Assessment of electric field distribution in anisotropic cortical and subcortical regions under the influence of tDCS

The focus of this study is to estimate the contribution of regional anisotropic conductivity on the spatial distribution of an induced electric field across gray matter (GM), white matter (WM), and subcortical regions under transcranial direct current stimulation (tDCS). The assessment was conducted using a passive high-resolution finite element head model with inhomogeneous and variable anisotropic conductivities derived from the diffusion tensor data. Electric field distribution was evaluated across different cortical as well as subcortical regions under four bicephalic electrode configurations. Results indicate that regional tissue heterogeneity and anisotropy cause the pattern of induced fields to vary in orientation and strength when compared to the isotropic scenario. Different electrode montages resulted in distinct distribution patterns with noticeable variations in field strengths. The effect of anisotropy is highly montage dependent and directional conductivity has a more profound effect in defining the strength of the induced field. The inclusion of anisotropy in the GM and subcortical regions has a significant effect on the strength and spatial distribution of the induced electric field. Under the (C3-Fp2) montage, the inclusion of GM and subcortical anisotropy increased the average percentage difference in the electric field strength of brain from 5% to 34% (WM anisotropy only). In terms of patterns distribution, the topographic errors increased from 9.9% to 40% (WM anisotropy only) across the brain.

[Clinicopathological and prognostic significance of ERα and ERβ expression in lung carcinomas: a tissue microarray study]

OBJECTIVE

To detect the expression of ERα and ERβ in lung carcinomas and investigate their clinicopathological and prognostic significance by using tissue microarray assay and immunohistochemical staining.

METHODS

Six hundred and ninety-eight lung cancer specimens were used in this study, including 651 cases of non-small cell lung carcimomas (NSCLCs) and 47 cases of small cell lung cancers (SCLCs). There were 309 cases of adenocarcimoma and 342 cases of squamous cell carcinoma. The expression of ERα and ERβ was analyzed by immunohistochemistry on paraffin-embedded sections.

RESULTS

In the normal lung tissues, expression of ERα and ERβ was 0% (0/35) and 25.0% (9/36), respectively. In the tumor tissues, ERα was expressed in 209 of 295 AC cases (70.8%), 169 of 330 SCC cases (51.2%) and 9 of 47 SCLC cases (19.1%) (P < 0.001). ERβ was expressed in 200 of 297 AC cases (67.3%), 140 of 322 SCC cases (43.5%) and 31 of 47 SCLC cases (66.0%) (P < 0.001). In NSCLC, the expression of ERα and ERβ was significantly associated with smoking, stage and lymph node metastasis, also with sex refer to ERβ (P < 0.05), but not significantly with age, tumor size and degree of differentiation (P > 0.05). Follow-up was completed in 398 NSCLC cases, and no significant correlation was found between the prognosis and expression of ERα and ERβ.

CONCLUSIONS

The expression of ERα and ERβ has significant difference in lung adenocarcinoma, squamous cell carcinoma and small cell lung cancer. In NSCLC, expression of ERα and ERβ is associated with smoking, stage, and lymph node metastasis. The expression of ERβ is higher in female than in male NSCLC patients.

Numerical investigation of white matter anisotropic conductivity in defining current distribution under tDCS

The study investigates the impact of white matter directional conductivity on brain current density under the influence of Transcranial direct current stimulation (tDCS). The study employed different conductivity estimation algorithms to represent conductivity distribution in the white matter (WM) of the brain. Two procedures, one mathematically driven and the second one based on the Diffusion tensor imaging (DTI) are considered. The finite element method has been applied to estimate the current density distribution across the head models. Strengths and weaknesses of these algorithms have been compared by analyzing the variation in current density magnitude and distribution patterns with respect to the isotropic case. Results indicate that anisotropy has a profound influence on the strength of current density (up to ≈50% in WM) as it causes current flow to deviate from its isotropically defined path along with diffused distribution patterns across the gray and WM. The extent of this variation is highly correlated with the degree of the anisotropy of the regions. Regions of high anisotropy and models of fixed anisotropic ratio displayed higher and wider degree of variations across the structures (topographic variations up to 48%), respectively. In contrast, models, which are correlated with the magnitude of local diffusion tensor behaved in a less exacerbated manner (≈10% topographic changes in WM). Anisotropy increased the current density strength across the cortical gyri under and between the stimulating electrodes, whereas a significant drop has been recorded in deeper regions of the GM (max % difference ≈±10). In addition, it has been observed that Equivalent isotropic trace algorithm is more suitable to incorporate directional conductivity under tDCS paradigm, than other considered approaches, as this algorithm is computationally less expensive and insensitive to the limiting factor imposed by the volume constraint.

The association between RhEPO and FN expression in glomerular mesangial cells

AIM

Erythropoietin (rhEPO) is increasingly being used in the treatment of anemia caused by miscellaneous reasons. The aim of our research is to investigate the effects of recombinant human erythropoietin (rhEPO) on cellular growth and fibronectin (FN) expression in glomerular mesangial cells.

