inguinal lymph node involvement (pN+ vs. pN-) and degree of tumor resection in "healthy" (> or = 2 cm vs. < 2 cm). 5-year survival rates among those patients receiving individualized operative care did not differ significantly. Patient survival rates were 70.3% by partial vulvectomy, 78.2% by simple vulvectomy without inguinal node dissection and 67.6% by radical vulvectomy and bilateral inguinal node dissection with or without postoperative-adjuvant irradiation. These findings, therefore, justify the individualized operative treatment of patients with vulvar carcinoma according to each patient's initial prognostic situation. The relatively seldom vulvar carcinoma should only be treated by experienced surgeons in an appropriate hospital environment. Moreover, assessment of histological sections must be standardized, reproducible and above all, include the very accurate evaluation of all resection edges.

[Development of breast surgery including plastic-reconstructive surgery results of the Universitätsfrauenklinik Leipzig]

The previous retrospective analysis surveys the introduction and development of breast surgery between 1992 and 1996 where a total of 741 procedures have been performed at our department. Recently, these operations represent about 10% of all gynecological procedures including small and extended operations. The total of breast surgical procedures have increased fivefold within the early introduction period of two years. Surgery of the breast was performed because of cancer in 335 cases (45%). Breast preserving procedures such as "wide excision" or segment resection with axillary nodal dissection (level I and II) respectively, have advanced from initially 46% in 1993 to 52% at present. 36% of women undergoing modified radical mastectomy receive an immediate breast reconstruction. So far, severe intraoperative complications were not encountered. The rate of postoperative and early complications needing therapy including cases with reoperation for postoperative haematoma formation (0.6%) or cases with impaired wound healing (3.1%) is assessed to be minor.

Survival and quality of life after percutaneous nephrostomy for malignant ureteric obstruction in patients with terminal cervical cancer

We describe 24 consecutive patients with cervical cancer stage III or IV who received palliative urinary diversion by percutaneous nephrostomy. All patients had proven malignant ureteric obstruction, uremia and failed ureteric stenting. 11 of 17 patients with extensive primary cancer and local lymph node involvement had an acceptable quality of life for 2 or more months while the mean survival was 5.6 months. Patients with disseminated metastasizing cancer were not satisfactorily served by nephrostomy.