Prognostic and predictive significance of 5-fluorouracil metabolic enzymes in colorectal cancer

2021

Background: Low levels of the 5-Fluorouracil (5-FU) metabolic enzymes, thymidylate synthase (TS), dihydropyrimdine dehydrogenase (DPD) and thymidine phosphorylase (TP) are linked to improved survival in colorectal cancer (CRC) patients receiving 5-FU chemotherapy. However, whether they are prognostic (related to tumor biology) or predictive (drug sensitivity) indicators is not clarified. This study aimed to (1) discriminate the prognostic and predictive significance of TS, DPD and TP and (2) ascertain the clinical and molecular subtype associations of the proteins in a large sample series. Methods: Tissue arrays containing sections from 956 stage 2/3 CRC cases were stained immunohistochemically for TS, DPD and TP. Associations with clinical and molecular characteristics and survival according to treatment status were assessed by Kruskall-Wallis and Kaplan-Meier analysis. Results: Low TS levels were associated with late stage, proximal tumor location and absence of microsatellite instability, low DPD with younger age and late stage and low TP with proximal tumor location. Low levels of all three enzymes associated with absence of tumor infiltrating lymphocytes. There were no associations with gender, grade or ras and p53 mutation. In stage 2 patients treated by surgery alone, those with low DPD levels had a worse survival than those with high levels (p<0.01). Stage 3 patients treated with chemotherapy had a better survival than those without in subgroups of patients with low TS (p=0.05), DPD (p<0.01) and TP (p=0.03) but not high levels of the proteins. Conclusions: Our results suggest the improved outcome of 5FU-treated patients with low tumor TS, DPD and TP levels may be due primarily to a benefit from adjuvant treatment rather than a favorable prognosis. TS, DPD and TP levels may be useful indicators for identifying CRC patients likely to benefit from 5-FU treatment.

No significant financial relationships to disclose.

Pathology reporting of breast cancer: trends in 1989-1999, following the introduction of mammographic screening in Western Australia

BACKGROUND

A survey of pathology reporting of breast cancer in Western Australia in 1989 highlighted the need for improvement. The current study documents (1) changes in pathology reporting from 1989 to 1999 and (2) changes in patterns of histopathological prognostic indicators for breast cancer following introduction of mammographic screening in 1989.

METHODS

Data concerning all breast cancer cases reported in Western Australia in 1989, 1994 and 1999 were retrieved using the State Cancer Registry, Hospital Morbidity data system, and pathology laboratory records.

RESULTS

Pathology reports improved in quality during the decade surveyed. For invasive carcinoma, tumour size was not recorded in 1.2% of pathology reports in 1999 compared with 16.1% in 1989 (p<0.001). Corresponding figures for other prognostic factors were: tumour grade 3.3% and 51.6% (p<0.001), tumour type 0.2% and 4.1% (p<0.001), vascular invasion 3.7% and 70.9% (p<0.001), and lymph node status 1.9% and 4.5% (p = 0.023). In 1999, 5.9% of reports were not in a synoptic/checklist format, whereas all reports were descriptive in 1989 (p<0.001). For the population as a whole, the proportion of invasive carcinomas <1 cm was 20.9% in 1999 compared with 14.5% in 1989 (p<0.001); for tumours <2 cm the corresponding figures were 65.4% and 59.7% (p = 0.013). In 1999, 30.5% of tumours were histologically well-differentiated compared with 10.6% in 1989 (p<0.001), and 61.7% were lymph node negative in 1999 compared with 57.1% in 1989 (p = 0.006). Pure ductal carcinoma in situ (DCIS) constituted 10.9% and 7.9% of total cases of breast carcinoma in 1999 and 1989, respectively (p = 0.01).

CONCLUSIONS

Quality of pathology reporting improved markedly over the period, in parallel with adoption of standardised synoptic pathology reports. By 1999, recording of important prognostic information was almost complete. Frequency of favourable prognostic factors generally increased over time, reflecting expected effects of mammographic screening.

A helpline for patients with chronic dermatological conditions

A telephone line was set up for patients with chronic dermatological diseases in response to patients' concerns about having a point of contact for advice and for more appropriate and timely access to care when they needed to be seen. The aims were firstly to improve the quality of care and empower patients by providing advice and support with a safety net for those discharged from the authors' service. The second aim was to increase efficiency by reducing unnecessary return appointments. An audit was undertaken to evaluate the telephone service. This showed that patients were reassured that they could access the service according to their needs. There was a high level of satisfaction with the initiative and the advice received. The data also showed that there was a significant improvement in the ratio of new outpatient slots to return appointment slots and waiting times for a first appointment.

