The role of magnetic resonance imaging (MRI) in focal therapy for prostate cancer: recommendations from a consensus panel

OBJECTIVE

To establish a consensus on the utility of multiparametric magnetic resonance imaging (mpMRI) to identify patients for focal therapy.

METHODS

Urological surgeons, radiologists, and basic researchers, from Europe and North America participated in a consensus meeting about the use of mpMRI in focal therapy of prostate cancer. The consensus process was face-to-face and specific clinical issues were raised and discussed with agreement sought when possible. All participants are listed among the authors. Topics specifically did not include staging of prostate cancer, but rather identifying the optimal requirements for performing MRI, and the current status of optimally performed mpMRI to (i) determine focality of prostate cancer (e.g. localising small target lesions of ≥0.5 mL), (ii) to monitor and assess the outcome of focal ablation therapies, and (iii) to identify the diagnostic advantages of new MRI methods. In addition, the need for transperineal template saturation biopsies in selecting patients for focal therapy was discussed, if a high quality mpMRI is available. In other words, can mpMRI replace the role of transperineal saturation biopsies in patient selection for focal therapy?

RESULTS

Consensus was reached on most key aspects of the meeting; however, on definition of the optimal requirements for mpMRI, there was one dissenting voice. mpMRI is the optimum approach to achieve the objectives needed for focal therapy, if made on a high quality machine (3T with/without endorectal coil or 1.5T with endorectal coil) and judged by an experienced radiologist. Structured and standardised reporting of prostate MRI is paramount. State of the art mpMRI is capable of localising small tumours for focal therapy. State of the art mpMRI is the technique of choice for follow-up of focal ablation.

CONCLUSIONS

The present evidence for MRI in focal therapy is limited. mpMRI is not accurate enough to consistently grade tumour aggressiveness. Template-guided saturation biopsies are no longer necessary when a high quality state of the art mpMRI is available; however, suspicious lesions should always be confirmed by (targeted) biopsy.

Seasonal Influenza Vaccine Effectiveness (SIVE): an observational retrospective cohort study – exploitation of a unique community-based national-linked database to determine the effectiveness of the seasonal trivalent influenza vaccine

Background

Globally, seasonal influenza is responsible for an estimated 3 to 5 million cases of severe illness and 250,000 to 500,000 deaths per year. It is uncertain to what extent national vaccination programmes can prevent this morbidity and mortality.

Objective

To determine the effectiveness of the seasonal trivalent inactivated influenza vaccine.

Design

We undertook a retrospective observational cohort study. A propensity score model was constructed and adjusted odds ratios (ORs) were calculated to assess differences in vaccine uptake according to a number of patient characteristics. Adjusted illness and mortality hazard ratios (HRs) were estimated from a Cox proportional hazards model adjusted for sex, age, socioeconomic status, smoking status, urban/rural location, clinical at-risk groups (i.e. patients with chronic respiratory, heart, kidney, liver or neurological disease, immunosuppression and diabetes), Charlson comorbidity index, previous pneumococcal and influenza vaccination, and number of previous primary care consultations, prescribed drugs and hospital admissions. We also included nursing home residence and social care support. Vaccine effectiveness (VE) was expressed as a percentage, and represents a reduction in risk provided by the vaccine for a given outcome (e.g. laboratory-confirmed influenza). This was calculated as 1 − HR, where HR is that of the measured clinical outcome in vaccinated compared with unvaccinated individuals. For estimates of VE derived from linked virological swab data, we carried out a nested case–control study design.

Setting

A national linkage of patient-level primary care, hospital, death certification and virological swab-linked data across nine influenza seasons (2000–9).

Participants

A nationally representative sample of the Scottish population during 1,767,919 person-seasons of observation. Cases of influenza were confirmed using reverse transcription-polymerase chain reaction (RT-PCR) in a subset of the population (n = 3323).

Interventions

Trivalent inactivated seasonal influenza vaccination (n = 274,071).