METHODS

Western blot was used to detect the expression of FN induced by rhEPO (1, 10, 100 and 1000U/mL). In vivo studies, male CD-1 mice were administered rhEPO subcutaneously at a single dose of 1000U/Kg. The cellular hypertrophy was quantified by counting cell number and calculating the ratio of cell protein to cell number.

RESULTS

1) Compared with the control group, the results of mesangial cells' growth stimulated by rhEPO were not significantly different; 2) RhEPO lead to hypertrophy of mesangial cells; 3) rhEPO induced FN expression of mesangial cell in a dose-dependent way. Compared to control, 100U/mL rhEPO enhanced the expression of FN significantly; 4) indirect immunofluorescence showed that rhEPO induced large amount deposition of FN in the intercellular space of mesangial cells; 5) in vivo studies, there were markedly increase of FN expression in mice received the injection of rhEPO.

CONCLUSION

RhEPO could up-regulated the expression of FN and induced glomerular mesangial cells hypertrophy. These results suggested rhEPO could induce dysfunction of renal glomerulus through its influence on the function of mesangial cells.

[Effect of polysaccharides from Radix Glycyrrhizae on migration and polyamines contents of IEC-6 cell]

OBJECTIVE

To study the effect of polysaccharides from Radix Glycyrrhizae on migration and polyamines (putrescine, spermidine and spermine) contents of IEC-6 cell.

METHODS

Cell migration model was induced by scratch method in each well,and the polyamines in IEC-6 cell was determined by pre-column derivation high performance liquid chromatography. The polysaccharides inhibited effect on migration and polyamines contents of IEC-6 cells, and on IEC-6 cell migration by DFMO (a polyamines synthesis inhibitor) and the polyamines contents in the cells were observed.

RESULTS

The polysaccharides (50 mg/L or 100 mg/L) was able to promote the cell migration, reverse the cell migration inhibition by DFMO, enhance the IEC-6 cell polyamines (putrescine, spermidine and spermine) contents in the process of cell migration and reverse the reduction of polyamines (putrescine, spermidine and spermine) induced by DFMO.

CONCLUSION

The effect of Radix Glycyrrhizae on the gastrointestinal mucosal damage repairing may be related to increasing polyamine content in cells and promoting cell migration.

Expressions of the γ2 chain of laminin-5 and secreted protein acidic and rich in cysteine in esophageal squamous cell carcinoma and their relation to prognosis

Previous studies have shown that the expressions of the γ₂ chain of laminin-5 and secreted protein acidic and rich in cysteine (SPARC) play important roles in oncogenesis and the development of carcinoma. To assess the expressions of laminin-5 γ₂ chain and SPARC in esophageal squamous cell carcinoma (SCC), and to clarify the prognostic significance of the expressions of laminin-5 γ₂ chain and SPARC in esophageal SCC, we detected the expressions of laminin-5 γ₂ chain and SPARC in cancer tissue and corresponding normal mucosa from 116 patients with advanced (stages II–IV) esophageal SCC using the tissue microarray-based immunohistochemistry and analyzed the correlation of the expressions with clinicopathologic characteristics and survival. We found that in normal esophageal tissues, laminin-5 γ₂ chain was expressed in the basement membrane, whereas in esophageal SCC tissues, laminin-5 γ₂ chain was expressed in the cytoplasm of carcinoma cells, with a positive rate of 72.4%. SPARC was not detected in normal esophageal mucosa, but was expressed in stromal fibroblasts in 84.6% of esophageal SCC cases and in cancer cells in 7.8% of esophageal SCC cases. There was a significant correlation between laminin-5 γ₂ chain and stromal SPARC expression in esophageal SCC (Spearman' s rho = 0.423, P < 0.001). The expressions of both laminin-5 γ₂ chain and stromal SPARC were correlated with survival (P = 0.032 and P = 0.034, respectively). In stage-II esophageal SCC, the expression of laminin-5 γ₂ chain was significantly correlated with survival (P = 0.023), while the expression of SPARC was not significantly correlated with survival (P = 0.154). Patients with elevated levels of laminin-5 γ₂ chain and SPARC expressions had a poorer prognosis than did those lacking elevated levels of laminin-5 γ₂ chain expression and/or elevated levels of SPARC expression (P = 0.001). In stage-II esophageal SCC, patients with elevated levels of laminin-5 γ₂ chain and SPARC expressions had a poorer prognosis (P < 0.001). These results suggest that laminin-5 γ₂ chain and SPARC may play roles in the progression of esophageal SCC and their simultaneous expression is correlated with poorer prognosis, especially in patients with stage-II SCC.

