Orthotopic, but reversed implantation of the liver allograft in situs inversus totalis-a simple new approach to a difficult problem

Situs inversus totalis is a rare congenital anomaly in which the heart and abdominal organs are oriented in a mirror image of normal. It provides a unique challenge as there is no established technique for liver transplantation in these patients. Employing two major alterations from our standard technique, a liver was transplanted in the left subphrenic space of a patient with situs inversus totalis. First, the liver was flipped 180 degrees from right to left (facing backward). Second, a reversed cavaplasty (anterior, not posterior, donor suprahepatic caval incision) was performed. Otherwise, it was standard, with end-to-end anastomoses of the portal vein, hepatic artery and bile duct. Three years after the entirely uneventful transplant, the recipient continues to enjoy the benefits of a normally functioning liver. The described technique prevented torsion, kinking and tension on the anastomosed structures by allowing the liver to sit naturally in an anatomical position in the left hepatic fossa. As it required no special measurements or maneuvers, the technique was easy to execute and required no donor liver size restrictions. This novel technique, with a reversed cavaplasty and a 180 degrees right-to-left flip of the liver into a left-sided hepatic fossa, may be ideal for situs inversus totalis.

Primary chemotherapy, stereotactic radiosurgery, or whole brain radiotherapy in non-small cell lung cancer (NSCLC) patients with asymptomatic brain metastases

e19063

Background: Approximately 25 to 30% of patients with lung cancer develop brain metastases at some stage and 12∼18% at the time of initial presentation. Whole brain radiotherapy (WBRT) has long been a mainstay of treatment of brain metastases. Another treatment approach, Stereotactic radiosurgery (SRS) is a method of delivering high doses of focal irradiation to a tumor while minimizing the irradiation to the adjacent normal tissue. However, the prognosis of NSCLC patients with asymptomatic brain metastases, who are not treated with SRS or WBRT, has not been fully investigated yet. This study aimed to analyze the outcome for various treatment modalities in NSCLC patients with asymptomatic brain metastases. Methods: We reviewed the medical records of 129 patients with a histopathologically proven NSCLC and a synchronous brain metastases between January 2003 and December 2007. The patients were categorized as primary chemotherapy, primary SRS, and primary WBRT group: primary chemotherapy (78 patients), primary SRS (24 patients), and primary WBRT (27 patients). Results: With median follow-up of 30.0 months (7.2 -70.7), the median overall survival (OS) for the entire patients was 15.6 months (0.5–50.7) and the progression free survival (PFS) was 6.1 months (0.3- 53.0). The OS was 22.4m for primary SRS group, 13.9m for primary chemotherapy group, and 17.7m for primary WBRT group; p=0.86). However, patients treated with primary SRS showed trend toward prolonged survival compared to those of primary WBRT p=0.06). Subset analysis of 110 adenocarcinoma patients showed that the median OS for patients treated with primary SRS was longer than those of primary WRBT (29.3m vs 17.7m p=0.01) or primary chemotherapy (29.3m vs 14.6m p=0.04). Conclusions: These results suggest that for NSCLC patients with asymptomatic brain metastases at first diagnosis, SRS rather than primary chemotherapy or WBRT might be considered as initial treatment, especially for patients with adenocarcinoma.

No significant financial relationships to disclose.

Clinical significance of type 1 insulin-like growth factor receptor and insulin-like growth factor binding protein-3 expression in squamous cell carcinoma of head and neck

