Effect of radiotherapy after breast-conserving treatment in women with breast cancer and germline BRCA1/2 mutations

PURPOSE

Recent laboratory data suggest a role for BRCA1/2 in the cellular response to DNA damage. There is a paucity of clinical data, however, examining the effect of radiotherapy (RT), which causes double-strand breaks, on breast tissue from BRCA1/2 mutation carriers. Thus the goals of this study were to compare rates of radiation-associated complications, in-breast tumor recurrence, and distant relapse in women with BRCA1/2 mutations treated with breast-conserving therapy (BCT) using RT with rates observed in sporadic disease.

PATIENTS AND METHODS

Seventy-one women with a BRCA1/2 mutation and stage I or II breast cancer treated with BCT were matched 1:3 with 213 women with sporadic breast cancer. Conditional logistic regression models were used to compare matched cohorts for rates of complications and recurrence.

RESULTS

Tumors from women in the genetic cohort were associated with high histologic (P =.0004) and nuclear (P =.009) grade and negative estrogen (P=.0001) and progesterone (P=.002) receptors compared with tumors from the sporadic cohort. Using Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer toxicity scoring, there were no significant differences in acute or chronic morbidity in skin, subcutaneous tissue, lung, or bone. The 5-year actuarial overall survival, relapse-free survival, and rates of tumor control in the treated breast for the patients in the genetic cohort were 86%, 78%, and 98%, respectively, compared with 91%, 80%, and 96%, respectively, for the sporadic cohort (P = not significant).

CONCLUSION

There was no evidence of increased radiation sensitivity or sequelae in breast tissue heterozygous for a BRCA1/2 germline mutation compared with controls, and rates of tumor control in the breast and survival were comparable between BRCA1/2 carriers and controls at 5 years. Although additional follow-up is needed, these data may help in discussing treatment options in the management of early-stage hereditary breast cancer and should provide reassurance regarding the safety of administering RT to carriers of a germline BRCA1/2 mutation.

Goal-setting in rehabilitation: report of a workshop to explore professionals' perceptions of goal-setting

OBJECTIVE

To explore the views of therapists, nurses and doctors working in a variety of rehabilitation settings on the goal-setting process.

METHODS

Sixteen rehabilitation staff from three different settings attended a goal-setting workshop in which the difficulties associated with goal-setting were described with their potential solutions.

RESULTS

Five difficulties with goal-setting were identified. (1) Formal goal-setting was felt to be an activity unusual for many of the patients although intrinsic to the activity of many professional groups. (2) Goal-setting is often insensitive to people's roles in the community. (3) Goal-setting in the hospital environment does not transfer easily to the community. (4) External factors (e.g. staff turnover) over which staff felt they had little control were important in the success of a goal-setting programme. (5) Goals tend to be formulated and owned by the team, rather than the patient.

CONCLUSIONS

Goal-setting is a very satisfactory activity for the team but to be as successful for the patient their needs must be acknowledged. People with mild disability and a short inpatient stay have different needs to those with acute onset severe permanent disability and those with chronic or progressive disability admitted from the community. Comparison of both process and outcome effects of different types of goal-setting is an area for future study.

Reactive hemophagocytic syndrome as a presenting feature of Hodgkin's disease

We report the case of a 60-year-old man with fever of unknown origin, severe pancytopenia, and rapidly developing splenomegaly due to reactive hemophagocytic syndrome and Hodgkin's disease. Reactive hemophagocytic syndrome is often rapidly fatal and, once this diagnosis is considered, an underlying infection or malignancy should be treated promptly. An extensive search of the literature revealed only two other cases of reactive hemophagocytic syndrome and Hodgkin's disease. This is the only reported patient who survived after being diagnosed as having reactive hemophagocytic syndrome and Hodgkin's disease.

Organogenesis and tissue regeneration of fallopian tube: a desired metaplastic transformation of mesodermal stem cells in live animal models (dogs)

The capacity of stem cells of peritonium of mesodermal origin to undergo metaplastic transformation and form different tissues developed from mesoderm germ layer is exploited with ulterior motive to use it in the management of human diseases. The excised fallopian tube was replaced with a tube on a stent constructed from autogenous peritoneum from a suitable donor site. The effect of the surroundings environment of the new tissue system to which the peritoneum stem cells are now exposed was studied for 3, 6 and 12 months period in live animal models. The gross and histological studies revealed development of all the component of the wall of the fallopian tube. The lumen of the constructed peritoneal tube was well preserved in its whole length including the anastomotic sites. The scientific rationale of the working hypothesis on which the work is based, is discussed.

