A large prospective trial of children with unilateral retinoblastoma with and without histopathologic high-risk features and the role of adjuvant chemotherapy: A Children’s Oncology Group (COG) study

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Background: The definition of histopathologic high-risk features (HRF) in enucleated eyes of children with unilateral retinoblastoma and their contribution to metastases is controversial. The COG completed a large, prospective international study to determine the prevalence of strictly defined histopathologic HRF that are predictors of recurrence and the role of chemotherapy to prevent recurrences. Methods: All patients who underwent enucleation for unilateral retinoblastoma were eligible for the study. Pathology slides were submitted for central review within 21 days of enucleation. Patients with evidence of one or more high-risk features (posterior uveal invasion grades IIC and D, concurrent optic nerve and choroid involvement and post-lamina optic nerve involvement) as determined by central review, received 6 cycles of chemotherapy consisting of carboplatin, vincristine and etoposide. All others were observed. All patients were followed for extraocular recurrences. Results: Patients were enrolled from February of 2005 until May 2010. As of July 2011, the median follow-up from enrollment was 1.9 years (max=5.3 years). Of 312 patients with central histopathology review, 49 patients had their risk classification changed (13% with no HRF had HRF, 24% with HRF had no HRF). Two patients developed extraocular disease and one patient died of unknown cause. The death and one of the extraocular relapses occurred among the 93 (2/93=2.2%, upper 95% CI 3.4%) patients assigned by the central review to receive chemotherapy, while one patient experienced extraocular relapse among the 209 (1/209=0.5%, upper 95% CI 0.6%) assigned to observation only. There is no evidence of a difference in the EFS and OS in these two groups. Conclusions: Preliminary results strongly suggest that a central review of pathology can spare a significant number of patients from exposure to chemotherapy. Chemotherapy may have contributed to fewer relapses in patients with high-risk features as defined in this study. The preliminary results from this study indicate an excellent outcome with this approach.

Cost burden of non-specific chest pain admissions

BACKGROUND

Non-cardiac aetiologies are common among patients presenting with chest pain.

AIM

To determine the cost of non-specific chest pain admissions to a tertiary referral, teaching hospital.

METHODS

Thrombolysis in myocardial infarction risk (TIMI) risk score, lengths of stay (LOS), investigations and diagnoses were recorded for patients admitted with chest pain. Non-specific chest pain was defined as chest pain where cardiac, pulmonary and gastroesophageal aetiologies were excluded. Costs of admissions were calculated.

RESULTS

Of 80 patients, 34 (4%) and 22 (28%) were diagnosed with non-specific chest pain and acute coronary syndrome, respectively. Non-specific chest pain admissions had a mean age of 54 (11; 35-74) years, LOS of 3.8 (2.6; 1-11) days and TIMI risk score of 1.4 (1.5; 0-5). Acute coronary syndrome admissions had a mean age of 67 (14; 43-94) years, LOS of 7.7 (4.3; 2-16) days and TIMI risk score of 3.1 (1.2; 0-5). The mean cost per non-specific chest pain admission was €3,729 (2,378; 1,034-10,468), or 48% of the mean cost per acute coronary syndrome admission of €7,667 (4,279; 1,963-16,071). Bed day costs account for >90% of overall costs. Only 7% of patients were weekend discharges. The mean interval to exercise stress test was 2.7(1.5; 1-7) days.

CONCLUSIONS

The mean costs of admission and LOS for patients with non-specific chest pain are significant. Extrapolating findings, annual national cost is estimated at approximately €71 million for this cohort, with 73,000 bed days consumed nationally. Delays from admission to tests and low percentage of weekend discharges prolong LOS.