6036

Background: Type 1 insulin-like growth factor receptor (IGF-1R) plays an important role in the growth and apoptosis of cancer cell. The activities of IGF-1R are modulated by a family of high-affinity insulin-like growth factor binding proteins (IGFBPs), of which IGFBP-3 is the major serum carrier protein. The expression and significance of IGF-1R and IGFBP-3 in squamous cell carcinoma of the head and neck (SCCHN) is unknown. Methods: This study explored immunohistochemical expression of IGF-1R and IGFBP-3 in tumor samples from 131 patients with surgically resected SCCHN. Results: The positive expression of IGF-1R and IGFBP-3 was observed in 96 (73.3%) and 117 (89.3%) patients. There were no significant differences in baseline characteristics between the positive and negative expressed groups of IGF-1R and IGFBP-3. With the median follow up of 53.5 months, 3 year progression free (PFS) and overall (OS) survival rate was 64.0% and 72.9%, neither IGF-1R nor IGFBP-3 expression had prognostic values in the whole cohort. Thirty-seven (67.3%) of 55 stage IV patients demonstrated IGF-1R positivity. The subgroup analysis of in stage IV patients showed the poor PFS ( = 0.029) and OS (pp = 0.025) in IGF-1R positive groups. In a multivariate analysis using IGF-1R expression and other clinicopathological parameters, the IGF-1R expression was remained as an independent factor for PFS (p = 0.037, HR = 2.816, 95% C.I. 1.065 - 7.446) and OS (p = 0.034, HR = 3.169, 95% C.I. 1.089 - 9.225). Conclusions: Our work exhibited that IGF-1R expression is frequent in SCCHN patients and related with poor survival in advanced stage, this could support the attempts using the IGF-1R inhibitor for treatment of SCCHN.

No significant financial relationships to disclose.

A phase II study of gemcitabine-based chemoradiotherapy (CCRT) after triplet induction chemotherapy (ICT) for locally advanced pancreatic cancer (LAPC): A Taiwan Cooperative Oncology Group (TCOG) study

e15562

The optimal management of LAPC remains controversial. The efficacy of CCRT is hampered by early systemic dissemination. To treat undetectable metastases and to select patients who are likely to benefit from CCRT, ICT followed by CCRT has recently been extensively evaluated in LAPC. Recently, we showed that triplet chemotherapy consisting of gemcitabine 800 mg/m2 (10 mg/m2/min) followed by oxaliplatin 85 mg/m2 and 48-hour infusion of 5-FU/LV 3,000 and 150 mg/m2 Q 2 weeks, the GOFL regimen, is feasible and active for pts with APC. Chemo-naïve pts with histo- /cytologically proven unresectable LAPC, and bi-dimensionally measurable diseases were eligible. Patients who did not experience disease progression (PD) after 6 cycles of GOFL would had CCRT consisting of weekly gemcitabine 400mg/m2 plus 50.4Gy/28 fractions of radiation 4–6 weeks later. After CCRT, pts were re-evaluated for surgical intervention and those with unresectable disease would continue GOFL until PD, unacceptable toxicity, patient's refusal or death. Among the 50 enrolled pts (24F/26M, median age 58.5 years), 48 had definitively unresectable diseases. After induction GOFL, 16 (32%) pts were off-studied because of PD in 12 (24%) and ICT-related toxicity in 4 (8%, PD/UE group). Among the 34 (68%) with objective response or stable disease after 6 cycles of ICT, 27 (54%) who completed the assigned multimodality treatment are categorized as CCRT group; whiles 7 (14%) who either declined CCRT (in 5) or still on ICT (in 2) are categorized as non-CCRT group. The median PFS and OS for the ITT population were 9.1 and 14.5 months, respectively. The median PFS for PD/UE, non-CCRT and CCRT groups were 2.1, 8.2 and 12.8 months, respectively; whiles the OS were 8.5, 15.0 and 18.3 months, respectively. The most common grade 3–4 toxicities were neutropenia (40%), anemia (14%), infection (16%), nausea (26%), vomiting (20%). Grade 2–3 peripheral neuropathy was observed in 7 of 29 who received post-CCRT GOFL. Conclusion: Three months of triplet ICT followed by gemcitabine-based CCRT is feasible and likely to prolong the survival of selected LAPC pts. Prospective, randomization study is warranted to validate the findings.

No significant financial relationships to disclose.