Main outcome measures

VE, pooled across seasons and adjusting for confounders, was estimated by determining laboratory-confirmed influenza, influenza-related morbidity and mortality including primary care influenza-like illnesses, hospitalisation and death from influenza and pneumonia.

Results

Most vaccines (93.6%;n = 256,474 vaccines) were administered to at-risk patients targeted for vaccination, with a 69.3% uptake among those aged ≥ 65 years (178,754 vaccinations during 258,100 person-seasons). For at-risk patients aged < 65 years there was a 26.2% uptake (77,264 vaccinations during 295,116 person-seasons). VE in preventing RT-PCR laboratory-confirmed influenza was 57.1% [95% confidence interval (CI) 31.3% to 73.3%]. VE was 18.8% (95% CI –103.7% to 67.6%) in patients aged ≥ 65 years and 59.6% (95% CI 21.9% to 79.1%) in those aged < 65 years at risk of serious complications from influenza. In the matched analysis (156,096 person-seasons), adjusted VE for reducing primary care consultations for influenza-like illnesses was 16.3% (95% CI 5.7% to 26.0%). VE in reducing hospitalisations was 19.3% for influenza and pneumonia (95% CI 8.3% to 29.1%) and 26.7% for pneumonia and chronic obstructive pulmonary disease (95% CI 19.8% to 32.9%). VE in reducing death due to influenza and pneumonia was 37.9% (95% CI 29.5% to 45.4%).

Conclusions

Few countries' health systems allow for the integrated and accessible data recording that made this study possible and made it feasible to collate centrally almost all hospitalisations and deaths attributed to influenza, thereby allowing completeness of reporting. Using these data, we found most influenza vaccines were administered to those at risk of serious complications from influenza. In a nationally representative cohort we found that the vaccine was associated with a significant decrease in the risk of RT-PCR-confirmed influenza (the decrease was substantial particularly for at-risk patients aged < 65 years) and complications arising from influenza (where more modest decreases were found). Although the modest size of our cohort made it possible to collate centrally almost all cases of influenza-related disease, analysis of subgroups (in particular older age groups) or by individual season resulted in poorer precision and wide CIs. Any future work should therefore aim to address this issue by ensuring adequate power to test VE in these subgroups of patients, while minimising the effect of bias, such as health-seeking behaviour.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Effects of the glyphosate-based herbicide Roundup WeatherMax® on metamorphosis of wood frogs (Lithobates sylvaticus) in natural wetlands

Amphibian tadpoles develop in aquatic environments where they are susceptible to the effects of pesticides and other environmental contaminants. Glyphosate-based herbicides are currently the most commonly used herbicide in the world and have been shown to affect survival and development of tadpoles under laboratory and mesocosm conditions. In the present study, whole wetland manipulations were used to determine if exposure to an agriculturally relevant application of Roundup WeatherMax(®), a herbicide formulation containing the potassium salt of glyphosate and an undisclosed surfactant, influences the development of wood frog tadpoles (Lithobates sylvaticus) under natural conditions. Wetlands were divided in half with an impermeable curtain so that each wetland contained a treatment and control side. Tadpoles were exposed to two pulses of this herbicide at an environmentally realistic concentration (ERC, 0.21 mg acid equivalent (a.e.)/L) and the predicted maximum environmental concentration (PMEC, 2.89 mg a.e./L), after which abundance, growth, development, and mRNA levels of genes involved in tadpole metamorphosis were measured. Results present little evidence that exposure to this herbicide affects abundance, growth and development of wood frog tadpoles. As part of the Long-term Experimental Wetlands Area (LEWA) project, this research demonstrates that typical agricultural use of Roundup WeatherMax(®) poses minimal risk to larval amphibian development. However, our gene expression data (mRNA levels) suggests that glyphosate-based herbicides have the potential to alter hormonal pathways during tadpole development.

An investigation of the protective effect of alpha+-thalassaemia against severe Plasmodium falciparum amongst children in Kumasi, Ghana

INTRODUCTION

Several factors influence the severity of Plasmodium falciparum; here, we investigate the impact of alpha+-thalassaemia genotype on P. falciparum parasitemia and prevalence of severe anaemia amongst microcytic children from Kumasi, Ghana.

