The reliability of nipple aspirate and ductal lavage in women at increased risk for breast cancer--a potential tool for breast cancer risk assessment and biomarker evaluation

PURPOSE

Ductal lavage, a technique used to sample epithelial cells from breast ducts, has potential use in risk assessment and biomarker evaluation among women at increased risk for breast cancer. However, little is known about the reliability of the procedure.

METHODS

We evaluated the reliability of nipple aspirate (NAF) and ductal lavage at two time points 6 months apart in women at increased risk for breast cancer. Eligible women had a 5-year Gail risk >or=1.66% or lifetime risk of >20%, and/or a family history or personal history of breast cancer. All ducts that produced NAF were cannulated. The kappa statistic was used to evaluate reliability of NAF production, cellular yield, and cytologic diagnosis.

RESULTS

Sixty-nine women (mean age, 47 years) were enrolled over 35 months. Forty-seven returned for a second visit. At baseline, 65% of premenopausal and 41% of postmenopausal women produced NAF (P = 0.05), of which 72% underwent successful lavage of at least one duct. Samples of inadequate cellular material for diagnosis were significantly more likely in postmenopausal women than in premenopausal women (P = 0.04). Of the women who returned for a second visit, 18 of 24 who produced NAF had at least one duct successfully cannulated. Twenty-four ducts in 14 women were lavaged twice. Among these ducts, cellular yield for the two time points was inconsistent (kappa = 0.33 +/- 0.13), and only fair cytologic agreement was observed (kappa = 0.32 +/- 0.15). Ductal lavage was associated with moderate discomfort.

CONCLUSION

Currently, the use of ductal lavage is limited by technical challenges in duct cannulation, inconsistent NAF production, a high rate of inadequate cellular material for diagnosis, fair cytologic reproducibility, and low participant return rates.

Recombinant Newcastle disease virus (NDV) with inserted gene coding for GM-CSF as a new vector for cancer immunogene therapy

This is the first report describing recombinant (rec) Newcastle disease virus (NDV) as vector for gene therapy of cancer. The gene encoding granulocyte/macrophage colony-stimulating factor (GM-CSF) was inserted as an additional transcription unit at two different positions into the NDV genome. The rec virus with the strongest production of the gene product (rec(GM-CSF)) was selected for our study. The insertion of the new foreign gene did neither affect the main features of NDV replication nor its tumor selectivity. The gene product was biologically active and stable. Tumor vaccine cells infected by rec(GM-CSF) stimulated human peripheral blood mononuclear cells (PBMC) to exert antitumor bystander effects in vitro in a tumor neutralization assay. These effects were significantly increased when compared to vaccine infected by rec(-) virus. Furthermore, rec(GM-CSF) led to a much higher interferon-alpha (IFN-alpha) production than rec(-) when added as virus or as virus-modified vaccine to PBMC. Two distinct cell types, monocytes and plasmacytoid dendritic cells were shown to contribute to the augmented IFN-alpha response of PBMC. In conclusion, the already inherent anti-neoplastic and immunostimulatory properties of NDV could be further augmented by the introduction of a therapeutic gene whose product initiates a broad cascade of immunological effects in the microenvironment of the vaccine.

Quantum chemistry calculations for molecules coupled to reservoirs: formalism, implementation, and application to benzenedithiol

Modern quantum chemistry calculations are usually implemented for isolated systems-big molecules or atom clusters; total energy and particle number are fixed. However, in many situations, like quantum transport calculations or molecules in a electrochemical environment, the molecule can exchange particles (and energy) with a reservoir. Calculations for such cases require to switch from the canonical to a grand canonical description, where one fixes the chemical potential rather than particle number. To achieve this goal, the authors propose an implementation in standard quantum chemistry packages. An application to the nonlinear charge transport through 1,4-benzenedithiol will be presented. They explain the leading finite bias effect on the transmission as a consequence of a nonequilibrium Stark effect and discuss the relation to earlier work.