Prognostic role of insulin-like growth factor receptor-1 (IGFR-1) and insulin-like growth factor binding protein-3 (IGFBP-3) expression in small cell lung cancer

e22155

Background: Insulin-like growth factor receptor-1 (IGFR-1) is a cellular membrane receptor overexpressed in many tumor cell lines and in some human tumors that seems to play a critical role in anti-apoptosis by enhancing cell survival. Also, insulin-like growth factor binding protein-3 (IGFBP-3) was reported to be a growth suppressor in variable pathways. Purpose of this study was to evaluate the state IGFR-1 and IGFBP-3 expression in patients with small cell lung cancer (SCLC) and its prognostic value. Methods: We analyzed IGFR-1 and IGFBP-3 expression in 194 SCLC tissues specimens by immunohistochemical stain. The relationship between IGFR-1 and IGFBP-3 expression and cliniopathological factors was evaluated. Univariate and multivariate analyses were performed to define its prognostic significance. Results: Median age was 63 years (range 38–85), 84% were men. One hundred-seventeen patients had extensive disease (60.3%), and 77 had limited disease (39.7%). With the median follow- up duration of 49.5 months (24–82), the median progression free survival (PFS) and overall survival (OS) were 8 months (95% CI: 7.3–8.7 months), and 14.4 months (95% CI: 12.7–16 months), respectively, The IGFR-1 expression was observed in 154 of 190 tumor tissues (79.4%), whereas there was no tissue stained by IGFBP-3. Multivariate analysis showed that stage (p<0.001), response to treatment (p<0.001), LDH level (p<0.001) were the independent prognostic factors for PFS, and age (p=0.014), LDH level (p<0.001), and stage (p<0.001) for OS. The IGFR-1 positivity was not associated with PFS or OS in the whole cohort. However, 84% of 115 extensive disease patients showed IGFR-1 positivity. The subgroup analysis revealed that OS was significantly longer for patients with IGFR-1 positive compared to those with IGFR-1 negative in extensive disease (11.3% vs 0% at 2year, p=0.034). Conclusions: These results suggest that IGFR-1 expression may be useful as a prognostic marker in patients with extensive disease of SCLC.

No significant financial relationships to disclose.

Development and validation of Korean breast cancer risk assessment tool

Abstract #4083

Introduction: The NCI breast cancer risk assessment tool of Gail model was used for counseling and chemoprevention of western breast cancer. Because Korean women have different incidence rates and risk factors, the Gail model can not properly estimate the breast cancer risk for Korean women. The author developed and validated a Korean breast cancer risk assessment tool, which would display the absolute breast cancer risks of Korean women.&#x2028; Methods: A risk model was established from a case-control study of 1687 cases of invasive carcinoma and 1238 controls. The risk factors selected were age, family history of the first and second relatives, body mass index, age at the first delivery, breast-feeding and a special test on the breasts. A baseline risk and individual breast cancer risk were calculated by a competing risk analysis. A discriminatory accuracy of the program was evaluated by a receiver operating characteristic (ROC) curve analysis.&#x2028; Results: The risk assessment tool was developed in the Internet web page, http://home.dankook.ac.kr/breast/brca/brca-e.htm. It calculated the relative risk and the estimated absolute risks following 5, 10 years and up to age 64, 74. The estimated risks of Korean women using this tool were less than the result of NCI risk assessment tool. The risk of breast cancer was highest in the age of forties. In the discriminatory accuracy, the area under curve (AUC) was 0.587. The curve presented a tendency of high specificity and low sensitivity.&#x2028; Conclusion: A web-based breast cancer risk assessment tool was developed for Korean women. This program had a limited discriminatory accuracy, but would be useful for the assessment of individual breast cancer risks, the selection of screening tools and preventive options of risk reduction for Korean women.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4083.