Management of treatment-emergent peripheral neuropathy in multiple myeloma

Peripheral neuropathy (PN) is one of the most important complications of multiple myeloma (MM) treatment. PN can be caused by MM itself, either by the effects of the monoclonal protein or in the form of radiculopathy from direct compression, and particularly by certain therapies, including bortezomib, thalidomide, vinca alkaloids and cisplatin. Clinical evaluation has shown that up to 20% of MM patients have PN at diagnosis and as many as 75% may experience treatment-emergent PN during therapy. The incidence, symptoms, reversibility, predisposing factors and etiology of treatment-emergent PN vary among MM therapies, with PN incidence also affected by the dose, schedule and combinations of potentially neurotoxic agents. Effective management of treatment-emergent PN is critical to minimize the incidence and severity of this complication, while maintaining therapeutic efficacy. Herein, the state of knowledge regarding treatment-emergent PN in MM patients and current management practices are outlined, and recommendations regarding optimal strategies for PN management during MM treatment are provided. These strategies include early and regular monitoring with neurological evaluation, with dose modification and treatment discontinuation as indicated. Areas requiring further research include the development of MM-specific, patient-focused assessment tools, pharmacogenomic analysis of patient DNA, and trials to assess the efficacy of pharmacological interventions.

Optimization of Enzymatic Hydrolysis Conditions for Preparation of Gingko Peptides from Ginkgo Nuts

Ginkgo nuts were used as raw material and peptides were prepared in turn with Neutral protease and Flavourzyme. In single-factor experiments of Neutral protease, conditions of temperature, pH, enzyme concentration and substrate concentration were optimized in term of degree of hydrolysis (DH). Based on the results of single-factor experiments, an orthogonal experiment (L9(3)4) was conducted to optimize the hydrolysis conditions of Neutral protease. The results showed that enzyme concentration, substrate concentration, reaction temperature and initial pH were the main variables that influenced DH. The highest DH was obtained when hydrolysis time, reaction temperature, initial pH, enzyme amount and substrate concentration were 4 h, 45 oC, 7.0, 1.8 mg/mL and 0.02 g/mL, respectively. Subsequently, the resulting solution was further hydrolyzed with Flavourzyme. Initial pH, temperature, time and enzyme concentration were optimized in term of DH. Finally, another orthogonal experiment (L9(3)4) was conducted to get the best enzymatic conditions of Flavourzyme, and enzyme concentration, initial pH, temperature and time were used as factors. The results showed that when Flavourzyme concentration, reaction temperature, initial pH and hydrolysis time were 9.0 mg/mL, 50 oC, 7.0 and 5 h, respectively, DH was the highest. The final degree of hydrolysis was 22.56%.

[Primary superficial small cell neuroendocrine carcinoma of esophagus: clinicopathologic and immunohistochemical analysis of 15 cases]

OBJECTIVE

To study the clinicopathologic and immunohistochemical features of primary superficial esophageal small cell neuroendocrine carcinoma (ESCNC).

METHODS

The clinical, pathologic and immunohistochemical features were retrospectively analyzed in 15 cases of superficial ESCNC. An immunohistochemical study for chromogranin A, neuron-specific enolase, synaptophysin, CD56, TTF-1, 34βE12, AE1/AE3, and CK10/13 was performed.

RESULTS

Superficial ESCNC accounted for 4.8%(15/312) of all cases of superficial carcinoma of the esophagus encountered during the same period. The median survival time was 19 months and the mean survival time was 23.7 months after diagnosis. The one, two and five-year survival rates were 10/15, 5/15 and 1/15, respectively. The immunophenotypic profile was as follows: neuron-specific enolase (15/15), synaptophysin (15/15), AE1/AE3 (15/15), CD56 (14/15), TTF-1 (9/15), chromogranin A (8/15), 34βE12 (1/15) and CK10/13 (0/15).

CONCLUSIONS

Superficial ESCNC is a rare and aggressive malignant tumor with poor prognosis. Surgical resection coupled with post-operative chemoradiotherapy is the mainstay of treatment. The immunohistochemical study is valuable in pathologic diagnosis and differential diagnosis.

Genetic alterations in pulmonary epithelioid hemangioendothelioma and epithelioid angiosarcoma

Epithelioid hemangioendothelioma (EHE) is a low-to-intermediate-grade vascular tumor that occurs in many organs, and epithelioid angiosarcoma (EA) is a subtype of angiosarcoma that is associated with high-grade malignancy. These two types of tumors have different forms of biological behavior. Pulmonary epithelioid hemangioendothelioma (PEH) and epithelioid angiosarcoma (PEA) are both very rare, and genetic studies on them are extremely limited. We examined and compared the cytogenetic characteristics of these two types of lung tumors in two patients utilizing the Array-Comparative Genomic Hybridization (Array-CGH) method. Considerable differences in the cytogenetic characteristics were observed between the two types of tumors. Small fragment gains (<10 MB) were dominant in PEH, whereas large fragment gains and deletions (>10 MB) were dominant in PEA. Some large fragment alterations, such as gains in chromosomes 19q and 19p, and deletions in chromosomes 9p and 13q, involved over half of a chromosome arm. PEH and PEA showed great cytogenetic differences; therefore, further genetic studies on these two types of tumors are warranted.

