A randomized, double-blind, placebo-controlled multicenter phase II study of the COX-2 inhibitor apricoxib (A) in combination with either docetaxel (doc) or pemetrexed (pem) in advanced non-small cell lung cancer (NSCLC) patients (pts) selected by urinary PGE-m suppression

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Background: Overexpression of COX-2 has been associated with advanced stage and worse outcomes in NSCLC, possibly due to elevated levels of the COX-2 dependent prostaglandin, PGE-2. COX-2 inhibitors in addition to standard therapy has been associated with superior outcome in pts in whom the urinary metabolite of PGE-2, PGE-M is suppressed by the inhibitor. We hypothesized that pts defined by PGE-M suppression would benefit from the addition of apr to doc or pem. Methods: Pts with NSCLC, progressive after one platinum based therapy, PS 0-1, normal organ function, alb ≥2.5, CCr ≥ 45 were eligible for screening. A 5 day run in period with apr 400mg qd was performed. Only pts with a ≥ 50% decrease in urinary PGE-M could actually enroll. Chemotherapy was doc 75 mg/m2 or pem 500 mg/m2 q21 d per the investigator plus apr/placebo (P) 400 mg qd. The primary endpoint was progression free survival (PFS). Results: A total of 109 pts were screened of whom 72 demonstrated ≥50% suppression and enrolled (table). Toxicity was similar between the arms. No improvement in PFS was seen with apricoxib vs. placebo. By chemotherapy assignment: pem/apr vs. pem/P : 103 days vs. 98 (p =.49); doc/apr vs. doc/P: 75 vs. 97 (p=.18). An adverse interaction between baseline PGE-M and doc was seen in survival (p=.026); each unit increase in urinary PGE-M increased the HR by 1.014 (p < 0.038 ) vs. pem (HR =.990, p=n.s.). There was no correlation between baseline PGE-M or magnitude of PGE-M suppression and benefit from apr. Conclusions: 1. Apr did not improve outcome despite patient selection. 2. There was a trend towards an adverse outcome when apr was combined with docetaxel, that was not evident with pemetrexed. 3. Baseline urinary PGE-M may be an adverse prognostic factor for treatment with doc. [Table: see text]

Surgery for early-stage small cell lung cancer

Limited-stage small cell lung cancer remains one of the more frustrating malignancies to treat. Current standard of care typically includes platinum-based chemotherapy with thoracic radiation, and although response to therapy is high, most patients will ultimately experience relapse and die of recurrent disease. No high-level data exist supporting surgical resection of early-stage disease; however, several retrospective reviews and small single-arm studies suggest surgery may benefit patients with very limited extent of disease. This article reviews the available literature, and proposes guidelines for including potentially curative resection in the management of patients with limited-stage small cell lung cancer.

Phase II study of celecoxib and docetaxel in non-small cell lung cancer (NSCLC) patients with progression after platinum-based therapy

INTRODUCTION

To evaluate the efficacy and toxicity of the combination of celecoxib and docetaxel in patients with advanced non-small cell lung cancer after failure of platinum-based therapy.

METHODS

Patients with relapsed non-small cell lung cancer received celecoxib 400 mg orally twice daily beginning 7 days before the first cycle of docetaxel and the celecoxib was continued with no interruption. Docetaxel 75 mg/m2 was administered intravenously on a 21-day cycle. The primary end point of the study was the 6-month survival rate.

RESULTS

Twenty-four patients were enrolled and twenty patients were treated (median age 60, M:F 16:8). Most patients had a baseline performance status of 1. The objective response rate was 10% (95% confidence interval [CI], 0-25%) and the 6-month survival rate was 59% (95% CI 37-80%). Median survival time was 6.9 months (95% CI, 2.8-15.2 months) and the 1- and 2-year survival rates were 36% (95% CI, 15-57%) and 1% (95% CI, 0-10%), respectively. The most frequent grade > or =3 adverse events were neutropenia (58%) and neutropenic fever (21%) which resulted in early closure of the trial.