Nanomachining with a mechanical manipulation system

This study describes about the development of a mechanical manipulation system that can perform three-dimensional nano-machining inside a scanning electron microscope (SEM). Experiments are carried out by constructing a precise machining platform integrated with pico-motors, linear stages and monolithic-silicon-based tips which is generally used in atomic-force microscope (AFM). This integrated system can easily manipulate the atoms in a workpiece inside an SEM. The platform consists of three translational stages along XYZ axis direction and one rotational stage, with a resolution of 30 nm. The system can be utilized to produce nanopattern such as nanolines, nanoscale characters on silicon substrate coated with gold (Au) and aluminum (Al). Molecular dynamics simulation model is used to analyze the machining mechanism from various machining parameters. The same AFM tip can be utilized to scratch away the unwanted material from the workpiece surface.

Mechanical properties of microwave hydrothermally synthesized titanate nanowires

In this investigation titanate nanowires were synthesized by a microwave hydrothermal process and their nanomechanical characterization was carried out by a compression experiment via buckling instability using a nanomanipulator inside a scanning electron microscope. Nanowires of diameters 120-150 nm and length tens of microns can be synthesized by keeping a commercial nanoparticle inside a microwave oven at 350 W and 210 °C for 5 h. The nanowire was clamped between two cantilevered AFM tips attached to two opposing stages of the manipulator for nanomechanical characterization. The elasticity coefficients of the titanate nanowires were measured by applying a continuously increasing load and observing the buckling instability of the nanowires. The buckling behavior of a nanowire was analyzed from the series of SEM images of displacement of the cantilever attached to the nanowire due to application of load. The critical loads for different sized titanate nanowires were determined and their corresponding Young's modulus was computed with the Euler pinned-fixed end model. The Young's modulus of these microwave hydrothermal process synthesized titanate nanowires were determined to be approximately in the range 14-17 GPa. This investigation confirms the capability of the nanomanipulator via the buckling technique as a constructive device for measuring the mechanical properties of nanoscale materials.

Variants in the 5q31 cytokine gene cluster are associated with psoriasis

A multitiered genetic association study of 25 215 single-nucleotide polymorphisms (SNPs) in three case-control sample sets (1446 patients and 1432 controls) identified three IL13-linked SNPs (rs1800925, rs20541 and rs848) associated with psoriasis. Although the susceptibility effects at these SNPs were modest (joint allelic odds ratios (ORs): 0.76 to 0.78; P(comb): 1.3E-03 to 2.50E-04), the association patterns were consistent across the sample sets, with the minor alleles being protective. Haplotype analyses identified one common, susceptible haplotype CCG (joint allelic OR=1.27; P(comb)=1.88E-04) and a less common, protective haplotype TTT (joint allelic OR=0.74; P(comb)=7.05E-04). In combination with the other known genetic risk factors, HLA-C, IL12B and IL23R, the variants reported here generate an 11-fold psoriasis-risk differential. Residing in the 5q31 cytokine gene cluster, IL13 encodes an important T-cell-derived cytokine that regulates cell-mediated immunity. These results provide the foundation for additional studies required to fully dissect the associations within this cytokine-rich genomic region, as polymorphisms in closely linked candidate genes, such as IRF1, IL5 or IL4, may be driving these results through linkage disequilibrium.

WITHDRAWN: Continuous electronic heart rate monitoring for fetal assessment during labor

BACKGROUND

Electronic fetal monitoring (EFM) is used in the management of labor and delivery in nearly three of four pregnancies in the United States. The apparent contradiction between the widespread use of EFM and expert recommendations to limit routine use indicates that a reassessment of this practice is warranted.

OBJECTIVES

To compare the efficacy and safety of routine continuous EFM during labor with intermittent auscultation, using the results of published randomized controlled trials (RCTs).

SEARCH STRATEGY

We identified RCTs by searching MEDLINE and the register maintained by the Cochrane Pregnancy and Childbirth Group, and by contacting experts, and reviewing published references. Date of last search: January 2001.