Pronounced slow β-relaxation in La-based bulk metallic glasses

Most metallic glasses (MGs) exhibit weak evidence of slow β-relaxation in their dynamic mechanical spectroscopy spectra. In contrast to other MGs, the La-based MGs we report here show a distinct slow β-relaxation peak in the mechanical relaxation measurements. We find that the slow β-relaxation behavior can be tuned by modification of the chemical composition and fragility. The structural origin of the slow β-relaxation and correlation between β-relaxation and α-relaxation in the MGs are also discussed. MGs with pronounced slow β-relaxation and tunable properties might provide a model system to investigate some long-standing issues in the glass field.

[Expression of fascin and CK14 in different histological types of cancer and its differential diagnostic significance]

OBJECTIVE

To investigate and analyze the expression of fascin and CK14 in multiple histological types of cancer and to explore the potential value of the two proteins as markers in diagnosis and differential diagnosis of various cancer types.

METHODS

Tissue microarray containing esophageal squamous cell carcinoma (SCC), lung SCC, larynx SCC, uterine cervical SCC, SCC of external genital organs, lung adenocarcinoma, gastric adenocarcinoma, colorectal adenocarcinoma, heptocellular carcinoma, pancreatic ductal adenocarcinoma, breast infiltrating ductal carcinoma, thyroid papillary carcinoma, uterine endometrioid adenocarcinoma, ovarian serous adenocarcinoma and renal clear cell carcinoma, 30 cases each, as well as corresponding normal controls was constructed. The expression of fascin and CK14 among different types of carcinoma and corresponding normal controls was detected by immunohistochemistry.

RESULTS

In normal esophagus, bronchus, larynx, uterine cervix and skin, fascin was mainly expressed in the basal cells or reserve cells, but the expression was diffuse in esophageal SCC, lung SCC, larynx SCC, uterine cervical SCC and SCC of external genital organs, with a positive rate of 90.0%, 90.0%, 96.7%, 78.6% and 89.7%, respectively. In the normal tissue of other organs, except breast and uterine endometrium, fascin was negative. In lung adenocarcinoma, gastric adenocarcinoma, colorectal adenocarcinoma, hepatocellular carcinoma, pancreatic ductal adenocarcinoma, breast infiltrating dutal adenocarcinoma, thyroid papillary carcinoma, uterine endometrioid adenocarcinoma, ovarian serous adenocarcinoma and renal clear cell carcinoma, the positive rates were 38.0%, 23.3%, 14.3%, 10.3%, 73.3%, 13.3%, 6.7%, 60.0%, 66.7% and 10.0%, respectively. The difference between fascin expression in SCC and in other histological types was statistically significant (P < 0.001). CK14 was mainly expressed in the basal cells, reserve cells or myoepithelia of normal tissues. The positive rates of CK14 were 76.7%, 36.7%, 83.3%, 60.7% and 96.3% in esophageal SCC, lung SCC, larynx SCC, uterine cervical SCC and SCC of external genital organs, respectively. It was weak and focal in lung adenocarcinoma, gastric adenocarcinoma, colorectal adenocarcinoma, hepatocellular carcinoma, pancreatic ductal adenocarcinoma, breast infiltrating dutal adenocarcinoma, thyroid papillary carcinoma, uterine endometrioid adenocarcinoma, ovarian serous adenocarcinoma, and renal clear cell carcinoma, with a positive rate of 13.3%, 13.3%, 20.7%, 41.4%, 46.7%, 6.7%, 40.0%, 13.3%, 20.0% and 6.7%, respectively. The difference between CK14 expression in SCC and in other histological types was statistically significant (P < 0.001). The difference between co-expression of fascin/CK14 in SCC and in other histological types was also statistically significant (P < 0.001).

CONCLUSION

Fascin and CK14 are highly expressed in SCC, compared with other histological types of carcinoma. Combination of fascin and CK14 should be a valuable marker in diagnosis and differential diagnosis of carcinoma.

An improved detrended moving-average method for monitoring the depth of anesthesia

The detrended moving-average (DMA) method is a new approach to quantify correlation properties in nonstationary signals with underlying trends. This paper monitored the depth of anesthesia (DoA) using modified DMA (MDMA) method. MDMA provides a power-law relation between the fluctuation function F(MDMA)(s) and the scale s: F(MDMA)(s)αs(α), where α is the slope of F(MDMA)(s) in the logarithm scale. We applied the MDMA to monitor the DoA by computing the scaling exponent F(α) and F(min) values. To validate the proposed method, we compared our results with the bispectral index (BIS) monitor. We found a close correlation between our results and BIS with r(F (min)) = 0.9346, r(2)(F(min)) = 0.9183, and r(F(α)) = 0.9458, r(2)(F(α)) = 0.8855. Our method reflects the state of consciousness of a patient undergoing general anesthesia faster than BIS as observed clinically. The minimum time delay between the BIS and F(min) trends was 12 s and the maximum was 178 s. Furthermore, in the case of poor signal quality, our results agreed with clinical observation, which indicates that our method can accurately estimate a patient's hypnotic state in such circumstances. F(α) and F(min) trends are responsive and their movement seems similar to changes in the clinical state of the patients.