METHODS

Seven hundred and thirty-two children (≤10 years) with P. falciparum were categorised into normocytic and microcytic (mean cell volume ≤76 fL). Microcytic individuals were genotyped for the -α(3.7) deletional thalassaemia mutation and parasite densities determined.

RESULTS

Amongst microcytic patients both parasite densities and prevalence of severe malaria parasitemia (≥100 000/μL) were significantly lower (P < 0.001) in the presence of an alpha+-thalassaemia genotype compared with non-alpha+-thalassaemia genotype. There was no evidence that alpha+-thalassaemia protected against severe anaemia. The protection conferred by alpha-thalassaemia genotype against severe P. falciparum parasitemia did not change with increasing age.

CONCLUSION

The severity of P. falciparum parasitemia was significantly lower in both the homozygous and heterozygous alpha+-thalassaemia groups compared with microcytic individuals with non-alpha+-thalassaemia genotype. The protective effect, from severe malaria, of the alpha+-thalassaemia allele does not alter with age.

Common carotid intima-media thickness does not add to Framingham risk score in individuals with diabetes mellitus: the USE-IMT initiative

AIMS/HYPOTHESIS

The aim of this work was to investigate whether measurement of the mean common carotid intima-media thickness (CIMT) improves cardiovascular risk prediction in individuals with diabetes.

METHODS

We performed a subanalysis among 4,220 individuals with diabetes in a large ongoing individual participant data meta-analysis involving 56,194 subjects from 17 population-based cohorts worldwide. We first refitted the risk factors of the Framingham heart risk score on the individuals without previous cardiovascular disease (baseline model) and then expanded this model with the mean common CIMT (CIMT model). The absolute 10 year risk for developing a myocardial infarction or stroke was estimated from both models. In individuals with diabetes we compared discrimination and calibration of the two models. Reclassification of individuals with diabetes was based on allocation to another cardiovascular risk category when mean common CIMT was added.

RESULTS

During a median follow-up of 8.7 years, 684 first-time cardiovascular events occurred among the population with diabetes. The C statistic was 0.67 for the Framingham model and 0.68 for the CIMT model. The absolute 10 year risk for developing a myocardial infarction or stroke was 16% in both models. There was no net reclassification improvement with the addition of mean common CIMT (1.7%; 95% CI -1.8, 3.8). There were no differences in the results between men and women.

CONCLUSIONS/INTERPRETATION

There is no improvement in risk prediction in individuals with diabetes when measurement of the mean common CIMT is added to the Framingham risk score. Therefore, this measurement is not recommended for improving individual cardiovascular risk stratification in individuals with diabetes.

Lessons and insights from ABO-incompatible lung transplantation

With ABO blood group incompatibility (ABOi) between donor and recipient becoming a part of mainstream living-donor renal transplantation, the applicability of ABOi to other areas of transplantation is being reconsidered. Here we present a case of inadvertent ABOi lung retransplantation managed successfully with initial plasmapheresis, antithymocyte globulin and intravenous immunoglobulin; and subsequently with oral cyclophosphamide and sirolimus in addition to tacrolimus and prednisolone. Interestingly, in the setting of solid levels of tacrolimus and sirolimus, the patient developed a fatal thrombotic microangiopathy of uncertain origin subsequent to the cessation of cyclophosphamide at 9 years posttransplant. It is apparent that ABOi lung transplantation can result in surprisingly successful long-term outcomes. Low pretransplant antibody titers likely aid this and, in pediatric neonatal or infant cases, this may not be uncommon. We must proceed cautiously as there are significant risks. Understanding the monitoring, prevention and treatment of lung transplant antibody-mediated rejection, while avoiding the long-term complications of overimmunosuppression, will be the keys to the success of future cases.

Systematic review and economic modelling of the relative clinical benefit and cost-effectiveness of laparoscopic surgery and robotic surgery for removal of the prostate in men with localised prostate cancer

BACKGROUND

Complete surgical removal of the prostate, radical prostatectomy, is the most frequently used treatment option for men with localised prostate cancer. The use of laparoscopic (keyhole) and robot-assisted surgery has improved operative safety but the comparative effectiveness and cost-effectiveness of these options remains uncertain.