CONCLUSIONS

The addition of celecoxib to docetaxel did not seem to improve the response rate and survival compared with docetaxel alone. The combination demonstrated considerable neutropenia and complications from febrile neutropenia that suggests celecoxib may enhance the marrow toxicity of docetaxel.

Non-small cell lung cancer staging: proposed revisions to the TNM system

Patients with non-small cell lung cancer (NSCLC) require careful staging at the time of diagnosis to determine prognosis and guide treatment recommendations. The seventh edition of the TNM Classification of Malignant Tumors is scheduled to be published in 2009 and the International Association for the Study of Lung Cancer (IASLC) created the Lung Cancer Staging Project (LCSP) to guide revisions to the current lung cancer staging system. These recommendations will be submitted to the American Joint Committee on Cancer (AJCC) and to the Union Internationale Contre le Cancer (UICC) for consideration in the upcoming edition of the staging manual. Data from over 100,000 patients with lung cancer were submitted for analysis and several modifications were suggested for the T descriptors and the M descriptors although the current N descriptors remain unchanged. These recommendations will further define homogeneous patient subsets with similar survival rates. More importantly, these revisions will help guide clinicians in making optimal, stage-specific, treatment recommendations.

Management of recurrent small cell lung cancer

Small cell lung cancer remains one of the more frustrating malignancies for oncologists to treat. Although responses to initial platinum-based chemotherapy are high, most are not durable, and many patients are candidates for further palliative chemotherapy. Therapeutic options include reinduction or single-agent chemotherapy, depending on the duration of response to front-line treatment. Topotecan is the only approved agent for patients with relapsed disease. Several phase II studies have shown a modest benefit with other agents used today, although combination chemotherapy should be avoided because of increased toxicity. Palliative care should always be the focus, especially in patients with recurrent or chemorefractory small cell lung cancer and a poor performance status.

Phase II trial of carboplatin, gemcitabine, and capecitabine in patients with carcinoma of unknown primary site

BACKGROUND

The purposes of this study were to evaluate efficacy and toxicity of the combination of carboplatin, gemcitabine, and capecitabine in patients with carcinoma of unknown primary site (CUP).

METHODS

Patients with CUP received carboplatin AUC 5 mg/mL a minute intravenously Day 1, gemcitabine 1000 mg/m(2) intravenously Days 1 and 8, and capecitabine 1600 mg/m(2) orally in divided doses, Days 1-14 of a 21-day cycle for up to 8 cycles. The primary endpoint of the study was objective response rate by intent-to-treat analysis.

RESULTS

Thirty-three patients were treated (median age, 58 years; men:women ratio, 19:14). Most patients had a baseline performance status of 1. The objective response rate was 39.4% (95% CI, 22.9%-57.9%) in all patients, 36.4% in 22 patients with well to moderately differentiated adenocarcinoma, and 40.0% in 20 patients with liver metastases. Median progression-free survival time was 6.2 months (95% CI, 5.4%-8.0%), and median survival time was 7.6 months (95% CI, 6.3-14.1). One and 2-year survival rates were 35.6% and 14.2%, respectively. The most frequent grade > or =3 adverse events were neutropenia (67%), thrombocytopenia (48%), and anemia (33%).

CONCLUSIONS

The combination of carboplatin, gemcitabine, and capecitabine is active in CUP, especially in patients with liver metastases. This regimen may be a potential therapy for CUP patients with good performance status, particularly those with a suspected origin below the diaphragm.

Differentiation between carcinoid and sarcoid with F-18 FDG PET and In-111 pentetreotide

A patient who presented with weight loss and recurrent left lower lobe pneumonia was diagnosed with endobronchial carcinoid. Chest CT scan demonstrated extensive mediastinal and hilar lymphadenopathy suggesting stage IIIB disease, but radionuclide imaging with In-111 pentetreotide and F-18 FDG PET diagnosed 2 distinct pathologic processes based on functional differences between neuroendocrine tumors (expressing somatostatin receptors) and sarcoidosis (intensely FDG-avid). The possible association of carcinoid with sarcoidosis and sarcoid-like reactions in regional lymph nodes should always be considered, and the staging process should include both anatomic and functional imaging and biopsy confirmation of suspected metastatic lesions.