A tool for assessing adverse events in phase I/II oncology clinical trials

6518

Background: RECIST and NCI's Common Terminology Criteria are accepted systems that have standardized the reporting of oncology clinical trial outcomes. A standard system for attributing causality to Serious Adverse Events (SAEs) is lacking which can impact drug development and patient safety. The objectives of this study were to: 1) understand the clinical reasoning behind causality assessment during phase I/II oncology clinical trials; and, 2) use this information to develop a causality assessment tool for oncology. Methods: In-depth interviews were conducted with oncologists and trial coordinators at 6 Canadian academic cancer centres. Five main conceptual categories were explored: clinical reasoning; information resources; tools; challenges and concerns; and education. Interviews were recorded and transcribed verbatim. Individual interview content analysis was followed by thematic analysis across the interview set. A new causality assessment tool was developed based upon the qualitative findings and an analysis of existing generic tools. Results: Thirty-two interviews were conducted between May and August 2006 (65% participation). Half of participants were female, 66% were oncologists and 42% had more than 10 years of clinical trial experience. Data showed that participants use a common strategy to assess causality: they gather information, eliminate alternative explanations, and consider the study drug as the cause of the SAE. Over half cited the quality of information resources as a major factor contributing to uncertainty when assessing causality. Participants expressed the need for a standardized approach to causality assessment in oncology clinical trials. The tool developed in this study guides users to consider 5 statements related to potential alternative etiologies and 4 related to other factors that support a drug-SAE connection. The user is asked for their overall impression using a continuous probability rating scale. Conclusions: Attributing causality to SAEs is complex and uncertain. Clinicians describe using a logical system of reasoning, but have encountered barriers which must be addressed. We have developed and are validating a new tool to assist cancer clinicians in providing higher quality safety data about new cancer drugs early in development.

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Tamoxifen (T) compared to placebo (P), after adjuvant chemotherapy (CT), in premenopausal women with early breast cancer (EBC): Interim results of NCIC-CTG MA.12

547

Background: In the early 1990’s, the role of adjuvant T in premenopausal women with EBC had not been clearly established. The efficacy of adjuvant T in hormone receptor (H) negative EBC was unclear. Methods: Eligible premenopausal women with node (N) +ve/high risk N -ve EBC, any H status, post surgery, received standard adjuvant CT (AC ×4, CMF ×6, CEF x6) then were randomized to T (20 mg/day) or P for 5 yrs. Overall survival (OS), disease-free survival (DFS) and toxicity/compliance were evaluated. Original sample size was 800 pts but based on slow accrual was reduced to 660. Mortality rate is lower than anticipated, and Data Safety Monitoring Committee approved reporting results after second interim analysis (152 deaths). Results: 1993–2000, 672 women randomized, median follow-up 8.4 yrs. For T vs P, 5 yr OS 87% vs 82% [Hazard Ratio HR 0.81 (95% CI 0.58–1.12), p = 0.19] and 5 yr DFS 78% vs 71% [HR 0.79 (95% CI 0.61–1.03), p = 0.09]. HR for OS (0.87 vs 0.78, p = 0.71) and DFS (0.79 vs 0.77, p = 0.87) were not significantly different for H +ve and H -ve tumors respectively. Compliance with T/P was suboptimal, 29% women stopping treatment within 2 yrs, and only 53% completing 5 yrs. Conclusions: Current results show only a trend towards improved DFS for premenopausal women with EBC who receive T after adjuvant CT. Other studies of similar design have shown improved DFS, but not OS, and meta-analysis may be more informative. Issues affecting results (slow accrual, improved outcomes for EBC, poor compliance, additional therapies) will be discussed.

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Parafibromin immunoreactivity: its use as an additional diagnostic marker for parathyroid tumor classification

Parafibromin is a protein product derived from the hyperparathyroidism 2(HRPT2) tumor suppressor geneand its inactivation has been coupled to familial and sporadic forms of parathyroid malignancy. In this study, we have conducted immunohistochemistry on 33 parathyroid carcinomas (22 unequivocal and 11 equivocal) using four parafibromin antibodies directed to different parts of the protein. Furthermore, for a fraction of cases, the immunohistochemical results were compared with known HRPT2 mutational status. Our findings show that 68% (15 out of 22) of the unequivocal carcinomas exhibited reduced expression of parafibromin while the 25 sporadic adenomas used as controls were entirely positive for parafibromin expression. Additionally, three out of the six carcinomas with known HRPT2 mutations showed reduced expression of parafibromin. Using all four antibodies, comparable results were obtained on the cellular level in individual tumors suggesting that there exists no epitope of choice in parafibromin immunohistochemistry. The results agree with the demonstration of a approximately 60 kDa product preferentially in the nuclear fraction by western blot analysis. We conclude that parafibromin immunohistochemistry could be used as an additional marker for parathyroid tumor classification, where positive samples have low risk of malignancy, whereas samples with reduced expression could be either carcinomas or rare cases of adenomas likely carrying an HRPT2 mutation.