OBJECTIVE

This study aimed to determine the relative clinical effectiveness and cost-effectiveness of robotic radical prostatectomy compared with laparoscopic radical prostatectomy in the treatment of localised prostate cancer within the UK NHS.

DATA SOURCES

MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, BIOSIS, Science Citation Index and Cochrane Central Register of Controlled Trials were searched from January 1995 until October 2010 for primary studies. Conference abstracts from meetings of the European, American and British Urological Associations were also searched. Costs were obtained from NHS sources and the manufacturer of the robotic system. Economic model parameters and distributions not obtained in the systematic review were derived from other literature sources and an advisory expert panel.

REVIEW METHODS

Evidence was considered from randomised controlled trials (RCTs) and non-randomised comparative studies of men with clinically localised prostate cancer (cT1 or cT2); outcome measures included adverse events, cancer related, functional, patient driven and descriptors of care. Two reviewers abstracted data and assessed the risk of bias of the included studies. For meta-analyses, a Bayesian indirect mixed-treatment comparison was used. Cost-effectiveness was assessed using a discrete-event simulation model.

RESULTS

The searches identified 2722 potentially relevant titles and abstracts, from which 914 reports were selected for full-text eligibility screening. Of these, data were included from 19,064 patients across one RCT and 57 non-randomised comparative studies, with very few studies considered at low risk of bias. The results of this study, although associated with some uncertainty, demonstrated that the outcomes were generally better for robotic than for laparoscopic surgery for major adverse events such as blood transfusion and organ injury rates and for rate of failure to remove the cancer (positive margin) (odds ratio 0.69; 95% credible interval 0.51 to 0.96; probability outcome favours robotic prostatectomy = 0.987). The predicted probability of a positive margin was 17.6% following robotic prostatectomy compared with 23.6% for laparoscopic prostatectomy. Restriction of the meta-analysis to studies at low risk of bias did not change the direction of effect but did decrease the precision of the effect size. There was no evidence of differences in cancer-related, patient-driven or dysfunction outcomes. The results of the economic evaluation suggested that when the difference in positive margins is equivalent to the estimates in the meta-analysis of all included studies, robotic radical prostatectomy was on average associated with an incremental cost per quality-adjusted life-year that is less than threshold values typically adopted by the NHS (£30,000) and becomes further reduced when the surgical capacity is high.

LIMITATIONS

The main limitations were the quantity and quality of the data available on cancer-related outcomes and dysfunction.

CONCLUSIONS

This study demonstrated that robotic prostatectomy had lower perioperative morbidity and a reduced risk of a positive surgical margin compared with laparoscopic prostatectomy although there was considerable uncertainty. Robotic prostatectomy will always be more costly to the NHS because of the fixed capital and maintenance charges for the robotic system. Our modelling showed that this excess cost can be reduced if capital costs of equipment are minimised and by maintaining a high case volume for each robotic system of at least 100-150 procedures per year. This finding was primarily driven by a difference in positive margin rate. There is a need for further research to establish how positive margin rates impact on long-term outcomes.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Automated mortality monitoring in Scotland from 2009

Mortality monitoring systems are important for gauging the effect of influenza and other wide ranging health threats. We present the daily all-cause mortality monitoring system routinely used in Scotland, which differs from others by using two different statistical models for calculating expected mortality. The first model is an extended Serfling model, which captures annual seasonality in mortality using sine and cosine terms, and is frequently seen in other systems. Serfling models fit to summer seasonality well, but not to the winter peak. Thus, during the winter, there are frequent 'excesses', higher than expected mortality, making it harder to directly judge if winter mortality is higher than in previous years. The second model, a Generalised Additive Model, resolves this by allowing a more flexible seasonal pattern that includes the winter peak. Thus, excesses under the second model directly indicate if winter mortality is higher than in previous years, useful, for example, in judging if a new strain of seasonal influenza is more likely to produce death than previous ones. As common in all-cause mortality monitoring systems, the Scottish system uses a reporting delay correction: we discuss the difficulties of interpretation when such a correction is used and possible avenues for future work that may address these difficulties.