SELECTION CRITERIA

Randomized controlled trials.

DATA COLLECTION AND ANALYSIS

Data were abstracted by one of us, and their accuracy was confirmed independently by a second person. A single reviewer assessed study quality based on criteria developed by others for RCTs. Data reported from similar studies were used to calculate a combined risk estimate for each of eight outcomes.

MAIN RESULTS

Our search identified 13 published RCTs addressing the efficacy and safety of EFM; no unpublished studies were found. Four trials that did not fulfil our selection criteria were excluded. The remaining nine trials included 18,561 pregnant women and their 18,695 infants in both high- and low-risk pregnancies from seven clinical centers in the United States, Europe, and Australia. Overall, a statistically significant decrease was associated with routine EFM for neonatal seizures (relative risk (RR) 0.51, 95% confidence interval (CI) 0.32-0.82). The protective effect for neonatal seizures was only evident in studies with high-quality scores. No significant differences were observed in 1-minute Apgar scores below four or seven, rate of admissions to neonatal intensive care units, perinatal deaths or cerebral palsy. An increase associated with the use of EFM was observed in the rate of cesarean delivery (RR 1.41, 95% CI 1.23-1.61) and operative vaginal delivery (RR 1.20, 95% CI 1.11-1.30).

AUTHORS' CONCLUSIONS

The only clinically significant benefit from the use of routine continuous EFM was in the reduction of neonatal seizures. In view of the increase in cesarean and operative vaginal delivery, the long-term benefit of this reduction must be evaluated in the decision reached jointly by the pregnant woman and her clinician to use continuous EFM or intermittent auscultation during labor.

Proteomic identification of potential protein markers in cerebrospinal fluid of GBS patients

Increased protein level in the cerebrospinal fluid (CSF) is a characteristic of patients with Guillain-Barré syndrome (GBS), an acute inflammatory autoimmune disorder in the peripheral nervous system (PNS). However, the molecular mechanisms underlying the disease remain poorly understood and so far no reliable disease-related markers are available. By comparing the CSF proteome of GBS patients with control subjects suffering from other neurological disorders, it may be possible to identify proteins that involve in the disease process and thus to study the pathogenesis of GBS. We used two-dimensional difference gel electrophoresis (2D DIGE) technique, in combination with matrix-assisted laser desorption ionization time of flight mass spectrometry (MALDI-TOF MS), to determine the abnormal CSF proteins in GBS patients. Our data showed that the levels of six proteins and their isoforms in CSF were significantly altered in GBS patients compared with controls. Haptoglobin, apolipoprotein A-IV and PRO2044 (unnamed protein) were considerably increased in the CSF of GBS patients, whereas transthyretin, apolipoprotein E and fibrinogen were considerably decreased. We concluded that these six proteins may be involved in the pathogenesis of GBS and call for further studying the role of these proteins in the pathogenesis of the disease.

The 620W allele is the PTPN22 genetic variant conferring susceptibility to RA in a Dutch population

OBJECTIVES

A missense SNP, C1858T, in PTPN22 has been identified as a genetic risk factor for rheumatoid arthritis (RA). Subsequent work has suggested that other variants in this gene, in particular a haplotype marked by the minor allele of rs3789604, are associated with RA in white North Americans independent of C1858T. We tested this hypothesis in an independent white Dutch study.

METHODS

A total of 667 RA patients and 286 controls were genotyped for 13 PTPN22 single nucleotide polymorphisms (SNPs) by allele-specific kinetic polymerase chain reaction. rs3789604 was genotyped in an additional 410 RA and 270 UA patients participating in the Leiden early arthritis inception cohort. We conducted single-marker and haplotype association tests.

RESULTS

The sole haplotype strongly associated with RA in our Dutch population carries the PTPN22 1858T allele. A second haplotype identical at all other SNPs tested except 1858 was not associated with disease. No significant association of the haplotype tagged by the 3' PTPN22 SNP, rs3789604, with RA susceptibility (P = 0.134) was observed in our sample set.