Capecitabine and radiation therapy preceded and followed by combination chemotherapy in advanced pancreatic cancer

PURPOSE

The primary objective of this study was to evaluate the tolerance and toxicity of radiation therapy (RT) and capecitabine in patients with advanced, unresectable pancreatic carcinoma. To control micrometastatic disease, combination chemotherapy (gemcitabine and cisplatin) before and after combined modality therapy (CMT) was planned.

METHODS AND MATERIALS

Patients with unresectable or metastatic pancreatic cancer were eligible. Gemcitabine 1000 mg/m2 and cisplatin 35 mg/m2 were administered on Days 1 and 8 of a 21-day cycle for two cycles. RT was then given to a dose of 50.4 Gy in 1.8 Gy fractions. Patients were treated with capecitabine 1330 mg/m2 daily during RT. After CMT, two additional cycles of gemcitabine and cisplatin completed the treatment.

RESULTS

Twenty-three patients were treated. Eighteen patients completed CMT. One patient was removed from study during CMT for toxicity issues. Treatment delays and dose reductions were common during the final two cycles of gemcitabine and cisplatin as a result of myelosuppression. Median survival was 10.1 months (95% confidence interval [CI] = 7.6, 13.7) for all 23 patients and 12.8 months (95% CI = 8.2, 18.9) for 18 patients without metastasis.

CONCLUSION

Combined modality therapy with RT and capecitabine was well tolerated. Chemotherapy after CMT was difficult to complete owing to cumulative myelosuppression. Survival, response, and toxicity were comparable to infusional 5-fluorouracil and RT.

Catalytic inhibition of human DNA topoisomerase IIalpha by hypericin, a naphthodianthrone from St. John's wort (Hypericum perforatum)

St. John's wort (Hypericum perforatum) is the most widely used herbal medicine for the treatment of depression. However, concerns have arisen about the potential of its interaction with other drugs due to the induction of cytochrome P450 isozymes 1A2 and 3A4 by the components hypericin and hyperforin, respectively. Structurally similar natural products are often employed as antitumor agents due to their action as inhibitors of DNA topoisomerases, nuclear enzymes that modify DNA during cellular proliferation. Preliminary findings that hypericin inhibited the DNA relaxation activity of topoisomerase IIalpha (topo II; EC 5.99.1.3) led us to investigate the mechanism of enzyme inhibition. Rather than stabilizing the enzyme in covalent complexes with DNA (cleavage complexes), hypericin inhibited the enzyme prior to DNA cleavage. In vitro assays indicate that hypericin is a potent antagonist of cleavage complex stabilization by the chemotherapeutics etoposide and amsacrine. This antagonism appears to be due to the ability of hypericin to intercalate or distort DNA structure, thereby precluding topo II binding and/or DNA cleavage. Supporting its non-DNA damaging, catalytic inhibition of topo II, hypericin was shown to be equitoxic to both wild-type and amsacrine-resistant HL-60 leukemia cell lines. Moreover, hypericin was incapable of stimulating DNA damage-responsive gene promoters that are activated by etoposide. As with the in vitro topo II assay, antagonism of DNA damage stimulated by 30 microM etoposide was evident in leukemia cells pretreated with 5 microM hypericin. Since many cancer patients experience clinical depression and concomitantly self-medicate with herbal remedies, extracts of St. John's wort should be investigated further for their potential to antagonize topo II-directed chemotherapy regimens.