Improving patients' postoperative sleep: a randomized control study comparing subcutaneous with intravenous patient-controlled analgesia

One hundred female patients undergoing major reconstructive plastic or gynaecological surgery were randomized to either receive subcutaneous patient-controlled analgesia (PCA) (bolus dose 2.5 mg diamorphine in 1 ml with a 20-minute lockout) or intravenous PCA (bolus dose 0.5 mg diamorphine in 1 ml with a 5-minute lockout). Data were collected by questionnaire and interview to evaluate the intervention on pain scores, quality of sleep on the first postoperative night, postoperative nausea and vomiting (PONV) and overall patient acceptability. The subcutaneous PCA group experienced less 'worse pain' (P < 0.01) and less sleep disturbance due to pain (P < 0.001). Subcutaneous PCA would appear to offer patients a safe and effective means of analgesia and may offer significant advantages over the intravenous route of administration.

Re-irradiation of head and neck tumors. Benefits and toxicities

Most patients with head and neck cancer that recurs after irradiation should be treated with curative surgery. In patients whose tumors are nonresectable, or if surgery would cause unacceptable morbidity, a trial of curative re-irradiation may be considered. Taking into account the overall poor prognosis of these patients and the high rate of late tissue toxicity, especially soft tissue necrosis, fistula formation, and potential nerve damage, patients should be carefully selected. Several sites, notably the larynx and nasopharynx, can be re-irradiated with a relatively high rate of locoregional tumor control. In other sites, several criteria may be used to select patients for curative re-irradiation: limited tumor size, a relatively long period since previous irradiation (a suitable, though arbitrary, minimal time period may be 1 year), good performance status, and lack of evidence of skin or soft tissue damage (skin fibrosis, atrophy or telangiectasis) by the previous irradiation course. Even when these selection criteria are used, the prognosis is poor, and long-term survival rates are low even if locoregional tumor control is achieved. Innovative strategies and techniques, including aggressive combined chemoradiation, hyperfractionation, and limiting the extent of irradiated tissues by using conformal irradiation, may improve locoregional control rates. It should be emphasized, however, that the only chance for achieving locoregional control and cure is through the delivery of a full dose of radiation, similar to the dose required for primary tumors. The delivery of a low radiation dose, commonly practiced to avoid complications, is expected to achieve palliation only.

Secondary T-acute lymphoblastic leukaemia mimicking blast crisis in chronic myeloid leukaemia

A 34-year-old man with chronic myeloid leukaemia (CML) firstly developed a lymphoid blast crisis of B-cell type. After a second chronic phase which lasted for > 4 years with maintenance chemotherapy of hydroxyurea, 6-mercaptopurine and methotrexate, he developed a T-cell acute lymphoblastic leukaemia of TcR-gammadelta+ type. Cytogenetic analysis revealed disappearance of the t(9;22) translocation and appearance of new abnormalities consistent with the diagnosis secondary acute leukaemia. To our knowledge, secondary leukaemia in CML has not previously been reported.

Regeneration of abdominal wall aponeurosis: new dimension in Marlex peritoneal sandwich repair of incisional hernia

Loss of abdominal wall substance is a major cause of incisional hernia formation. It makes repair of this iatrogenic human ailment a difficult surgical problem. The abdominal wall substance loss has compelled the world's surgical community dealing with this condition to substantiate the repair with extra material such as skin, fascia, wire mesh, and lately biocompatible synthetic mesh. Even though the synthetic mesh is compatible and well tolerated by body tissues, it is not without complications. Regenerative repair in the region of the abdominal wall with substance loss is probably the best repair if it can be achieved. With reasonable success in animal experiments and the positive regenerative capacity of stem cells to transform the peritoneum into an aponeurotic layer, the new technique using a Marlex peritoneal sandwich for repair of large incisional hernias was attempted but was not reported in the article published in the World Journal of Surgery in 1991. The present study is based on experiments on seven mongrel dogs. A suitable embryonal segment of autogenous peritoneum was excised and transferred to the rectus sheath region. The gross appearance of the grafted membrane 3 months after operation revealed tough, thick tissue formation. The histology confirmed the presence of collagen fiber tissue in layers similar to the aponeurosis in the grafted peritoneal membrane. The use of this regeneration in the Marlex peritoneal sandwich technique of repair of large incisional hernias and the scientific rationale of tissue regeneration by desired metaplasia is discussed.