Immunochemotherapy with intensive consolidation for primary CNS lymphoma: a pilot study and prognostic assessment by diffusion-weighted MRI

PURPOSE

We evaluated a novel therapy for primary central nervous system lymphoma (PCNSL) with induction immunochemotherapy with high-dose methotrexate, temozolomide, and rituximab (MT-R) followed by intensive consolidation with infusional etoposide and high-dose cytarabine (EA). In addition, we evaluated the prognostic value of the minimum apparent diffusion coefficient (ADC(min)) derived from diffusion-weighted MRI (DW-MRI) in patients treated with this regimen.

EXPERIMENTAL DESIGN

Thirty-one patients (median age, 61 years; median Karnofsky performance score, 60) received induction with methotrexate every 14 days for 8 planned cycles. Rituximab was administered the first 6 cycles and temozolomide administered on odd-numbered cycles. Patients with responsive or stable central nervous system (CNS) disease received EA consolidation. Pretreatment DW-MRI was used to calculate the ADC(min) of contrast-enhancing lesions.

RESULTS

The complete response rate for MT-R induction was 52%. At a median follow-up of 79 months, the 2-year progression-free and overall survival were 45% and 58%, respectively. For patients receiving EA consolidation, the 2-year progression-free and overall survival were 78% and 93%, respectively. EA consolidation was also effective in an additional 3 patients who presented with synchronous CNS and systemic lymphoma. Tumor ADC(min) less than 384 × 10(-6) mm(2)/s was significantly associated with shorter progression-free and overall survival.

CONCLUSIONS

MT-R induction was effective and well tolerated. MT-R followed by EA consolidation yielded progression-free and overall survival outcomes comparable to regimens with chemotherapy followed by whole-brain radiotherapy consolidation but without evidence of neurotoxicity. Tumor ADC(min) derived from DW-MRI provided better prognostic information for PCNSL patients treated with the MTR-EA regimen than established clinical risk scores.

BS3-2: Mammary Stroma as an NSAID Target; Implications for Pregnancy-Associated Breast Cancer

Utilizing a young women's breast cancer cohort from the University of Colorado Cancer Center, we show that women diagnosed as late as five-ten years postpartum have worse prognosis than nulliparous women or women diagnosed during pregnancy, and represent ∼50% of all young women's breast cancer patients. We propose that breast involution following pregnancy accounts for this poor prognosis. Characterization of involution identifies tissue remodeling programs that share similarities with microenvironments known to promote metastasis. Using SHG imaging, we find fibrillar collagen bundles with radially-aligned fibers similar to those observed in invasive tumors deposited in the involuting gland. By immunohistochemistry and FACS we find macrophages with an M2-polarization-like profile similar to tumor-associated macrophages at abundant levels during involution. In three independent mouse models for postpartum breast cancer, we isolate postpartum mammary gland involution as a driving force for cancer progression. Mammary tumors arising in the mouse involuting microenvironment express COX-2 and isolated tumor cells are motile and invasive in a collagen-1/COX-2 dependent manner. Targeting involution-macrophages as likely mediators of tumor promotion was accomplished using a previously described mouse transgenic model. Macrophage depletion during involution had catastrophic effects on normal mammary gland involution. Conversely, inhibition of COX-2 with celecoxib, aspirin or ibuprofen did not interfere with postpartum lobular regression. COX-2 inhibition did decrease tumor growth, local tumor cell dispersion and lung metastasis. NSAID treatment also suppressed collagen and tenascin-C deposition in the involuting microenvironment, suggesting that modulation of extracellular matrix proteins may be a novel mechanism by which NSAIDs exhibit chemopreventive activity. Our studies indicate two distinct roles for COX-2 in the postpartum setting. COX-2 activity within the tumor cell is required for invasiveness and COX-2 activity in the host promotes collagen fibrillogenesis. Several correlative observations implicate the collagen/COX-2 pathway in postpartum breast cancer in women: involuting breast tissue has increased collagen with radially aligned fibers, analysis of 11 publically available microarray data sets shows high COL1A and COX-2 independently correlate with decreased relapse free-survival in young breast cancer patients, and COX-2 protein is observed in DCIS lesions in postpartum cases at higher levels than nulliparous cases.