Automated mortality monitoring in Scotland from 2009

Binary file ES_Abstracts_Final_ECDC.txt matches

Vaccine effectiveness of 2011/12 trivalent seasonal influenza vaccine in preventing laboratory-confirmed influenza in primary care in the United Kingdom: evidence of waning intra-seasonal protection

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Effectiveness of seasonal 2012/13 vaccine in preventing laboratory-confirmed influenza infection in primary care in the United Kingdom: mid-season analysis 2012/13

The early experience of the United Kingdom (UK) is that influenza B has dominated the influenza 2012/13 season. Overall trivalent influenza vaccine (TIV) adjusted vaccine effectiveness (VE) against all laboratory-confirmed influenza in primary care was 51% (95% confidence interval (CI): 27% to 68%); TIV adjusted VE against influenza A alone or influenza B alone was 49% (95% CI: -2% to 75%) and 52% (95% CI: 23% to 70%) respectively. Vaccination remains the best protection against influenza.

Approaching zero: temporal effects of a restrictive antibiotic policy on hospital-acquired Clostridium difficile, extended-spectrum β-lactamase-producing coliforms and meticillin-resistant Staphylococcus aureus

A restrictive antibiotic policy banning routine use of ceftriaxone and ciprofloxacin was implemented in a 450-bed district general hospital following an educational campaign. Monthly consumption of nine antibiotics was monitored in defined daily doses (DDDs) per 1000 patient-occupied bed-days (1000 pt-bds) 9 months before until 16 months after policy introduction. Hospital-acquired Clostridium difficile, meticillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum β-lactamase (ESBL)-producing coliform cases per month/1000 pt-bds were identified and reviewed throughout the hospital. Between the first and final 6 months of the study, average monthly consumption of ceftriaxone reduced by 95% (from 46.213 to 2.129 DDDs/1000 pt-bds) and that for ciprofloxacin by 72.5% (109.804 to 30.205 DDDs/1000 pt-bds). Over the same periods, hospital-acquisition rates for C. difficile reduced by 77% (2.398 to 0.549 cases/1000 pt-bds), for MRSA by 25% (1.187 to 0.894 cases/1000 pt-bds) and for ESBL-producing coliforms by 17% (1.480 to 1.224 cases/1000 pt-bds). Time-lag modelling confirmed significant associations between ceftriaxone and C. difficile cases at 1 month (correlation 0.83; P<0.005), and between ciprofloxacin and ESBL-producing coliform cases at 2 months (correlation 0.649; P=0.002). An audit performed 3 years after the policy showed sustained reduction in C. difficile rates (0.259 cases/1000 pt-bds), with additional decreases for MRSA (0.409 cases/1000 pt-bds) and ESBL-producing coliforms (0.809 cases/1000 pt-bds). In conclusion, banning two antibiotics resulted in an immediate and profound reduction in hospital-acquired C. difficile, with possible longer-term effects on MRSA and ESBL-producing coliform rates. Antibiotic stewardship is fundamental in the control of major hospital pathogens.

Abstract P4-13-08: Diabetes, Related Factors and Breast Cancer Risk

Diabetes and breast cancer are both extremely common conditions in women and may share common risk factors. It is natural to investigate any potential common risk factors and to seek biological clarification and improve prospects for prevention.

Therefore, in order to help clarify the potential association between diabetes, related factors and breast cancer risk, a comprehensive literature review and formal meta-analysis was carried out, planned, conducted and reported following PRISMA guidelines regarding meta-analysis of observational studies. Variables studies in relation to breast cancer risk were adiposity, physical activity, glycaemic load, glycaemic index, diabetes, IGF-1, fasting glucose, fasting insulin and C-peptide, adiponectin and metformin and glargine use among patients with diabetes. For all variables except diabetes and breast cancer, only prospective studies were included in meta-analyses. Summary Relative Risks (SRR) and corresponding 95% Confidence Intervals (CI) were calculated from random effect models.