Interaction of the human immunodeficiency virus type 1 nucleocapsid with actin

The nucleocapsid (NC) domain of the retrovirus Gag protein plays several important roles in the viral life cycle, including virus assembly, viral genomic RNA encapsidation, primer tRNA placement, and enhancement of viral reverse transcription. In this study, deletion of NC domain of human immunodeficiency virus type 1 (HIV-1) Gag was found to drastically reduce virus particle production in CD4(+) T cells. Cellular fractionation experiments showed that although most of the uncleaved wild-type HIV-1 Gag, unmyristylated Gag, and p6(Gag) domain-truncated Gag molecules copurified with the host cell cytoskeleton, most of the mutant Gag molecules lacking both the NC and p6(Gag) domains failed to cofractionate with cytoskeleton. In wild-type virus-infected cells, in which the viral protease was active, the cleaved NCp7 copurified with the cytoskeleton, whereas most of the MAp17 and CAp24 did not. Monoclonal antibody against actin coimmunoprecipitated full-length Gag and p6(Gag) domain-truncated Gag molecules from cell lysates but failed to precipitate the truncated mutant Gag molecules lacking NC plus p6(Gag). Purified recombinant NCp7, but not CAp24, was able to bind F-actin in cosedimentation experiments. Furthermore, wild-type NCp7 and a zinc finger mutant NCp7(F16A), like a cellular actin-binding protein (the villin headpiece), bound F-actin in a dose-dependent fashion in vitro. Taken together, these results suggest that HIV-1 NCp7 can bind F-actin directly and that interaction between HIV-1 Gag and the actin cytoskeleton through the NC domain may play an important role in HIV-1 assembly and/or other steps of the viral life cycle.

The role of nucleocapsid of HIV-1 in virus assembly

The role of the nucleocapsid protein of HIV-1 Gag in virus assembly was investigated using Gag truncation mutants, a nucleocapsid deletion mutant, and point mutations in the nucleocapsid region of Gag, in transfected COS cells, and in stable T-cell lines. Consistent with previous investigations, a truncation containing only the matrix and capsid regions of Gag was unable to assemble efficiently into particles; also, the pelletable material released was lighter than the density of wild-type HIV-1. A deletion mutant lacking p7 nucleocapsid but containing the C-terminal p6 protein was also inefficient in particle release and released lighter particles, while a truncation containing only the first zinc finger of p7 could assemble more efficiently into virions. These results clearly show that p7 is indispensable for virus assembly and release. Some point mutations in the N-terminal basic domain and in the basic linker region between the two zinc fingers, which had been previously shown to have reduced RNA binding in vitro [Schmalzbauer, E., Strack, B., Dannull, J., Guehmann, S., and Moelling, K. (1996). J. Virol. 70: 771-777], were shown to reduce virus assembly dramatically when expressed in full-length viral clones. A fusion protein consisting of matrix and capsid fused to a heterologous viral protein known to have nonspecific RNA binding activity [Ribas, J. C., Fujimura, T., and Wickner, R. B. (1994) J. Biol. Chem. 269: 28420-28428] released pelletable material slightly more efficiently than matrix and capsid alone, and these particles had density higher than matrix and capsid alone. These results demonstrate the essential role of HIV-1 nucleocapsid in the virus assembly process and show that the positively charged N terminus of p7 is critical for this role.

Treatment, patterns of failure, and survival of patients with Stage I nodal and extranodal non-Hodgkin's lymphomas, according to data in the population-based registry of the Comprehensive Cancer Centre West

BACKGROUND

Primary extranodal lymphomas (EN-NHLs) are a heterogeneous category of tumors that are considered to be different from primary nodal non-Hodgkin's lymphomas (N-NHLs). To what extent these differences have clinical implications is currently not very clear, because knowledge of EN-NHL as a separate group is limited.

METHODS

Using data from the Comprehensive Cancer Centre West (CCCW) population-based NHL registry in the Netherlands, N-NHL and EN-NHL patients were compared to determine differences in characteristics at diagnosis, responses to treatment, patterns of failure, and survival.

RESULTS

At presentation, EN-NHL patients had poorer performance scores and more often bulky tumors compared with N-NHL patients, resulting in poorer responses to treatment (complete response rates were 72% and 84%, respectively; P=0.04) and inferior 5-year overall survival (49% and 63%, respectively; P=0.003). Among EN-NHL patients, considerable variations in response, survival, and relapse rates were observed, with gastric NHL patients having the best and central nervous system NHL patients having the worst prognosis (66% and 7% 5-year overall survival, respectively). Relapse rates for N-NHL and EN-NHL patients did not differ (39% and 36% 5-year relapse rates, respectively), whereas among EN-NHL patients considerable differences in relapse rates were noted. Relapses among N-NHL patients were mainly found in nodal sites, whereas recurrent disease in EN-NHL patients was mainly found in extranodal sites.