Different somatic alterations of the HRPT2 gene in a patient with recurrent sporadic primary hyperparathyroidism carrying an HRPT2 germline mutation

Early onset of primary hyperparathyroidism (PHPT) and multiglandular involvement suggest a familial form in which germline mutation of a PHPT-related gene(s) and a somatic event at the same locus can be often demonstrated. We investigated the involvement of multiple endocrine neoplasia type 1 (MEN1) and HRPT2 genes in a 39-year-old man with recurrent PHPT. PHPT was firstly diagnosed at the age of 21 and the patient had two recurrences separated by extended periods of normocalcemia. This unusual history prompted us to investigate other family members and study the MEN1 and HRPT2 genes. An HRPT2 germline missense mutation in exon 3 (R91P) was found in the index case, which was associated with different HRPT2 somatic alterations in each of the three examined parathyroid tumors. These findings are consistent with Knudson's 'two hit' concept of biallelic inactivation of classical tumor suppressor genes. Screening of 15 asymptomatic relatives was negative for the R91P germline mutation. All the three abnormal parathyroid specimens showed cystic features at histology and were negative for parafibromin immunostaining. In one specimen, diffuse parafibromin staining was evident in a rim of normal parathyroid tissue surrounding the adenomatous lesion. Our study shows that different somatic genetic events at the HRPT2 locus are responsible for the asynchronous occurrence of multiple adenomas in a patient carrying an HRPT2 germline mutation. The finding of diffuse parafibromin staining in a rim of normal parathyroid tissue, but not in the contiguous adenomatous lesion, reinforces the concept that loss of parafibromin expression is responsible for the development of parathyroid tumors in this setting.

Audiological long-term results following stapedotomy with stapedial tendon preservation

Various functions are attributed to the stapedial reflex: as a low-frequency filter, it improves hearing in noise and serves in the protection against acoustic trauma. Our study analyzed 25 patients who had undergone argon laser stapedotomy with preservation of the stapedial tendon compared to patients without tendon preservation. Long-term audiological results are presented. Seventy-six percent of the patients had a residual postoperative air-bone gap of 10 dB or better and 97% of the patients 20 dB or better following stapedotomy with preservation of the stapedial tendon; these results are equal to those of patients without tendon preservation. The comparison of the uncomfortable threshold level showed no statistical difference between patients with and without tendon preservation, but patients with tendon preservation showed a tendency to better results in the sound-noise ratio. These favorable results remained constant in long-term controls.

Delays in diagnosis and initiating treatment for patients with lung cancer

6102

Background: Many patients with lung cancer report delays in the diagnosis of their disease. This situation may contribute to advanced stage at diagnosis and poor long term survival. This study explores the delays experienced by patients referred to a regional cancer centre with lung cancer. Methods: A prospective cohort of patients referred to a regional cancer centre with newly diagnosed lung cancer were surveyed over a 3 month period. Surgically resected patients were not included as they were treated at another site. Patients were asked when they first experienced symptoms, when they saw their doctor, what tests were done, when they saw a specialist and when they started treatment. A medical record review was employed to validate the data patients provided. Descriptive statistics were used to summarize the different time intervals. Results: 56 of 73 patients consented (RR 77%). However, only 52 patients (30M, 22F) were interviewed as two expired before being interviewed and two could not be contacted. The mean age was 68 yrs. Stage distribution was as follows: IB/IIA 10%, IIIA 20%, IIIB/IV 70%. The initial treatment was as follows: 10% of patients supportive care alone, 19% chemotherapy, 44% radiation and 27% had combined chemoradiation. Patients waited a median of 21 days (IQR 7–51d) before seeing a doctor and a further 22d (IQR 0–38d) to complete any investigations. The median time from presentation to specialist referral was 27d (IQR 12–49d) and a further 63d (IQR 44–102d) to complete investigations. The median wait time to start treatment once patients were seen at the cancer centre was 10d (IRQ 2–28d). The overall time from development of first symptoms to starting treatment was 139d (IQR 100–174d). Conclusions: Lung cancer patients experience substantial delays from development of symptoms to first initiating treatment. There is a need to develop and evaluate rapid assessment clinics for patients with suspected lung cancers.

No significant financial relationships to disclose.