For breast cancer at all ages, the calculated risks were as follows: diabetes (SRR = 1.27 95% CI (1.16, 1.39); physical activity (SRR = 0.88, 95% CI (0.85, 0.92)); glycaemic load (SRR = 1.06, 95% CI (1.00, 1.12)); glycaemic index (SRR = 1.04, 95% CI (0.99, 1.10)); fasting glucose (SRR = 1.12, 95% CI (1.01, 1.24)); serum insulin (SRR = 1.18, 95% CI (0.75, 1.85)); c-peptide (SRR = 1.29, 95% CI (0.91, 1.82)); adiponectin (SRR = 1.16, 95% CI (0.93, 1.46)); metformin (SRR = 1.00, 95% CI (0.69, 1.46)); and glargine (SRR = 1.11, 95% CI (1.00, 1.24)). An increase of 5 units in Body Mass Index (a weight increase if 14.5 kg in a person 1.70 metres tall) was associated in post-menopausal breast cancer (SRR = 1.12, 95% CI (1.08, 1.16)) but not at pre-menopausal ages (SRR = 0.83, 95% CI (0.72, 0.95)). Serum insulin was associated with breast cancer at post-menopausal ages but not at pre-menopausal ages whereas with c-peptide there was a significant association at pre-menopausal ages but not post-menopausal. For IGF-1, Hodge's Standardised Mean Difference (HSMD) was calculated in cohort studies and there was no significant association with breast cancer at all ages (HSMD = 0.003, 95% CI (−0.059, 0.065)), at post-menopausal ages (HSMD = −0.014, 95% CI (−0.106, 0.077)) or at pre-menopausal ages (HSMD = 0.039, 95% CI (−0.038, 0.117)).

The risk of breast cancer is increased among post-menopausal women who have diabetes. Among those factors related to diabetes, key risk factors for breast cancer appear to be adiposity and lack of physical activity which are both related to the risk of developing diabetes. Action on these lifestyle factors should form the basis of a common prevention strategy. There is a need to re-evaluate potential biological mechanisms to explain the increased risk in post-menopausal women with diabetes.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-13-08.

Abstract P4-13-07: Meta-analysis of epidemiological studies of Insulin Glargine and Breast Cancer Risk

After having lain dormant for a while, the association between diabetes, its risk factors and treatments, and cancer risk and death is now high on the clinical and research agenda. The microscope is currently focused on the relationships between Pioglitazone and Bladder Cancer, Exenatide and Pancreas Cancer, Liraglutide and pancreas cancer and insulin use and lung cancer. The potential association between use of insulin glargine and breast cancer risk has been the subject of recent major studies.

All data regarding cancer risk and use of insulin glargine has been assembled and meta-analyses performed using state-of-the-art statistical methodology. A random effects model was employed with tests for heterogeneity (I2) and publication bias. These meta-analyses are based on reports from 21 epidemiological studies involving over one million patients and 3 million person-years of observation.

Based on independent estimates from these studies, the Summary Relative Risk (SRR) for all forms of cancer was (SRR = 0.91, 95% CI (0.84, 0.99)), and for breast cancer SRR = 1.11 (95% CI (1.00, 1.48)). For new users of glargine, the SRR for breast cancer was SRR = 1.22 (95% CI (1.00, 1.48)). For colorectal cancer the SRR = 0.83 (95% CI (0.74, 0.94)) and for prostate cancer SRR = 1.14 (95% CI (0.93, 1.39)). Overall, the risk of developing cancer among users of insulin glargine is reduced compared to the risk of users of other insulins. Similarly, the risk of colorectal cancer is reduced among users of glargine.