CONCLUSION

We conclude that C1858T is the sole PTPN22 variant predisposing to RA in our white Dutch sample set.

Phase I/II trial of the prostate-specific membrane antigen (PSMA)-targeted immunoconjugate MLN2704 in patients (pts) with progressive metastatic castration resistant prostate cancer (CRPC)

4500

Background: MLN2704 is an immunoconjugate that utilizes the PSMA-targeted monoclonal antibody MLN591 to deliver the maytansinoid antimicrotubule agent DM1 directly to prostate cancer cells. This multicenter trial was designed to determine the tolerability, optimal dosing schedule and efficacy of MLN2704 in pts with progressive metastatic CRPC. Methods: Pts aged ≥18 yrs with progressive metastatic CRPC received MLN2704 i.v. over 2.5 hr q1wk, q2wks or q3wks for 12 wks, with additional doses permitted in responders. Doses within a given schedule were escalated in 40% increments in the absence of excessive dose-limiting toxicity (DLT). Results: 61 pts have been treated. The most common adverse events (AEs) were nausea, fatigue, and schedule-dependent neurotoxicity. The only DLT was gr 3 hepatic transaminitis in 1/6 pts at 330 mg/m2 q2wks; the only gr 4 AE was transient neutropenia, in 2 pts (330 mg/m2 q2wks and q3wks). Declines in PSA were most frequent at 330 mg/m2 q2wks ( table ), including 49–88% PSA declines in 4/6 pts. However, given the frequency of grade 2–3 peripheral neuropathy an additional cohort is being treated with 330mg/m2 on days 1 and 15 of a 6-wk cycle. Initial results with this 6-wk schedule indicate PSA declines with a lower incidence of gr 2–3 toxicities, particularly neuropathy. Conclusions: Accrual to the dose-escalation phase is complete. Dose-dependent antitumor effects were seen. Peripheral neuropathy has limited continuous dosing at higher dose levels prompting a schedule change. Accrual to the 6-wk schedule is continuing.

[Table: see text]

[Table: see text]

A case-control study evaluating differences in resource utilization between diabetic and non-diabetic cancer patients undergoing chemotherapy

6126

Background: Patients with diabetes mellitus (DM) and cancer have been noted to have worse overall and disease-free survival compared to those without DM. However, there is a paucity of data addressing why diabetic cancer patients have worse outcomes. We performed a retrospective case-control study to evaluate cancer patients undergoing chemotherapy comparing persons with and without DM to evaluate differences in resource utilization and mortality. Methods: Using chart review and tumor registry data from January 2001 through December 2003, we identified DM patients 18 years or older, treated with chemotherapy at the Gainesville Veterans Administration Medical Center (GVAMC) for lung, colon, or head and neck cancer. Non-diabetic (Non-DM) controls were matched for age, cancer type and stage. A comorbidity score was calculated based on a previously validated measurement scale, Adult Comorbidity Evaluation 27 (ACE-27). The primary outcome measure was the number of inpatient hospital days in the first year after diagnosis. Secondary outcome measures included the total number of outpatient visits, emergency room (ER) visits, infusion room visits for chemotherapy, blood transfusions, home health consults, telephone calls, and mortality. Results: A total of 42 DM cases and 42 non-DM controls were identified who had undergone similar treatments with radiation and surgery. The DM patients had higher comorbidity ACE 27 scores when corrected for the cancer being treated, median 3.0 versus 2.0, p < 0.005. The table summarizes the results. Mortality was the same (15) for both the DM and non-DM patients at one year. Conclusions: Cancer patients with DM undergoing chemotherapy have significantly more comorbidities and utilize more outpatient visits compared to non-DM. However, all other measures of resource utilization and mortality appear similar. Further studies to identify causes of increased utilization should be done.

[Table: see text]

No significant financial relationships to disclose.