In summary, our studies suggest further research into COX-2 inhibitor use might provide a novel strategy to improve the prognosis of young women should they be diagnosed with postpartum breast cancer. The question of whether an NSAID based intervention study could be aimed at recently pregnant women at high risk for breast cancer also remains to be determined, but is an extremely desirable objective given that the ∼ 6 million pregnancies in the US per year.

Supported by grants from DoD Synergistic Idea Awards BC060531 & BC10400/001, Komen Foundation KG090629, DoD Idea Award BC074970 to PJK, ACS New England Division Postdoctoral Fellowship Spin Odyssey PF-08-257-01-CSM to TRL and DoD Predoctoral Grants BC073482 to JO and BC100910 to HM.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr BS3-2.

Vaginal progesterone reduces the rate of preterm birth in women with a sonographic short cervix: a multicenter, randomized, double-blind, placebo-controlled trial

OBJECTIVES

Women with a sonographic short cervix in the mid-trimester are at increased risk for preterm delivery. This study was undertaken to determine the efficacy and safety of using micronized vaginal progesterone gel to reduce the risk of preterm birth and associated neonatal complications in women with a sonographic short cervix.

METHODS

This was a multicenter, randomized, double-blind, placebo-controlled trial that enrolled asymptomatic women with a singleton pregnancy and a sonographic short cervix (10-20 mm) at 19 + 0 to 23 + 6 weeks of gestation. Women were allocated randomly to receive vaginal progesterone gel or placebo daily starting from 20 to 23 + 6 weeks until 36 + 6 weeks, rupture of membranes or delivery, whichever occurred first. Randomization sequence was stratified by center and history of a previous preterm birth. The primary endpoint was preterm birth before 33 weeks of gestation. Analysis was by intention to treat.

RESULTS

Of 465 women randomized, seven were lost to follow-up and 458 (vaginal progesterone gel, n=235; placebo, n=223) were included in the analysis. Women allocated to receive vaginal progesterone had a lower rate of preterm birth before 33 weeks than did those allocated to placebo (8.9% (n=21) vs 16.1% (n=36); relative risk (RR), 0.55; 95% CI, 0.33-0.92; P=0.02). The effect remained significant after adjustment for covariables (adjusted RR, 0.52; 95% CI, 0.31-0.91; P=0.02). Vaginal progesterone was also associated with a significant reduction in the rate of preterm birth before 28 weeks (5.1% vs 10.3%; RR, 0.50; 95% CI, 0.25-0.97; P=0.04) and 35 weeks (14.5% vs 23.3%; RR, 0.62; 95% CI, 0.42-0.92; P=0.02), respiratory distress syndrome (3.0% vs 7.6%; RR, 0.39; 95% CI, 0.17-0.92; P=0.03), any neonatal morbidity or mortality event (7.7% vs 13.5%; RR, 0.57; 95% CI, 0.33-0.99; P=0.04) and birth weight < 1500 g (6.4% (15/234) vs 13.6% (30/220); RR, 0.47; 95% CI, 0.26-0.85; P=0.01). There were no differences in the incidence of treatment-related adverse events between the groups.

CONCLUSIONS

The administration of vaginal progesterone gel to women with a sonographic short cervix in the mid-trimester is associated with a 45% reduction in the rate of preterm birth before 33 weeks of gestation and with improved neonatal outcome.