Participation of disadvantaged parents in child care research

AIM

To assess the level to which parents from deprived and socially dysfunctional families collaborate in complex and time-consuming research.

DESIGN

Home-based study, of early physiological development in infants from a severely deprived area. Overnight continuous recordings of deep-body temperature with twice daily urine collection, parental daily diary of life-events and completion of child care social and psychological assessment by interview questionnaire. Measurements taken between age 6-12 weeks, each lasted 8-12 h per night, averaging four nights per baby. Level of parental participation assessed in relation to ongoing lifestyle pressures. Setting Home based. Inner city deprived estate.

PARTICIPANTS

Random sample of mothers with newborn healthy infants.

MEASUREMENTS

A total of 87 overnight deep body temperature recordings were made on 22 infants each lasting 8-12 h; 174 urine samples were taken; and 22 sets of questionnaires were completed.

RESULTS

Of 62 inner city deprived parents, 39 (62%) agreed to participate. 22 (35%) completed the study. Ongoing lifestyle pressures were high including incidents of burglary, fire and family violence. Family and partner pressures and life crises overwhelmed 10 non-participations.

CONCLUSIONS

Research partnerships can be developed with underprivileged families facing severe life-events. Parents were highly motivated to complete what they perceived as important infant care research.

Cisplatin and gemcitabine induction chemotherapy followed by concurrent chemoradiotherapy or surgery for locally advanced non-small cell lung cancer

BACKGROUND

We report a study of induction chemotherapy followed by concurrent chemoradiotherapy for stage IIIA/IIIB non-small cell lung cancer.

METHODS

Patients received two cycles of induction chemotherapy with cisplatin 100 mg/m(2) on day 1 and gemcitabine 1000 mg/m(2) on days 1, 8, and 15 of a 28-day cycle. If the disease was resectable [corrected] surgery was followed with two further cycles. If unresectable, patients received cisplatin 100 mg/m(2) day 1, 29 with 5-fluorouracil 1000 mg/m(2) per 24 h continuous infusion for 96 h on days 2-5 and days 30-33 of the radiotherapy administration. Radiation therapy consisted of 63 Gy, 35 fractions, 7 weeks.

RESULTS

Of 48 patients, 40% had a partial response to induction chemotherapy. Four of eleven patients with stage IIIA tumours had resectable disease. The remaining seven patients plus 37 with stage IIIB disease had chemoradiotherapy. Response at the completion of all therapy was 62% (IIIA 73%, IIIB 59%). For all patients the median survival was 15.3 months: 1 year and 3 years, 58% and 25%, respectively. Those with IIIB disease responding to induction chemotherapy had significantly superior survival to those that did not respond (37 months vs 11 months; P = 0.005). This remained significant from a landmark at 8 weeks after the start of treatment (P = 0.01).

CONCLUSION

These results are equivalent to other studies using induction chemotherapy prior to concurrent chemoradiotherapy. Response to induction chemotherapy may have major prognostic significance.

Optimal duration of eptifibatide infusion in percutaneous coronary intervention (an ESPRIT substudy)

Although randomized trials have clearly demonstrated the clinical efficacy with regimens of platelet glycoprotein IIb/IIIa antagonists that result in >80% inhibition of baseline platelet aggregation in percutaneous coronary intervention (PCI), there are no data available concerning the optimal duration of infusion of these agents. In an era when the length of hospitalization has a major impact on health care costs, the determination of the optimal duration of the infusion of these drugs after PCI is of great relevance. The investigators therefore sought to determine the optimal length of the infusion of eptifibatide after PCI by analyzing the outcomes of patients enrolled in the Enhanced Suppression of the Platelet IIb/IIIa Receptor With Integrilin Therapy trial who were randomized to treatment with eptifibatide.

Treatment optimisation using external beam radiation in gynaecological cancers

The majority of patients with gynaecological cancers present with advanced stages in which external beam radiation forms a major component of the treatment. These patients undergo simulation for treatment planning prior to radiation. Currently the lower extent of the disease is evaluated by vaginal examination and marked using a lead wire on the anterior abdominal wall in the pelvic region. A 2 cm margin inferior to this level is used as the lower border of the treatment field. The suggested modified technique includes the placement of an indigenously designed perspex vaginal obturator with graduations at 1 cm distance from its tip. Following vaginal examination the obturator can be inserted into the vagina and fixed at the predefined length using a fixation device. The radio-opaque markers can be seen even in the lateral films. Twentyfive consecutive patients underwent the procedure and the differences between the two methods of marking the lower border were calculated. The external lead wire was inferior to the internal obturator in 19 patients (76%) ranging from 0.5 cm to 3 cm (median 1.5 cm, mean 1.37 cm). It was at the same level in 4 patients (16%) and 1 cm superior to the internal obturator in 2 (8%). With the modified technique using the internal obturator application for delineating the lower border of vaginal disease or vault, it was possible to decrease the length of field thereby reducing the chances of treatment-related toxicity, especially groin and vulval reactions, as well as avoiding treatment interruptions.

