Long-term (6 and 12 months) follow-up of two prospective, randomized, controlled phase III trials of photodynamic therapy with BF-200 ALA and methyl aminolaevulinate for the treatment of actinic keratosis

Background

Two phase III trials of photodynamic therapy (PDT) with BF-200 ALA, a recently approved nanoemulsion formulation of 5-aminolaevulinic acid (ALA) demonstrated high clearance rates in mild-to-moderate actinic keratosis (AK). The comparison to a registered methyl aminolaevulinate (MAL) cream demonstrated significantly superior total patient clearance rates.

Objectives

To evaluate long-term efficacy and safety of PDT for AK 6 and 12 months after the last PDT with BF-200 ALA, MAL or placebo.

Methods

The follow-up phase (FUP) was performed with patients of two phase III studies. Both studies compared BF-200 ALA with placebo, one of the studies additionally with MAL. Overall recurrence rates and various subgroups (light source, lesion severity, lesion location, complete responders after first PDT) were assessed 6 and 12 months after the last PDT.

Results

Recurrence rates were similar for BF-200 ALA and MAL, with a tendency to lower recurrence rates for BF-200 ALA. The proportion of patients who were fully cleared during PDT and remained completely clear for at least 12 months after PDT were 47% for BF-200 ALA (both studies) and 36% for MAL treatment. The subgroup that was illuminated with narrow wavelength LED lamps reached 69% and 53% for BF-200 ALA (both studies, respectively) and 41% for MAL. No safety concerns were reported.

Conclusions

The FUP data confirmed the high efficacy and safety of PDT with BF-200 ALA. The slightly lower recurrence rates after BF-200 ALA treatment compared with MAL treatment enhanced the better treatment outcome due to the significantly superior efficacy.

[Phlebology in German departments of dermatology. An analysis on behalf of the German Society of Phlebology]

BACKGROUND

Phlebologic diseases have become extremely common and have major socio-economic impact. However, the percentage of dermatologists working in phlebology appears to be decreasing according to the data of the German Society of Phlebology (DGP).

METHODS

To investigate the reasons for this development, we--on behalf of the DGP--sent a questionnaire to 120 German Departments of Dermatology in autumn 2012.

RESULTS

In 76 returned questionnaires, the number of physicians with additional fellowship training in phlebology averaged 1.5; the average number of those who fulfill the criteria for training fellows in phlebology was 0.9. In 71.1 % of the departments there was a phlebologist. A special phlebologic outpatient clinic existed in 73.7 % of the departments. Sonography with Doppler (89.5 %) and duplex (86.8 %) was used as the most frequent diagnostic tool. For therapy, compression (94.7 %), sclerotherapy (liquid 78.9 %, foam 63.2 %, catheter 18.4 %), endoluminal thermic procedures (radio wave 28.9 %, laser 17.1 %) and surgery (especially crossectomy and stripping 67.1 %, phlebectomy of tributaries 75 %) were used. The average number of treatments was very heterogenous in the different departments.

CONCLUSIONS

Phlebology definitely plays an important role in dermatology. Most departments fulfill the formal criteria for the license to conduct advanced training in phlebology. A wide spectrum of phlebological diagnostic and therapeutic procedures is available.

[Rosacea: Clinical features and classification]

Rosacea is a frequent chronic dermatological disorder mainly affecting the face. Since it affects the appearance, it can be very distressing for the patient leading to psychosocial disturbances. Rosacea occurs in adults, peaking between 40 and 50 years of age. The course of rosacea is quite variable and the disease may stop at any stage. Generally, three main stages are differentiated: erythemato-teleangiectatic rosacea (rosacea stage I), papulopustular rosacea (rosacea stage II), hyperglandular-hypertrophic rosacea (rosacea stage III). Besides these main manifestations numerous special forms exist, which often lead to difficulties in the differential diagnoses and require specific therapeutic strategies. These include rosacea conglobata, rosacea fulminans, granulomatous rosacea, persisting edema, (Morbihan disease), gram negative rosacea, ocular rosacea, and steroid rosacea. Recently increasing numbers of patients have been observed, whose rosacea was were induced by inhibitors of epidermal growth factors (cetuximab, geftinib) used as chemotherapy in patients with different malignancies. These side effects have been described as acneiform eruptions but at least some of the described patients have a rosacea-like appearance; therefore, this form can be classified as a subset of drug induced rosacea.