Final results of a phase I study of daily oral AZD2171, an inhibitor of vascular endothelial growth factor receptors (VEGFR), in combination with carboplatin (C) + paclitaxel (T) in patients with advanced non-small cell lung cancer (NSCLC): A study of the National Cancer Institute of Canada Clinical Trials Group (NCIC CTG)

3054

Background: AZD2171 is a potent oral inhibitor of the tyrosine kinase activity of all VEGFR subtypes. This study was undertaken to determine the recommended phase II dose of AZD2171 in conjunction with standard doses of C and T, and to assess the tolerability, safety, PK profile and anti-tumor activity of this combination. Methods: Patients with stage IIIB / IV NSCLC (any histology); PS 0–2; no prior chemotherapy for metastatic disease and no significant hemoptysis / bleeding, were eligible. Treated, clinically stable brain metastases were permitted. C - AUC 6, and T - 200 mg/m2 over 3 hours, q3weekly. AZD2171 commenced day 2 cycle 1 at a starting dose of 30 mg po daily. PK profile of all was drugs performed during cycles 1 and 2. Response was assessed by RECIST every second cycle. Results: 20 patients were enrolled: AZD2171 30 mg (9 pts) and 45 mg (11 pts). Median age 58; 19 PS 0 / 1; 8 females. At 30 mg, one confirmed DLT was observed (grade 3 ALT); hypertension ≥ grade 2 was seen in 6 pts, prompting the institution of a standardized algorithm for management of this predictable toxicity. Of the first 3 pts enrolled to the 45 mg dose level, one DLT was observed (grade 3 febrile neutropenia with grade 3 mucositis); no further DLT was observed in the expanded cohort. Other common toxicities: fatigue, anorexia, mucositis and diarrhea. Hematologic toxicity was not greater than that expected with CT alone. No hemoptysis was seen. To date, 15 pts are evaluable for response: 6 PR, 8 SD and 1 PD. Many SD pts had evidence of tumor shrinkage, including central cavitation. Conclusions: Toxicities of this combination appear manageable and predictable. Full single-agent dose of AZD2171 may be administered with standard C+T. Hypertension, a typical toxicity of inhibitors of VEGF signaling, was observed but manageable. Encouraging anti-tumor activity of the combination has been observed. NCIC CTG BR.24, a phase II/III trial of C+T with AZD2171/placebo is underway.

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Efficacy and safety of silver textile in the treatment of atopic dermatitis (AD)

BACKGROUND

Patients with atopic dermatitis (AD) have an increased tendency to develop bacterial skin infections. Colonization with Staphylococcus aureus is known to be a major trigger and might also play a pathophysiological role. Because of their antiseptic action, silver-coated textiles suppress S. aureus colonization and toxin formation, thus damping the inflammatory reaction.

OBJECTIVES

To evaluate the clinical effectiveness and safety of a special silver textile in the treatment of patients suffering from acute AD.

METHODS

In a randomized phase II monocenter parallel-group comparative study 30 patients were recruited (average age 25.5 years, min. 4 years, max. 70 years) who were affected by AD in an acute phase. During the first study phase from Day 1 to Day 14, 10 patients received a silver textile (Group 1), 10 a silver-free textile (Group 2), and 10 prednicarbate ointment (Group 3). In the second phase from Day 15 to Day 28 all patients wore the silver textile, and during the follow-up period from Day 28 to Day 56 no textiles were used. Prednicarbate ointment was allowed as emergency medication, but ointment consumption was measured. The overall severity of the disease was evaluated using the SCORAD index as the primary efficacy parameter. Secondary parameters included severity of pruritus and the patients' assessment of their disease control (uncontrolled, limited, good or complete). Safety tests included hematology, blood chemistry, urinalysis for silver, and physical examination for silver deposits in the skin and mucous membranes.

RESULTS

The initial SCORAD was 61.6 (IQR 26.6, min. 30.6, max. 99.9). At the end of the Study Phase 1 the SCORAD had improved significantly in the patients of Groups 1 (74.6-29.9, p = 0.005) and 3 (57.8-24.0, p = 0.009). During Study Phase 2 healing of eczema continued in Group 1 (SCORAD 29.9-18.1, p = 0.037), was observed in Group 2 (48.2-24.1, p = 0.015), and remained at an improved level in Group 3 (SCORAD 24-23.5). Consumption of prednicarbate ointment (Phase 1, Phase 2, follow-up period, medians are given): Group 1: 135 g, 10 g, 45 g; Group 2: 13 g, 0 g, 0 g; Group 3: 145 g, 30 g, 90 g. Silver textiles reduced the severity of the pruritus (p = 0.031); silver-free textiles (n.s.) and prednicarbate (n.s.) were less effective. No undesired events were observed.