Bisphosphonate infusions: patient preference, safety and clinic use

GOALS OF WORK

We set out to assess the preference of patients with common cancers involving bone receiving intravenous bisphosphonate therapy for either pamidronate (P) or zoledronic acid (Z) and their preference for the location of the infusion (clinic or home). We also aimed to monitor these patients' renal safety, and to compare their time in clinic to receive P and Z infusions.

PATIENTS AND METHODS

Enrolled in the study were 184 patients, and all received initial infusions of Z (so any first infusion reactions did not confound preferences for P). For their second and third infusions, patients were randomized to receive Z then P or P then Z, and questioned on their preferences. For up to 1 year they continued on Z infusions every 3-4 weeks, while their renal safety was monitored. Where practical, later infusions were given at home (rather than in the clinic) and patients questioned on their preferred infusion location. In a convenience subset of 43 patients, clinic use for Z and P infusions was also measured by timing infusions and other procedures.

MAIN RESULTS

Of 144 patients who received a third infusion, 138 responded to questions on bisphosphonate preference, and of these 138, 92% (127) preferred Z to P, because shorter infusions caused less disruption to their day. Only 12% of eligible patients (16/138) received home infusions, but 13/14 questioned preferred this location. Among 184 patients, 19 episodes of renal impairment were noted, mostly owing to disease progression (e.g. obstructive uropathy), with none linked to Z therapy. The mean clinic time taken to receive Z and any concomitant therapy was about half that for P (78 vs 161 min).

CONCLUSIONS

Cancer patients prefer shorter bisphosphonate infusions-and at home, where practical. Regular Z 4 mg infusions appear to be safe in these patients, with routine monitoring of serum creatinine. Using Z rather than P could save busy cancer centres time and improve patient satisfaction.

The -174 G/C gene polymorphism in interleukin-6 is associated with an aggressive breast cancer phenotype

Serum and tissue levels of interleukin-6 (IL-6) have been implicated in the biological phenotype of breast carcinoma. A common G/C polymorphism at position −174 of the IL-6 promoter can influence the expression level of this gene. We therefore investigated for associations between this polymorphism and various phenotypic features in a series of 256 breast cancers. Individuals who were homozygous for the C allele (n=55) were more likely to have higher-grade tumours (P=0.039) with ductal histology (P=0.030) compared to those harbouring at least one wild-type G allele (n=201). Homozygosity for the C allele was also associated with significantly worse overall survival (P=0.031). We conclude that the −174 C allele of IL-6 is associated with a more aggressive breast cancer phenotype.

Overnight deep body temperature and urinary cortisol excretion in infants from economically deprived areas

OBJECTIVES

To assess the pattern of postnatal physiological maturation in economically deprived infants by measuring the age-related changes in deep body temperature during night-time sleep.

SETTING

Inner city Leicester, UK.

PARTICIPANTS

Forty-eight infants aged 6-21 weeks from economically deprived areas and 87 control infants from more affluent areas.

OUTCOME MEASURES

Average deep body temperature between 2 and 4 h after bedtime, overnight and early morning urinary cortisol excretion.

RESULTS

Both groups showed a decline in overnight deep body temperature with age that averaged 0.030 degrees C per week (SE = 0.003). Over the age range studied, the average age-adjusted overnight temperature in the infants from deprived homes was 0.090 degrees C (SE = 0.028) higher than that for the affluent group (P = 0.001). Deprived infants had on average 51% higher overnight urinary cortisol and 80% higher morning cortisol. The differences remained when the effects of room temperature, clothing, smoking, birthweight and gestational age were taken into account.

CONCLUSION

These indicators of postnatal physiological maturation suggest that infants from economically deprived homes mature less quickly. This might increase their vulnerability to illness.