Uncertainty and sensitivity analysis for anisotropic inhomogeneous head tissue conductivity in human head modelling

The accuracy of an electroencephalography (EEG) forward problem partially depends on the head tissue conductivities. These conductivities are anisotropic and inhomogeneous in nature. This paper investigates the effects of conductivity uncertainty and analyses its sensitivity on an EEG forward problem for a spherical and a realistic head models. We estimate the uncertain conductivities using an efficient constraint based on an optimization method and perturb it by means of the volume and directional constraints. Assigning the uncertain conductivities, we construct spherical and realistic head models by means of a stochastic finite element method for fixed dipolar sources. We also compute EEG based on the constructed head models. We use a probabilistic sensitivity analysis method to determine the sensitivity indexes. These indexes characterize the conductivities with the most or the least effects on the computed outputs. These results demonstrate that conductivity uncertainty has significant effects on EEG. These results also show that the uncertain conductivities of the scalp, the radial direction of the skull and transversal direction in the white matter are more sensible.

Superficial primary small cell carcinoma of the esophagus: clinicopathological and immunohistochemical analysis of 15 cases

Primary esophageal small cell carcinoma (PESCC) is a relatively rare and aggressive tumor with poor prognosis. Systemic spreading and metastasis often occur at diagnosis. Although 5-year survival rate of superficial squamous cell carcinoma of the esophagus can be 86.1%, 5-year survival rate of superficial PESCC is still relatively low. This study mainly retrospectively analyzed clinicopathological and immunohistochemical features of 15 cases of superficial PESCC in our hospital from 1990 to 2004, in order to find suitable diagnostic markers and applicable therapies for this disease. The records mainly included presenting symptoms, demographics, diagnostic method, histopathology, follow-up, and therapy. Immunohistochemical staining of chromogranin A (CgA), neuron-specific enolase (NSE), synaptophysin (Syn), neuronal cell adhesion molecules (CD56), thyroid transcription factor-1 (TTF-1), cytokeration 34betaE12 (CK34betaE12), cytokeratin (AE1/AE3), and cytokeratin 10/13 was performed. Incidence of superficial PESCC accounted for 4.8% of that of superficial carcinoma of the esophagus during the same period. Initial symptoms of all patients were dysphagia or accompanied with retrosternal pain and upper abdominal pain, and duration of these symptoms was 75 days averagely. Mean age of patients was 58.8 years old, and the male-to-female ratio was 2.75 : 1. Lesions were mainly located at middle thoracic esophagus. One, 2, and 5-year survival rates were 66.7, 33.3, and 6.7%, respectively. The median survival time was 19 months and mean survival time was 23.7 months after diagnosis. The percentages of PESCC samples with positive immunoreactivity were NSE 100%, Syn 100%, AE1/AE3 100%, CD56 93.3%, TTF-1 60%, CgA 53.3%, CK34betaE12 6.7%, and cytokeratin 10/13 0%, respectively. Our study suggested that PESCC was a rare and aggressive tumor with high malignancy. Superficial PESCC had rapid progression and poor prognosis compared with superficial squamous cell carcinoma of the esophagus at the same stage. The systemic therapy based on combination of postoperative chemotherapy and radiotherapy might be an effective approach for the treatment of superficial PESCC as a systemic disease. Higher proportion of positive labeling of NSE, Syn, AE1/AE3, CD56, TTF-1, and CgA in PESCC was valuably applied in diagnosis and differential diagnosis.

Identification of tumor stem-like cells in a mouse myeloma cell line

We used colony formation assay in the soft agar media or the serum-free media, the methods of identifying BrdU-label-retaining cells and the SP cells as well as the tumorigenicity test in BALB/c mice, respectively, to analyze tumor stem like cells in the SP2/0 cell line. The results showed that a few SP2/0 cells were capable of forming colonies in the soft agar media, contained BrdU-label-immortal strand in the SP2/0 cell line. The SP2/0 cells in the serum-free media gained higher tumorigenicity in the BALB/c mice than the SP2/0 cells cultivated in the complete media did. Overall, only a few of the SP2/0 cells were found to possess the characteristics of tumor stem-like cells, such as high proliferative potency, more self-renewal and stronger tumorigenesis, or greater similarity to the tumor stem cells (TSCs) traits. The biology of tumor stem-like cells contributes to the identification of molecular targets important for future tumor therapy.