Population dependent effects of photoperiod on diapause related physiological traits in an invasive beetle (Leptinotarsa decemlineata)

Organisms undergoing latitudinal range expansion face a change in the photoperiod which can lead to a mismatch between the timing of seasonal changes in physiological and life history traits with seasonal environmental changes. This mismatch can lead to lowered survival, for example, due to unsynchronized diapause timing. Successful range expansion even in recent introductions requires that organisms which use the photoperiod for seasonal predictions should show interpopulational differences in photoperiodic responses at different latitudes, as the photoperiod is a function of latitude. We investigated among population differences in photoperiodic responses of life history and physiological traits linked to diapause in the invasive beetle Leptinotarsa decemlineata. Beetles from a northern marginal and a southern European population were reared under short day (12:12L:D) and long day (18:6L:D) photoperiods. Both populations reacted similarly to the short day photoperiod. Their abdominal total lipid content increased and water content decreased which suggests that the beetles prepared for diapause. This was also indicated by low mortality during diapause. In the long day photoperiod large interpopulational differences were found, the southern population ceased lipid accumulation after 5 days, while the northern population continued lipid accumulation as beetles in the short day photoperiod. This indicates that the northern population has a longer critical photoperiod than the southern one. Abdominal total lipid stores in 10 day old beetles were shown to be predominantly composed of neutral lipids (85%), most likely representing storage triacylglycerols. Fatty acid profiles of both the neutral lipids and the phospholipids showed large shifts during the first 10 day of adult life, predominantly in the fractions of 18:0, 18:1ω9, 18:2ω6 and 18:3ω3. Although the degree of unsaturation increased with age, it was not higher in diapausing than non-diapausing beetles. This indicates that this species does not increase diapause related cold tolerance via homeoviscous adaptation, and might have developed other means to cope with suboptimal temperatures, such as behavioral adaptations.

Photodynamic therapy with BF-200 ALA for the treatment of actinic keratosis: results of a multicentre, randomized, observer-blind phase III study in comparison with a registered methyl-5-aminolaevulinate cream and placebo

BACKGROUND

Photodynamic therapy (PDT) with 5-aminolaevulinic acid (ALA) or its methylester [methyl-5-aminolaevulinate (MAL) or 5-amino-4-oxopentanoate] was recently ranked as first-line therapy for the treatment of actinic keratosis (AK) and is an accepted therapeutic option for the treatment of neoplastic skin diseases. BF-200 ALA (Biofrontera Bioscience GmbH, Leverkusen, Germany) is a gel formulation of ALA with nanoemulsion for the treatment of AK which overcomes previous problems of ALA instability and improves skin penetration.

OBJECTIVES

To evaluate the efficacy and safety of PDT of AKs with BF-200 ALA in comparison with a registered MAL cream and with placebo.

METHODS

The study was performed as a randomized, multicentre, observer-blind, placebo-controlled, interindividual trial with BF-200 ALA, a registered MAL cream and placebo in a ratio of 3:3:1. Six hundred patients, each with four to eight mild to moderate AK lesions on the face and/or the bald scalp, were enrolled in 26 study centres in Germany, Austria and Switzerland. Patients received one PDT. If residual lesions remained at 3months after treatment, PDT was repeated.

RESULTS

PDT with BF-200 ALA was superior to placebo PDT with respect to patient complete clearance rate (78·2% vs. 17·1%; P<0·0001) and lesion complete clearance rate (90·4% vs. 37·1%) at 3months after the last PDT. Moreover, superiority was demonstrated over the MAL cream regarding the primary endpoint patient complete clearance (78·2% vs. 64·2%; P<0·05). Significant differences in the patient and lesion complete clearance rates and severity of treatment-related adverse events were observed for the narrow- and broad-spectrum light sources.