CONCLUSIONS

In this population-based study, Stage I EN-NHL patients as a group had a poorer prognosis than N-NHL patients. However, among EN-NHL patients, considerable differences in response, relapse risk, and survival were observed. The failure analysis conducted in this study suggests that patterns of dissemination for N-NHL and EN-NHL are different.

[Addisonian crisis provoked by levothyroxine substitution therapy]

A women aged 36 with a positive family anamnesis for autoimmune endocrine diseases and a history of thyroid diseases, developed major complaints of general malaise, orthostatic hypotension and loss of appetite after the start of a treatment with levothyroxin because of (sub)clinical hypothyroidism. She was found to suffer from primary adrenocortical insufficiency masked by excessive use of liquorice and a lowered metabolism, but which via the suppletion with thyroid hormone had led to an addisonian crisis.

Mutations of the human immunodeficiency virus type 1 p6Gag domain result in reduced retention of Pol proteins during virus assembly

One of the crucial steps in the assembly of the human immunodeficiency virus type 1 (HIV-1) and other retroviruses is the incorporation and retention of all the key viral enzymes in released virions. The viral enzymes protease, reverse transcriptase, and integrase of HIV-1 are initially synthesized as Gag-Pol fusion polyproteins. It has been shown that the incorporation of Gag-Pol polyproteins during virus assembly requires the Gag domains that are shared by the Gag and Gag-Pol precursors. We now report that truncation of the C-terminal p6 domain of HIV-1 Gag, which is present in the Gag precursor but not in the Gag-Pol precursor, drastically reduced the amount of Pol proteins in the mutant virions. Mutations in the lentivirus conserved motif P(T/S)APP in p6 also drastically reduced the amount of Pol proteins in mutant virions. The steady-state levels of Gag-Pol precursors and cleaved Pol proteins in the transfected cells were not affected by mutations in p6. The incorporation of unprocessed Gag-Pol precursors into p6 mutant virions was detected when the viral protease was mutated, suggesting that the interactions among mutant Gag molecules and Gag-Pol precursors were not significantly affected. These results suggest that the p6 domain of HIV-1 Gag may play an important role in recruiting or retaining cleaved Pol proteins during virus assembly.

The role of reduced ear size in the prenatal detection of chromosomal abnormalities

A prospective ultrasound study was performed between 18 and 38 weeks' gestation on 29 fetuses in a high-risk population, defined by the presence of structural anomalies, in order to investigate the usefulness of fetal ear measurements in the prenatal prediction of chromosomal abnormality. The prevalence of abnormal chromosomes was 34 per cent. The sensitivity (SE), specificity (SC), positive predictive values (PPV), and negative predictive values (NPV) of ear length for the detection of chromosomal abnormality were 80, 84.2, 72.7 and 88.9 per cent. The SE, SC, PPV, and NPV of ear width were 40, 94.7, 80 and 75 per cent. Fetal ear measurements may be a useful adjunct to the various ultrasound parameters in the prenatal detection of chromosome abnormality in a high-risk population of fetuses with structural anomaly(ies).

Detection of Cryptosporidium parvum oocysts in faeces: comparison of conventional coproscopical methods and the polymerase chain reaction

Conventional and coproscopical methods were compared with the polymerase chain reaction (PCR) for the detection of Cryptosporidium oocysts in bovine faeces. Oocysts were not detected in samples seeded with 10,000 oocysts following formol ether sedimentation and examination using auramine phenol (AP) or by immunofluorescent (IF) staining. When oocysts were concentrated using sucrose flotation the threshold of detection was 4000 oocysts per gram for both staining methods. Following salt flotation 4000 oocysts per gram could be reliably detected by AP staining but the detection limit was increased to 6000 oocysts per gram using IF staining. The recovery of oocysts was significantly less than expected for all techniques. A specific PCR coupled with immunomagnetic particle separation (IMS) of samples detected five oocysts per ml of diluted faeces, which corresponds to 80-90 oocysts per gram. Even allowing for the dilution of formed faecal samples, required for IMS, this represents an increase in sensitivity of several orders of magnitude over the conventional corpodiagnostic methods.