Interaction between sorafenib and erlotinib

2500

Background: The combination of sorafenib plus erlotinib was evaluated in patients with recurrent glioblastoma (GBM). In addition to defining the maximum tolerated dose (MTD), pharmacokinetics (PKs) for single agent and combination were determined. Methods: Adults with recurrent GBM with the usual phase I inclusion/exclusion criteria were eligible. No enzyme inducing anti-epileptic agents were allowed. Starting doses for erlotinib and sorafenib were 100mg PO QD and 200 mg PO BID, respectively, for 28 days (a cycle). For cycle 1 PKs, erlotinib was started on day 1 followed on day 2 by sorafenib. Eight plasma samples were collected over 24hrs on days 1, 15 and 28. Sorafenib and its metabolite (N-oxide) were analyzed by HPLC and erlotinib and OSI-420 by LC/MS. PK parameters were characterized by standard non-compartmental methods. Results: The MTD was sorafenib 200 mg PO BID and erlotinib 100 mg PO QD. The PKs for erlotinib (OSI) are displayed below. Conclusions: The PKs for sorafenib are in agreement with previous reports and not affected by the co-administration of erlotinib. However, there is an apparent affect of sorafenib on the PKs of erlotinib. The expected accumulation of erlotinib's Cmax and AUC at steady-state was not observed. This interaction results in at least a 2+ fold decrease in exposure to erlotinib and its active metabolite. The interaction does not appear to be the classical enzyme induction due to the rapidity of the onset/offset. This same phenomenon has been reported with the co-administration of sorafenib with gefitinib (Clin Cancer Res 13:2684,2007). Increasing the maximal velocity (Vmax) of CYP3A4, not the quantity of enzyme, is suggested as a testable hypothesis (J Pharmacol Exp Ther 290:1.1998). The clinical relevance of this interaction with regard to toxicity and efficacy warrants further evaluation.

[Table: see text]

No significant financial relationships to disclose.

Correlative tumor molecular profiling and plasma biomarker analysis in a phase II study of XL184 in patients with progressive or recurrent glioblastoma multiforme (GBM)

2049

Background: XL184 is an oral inhibitor of MET, RET, KIT, and VEGFR-2 with potent antitumor effects in preclinical models of GBM. Clinically, elevated levels of MET, KIT, VEGFR-2, and VEGF-A are found in GBM, where MET and KIT levels correlate with poor prognosis. XL184–201 is a fully enrolled GBM study (N = 46) which mandated collection of archival tumors and serial plasma samples. The encouraging clinical activity of XL184 in this study is the subject of a separate abstract. Methods: Tumor profiling focused on genomic alterations prevalent in GBM, reflecting dysregulation of key signaling pathways (Nature 2008; 455:1061), or XL184 targets. Plasma samples were analyzed with ELISA assays. Correlation of results with clinical outcomes is a secondary objective of study XL184–201. Results: Tumor genotyping assessments included EGFR and KIT copy number; PTEN, PIK3CA, PIK3R1, and NF1 sequencing, as well as MGMT and PTEN promoter methylation. Results from the first 12 cases indicate sequence variations & frequencies similar to reports in the literature. IHC analysis of MET, RET, and VEGFR-2 protein expression was also performed. In ∼ 80% of samples, tumor cells stained positive for MET with a lower fraction positive for RET and VEGFR-2 in tumor cells (42% and 58%, respectively). RET and VEGFR-2 expression was often seen in tumor-associated blood vessels, while MET signal in blood vessels was more limited (33%). Preliminary biomarker analysis established significant modulation of plasma levels of VEGF-A, sMET, sVEGFR-2, sKIT, and PlGF, consistent with multiple on target effects. Objective response was observed in the presence or absence of tumor EGFR amplification, PTEN mutation, and MGMT promoter methylation. The potential predictive value of these and other biomarkers is under investigation. Conclusions: Plasma biomarkers confirm pharmacodynamic activity of XL184 in advanced GBM where marked clinical activity has been observed. Upon completed analysis of a full set of biological samples and with mature clinical data, predictive markers for clinical activity of XL184 will be evaluated.

[Table: see text]

Phase I trial of vatalanib (PTK787) in combination with standard radiation and temozolomide in patients with newly diagnosed glioblastoma

2035

Background: Anti-vascular endothelial growth factor (VEGF) agents are hypothesized to work synergistically with chemotherapy and radiation (RT). Vatalanib (MW 347, T1/2 4.6 h) is an oral, pan-VEGFR tyrosine kinase inhibitor that has shown activity in patients with recurrent glioblastoma. Methods: This phase I study was designed to determine the maximal tolerated dose of vatalanib in combination with RT and TMZ for patients with newly diagnosed GBM who were taking enzyme-inducing anti-epileptic drugs. RT and TMZ were administered at standard doses. Vatalanib was initiated 5 days prior to the start of RT and continued daily until tumor progression, unacceptable toxicity or a maximum of up to 12 cycles of post-RT TMZ. Cohorts of 3 patients were treated during RT and TMZ at doses of 250mg daily, 250mg BID, or 500mg BID of vatalanib. Following the completion of RT, patients were treated with vatalanib 750mg BID for the remainder of the study. Results: Nineteen patients were enrolled of which 17 took 5 or more days of vatalanib (1 patient withdrew consent prior to start of vatalanib and 1 withdrew consent after only 1 dose). The median age was 58 and the median KPS was 90. Eight patients had a diagnostic biopsy only. The MTD has not been reached. Potentially related grade 3–4 toxicities included elevated transaminases (2 patients), thrombocytopenia (1 patient), leukopenia (1 patient), neutropenia (1 patient), depressed level of consciousness (1 patient), and fatigue (1 patient). Only 1 patient suffered an asymptomatic intracerebral hemorrhage and no patient experienced wound dehiscence or infection. Five patients remain on vatalanib and the median follow-up for all patients is 6.5 months. Seven patients have died. The best responses for the 13 patients who completed combination RT/TMZ/vatalanib was 2 PR, 7 SD, and 2 PD. Two patients were clinically stable with biopsy proven pseudoprogression. Median PFS is 18.4+ months and OS has not been reached. Conclusions: Vatalanib is safe and well tolerated when added to standard RT and TMZ. The MTD has not been reached and dose escalation continues in this population of patients on enzyme inducing anti-epileptic drugs.