While the lower bound of the 95% confidence interval is 1.00, the risk of breast cancer does not increase with increasing duration of use of glargine. In some studies the trend in risk with increasing duration of use goes in opposite directions. The development of a detectable breast cancer from the initial carcinogenic event depends on the tumour doubling time. The time for a de novo breast cancer to become detectable ranges from 12.3 years for a doubling time of 150 days; 16.4 years for a doubling time of 200 days; and 20.5 years for a doubling time of 250 days. Most published studies have a maximum of 3–4 years of glargine use.

The databases employed in these analyses were not designed for such epidemiological investigation. A major limitation is the absence of knowledge as to why a potential treatment was prescribed for an individual and why a change in therapy was indicated. Further potential limitations to this meta-analysis include that the comparison group was not the same in all studies but this could also be seen as a strength. The meta-analysis of the randomized trials had several insulin comparators and the retinopathy study had NPH as the comparator. This is not likely to invalidate the findings of this analysis nor would the fact that different adjustments were made in the individual studies.

The current evidence gives no support to the hypothesis that insulin glargine is associated with an increased risk of cancer as compared to other insulins and should give reassurance to physicians and their patients. In respect to breast cancer, there is no indication of a causal association between use of insulin glargine and increased risk of breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-13-07.

International consensus on (ICON) pediatric asthma

Asthma is the most common chronic lower respiratory disease in childhood throughout the world. Several guidelines and/or consensus documents are available to support medical decisions on pediatric asthma. Although there is no doubt that the use of common systematic approaches for management can considerably improve outcomes, dissemination and implementation of these are still major challenges. Consequently, the International Collaboration in Asthma, Allergy and Immunology (iCAALL), recently formed by the EAACI, AAAAI, ACAAI, and WAO, has decided to propose an International Consensus on (ICON) Pediatric Asthma. The purpose of this document is to highlight the key messages that are common to many of the existing guidelines, while critically reviewing and commenting on any differences, thus providing a concise reference. The principles of pediatric asthma management are generally accepted. Overall, the treatment goal is disease control. To achieve this, patients and their parents should be educated to optimally manage the disease, in collaboration with healthcare professionals. Identification and avoidance of triggers is also of significant importance. Assessment and monitoring should be performed regularly to re-evaluate and fine-tune treatment. Pharmacotherapy is the cornerstone of treatment. The optimal use of medication can, in most cases, help patients control symptoms and reduce the risk for future morbidity. The management of exacerbations is a major consideration, independent of chronic treatment. There is a trend toward considering phenotype-specific treatment choices; however, this goal has not yet been achieved.

M-HIFU inhibits tumor growth, suppresses STAT3 activity and enhances tumor specific immunity in a transplant tumor model of prostate cancer

Objective

In this study, we explored the use of mechanical high intensity focused ultrasound (M-HIFU) as a neo-adjuvant therapy prior to surgical resection of the primary tumor. We also investigated the role of signal transducer and activator of transcription 3 (STAT3) in M-HIFU elicited anti-tumor immune response using a transplant tumor model of prostate cancer.

Methods

RM-9, a mouse prostate cancer cell line with constitutively activated STAT3, was inoculated subcutaneously in C57BL/6J mice. The tumor-bearing mice (with a maximum tumor diameter of 5∼6 mm) were treated by M-HIFU or sham exposure two days before surgical resection of the primary tumor. Following recovery, if no tumor recurrence was observed in 30 days, tumor rechallenge was performed. The growth of the rechallenged tumor, survival rate and anti-tumor immune response of the animal were evaluated.

Results

No tumor recurrence and distant metastasis were observed in both treatment groups employing M-HIFU + surgery and surgery alone. However, compared to surgery alone, M-HIFU combined with surgery were found to significantly inhibit the growth of rechallenged tumors, down-regulate intra-tumoral STAT3 activities, increase cytotoxic T cells in spleens and tumor draining lymph nodes (TDLNs), and improve the host survival. Furthermore, M-HIFU combined with surgery was found to significantly decrease the level of immunosuppression with concomitantly increased number and activities of dendritic cells, compared to surgery alone.

Conclusion

Our results demonstrate that M-HIFU can inhibit STAT3 activities, and when combined synergistically with surgery, may provide a novel and promising strategy for the treatment of prostate cancers.