CONCLUSIONS

BF-200 ALA is a very effective, well-tolerated new formulation for AK treatment with PDT and is superior to a registered MAL medication. Efficacies and adverse events vary greatly with the different light sources used.

Transitions of gene expression induced by short-term blue light

Blue light modulates many processes in plants and plant cells. It influences global and long-term responses, such as seedling development and phototropism, and induces short-term adaptations like stomatal opening and chloroplast movement. Three genes were identified as important for the latter process, namely PHOT1, PHOT2 and CHUP1. The former two phototropin blue light receptors act in perception of the blue light signal. The protein CHUP1 is localised to the outer envelope membrane of chloroplasts and is involved in chloroplast movement. To explore whether short-term reactions required for chloroplast movement are under transcriptional control, we analysed the transcriptome in wild-type Arabidopsis thaliana, phot1, phot2 and chup1 with different blue light treatments for 5 or 30 min. Blue light-induced changes in transcription depended on illumination time and intensity. Illumination with 100 μmol·m(-2) · s(-1) blue light induced down-regulation of several genes and might point to cascades that could be important for sensing low levels of blue light. Analysis of the transcriptome of the mutants in response to the different light regimes suggests that the transcriptional response to blue light in the wild-type can be attributed to phot1 rather than phot2, suggesting that blue light-induced alteration of expression is a function of phot1. In contrast, the blue light response at the transcriptional level of chup1 plants was unique, and confirmed the higher light sensitivity of this mutant.

Pathophysiology of visual disturbances occurring after foam sclerotherapy

Background

Visual disturbances (VDs) are reported with an average rate of 1.4% after foam sclerotherapy (FS). Some clinical clues indicate that they could correspond to migraine with aura (MA).

Aims

To validate the hypothesis that VDs occurring after FS correspond to MA and are not transient ischaemic cerebro-vascular events.

Method

A prospective multicentre study was carried out by the French Society of Phlebology in collaboration with the Neurology Department of the Marseille University Hospital (France). We included prospectively and consecutively all patients who experienced VDs after FS using air to make the foam. The patients were assessed (1) clinically with a specific form describing procedures of FS and recording neurological symptoms, later analysed by a neurologist specialized in migraine; and (2) by a brain diffusion-weighted magnetic resonance imaging (MRI) (T1, T2, T2*, diffusion) carried out within two weeks and analysed by a neuroradiologist.

Results

Twenty patients, 16 women and four men, were included in 11 phlebology clinics. All kinds of veins were treated. VDs occurred in average seven minutes after FS. Clinical assessment showed that VDs presented characteristics of MA in all patients, with headache in 10 and without in 10. Paresthesia was observed in five patients and dysphasic speech disturbance in one. Fifteen patients (75%) had a personal history of migraine. Fifteen MRIs were performed within two weeks (mean: 8 days) and three were late (26 days). All of them were normal. MRI was not performed in two patients.

Conclusion

These results show that VDs occurring after FS correspond to MA and are not transient ischaemic cerebro-vascular events. We suggest a pathophysiological hypothesis resting on the release of endothelin that would reach the cerebral cortex through a paten foramen ovale.

[Rosacea 2009 : new advances in pathophysiology, clinical staging and therapeutic strategies]

Rosacea is one of the most common dermatoses of adults. In recent years many studies have contributed to a better understanding of the pathophysiology of rosacea. They suggest that an altered innate immune response is involved in the vascular and inflammatory manifestations seen in rosacea. A good understanding of the disease and its special features is necessary for the differential diagnosis of the many clinical subtypes and for a stage- and phase-specific treatment approach. Topical treatments that are widely accepted are metronidazole and azelaic acid; agents under investigation that show promise include permethrin, calcineurin inhibitors and sulfur compounds. For systemic therapy antibiotics (tetracyclines, macrolides) and recently doxycycline in anti-inflammatory rather than anti-microbial dosages are used, as well as isotretinoin in severe cases. Findings such as rhinophyma and telangiectases can be treated using different laser systems or dermabrasion. This article gives an overview regarding rosacea, a challenging condition with multiple therapeutic options.