[Table: see text]

Use of neurovascular imaging in GBM patients (pts) to quantify early physiologic changes after treatment with XL184, an inhibitor of multiple receptor tyrosine kinases: Results from a phase II study

2048

Background: Treatment of recurrent glioblastoma by targeting VEGF has gained recent attention. Bevacizumab (bev) or cediranib block VEGFR signaling which is detectable within one day by MRI; early changes on MRI may correlate with clinical outcome. XL184 is a potent orally bioavailable inhibitor of MET, RET, KIT, and VEGFR2; MET and VEGFR2 have been shown to play important roles in tumor angiogenesis. In preclinical models, simultaneous inhibition of MET and VEGFR2 with XL184 results in profound regression of tumor vasculature which is qualitatively different from that observed with other antiangiogenic agents. Methods: A multicenter phase II study of XL184 in 46 pts with relapsed or progressive GBM with primary endpoints of 6-month progression free survival and safety is fully enrolled. Vascular neuroimaging including DCE-MRI, CBV/CBF, diffusion, and magnetic resonance spectroscopy (MRS) is performed in these GBM pts treated with XL184. Lesion volumes are also calculated. Assessments are at baseline, 24 hours post first dose, at 4 weeks and 8 weeks. Results: As of January 1, 2009, 38 pts have undergone imaging. In all 9 pts with imaging available at Day 28, decreases in tumor size were seen on post-Gd T1 (mean drop 51%, SD 31%, p = 0.03 by t-test) and FLAIR (mean drop 53%, SD 20%, p = 0.001) consistent with an anti-vascular/anti-edema effect. In 11 of 14 pts T1 volume decrease was visible on Day 1 (mean drop 20%, SD 12%, p = 0.01), consistent with the rapid changes seen with VEGF inhibition. Two of 3 pts with no Day 1 decrease in enhancing lesion volume were bev-pretreated. Pts treated with other VEGF inhibitors (vandetanib, VEGF-TRAP) responded similarly to naïve pts at Day 1 and 28. Assessment of Ktrans in 5 pts showed a 79% decrease (SD 13%, p = 0.04). MRS from 3 pts showed an increase of the NAA/Choline ratio (10–100%) between the baseline and Day 28 scans, and a decrease in lipid levels (50–100%), suggesting inhibition of tumor progression. Conclusions: Treatment with XL184 results in significant decreases in lesion volume and Ktrans at Day 1 and even greater decreases at Day 28, suggestive of biological activity in GBM.

[Table: see text]

Phase I/II study of erlotinib and temsirolimus for patients with recurrent malignant gliomas (MG) (NABTC 04–02)

2004

Background: Glioblastomas (GBM) frequently have EGFR amplification/mutations and inactivation of PTEN. Although single agent EGFR and mTOR inhibitors have limited activity, combinations of these agents may be more effective. Methods: The North American Brain Tumor Consortium conducted a phase I/II study of the EGFR inhibitor erlotinib in combination with the mTOR inhibitor temsirolimus in recurrent MG. Eligibility criteria were histologically proven GBM and anaplastic gliomas (AG), radiologic progression, >18 years old, KPS >60, adequate bone marrow and organ function. There was no limit on the number of prior relapses for phase I and no more than two prior relapses for phase II. Patients must not be receiving enzyme-inducing antiepileptic drugs. The dose of erlotinib was 150 mg/d in phase I and titrated up to maximum of 200mg/d in phase II depending on tolerability. Patients initially received temsirolimus 50 mg i.v. once weekly and the dose adjusted based on toxicities. Escalation was performed in groups of three. MTD was defined as the dose with 1/6 or fewer patients with dose-limiting toxicities (DLTs). Primary endpoint for the phase II component was PFS6. Results: In phase I, 22 patients were enrolled (15 GBM; 7 AG). Median age was 54 years (26–74); median KPS 90 (70–100); median prior relapses 1 (0–3). The MTD was determined to be 150 mg of erlotinib daily combined with 15 mg of temsirolimus weekly. DLTs were rash, mucositis, and liver function abnormalities. Pharmacokinetic data were similar to that for single agent erlotinib and temsirolimus; there was no interaction between the two drugs. AUC accumulation ratios between cycle 1 and 2 for erlotinib and OSI-420 were 3.6 and 4.6, respectively. In phase II, there were 56 patients (including 12 phase I patients treated at the MTD): 40 GBM; 16 AG, median age 47 years (20–72); median KPS 90 (range 60–100), median prior relapses 1 (range 1–3). Six patients discontinued therapy as a result of toxicities. For GBM patients, there was no PR, 30% SD, and PFS6 was 12.5%. For AG patients there was 12.5% PR, 12.5% SD, and PFS6 was 6.25%. Conclusions: The combination of erlotinib and temsirolimus was associated with a higher than expected incidence of toxicities and had minimal activity in recurrent MG.