Influence of prepartum protein and energy concentrations for dairy goats during pregnancy and early lactation

Sixty-three multiparous Alpine does were blocked by pregnancy type (single vs. multiple) on d 90 of pregnancy and assigned to one of nine diets to evaluate the interaction of prepartum protein and energy intake on BW change, kidding, and subsequent production and composition of milk. Treatments were factorial with three percentages of CP (8.5, 11.5, and 14.5% of DM) and three concentrations of metabolizable energy (1.80, 2.16, and 2.53 Mcal/kg of DM). Does were fed for ad libitum intake during pregnancy and switched to a lactation diet (16% CP and 2.35 Mcal of metabolizable energy/kg of DM) after parturition. Milk production and composition were recorded for the first 15 wk of lactation. Prepartum BW gain increased quadratically as protein amount increased but was unaffected by energy. Kidding rate, litter weight, and gestation length were unaffected by protein or energy amounts. Milk production in the subsequent lactation increased quadratically in response to prepartum CP (2.59, 3.26, and 3.07 kg/d for 8.5, 11.5, and 14.5% CP, respectively). Milk production increased linearly in response to prepartum metabolizable energy concentration (2.63, 3.05, and 3.26 kg/d for 1.80, 2.16, and 2.53 Mcal/kg of DM, respectively). Milk fat percentage increased linearly in response to increased prepartum energy. Production of milk fat, protein, SNF, FCM, and SCM were affected quadratically by increased prepartum CP and linearly by prepartum energy, following the pattern for milk production. The present recommendations for prepartum CP and energy appear to be adequate for gestation and subsequent lactation performance of dairy goats.

Squamous cell carcinoma of perineal urethrostomy

Urethral malignancies are rare while only few cases of urethral carcinoma following urethroplasty have been reported in the literature. We present a case of squamous cell carcinoma at perineal urethrostomy.

Human lymphokine-activated killer cells are cytotoxic against cells infected with Toxoplasma gondii

Experiments were conducted to determine whether human lymphokine-activated killer (LAK) cells are cytotoxic against cells infected with Toxoplasma gondii. Nylon wool nonadherent (NWNA) peripheral blood lymphocytes, as well as purified natural killer cell (NK) (CD3- CD16+ CD56+) and T (CD3+ CD16- CD56-) cells obtained from five healthy T. gondii seronegative volunteers exhibited minimal cytotoxic activity against T. gondii-infected cells. When standard LAK (S-LAK) cell preparations were induced by incubation of NWNA cells with recombinant interleukin 2, induction of remarkable cytotoxic activity against T. gondii-infected cells. When standard in LAK cell preparations from each of the volunteers. The phenotype of the LAK precursor and effector cells varied depending on the target cell used. Whereas the precursor and the effector cells of most of the LAK activity against K562 and Daudi cells were cells with NK phenotype, when T. gondii-infected cells were used as targets, both cells with NK and T cell phenotypes were precursors and effectors of the lysis. When cytotoxic activity of S-LAK cells was compared with the activity of adherent LAK (A-LAK) cells, A-LAK cells displayed higher cytotoxic activity against T. gondii-infected cells, as well as against K562 and Daudi cells. Cold target inhibition experiments suggested that there is a subset of LAK effector cells capable of lysing both T. gondii-infected cells and Daudi cells, whereas other subsets preferentially or exclusively lyse one of these target cells.

Significance of pathological parameters of endomyocardial biopsy in clinical outcome of patients of dilated cardiomyopathy--II. Value of cardiac immune complexes and heart reactive antibodies

We have evaluated the status of cardiac immune complexes and heart reactive antibodies in endomyocardial biopsies (EMB) and patients' sera from cases of dilated cardiomyopathy (DCM) using immunofluorescence. This was done with an aim to test whether this parameter can be of diagnostic and/or prognostic value in cases of DCM in its inflammatory and non inflammatory stages. Deposition of IgG was consistently observed in all cases of DCM regardless of the presence or absence of inflammation. Complement was detected in only a few while IgG and C3 together was seen to be deposited in only 4 cases. IgA and IgM were noted in an occasional case only. Heart reactive antibodies were seen in 13 of the 23 cases of DCM. Light microscopically, in 7 of the 23 biopsies mild focal lymphocytic myocarditis was detected. Presence of IgG in EMB and a low left ventricular ejection fraction (LVEF 35%) in almost all the cases, highlight the prognostic significance of IgG (in EMB) as an independent parameter. Based on this small study, it is difficult to attach significance to these observations as regards predicting the outcome of these patients. Nevertheless, the present study initiates evaluation of one of the parameters which is accessible and can be easily carried out in most routine laboratories for diagnosis, prognosis, and eventually monitoring of therapy in patients of DCM. Importance of immunofluorescence technique can be further strengthened by evaluating a larger number of cases with varying duration of symptoms and a follow up study of cases of DCM.