Abstract 832: Evaluation of relevance of genes expressed in cancer stem cells and under hypoxia in astrocytic brain tumors

The dismal prognosis of patients suffering from astrocytomas, especially glioblastoma multiforme (GBM) emphasizes the need for more precise expressional characterization of these tumors in order to identify potential prognostic factors and therapeutic targets. Tumor growth leads to formation of low oxygenated regions that are considered as stem cell niches. GBM are described with high cancer stem cell content and with hypoxic and necrotic areas. This study investigates in astrocytomas WHO grade II to IV the transcript levels of genes expressed in cancer stem cells (NANOG, ALDH1A1, ALDH3A1, CD133, NOTCH1, ABCB1, ABCG2) and hypoxia regulators and regulated genes (HIF1α, HIF2α, CA9, VEGF). A relationship between some of these factors and patient survival or tumor grade has been reported in previous studies.

Tissue samples (ts) from 46 patients were histologically graded as: 12 diffuse astrocytomas (DA) gr II, 6 anaplastic astrocytomas (AA) gr III and 28 GBM gr IV. RNA was isolated from ts. Gene expression levels measured by real-time qRT-PCR in the separate tumor samples were compared to levels found in 6 non-tumor ts from patients suffering epileptic lesions and to beta actin. Relative quantities were compared between ts groups by Mann-Whitney test and log-transformed for Pearson correlation calculation.

Increase of HIF2α (200-fold), CA9 (2.7-fold) and VEGF (3.4-fold) mRNA was observed in GBM compared to non-tumor or DA (p&lt;0.05). HIF1α and NANOG mRNA levels did not change (p&gt;0.05). In contrast, a decrease of expression in GBM compared to DA of ABCB1 (10-fold), ABCG2 (10-fold), NOTCH1 (4.2-fold) and ALDH1A1 (6.8-fold) mRNA was observed (p&lt;0.05). ALDH3A1 mRNA was increased 29-fold in GBM compared to DA, but decreased 270-fold compared to non-tumor (p&lt;0.05). Weak and interesting significant correlations of mRNA levels were observed between NOTCH1, NANOG, ABCG2 and ALDH1A1 (Pearson's coefficient P=0.43 to 0.60), between NANOG and CA9 (P=0.67) and between VEGF and ALDH1A1 (P=-0.43). Primary analysis of expression and survival data indicates a significant connection of overall survival and expression of ALDH1A1. Low ALDH1A1 mRNA correlates with a poor prognosis. Part of our findings could be confirmed by comparison with mRNA levels from public database Rembrandt (Repository of Molecular Brain Neoplasia Data) containing results from experiments with gene expression and copy number arrays.

Conclusion: Transcript levels of analyzed genes are significantly related to tumor grade, except are HIF1α and NANOG. Decreased transcript levels of genes expressed in cancer stem cells are in contrast to a high content of cancer stem cells described for GBM. Expression levels of most of the investigated genes can be considered promising candidates as prognostic and diagnostic markers in astrocytomas.

This project was supported in part by a grant from the Herzfelder-Familien-Stiftung, Austria.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 832.