Reduction of myocardial ischemic injury following coronary intervention (the MC-1 to Eliminate Necrosis and Damage trial)

Myocardial ischemic injury complicating acute myocardial infarction (AMI) and coronary revascularization procedures remains an unresolved clinical dilemma. In preclinical studies, treatment with pyridoxal-5'-phosphate monohydrate (MC-1), a vitamin B6 metabolite, has demonstrated cardioprotective effects. Sixty patients scheduled for elective percutaneous coronary intervention (PCI) who had clinically high-risk characteristics for ischemic complications were randomized to treatment with MC-1 or placebo in a 2:1 double-blinded fashion. The primary end point was defined as infarct size as measured by area under the curve creatine kinase MB (CK-MB) enzymes. Secondary end points included periprocedural ischemia as assessed by continuous electrocardiographic monitoring, 30-day major adverse cardiac events, and net clinical safety, which included liver function testing. The primary end point, median periprocedural CK-MB area under the curve, was reduced from 32.9 ng/ml in the placebo group to 18.6 ng/ml with MC-1 treatment (p = 0.038), reflecting a shift in the distribution of CK-MB. By categorical classification, the occurrence of 30-day nonfatal AMI did not differ between groups. There were no deaths, and 30-day composite adverse event rates were similar (17.9% MC-1 vs 15.0% placebo, p = 1.0). There were no significant differences in ischemia parameters per continuous electrocardiographic monitoring, and no safety issues were identified. In this phase II pilot study, treatment of high-risk patients who underwent PCI with MC-1 was associated with a decrease in the total amount of CK-MB released after PCI. These results support the evaluation of MC-1 in pivotal trials of patients at risk for developing myocardial ischemia, infarction, or reperfusion injury.

Relapse patterns after chemo-radiation for carcinoma of the oesophagus

AIM

The detailed review of patterns of failure in this report was undertaken to identify the continuing obstacles to the successful management of oesophageal cancer, and to establish whether there is a case to compare definitive chemo-radiation (Def-CR) and surgery for patients with squamous cancer in a randomized controlled trial.

MATERIALS AND METHODS

First and subsequent sites of failure were reviewed in 274 patients treated with Def-CR using two cycles of cisplatin, infusional fluorouracil and 60 Gy; and 92 patients with limited chemo-radiation (CR), using one cycle and 35 Gy, followed by surgery (CR-Surg). All were treated on prospective non-randomized trials run by the Trans-Tasman Radiation Oncology Group between 1985 and 1999. Failure patterns were analysed using competing risks methodology, and pre-treatment variables predicting survival were identified by proportional hazards modelling.

RESULTS

Site, stage, performance status and gender were independently predictive of survival following Def-CR. Local failure was evident in 42.3% of patients, but distant failure in isolation occurred in an additional 18.1%. Lowest rates of local and distant failure at 5 years (29.9% and 26%) occurred in patients with squamous cancer (SCC) located in the upper-third, whose 5-year survival was also the most favourable (49.2%). Survival was least favourable in patients with adenocarcinoma (AC) in the lower two-thirds (18.1%) due to higher rates of local (51.5%) and distant (36.1%) failure. Local failure occurred in 31.5% of patients undergoing CR-Surg but distant failure in isolation was observed in a further 34.7%. Outcomes were least favourable in patients with AC of the lower-third in whom 57.7% failed distantly and 5-year survival was 3.8%. Response to pre-operative chemo-radiation was also strongly predictive of outcome. Patients with no residual cancer in the resection specimen had the lowest rates of local (0%) and distant (16.7%) failure and the best survival (64.9%). Survival in patients with residual cancer in nodes, however, was extremely poor (3.5%) with distant failure occurring in 66.7%.

CONCLUSION

The concurrent administration of chemotherapy with radiotherapy seems to have improved loco-regional control and has exposed distant failure as an obstacle to further improvements in outcome. Site, histological subtype, gender and response to chemo-radiation may predict biological differences in oesophageal cancer (OC) that influence outcome. A good case for a randomized comparison between Def-CR and CR-Surg in patients with SCC in the lower two-thirds exists.

Assessment of the accuracy of transrectal ultrasonography in anorectal neoplasia

BACKGROUND

Accurate preoperative staging of anorectal neoplasia is required to identify patients for whom local excision or adjuvant therapy may be appropriate. The objectives of this study were to review the accuracy of endoluminal transrectal ultrasonography (TRUS) in the staging of rectal cancers and to determine the learning curve before optimal staging accuracy can be achieved.

METHODS

The results of all TRUS examinations for the assessment of anorectal neoplasia performed by two colorectal surgeons at two teaching hospitals of the University of Sydney from 1991 to 2001 were collected prospectively.

