Häufigkeit psychischer Begleiterkrankungen und der Wunsch nach psychosozialer Unterstützung bei Tumorpatienten im Akutkrankenhaus

BACKGROUND AND OBJECTIVE

A diagnosis of cancer can overpower a patient's ability to cope and thus can increase the prevalence of psychiatric disorders in this group of patients. It was the aim of this study to estimate that prevalence in tumor patients during their acute treatment.

PATIENTS AND METHODS

689 patients with malignancies were interviewed using the structure clinical interview connected with the Diagnostic and Statistical Manual of Mental Disorders IV [SCID]) DSM-IV during their first days of inpatient treatment. The patients' wishes for psychosocial support by the oncological team were assessed.

RESULTS

32 % of the patients were diagnosed having a psychiatric disorder, e. g. depression. Prevalence was greater among female and/or young patients, those who had little money, were receiving chemotherapy and those who had not yet been diagnosed with cancer but in whom it was suspected. Some types of tumor were more likely to be associated with a mental disorder, for instance gynecological and head-and-neck malignancies. 83 % of the patients asked for psychosocial help from the treating physician, 44 % from the social worker, 30 % from the clinical psychologist, and 8 % from a spiritual adviser. Support was especially needed by patients who felt sad or depressed, and in those who lacked social support: these needs were unrelated to tumor stage and time since diagnosis.

CONCLUSIONS

Inpatient cancer patients frequently suffer from a psychiatric disorder. The majority of them would like to get psychosocial support, especially from their treating physician. It should be recognized that it is not only palliative care patients with advanced disease who need psychosocial treatment and support.

[Quality of life and voice intelligibility in laryngeal cancer patients--relevance of the "satisfaction paradox"]

BACKGROUND

Aim of this study was to compare postoperative quality of life and voice intelligibility of laryngeal cancer patients.

PATIENTS AND METHODS

Two studies assessed the quality of life (by EORTC QLQ-C30 and EORTC QLQ-H&N35) and the voice intelligibility (by PLTT and FPAL) of 218 laryngectomized and 151 partially resected patients. The data of 86 patients was analysed on the basis of matched pairs (matching criteria: sex and tumour stage).

RESULTS

The smelling and tasting of the laryngectomized patients were more affected. Other domains of quality of life did not differ significantly between the groups. The subjective assessment of voice intelligibility led to worse results among the patients with partial laryngectomy, although the objective test proved the contrary.

CONCLUSIONS

Subjective and objective assessment of quality of life can differ, which led to paradox results in this study, especially for voice intelligibility. This might be due to the fact that partially resected patients have higher expectations of their operation.

Bedeutung psychosozialer Faktoren bei der Stimmrehabilitation nach Laryngektomie

BACKGROUND

Often it is assumed that psychosocial and sociodemographic factors cause the success of voice rehabilitation after laryngectomy. Aim of this study was to analyze the association between these parameters.

METHODS

Based on tumor registries of six ENT-clinics all patients were surveyed, who were laryngectomized in the years before (N = 190). Success of voice rehabilitation has been assessed as speech intelligibility measured with the postlaryngectomy-telephone-intelligibility-test. For the assessment of the psychosocial parameters validated and standardized instruments were used if possible. Statistical analysis was done by multiple logistic regression analysis.

RESULTS

Low speech intelligibility is associated with reduced conversations (OR 0.970) and social activity (OR 1.049). Patients are more likely to talk with esophageal voice when their motivation for learning the new voice was high (OR 7.835) and when they assessed their speech therapist as important for their motivation (OR 4.794). The risk to communicate merely by whispering is higher when patients live together with a partner (OR 5.293), when they talk seldomly (OR 1.017) and when they are not very active in social contexts (OR 0.966).

CONCLUSIONS

Psychosocial factors can only partly explain how voice rehabilitation after laryngectomy becomes a success. Speech intelligibility is associated with active communication behaviour, whereas the use of an esophageal voice is correlated with motivation. It seems that the gaining of tracheoesophageal puncture voice is independent of psychosocial factors.

Mouse double minute antagonist Nutlin-3a enhances chemotherapy-induced apoptosis in cancer cells with mutant p53 by activating E2F1

MDM2 is a critical negative regulator of the p53 tumor suppressor protein. Recently, small-molecule antagonists of MDM2, the Nutlins, have been developed to inhibit the p53-MDM2 interaction and activate p53 signaling. However, half of human cancers have mutated p53 and they are resistant to Nutlin treatment. Here, we report that treatment of the p53-mutant malignant peripheral nerve sheath (MPNST) and p53-null HCT116 cells with cisplatin (Cis) and Nutlin-3a induced a degree of apoptosis that was significantly greater than either drug alone. Nutlin-3a also increased the cytotoxicity of both carboplatin and doxorubicin in a series of p53-mutant human tumor cell lines. In the human dedifferentiated liposarcoma cell line (LS141) and the p53 wild-type HCT116 cells, Nutlin-3a induced downregulation of E2F1 and this effect appeared to be proteasome dependent. In contrast, in MPNST and HCTp53-/- cells, Nutlin-3a inhibited the binding of E2F1 to MDM2 and induced transcriptional activation of free E2F1 in the presence of Cis-induced DNA damage. Downregulation of E2F1 by small interfering RNA significantly decreased the level of apoptosis induced by Cis and Nutlin-3a treatment. Moreover, expression of a dominant-negative form of E2F1 rescued cells from apoptosis, whereas cells overexpressing wild-type E2F1 showed an increase in cell death. This correlated with the induction of the proapoptotic proteins p73alpha and Noxa, which are both regulated by E2F1. These results indicate that antagonism of MDM2 by Nutlin-3a in cells with mutant p53 enhances chemosensitivity in an E2F1-dependent manner. Nutlin-3a therefore may provide a therapeutic benefit in tumors with mutant p53 provided it is combined with chemotherapy.