A study in animal ethics in New Brunswick

Society uses animals in ever-increasing numbers and ways, providing ethical challenges. Decisions about animal use are guided by the social consensus ethic towards animals. Because there is no clear social consensus ethic, these decisions are difficult. Society's ethic is changing and a "new ethic" towards animals is emerging. This study addressed the need to better understand society's ethics towards animals. Qualitative research methodology (focus groups) was used to study 7 different animal-interest groups. Qualitative data analysis was computer-aided. The group ethical position towards animals of its own group interest was determined for each group. The animal welfare, companion animal, and veterinary groups took Rollin's Position, a position based on both the Utilitarian and the Rights Principles; the farmer and trapper groups the Utilitarian/Land Ethic position, a dual position based on actions producing the greatest amount of pleasure and the least amount of pain for the greatest number, and preserving the integrity, stability, and beauty of the biotic community; the hunter group the Utilitarian/Judeo-Christian position, a dual position based on actions producing the greatest amount of pleasure and the least amount of pain for the greatest number, and having dominion over animals; and the naturalist group took Rollin's Position/Land Ethic. All these groups perceived medium to extreme ethical responsibility towards animals of their own group's interest that are used by others. The study showed that the predicted "new ethic" towards animals is in New Brunswick society and it is Rollin's Position.

Cephalometric appraisal of posttreatment vertical changes in adult orthodontic patients

The purpose of this study was to evaluate vertical facial changes in adult orthodontic patients and to evaluate the stability of these changes. Thirty-three patients (8 males and 25 females) were examined. The patients had been treated with full fixed edgewise appliance mechanics and exhibited at least 1.0 degrees of clockwise rotation of the mandible during treatment. Mandibular rotation was determined by the angular change in the Y-axis to the Frankfort plane. Twelve angular and 14 linear skeletal and dental measurements and 3 skeletal ratios were derived from pretreatment (T1), posttreatment (T2), and postretention (T3) cephalometric radiographs. Paired t tests were used to compare vertical changes that occurred as a result of orthodontic treatment and their stability or relapse tendency during the retention and postretention periods. Twenty-five percent (P <.001) of the opening rotation of the mandible recovered during the posttreatment period, resulting in a significant overall rotation that was maintained. Both treatment and posttreatment changes in the Y-axis angle showed a high correlation with the horizontal position of pogonion (r = -0.797 and -0.889, respectively). Only overjet showed a low correlation between treatment changes and posttreatment changes in the Y-axis angle. Stepwise regression analysis of pretreatment variables and treatment changes failed to predict the behavior of the Y-axis angle change.

Core structure of the envelope glycoprotein GP2 from Ebola virus at 1.9-A resolution

Ebola virions contain a surface transmembrane glycoprotein (GP) that is responsible for binding to target cells and subsequent fusion of the viral and host-cell membranes. GP is expressed as a single-chain precursor that is posttranslationally processed into the disulfide-linked fragments GP1 and GP2. The GP2 subunit is thought to mediate membrane fusion. A soluble fragment of the GP2 ectodomain, lacking the fusion-peptide region and the transmembrane helix, folds into a stable, highly helical structure in aqueous solution. Limited proteolysis studies identify a stable core of the GP2 ectodomain. This 74-residue core, denoted Ebo-74, was crystallized, and its x-ray structure was determined at 1.9-A resolution. Ebo-74 forms a trimer in which a long, central three-stranded coiled coil is surrounded by shorter C-terminal helices that are packed in an antiparallel orientation into hydrophobic grooves on the surface of the coiled coil. Our results confirm the previously anticipated structural similarity between the Ebola GP2 ectodomain and the core of the transmembrane subunit from oncogenic retroviruses. The Ebo-74 structure likely represents the fusion-active conformation of the protein, and its overall architecture resembles several other viral membrane-fusion proteins, including those from HIV and influenza.