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A phase II study of XL184 in patients (pts) with progressive glioblastoma multiforme (GBM) in first or second relapse

2047

Background: XL184 is a potent orally bioavailable inhibitor of MET, RET, KIT, and VEGFR2. Elevated levels of VEGFR2 and its ligand VEGF are found in GBM, and elevated levels of MET and KIT are correlated with poor prognosis in GBM pts. Treatment with XL184 results in potent inhibition of GBM in preclinical models. Methods: This is a phase II study of 46 pts with recurrent GBM who received XL184 175mg PO qd. Co-primary objectives are 6-month progression-free survival (PFS6) and safety. Secondary objectives include response rate (per MacDonald Criteria), duration of response, overall survival, pharmacodynamic and pharmacokinetic parameters, vascular imaging, and changes in steroid usage. Results: As of January 6, 2009, all 46 pts have been enrolled. At least 1 post-baseline tumor assessment at 4 weeks was available for 26 pts. Of these, 17 pts had not received prior therapy with an anti-angiogenic agent, whereas 9 pts had received prior therapy with bevacizumab (n = 6), vandetanib (n = 2), or VEGF-TRAP (n = 1). Safety: 6 pts have experienced a total of 9 possibly related grade 3/4 SAEs including increased troponin I and myocarditis (n = 1); dehydration, nausea, and fatigue (n = 1); elevated ALT (n = 1); pulmonary embolism (n = 2); and CNS hemorrhage (n = 1). 24/46 (52%) pts have required a dose interruption or reduction due to AEs or SAEs. Based on investigator assessment of bidimensional contrast-enhancing tumor measurements, 10 pts (38%) had a best radiologic response of >= 50% reduction from baseline (including 1 pt with a 100% reduction), 9 pts (35%) had tumor measurement changes ranging from +24% and -49%, and 7 pts (27%) had a >= 25% increase in tumor burden. Of the 17 anti-angiogenic-naïve pts, 9 (53%) had a best radiologic response of >= 50% reduction in tumor burden. 1 pt with prior vandetanib therapy has experienced a best radiologic response of >= 50%. Of the 4 pts with > 6 months follow-up, 3 remain on study with a sustained radiologic response. Conclusions: XL184 at a dose of 175 mg PO qd, has demonstrated substantial activity in pts with progressive or recurrent GBM. Updated safety and efficacy results including centrally reviewed PFS6 and response rate will be reported.

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Phase II trials of erlotinib or gefitinib in patients with recurrent meningiomas

2062

Background: No effective treatment is available for recurrent meningiomas when surgical and radiation options are exhausted. The epidermal growth factor receptor (EGFR) is often over-expressed in meningiomas and may promote tumor growth. In open label, single arm phase II studies of the EGFR inhibitors gefitinib (NABTC 00–01) and erlotinib (NABTC 01–03) for recurrent malignant gliomas, we included exploratory subsets of recurrent meningioma patients. We have pooled the data and report the results here. Methods: Patients with recurrent histologically confirmed meningiomas and no more than two previous chemotherapy regimens were treated with gefitinib 500 mg/day or erlotinib 150 mg/day until tumor progression or unacceptable toxicity. Results: Twenty-five eligible patients were enrolled with median age 57 years (range 29–81) and median Karnofsky performance status (KPS) score 90 (range 60–100). Sixteen patients (64%) received gefitinib and nine (36%) erlotinib. Eight patients (32%) had benign tumors, 9 (36%) atypical, and eight (32%) malignant. For benign tumors, the 6-month progression-free survival (PFS6) was 29%, 12-month PFS (PFS12) 0%, 6-month overall survival (OS6) 63%, and 12-month OS (OS12) 50%. For atypical/malignant tumors, PFS6 was 25%, PFS12 19%, OS6 81%, and OS12 68%. There were no significant PFS or OS differences by histology. Of 21 evaluable patients, there were no responses; eight patients (38%) had stable disease, and 13 (62%) had progressive disease. Treatment was well-tolerated. Rash was not a significant predictor of PFS or OS. Conclusions: Neither gefitinib nor erlotinib appear to have significant activity against recurrent meningioma. The role of EGFR inhibitors in meningiomas is unclear but evaluation of EGFR inhibitors in combination with other targeted molecular agents may be warranted.

No significant financial relationships to disclose.

Theoretical basis for identification of different anesthetic states based on routinely recorded EEG during operation

In this paper, we present a new method to identify anesthetic states based on routinely recorded electroencephalogram (EEG). The identification of anesthesia stages are conducted using fast Fourier transform (FFT) and modified detrended fluctuation analysis (DFA) method. Simulation results demonstrate that this new method can clearly discriminate all five anesthesia states: very deep anesthesia, deep anesthesia, moderate anesthesia, light anesthesia and awake.