A cleaner river: long term use of semipermeable membrane devices demonstrate that concentrations of selected organochlorines and PAHs in the Brisbane River estuary, Queensland have reduced substantially over the past decade

We first used semipermeable membrane devices as samplers to evaluate concentrations of organochlorines and PAHs in the Brisbane River in 1998. Here we revisit this work and repeat the study a decade later in the same season (summer), also taking account of results from a similar study involving PAHs in the summer of 2001-2002. The accumulation of organochlorines and most PAHs in the samplers in the recent assessment was substantially less than in the 1998 deployment, suggesting that the ambient concentrations of these chemicals have decreased considerably over the last decade. In all cases there was high reproducibility of the mass of chemicals accumulated in the sampler. We used performance reference compounds in the later deployment, and assuming that the kinetics were similar in both deployment periods, we estimate that the concentration of dieldrin, the organochlorine found at highest concentrations, decreased from approximately 3.9 ng/L to about 1.4 ng/L. The decrease of most other analytes of interest including DDE and DDD was greater, potentially indicating that dieldrin is still entering the Brisbane River through run-off from urban areas where it was used widely for treatment of termites until 1995. DDT use in Australia ceased in the mid 1980s.

Correlated electron state in Ce(1-x)Yb(x)CoIn5 stabilized by cooperative valence fluctuations

X-ray diffraction, electrical resistivity, magnetic susceptibility, and specific heat measurements on Ce(1-x)Yb(x)CoIn5 (0≤x≤1) reveal that many of the characteristic features of the x=0 correlated electron state are stable for x≤0.775 and that phase separation occurs for x>0.775. The stability of the correlated electron state is apparently due to cooperative behavior of the Ce and Yb ions, involving their unstable valences. Low-temperature non-Fermi liquid behavior is observed and varies with x, even though there is no readily identifiable quantum critical point. The superconducting critical temperature T(c) decreases linearly with x towards 0 K as x→1, in contrast with other HF superconductors where T(c) scales with T(coh).

Guideline for the management of chronic obstructive pulmonary disease--2011 update

OBJECTIVE

To revise the South African Guideline for the Management of Chronic Obstructive Pulmonary Disease (COPD) based on emerging research that has informed updated recommendations.

KEY POINTS

(1) Smoking is the major cause of COPD, but exposure to biomass fuels and tuberculosis are important additional factors. (2) Spirometry is essential for the diagnosis and staging of COPD. (3) COPD is either undiagnosed or diagnosed too late, so limiting the benefit of therapeutic interventions; performing spirometry in at-risk individuals will help to establish an early diagnosis. (4) Oral corticosteroids are no longer recommended for maintenance treatment of COPD. (5) A therapeutic trial of oral corticosteroids to distinguish corticosteroid responders from non-responders is no longer recommended. (6) Primary and secondary prevention are the most cost-effective strategies in COPD. Smoking cessation as well as avoidance of other forms of pollution can prevent disease in susceptible individuals and ameliorate progression. Bronchodilators are the mainstay of pharmacotherapy, relieving dyspnoea and improving quality of life. (7) Inhaled corticosteroids are recommended in patients with frequent exacerbations and have a synergistic effect with bronchodilators in improving lung function, quality of life and exacerbation frequency. (8) Acute exacerbations of COPD significantly affect morbidity, health care units and mortality. (9) Antibiotics are only indicated for purulent exacerbations of chronic bronchitis. (10) COPD patients should be encouraged to engage in an active lifestyle and participate in rehabilitation programmes.

OPTIONS

Treatment recommendations are based on the following: annual updates of the Global Obstructive Lung Disease (GOLD), initiative, that provide an evidence-based comprehensive review of management; independent evaluation of the level of evidence in support of some of the new treatment trends; and consideration of factors that influence COPD management in South Africa, including lung co-morbidity and drug availability and cost.

OUTCOME

Holistic management utilising pharmacological and nonpharmacological options are put in perspective.

EVIDENCE

Working groups of clinicians and clinical researchers following detailed literature review, particularly of studies performed in South Africa, and the GOLD guidelines. BENEFITS, HARMS AND COSTS. The guideline pays particular attention to cost-effectiveness in South Africa, and promotes the initial use of less costly options. It promotes smoking cessation and selection of treatment based on objective evidence of benefit. It also rejects a nihilistic or punitive approach, even in those who are unable to break the smoking addiction.