Effectiveness and duration of orthodontic treatment in adults and adolescents

The purpose of this investigation was to compare the effectiveness and duration of orthodontic treatment in adults and adolescents with a valid and reliable occlusal index. Another aim was to evaluate variables that may influence the effectiveness and duration of orthodontic treatment in general. Pretreatment and posttreatment study models were scored using the Peer Assessment Rating Index. The difference in scores between pretreatment and posttreatment stages reflects the degree of improvement and therefore the effectiveness of treatment. Variables that reflect patient compliance were recorded from written treatment records from three private orthodontic practices. The sample consisted of 32 adults (mean age, 31.3 years) and 40 adolescents (mean age, 12.9 years), all of whom had four premolars extracted as part of the treatment strategy. The results indicated that there were no statistically significant differences (P > .05) between adults and adolescents regarding treatment effectiveness (occlusal improvement) and treatment duration. Multiple regression techniques revealed that the number of broken appointments and appliance repairs explained 46% of the variability in orthodontic treatment duration and 24% of the variability in treatment effectiveness. Furthermore, orthodontic treatment of the buccal occlusion and overjet explained 46% of the variability in treatment duration.

A comparative study of anchorage in bioprogressive versus standard edgewise treatment in Class II correction with intermaxillary elastic force

The primary purpose of this study was to evaluate the effectiveness of cortical anchorage, by comparing two groups of patients with Class II malocclusions that were treated successfully with Class II elastics. One group of 30 previously treated patients had a utility arch used to set up cortical anchorage in the lower arch before Class II elastic wear; the second group was treated with standard edgewise mechanics where anchorage preparation consisted of full appliances, a well-aligned mandibular arch, and a rectangular arch wire. The groups were selected according to age, sex, and the amount of Class II elastic usage. Pretreatment and posttreatment cephalometric radiographs were used to generate 32 variables. A Student's t test was used to evaluate treatment change between the groups and revealed that there were no statistically significant differences. Lower molar teeth extruded and moved mesially equally in both groups. Although cortical anchorage did not retard lower molar movement, it was no less effective in controlling molar movement with a partial appliance than the fully banded standard edgewise appliance.

Opening rotations of the mandible during and after treatment

In this retrospective cephalometric study of mandibular rotational change, we studied 60 cases. All patients were treated with full fixed appliances and exhibited an opening rotation of at least 1.5 degrees during treatment, as measured on the basis of the angle of the Y-axis to the sella-nasion line (SN). Our objective was to determine whether this opening rotation was sustained during retention. Paired t tests were used to test the hypothesis that the treatment change or opening rotation was stable and that these patients did not return to their original mandible-to-cranium relationship in the posttreatment period. Stepwise regression analysis was used to determine which (if any) changes in the independent variables during treatment could predict the subsequent behavior of the angle of the mandibular plane to the SN and the angle of the Y-axis to the SN during retention. During treatment, the mean increase in the angle of the Y-axis to the SN was 2.43 degrees. After an average posttreatment period of 54 months, this angle was reduced on average by only 0.73 degrees. Stepwise linear-regression analysis indicated that none of the treatment changes seen in the independent variables strongly predicted the ensuing closing rotation seen during retention. The correlation coefficient between the Y-axis angle and the mandibular-plane angle during treatment was 0.67. Mandibular opening rotations as a consequence of orthodontic treatment do not invariably return to the pretreatment value, and their negative effects--although sometimes small--cannot be discounted. Because the preponderant evidence of a closing rotation occurs in the terminal pubertal growth stages, the net effect may be even more significant.