CONCLUSION

The elastic silver textile worn directly against the skin led to an impressive improvement of AD and a reduction in the use of prednicarbate ointment.

Phase II Study of Troxacitabine (BCH-4556) in Patients with Advanced Non-Small-Cell Lung Cancer

Troxacitabine. a promising new L-nucleoside, inhibits DNA polymerase and leads to complete DNA chain termination. The National Cancer Institute of Canada Clinical Trials Group (NCIC-CTG) conducted a phase II study to assess the efficacy and toxicity of troxacitabine in untreated patients with advanced non-small-cell lung cancer (NSCLC). Previously untreated patients were eligible if they had inoperable stage IIIB or IV NSCLC, ECOG PS < or = 2, adequate hematology and biochemistry, and at least one bidimensionally measurable lesion. Patients with prior malignancy or brain metastases were excluded. Troxacitabine (10 mg/m(2)) was administered intravenously over 30 minutes every 3 weeks. Between June 1999 and May 2000, 17 eligible patients received treatment. Patient characteristics included: median age 64 years; female 41%; stage IV (94%); PS 0 (12%), 1 (59%), and 2 (29 %), 3 or more disease sites (59%). In 17 patients, there were 8 stable disease, 9 disease progression, and no objective responses. Median duration of stable disease was 3.6 months (range = 2.0-7.1). A total of 56 cycles were administered (median = 3), and 88% of patients received 90% or more of the planned dose intensity. The majority (82%) of patients experienced skin rash. Hematologic and biochemical toxicities, grade 3/4 (%) were: granulocytopenia (41), anemia (12), thrombocytopenia (6), and hyperglycemia (6). Troxacitabine appears to have little activity in NSCLC in the dose and schedule tested.

Acute generalized exanthematous pustulosis induced by the antifungal terbinafine: case report and review of the literature

Cutaneous drug reactions occur with a frequency of 1-8% and can be higher for certain classes of drugs. They can range from mild morbilliform eruptions to more severe forms such as drug-hypersensitivity syndrome, toxic epidermal necrolysis or anaphylaxis. Acute generalized exanthematous pustulosis (AGEP) is considered to be a clinical reaction pattern, which is induced in over 90% of the cases by systemic drugs. It is a rare presentation of an adverse drug reaction most frequently triggered by anti-infectious drugs. A high proportion of these cases have been attributed to aminopenicillins and macrolides. We report a terbinafine-induced AGEP in a 68-year-old male confirmed by lymphocyte stimulation in vitro, and review the published cases induced by antimycotic drugs with special emphasis on terbinafine-triggered cases.

IgM-enriched immunoglobulin (pentaglobin) positively influences the course of post-surgical intra-abdominal infections

BACKGROUND

Polyvalent IgM-enriched intravenous human immunoglobulin (IVIG) preparations are discussed to be beneficial regarding sepsis outcome.

MATERIALS AND METHODS

Sixty-four patients with abdominal infection were treated with Pentaglobin or Albumin. Serum levels of endotoxin and chemokines were determined.

RESULTS

Incidence of fever was 19/28 in the pentaglobin and 18/26 in the albumin group, the percentage of days with fever was 34 +/- 26 for pentaglobin and 43 +/- 25 for albumin (mean +/-SD). Procalcitonin levels of the pentaglobin treated patients fell under the upper limit of normal on day six whereas levels of albumin patients remained elevated.

CONCLUSION

Pentaglobin has a positive influence on the course of post-surgery intra-abdominal infection.

[Sudden hearing loss]

Sudden hearing loss is a reduction of sensoneurinal sound perception with a sudden onset. It is usually occurring only in one ear and without a recognizable cause. If a hearing loss is suspicioned due to otoscopic and tuning fork test findings, the patient should rapidly be sent to an ENT-specialist because of the possible consequences. After the first examinations by means of ear microscopy and audiogram further diagnostics may be necessary. If no cause is found, the idiopathic sensorineural hearing loss remains as the exclusion diagnosis. Therapy follows a polypragmatic approach based on the different theories of its origin. Therefore mainly antiinflammatory, antiviral and vasoactive drugs are applied. The high spontaneous healing rate and the still pending proof of effectiveness of all types of therapy used so far must be considered.