Liquid-phase continuity and solute concentration dynamics during evaporation from porous media: pore-scale processes near vaporization surface

Evaporation from porous media involves complex pore scale transport processes affecting liquid phase distribution and fluxes. Often, the initial evaporation rate is nearly constant and supplied by capillary flow from wetted zones below to the surface. Sustaining constant flow against gravity hinges on an upward capillary gradient and on liquid phase continuity with hydraulic conductivity sufficient for supplying evaporative flux. The pore scale liquid phase adjustments during evaporative displacement necessary for maintaining a constant flux have been postulated but rarely measured. In this study we employed detailed imaging using x-ray synchrotron radiation to study liquid phase distribution and dynamics at the most sensitive domain just below the surface of evaporating sand columns. Three-dimensional images at a resolution of 7 microns were obtained from sand column (mean particle size 0.6 mm) initially saturated with calcium iodide solution (4% by mass) to enhance image contrast. Detailed imaging of near-surface liquid phase distribution during evaporation confirmed phase continuity at micrometric scale and provided quantitative estimates of liquid conductance in agreement with values required to supply evaporative flux. Temporal variations in bulk salt concentrations determined from x-ray attenuation were proportional to evaporative water mass loss. Highly resolved salt concentration images revealed existence of evaporating chimneys that supply the bulk of evaporative demand. Delineated mass loss dynamics and salt distribution measured by the x-ray attenuation were in reasonable agreement with a simplified analytical convection-diffusion model for salt dynamics during evaporation from porous media.

[Vertebroplasty: 10 years clinical and radiological follow-up]

OBJECTIVES

Ten years follow-up of the first patients treated with percutaneous vertebroplasty.

PATIENT AND METHODS

Eighteen patients were retrospectively reviewed having undergone vertebroplasty in our centre between 1989 and 1998. Eight were treated for angioma, eight for osteoporotic compression and two followed for myeloma. They all underwent clinical and radiological evaluation in 2007 (standard X-rays, CT scan and MRI). These examinations were compared to prior baseline pre- and post-therapeutic images.

RESULTS

Radiological characteristic of cement remained unchanged in the long term and there was no modification of anatomical structures in contact with it. Even if the distribution of cement was asymmetrical there was no fracture of the treated vertebras at distance. Degenerative changes of discs facing the vertebroplasty were not more pronounced than for distant discs. We found no significant signal or density anomaly of disc in contact direct with cement. 38.8 % of the patients presented new fractures (n=30). Seventy percent of the fractures were multiple and contiguous. In the long term, all patients reported improvement of pain after the procedure.

CONCLUSION

In our series, we found a good stability of treatment over time. This study shows the long-term safety of percutaneous acrylic vertebroplasty, in particular harmlessness of cement for bone and discs in contact.

[Arterial spin labeling: state of the art]

Arterial spin labeling (ASL) perfusion MR imaging is a technique by which water from circulating arterial blood is magnetically labeled and acts as a diffusible tracer allowing non-invasive measurement of cerebral blood flow. In this paper, the technique and current applications in neuroimaging will be reviewed.

CURRENT STATUS

First, the technical principles of ASL will be reviewed and both available techniques (continuous and pulsed ASL) explained. A review of the literature will demonstrate advances with the techniques of ASL and its clinical impact. Clinical research involves normal volunteers and patients with ischemic and tumoral pathologies.

CONCLUSION

Recent technical advances have improved the sensitivity of ASL perfusion MR imaging. The routine clinical use of ASL at 3.0 Tesla should increase over the next few years.

Balloon-related complications and technical failures in kyphoplasty for vertebral fractures

BACKGROUND AND PURPOSE

Our aim was to describe the immediate or early complications and technical failures occurring during balloon kyphoplasty (BKP) procedures and attributable to balloon inflation.

MATERIALS AND METHODS

We performed a retrospective review of all consecutive kyphoplasty procedures performed in our institution from May 2005 to October 2006. Fifty-one patients were treated by BKP at 75 spinal levels, and 137 vertebroplasties were performed as well.

RESULTS

Several recurrent complications or procedural failures were observed during BKP: cortical or endplate fracture by balloon expansion (4 vertebrae), partial vertebral re-collapse after deflation (4 vertebrae), balloon rupture during inflation (5 vertebrae), and transient hyperalgia after the procedure (11 patients, 27.5%).

CONCLUSIONS

Several symptomatic or asymptomatic complications and technical failures can occur during BKP. Some modifications of the usual kyphoplasty technique may decrease the frequency of these complications.