An assessment of treatment outcome in American Board of Orthodontics cases

In a retrospective study, 90 American Board of Orthodontic (ABO) cases were evaluated for treatment outcome. Changes in occlusion, cephalometric skeletal and dental variables, soft tissue variables, and root resorption were evaluated. The occlusions of completed ABO cases were compared with 147 naturally occurring good-to-excellent occlusions from the Andrews Foundation for Education and Research, using the Ideal Tooth Relationship Index (ITRI). Cephalometric variables were evaluated in relation to an "acceptable range" based on established standards. Photographs were evaluated for lip posture at rest and at closure, and the incidence and the severity of root resorption of maxillary and mandibular teeth excluding second molars were evaluated from panoramic radiographs. After treatment, occlusions of ABO cases scored significantly higher overall and for all ITRI segments except the anterior interarch segment when compared with Andrew's sample. In all the ABO cases, ideal overjet and overbite were attained. Cephalometrically, the mandibular plane and the Y-axis angle showed no significant change as a result of treatment. However, skeletal dysplasia (ANB) and skeletal convexity (Na-A-Po) showed improvement. Dentally, the maxillary incisor position and inclination, the interincisal angle, and the lower incisor position ended within the acceptable range, whereas the lower incisors were proclined. Soft tissue variables also improved, lip balance and harmony, closure at rest, and closure without strain all improved. The nasolabial angle showed little change. Most of the root resorption was minor in nature and involved the maxillary and mandibular central and lateral incisors. In conclusion, the ABO cases were well treated and showed marked improvement in occlusion, cephalometric, and soft tissue changes, although experiencing minor iatrogenic effects.

Verification of the role of PCP 4-monooxygenase in chlorine elimination from pentachlorophenol by Flavobacterium sp. strain ATCC 39723

The bacterial enzyme PCP 4-monooxygenase from Flavobacterium sp. strain ATCC 39723 catalyzes the oxygenolytic removal of the first chlorine from pentachlorophenol. PCP 4-monooxygenase is an FAD binding, NADPH requiring oxygenase, with similar functional domains as other bacterial flavoprotein monooxygenases specific for phenolic substrates. However, the definitive proof for the singular role of an oxygenolytic elimination of the primary chlorine from pentachlorophenol by Flavobacterium sp. has awaited the development of a genetic system whereby targeted mutagenesis via allelic exchange could be carried out with the corresponding gene from PCP 4-monooxygenase, pcpB. We report the development of a genetic system for Flavobacterium sp. strain ATCC 39723, and its application in targeted mutagenesis of the pcpB allele for elimination of PCP 4-monooxygenase activity.

Long-term stability after orthodontic treatment: nonextraction with prolonged retention

A sample of 22 previously treated orthodontic cases was studied to evaluate long-term stability. All cases were treated nonextraction with fixed edgewise appliances and were without retainers a minimum of 5 years. Data were obtained from study models, although 14 of the 22 cases had longitudinal cephalometric radiographs. The average retention time with a mandibular fixed lingual retainer was 8.4 years. The irregularity index pretreatment was 8.0 mm in the maxillary arch and 5.2 mm in the mandibular arch; at the end of treatment it was 0.9 mm and 1.0 mm, respectively, and at the postretention stage it was 2.0 mm and 2.4 mm, respectively. Resolution of the lower irregularity index was accomplished without incisor advancement or distal movement of the mandibular molar, however, both arches were expanded transversely. During the posttreatment stage all variables showed relapse except for the expanded maxillary canines and premolars. However, the mandibular anterior segment demonstrated relatively good alignment at the long-term stage, which may be a reflection of prolonged mandibular retention.

Detection of Clavibacter michiganensis subsp. sepedonicus by DNA amplification

Control of bacterial ring rot ultimately depends on the accurate and sensitive detection of C. michiganensis subsp. sepedonicus in infected potato tissues and tubers. Polymerase chain reaction (PCR) based detection of C. michiganensis subsp. sepedonicus appears to have the potential to circumvent many of the problems currently associated with detection of this phytopathogen. PCR reactions using primers specific to C. michiganensis subsp. sepedonicus and genomic DNAs from related strains, including phytopathogens, did not produce any amplification products. C. michiganensis subsp. sepedonicus was detectable from a mixture of potato and bacterial DNA by amplification of a DNA sequence specific to C. michiganensis subsp. sepedonicus. Detection by DNA amplification allowed direct processing of plant tissue samples, and circumvented the need for prior isolation of the suspected phytopathogen.