RECOMMENDATIONS

These include primary and secondary prevention; early diagnosis, staging of severity, use of bronchodilators and other forms of treatment, rehabilitation, and treatment of complications. Advice is provided on the management of acute exacerbations and the approach to air travel, prescribing long-term oxygen and lung surgery including lung volume reduction surgery.

VALIDATION

The COPD Working Group comprised experienced pulmonologists representing all university departments in South Africa and some from private practice, and general practitioners. Most contributed to the development of the previous version of the South African guideline. GUIDELINE SPONSOR: The meeting of the Working Group of the South African Thoracic Society was sponsored by an unrestricted educational grant from Boehringer Ingelheim and Glaxo-Smith-Kline.

Mutations in GNA11 in uveal melanoma

BACKGROUND

Uveal melanoma is the most common intraocular cancer. There are no effective therapies for metastatic disease. Mutations in GNAQ, the gene encoding an alpha subunit of heterotrimeric G proteins, are found in 40% of uveal melanomas.

METHODS

We sequenced exon 5 of GNAQ and GNA11, a paralogue of GNAQ, in 713 melanocytic neoplasms of different types (186 uveal melanomas, 139 blue nevi, 106 other nevi, and 282 other melanomas). We sequenced exon 4 of GNAQ and GNA11 in 453 of these samples and in all coding exons of GNAQ and GNA11 in 97 uveal melanomas and 45 blue nevi.

RESULTS

We found somatic mutations in exon 5 (affecting Q209) and in exon 4 (affecting R183) in both GNA11 and GNAQ, in a mutually exclusive pattern. Mutations affecting Q209 in GNA11 were present in 7% of blue nevi, 32% of primary uveal melanomas, and 57% of uveal melanoma metastases. In contrast, we observed Q209 mutations in GNAQ in 55% of blue nevi, 45% of uveal melanomas, and 22% of uveal melanoma metastases. Mutations affecting R183 in either GNAQ or GNA11 were less prevalent (2% of blue nevi and 6% of uveal melanomas) than the Q209 mutations. Mutations in GNA11 induced spontaneously metastasizing tumors in a mouse model and activated the mitogen-activated protein kinase pathway.

CONCLUSIONS

Of the uveal melanomas we analyzed, 83% had somatic mutations in GNAQ or GNA11. Constitutive activation of the pathway involving these two genes appears to be a major contributor to the development of uveal melanoma. (Funded by the National Institutes of Health and others.).

Simethicone retinopathy in an immature infant

The authors describe retinal findings in an immature infant consuming simethicone, a common over-the-counter drug used in the treatment of colic. The lesions are most consistent with an embolic phenomenon possibly from systemic absorption of a medication such as simethicone.

What goes down must come up: role of the posteromedial cortices in encoding and retrieval

The hypothesis that the neural network supporting successful episodic memory retrieval overlaps with the regions involved in episodic encoding has garnered much interest; however, the role of the posteromedial regions remains to be fully elucidated. Functional magnetic resonance imaging (fMRI) studies during successful encoding typically demonstrate deactivation of posteromedial cortices, whereas successful retrieval of previously encoded information has been associated with activation of these regions. Here, we performed an event-related fMRI experiment during an associative face-name encoding and retrieval task to investigate the topography and functional relationship of the brain regions involved in successful memory processes. A conjunction analysis of novel encoding and subsequent successful retrieval of names revealed an anatomical overlap in bilateral posteromedial cortices. In this region, a significant negative correlation was found: Greater deactivation during encoding was related to greater activation during successful retrieval. In contrast, the hippocampus and prefrontal cortex demonstrated positive activation during both encoding and retrieval. Our results provide further evidence that posteromedial regions constitute critical nodes in the large-scale cortical network subserving episodic memory. These results are discussed in relation to the default mode hypothesis, the involvement of posteromedial cortices in successful memory formation and retention, as well as potential implications for aging and neurodegenerative disease.