RESULTS

Of the 433 patients examined by TRUS, 356 were included, of whom 263 (73.9 per cent) had nodal status assessed histologically. Of the 77 patients excluded, 50 had undergone radiotherapy before operation. TRUS achieved excellent accuracy when compared with histopathology reports using kappa statistics for standard Union Internacional Contra la Cancrum (UICC) staging (kappa = 0.89), tumour wall penetration (kappa = 0.70), lymph node detection (kappa = 0.66) and a proposed new staging system (kappa = 0.94). In addition, the increase in TRUS accuracy with operator experience demonstrates the need to perform 50 or more procedures before optimal accuracy is achieved.

CONCLUSION

TRUS provides an appropriate investigation with which to select patients with T1 tumours for local excision, and patients with T3 or T4 tumours for preoperative radiotherapy. The relative inaccuracy of staging T2 tumours by TRUS has led to a proposed alternative ultrasonographic staging system.

Characterisation of colorectal cancers showing hypermethylation at multiple CpG islands

BACKGROUND AND AIMS

A subgroup of colorectal cancers (CRC) referred to as the CpG island methylator phenotype (CIMP+) shows simultaneous methylation of multiple CpG islands. The clinicopathological and molecular characteristics of this phenotype remain uncertain however.

METHODS

We analysed methylation of CpG islands in the p16 and MDR1 genes and MINT-2 clone in 275 stage II/III CRCs.

RESULTS

Concurrent methylation of two or more CpG islands was observed in 32% of cases and was considered to represent CIMP+. These were often poorly differentiated, had less TP53 mutations, and originated frequently in the proximal or higher stage CRC compared with CIMP- tumours (p<0.05 for each). CIMP+ had no prognostic significance in stage II or stage III CRC treated by surgery alone. hMLH1 methylated tumours comprised the majority (81%) of cases with microsatellite instability, were frequently observed in older female patients, were often poorly differentiated or CIMP+, and contained wild-type K-ras (p<0.05 for each). Females who were heterozygous or homozygous for the C677T MTHFR polymorphism were at increased risk of developing CIMP+ CRC (odds ratio 2.17, 95% confidence interval 1.03-4.57; p=0.037).

CONCLUSIONS

These observations made in a relatively large unselected series of CRC support the notion that CIMP+ characterises a subgroup of tumours with distinctive phenotypic features.

Is glycoprotein IIb/IIIa antagonism as effective in women as in men following percutaneous coronary intervention? Lessons from the ESPRIT study

OBJECTIVE

The study was done to determine whether eptifibatide, a platelet glycoprotein (GP) IIb/IIIa antagonist, prevents ischemic complications following percutaneous coronary interventions (PCIs) in women as well as in men.

BACKGROUND

Eptifibatide reduces ischemic complications after nonurgent coronary stent interventions.

METHODS

We compared outcomes in women (n = 562) and men (n = 1,502) enrolled in the Enhanced Suppression of the Platelet GP IIb/IIIa Receptor with Integrilin Therapy (ESPRIT) trial of double-bolus eptifibatide during PCI.

RESULTS

Women in the ESPRIT trial were older, and more frequently had hypertension, diabetes mellitus, or acute coronary syndromes, but were less likely to have prior PCI or coronary artery bypass graft surgery. The primary end point, a composite at 48 h of death, myocardial infarction (MI), urgent target vessel revascularization (TVR), and unplanned GP IIb/IIIa use, occurred in 10.5% of women and 7.9% of men (p = 0.082). The composite of death, MI, or TVR after one year occurred in 24.5% of women compared with 18% of men (p = 0.0008). At 48 h, eptifibatide reduced the composite of death, MI, and TVR from 14.5% to 6.0% in women versus 9.0% to 6.8% in men. At one year, these differences persisted: 28.9% versus 20.0% for women and 19.5% versus 16.6% for men. No statistical interaction existed between treatment and gender at either 48 h (p = 0.063) or one year (p = 0.2). Bleeding occurred more commonly in women (5.5% vs. 2.6%, p = 0.002), and was more common in eptifibatide-treated women. After adjustment for age, weight, and hypertension, no interaction between treatment and gender was present.

CONCLUSION

Eptifibatide is effective to prevent ischemic complications of PCI in women and may eliminate gender-related differences in PCI outcomes.

Simulation of organismic morphology and behavior by synthetic poly-alpha-amino acids

Experiments imitating spontaneous geothermal occurrences have yielded most of the amino acids found in protein. All of the amino acids found in protein are simultaneously condensed, by heating in a range of appropriate conditions, to polymers which have many of the properties of proteins. These properties include molecular weights of many thousand, digestibility by proteolytic enzymes, and catalytic activities. One of the other properties is the tendency to form structured units; these units have many of the attributes of biocells. The processes indicated, and others, comprise a conceptual continuum which, according to accumulated information, must have occurred under the conditions existing in regions of the primitive Earth.