Health-related quality of life among children and adolescents: associations with obesity

OBJECTIVE

To assess the impact of obesity on health-related quality of life (HRQOL) of children, and to compare HRQOL scores of obese children in a hospital versus community setting.

DESIGN

A cross-sectional study in two clinical samples.

SUBJECTS

A total of 182 children and adolescents recruited from the community pediatric clinics and a hospital-based obesity clinic.

MEASUREMENTS

Obesity was defined as body mass index (BMI) >95th percentile for age and gender. Subjects were divided into quartiles of BMI Z-scores each containing 45 or 46 children. The first two quartiles correspond to normal BMI, 3rd and 4th quartiles represent moderate and severe obesity, respectively. HRQOL was assessed by the Pediatric Quality of Life Inventory (PedsQL) questionnaire submitted by both children and their parents.

RESULTS

Obese children reported significantly lower HRQOL in physical, social and school domains compared with normal weight children (P<0.01). Analyzing results of HRQOL by BMI quartiles showed that the emotional and school domains scores of the moderately obese children were similar to the normal BMI quartiles. Only in the 4th quartile, that of children with severe obesity, were scores significantly lower. In contrast, in both physical and social domains scores decreased progressively with increased BMI Z-scores. In the obese group, parents' scores were lower than the children's in all domains. HRQOL scores of obese children assessed in the hospital clinic were similar to that of obese children assessed in the community.

CONCLUSIONS

Moderately obese children had similar emotional and school HRQOL scores as normal weight children, whereas in the physical domain, a significant difference was documented even in moderate obesity. Parents of obese children perceived their child's HRQOL lower than the children themselves. We believe that intervention programs aimed at improving HRQOL should be directed to both parents and children. Understanding the resilience of moderately obese children in school and emotional domains may assist us in the management of childhood obesity.

De novostructural chromosomal imbalances: molecular cytogenetic characterization of partial trisomies

De novo structural chromosomal imbalances represent a major challenge in modern cytogenetic diagnostics. Based solely on conventional cytogenetic techniques it may be impossible to identify the chromosomal origin of additional chromosomal material. In these cases molecular cytogenetic investigations including multicolor-FISH (M-FISH), spectral karyotyping (SKY), multicolor banding (MCB) and cenM-FISH combined with appropriate single-locus FISH probes are highly suitable for the determination of the chromosomal origin and fine characterization of derivative chromosomes. Here we report on four patients with de novo chromosomal imbalances and distinct chromosomal phenotypes, three of them harboring pure partial trisomies: a mildly affected boy with pure partial trisomy 10q22.2-->q22.3 approximately 23.1 due to an interstitial duplication, a girl with pure trisomy 12p11.21-->pter and atypically moderate phenotype as the consequence of an X;autosome translocation, and a girl with multiple congenital abnormalities and severe developmental delay and a 46,XX,15p+ karyotype hiding a trisomy 17pter-->17q11.1. The fourth patient is a girl with minor phenotypic features and mental retardation with an inverted duplication 18q10-->p11.31 combined with a terminal deletion of 18p32. The clinical pictures are compared with previously described patients with focus on long term outcome.

A putative tumor suppressor role for Wnt-signaling in sarcomagenesis

9507

Background: We sought to elucidate the relationship between the human adult mesenchymal stem cell (hMSC), Wnt signaling and sarcomagenesis. Methods: In vitro hMSC differentiation, microarray gene expression analysis, distance correlation analysis, and standard molecular biology techniques were used to explore the role of Wnt in controlling the differentiation of both hMSCs and high grade undifferentiated sarcoma (HGUS; MFH, malignant fibrous histiocytoma), a common form of adult soft tissue sarcoma. Results: We determined that 1) hMSCs appear to be the progenitor cells of HGUS/MFH; 2) Dickkopf-1 (Dkk1), a specific inhibitor of Wnt signaling, is overexpressed in MFH as compared to other sarcoma subtypes and is involved in the proliferation of hMSCs; 3) in hMSCs, Dkk1 levels decline and nuclear β-catenin accumulates as hMSCs reach confluence, a prerequisite for initiation of in vitro differentiation, while in an MFH cell line Dkk1 levels do not decline and there is no nuclear β-catenin accumulation; 3) MFH cells appear to be primed for differentiation and express early markers of mesenchymal differentiation, then undergo apoptosis, if nuclear β-catenin is manipulated to enter the nucleus; 4) Wnt2 signals via the canonical β-catenin pathway and is responsible for “commitment” of hMSC and an MFH cell line to various differentiation pathways, while Wnt5a signals via the non-canonical JNK pathway in preventing apoptosis upon appropriate commitment toward differentiation. Conclusions: We identified the contribution of canonical and non-canonical Wnt signaling in the differentiation of hMSCs and showed that enhancing signaling via these pathways could be exploited as a potential target for therapy for high grade undifferentiated sarcomas. These data implicate Wnt-signaling as a mechanism of tumor suppression in early sarcomagenesis.

No significant financial relationships to disclose.

A phase I trial of doxorubicin and flavopiridol in soft tissue sarcoma

9523

Background: Flavopiridol, a potent cyclin dependent kinase inhibitor, has been shown in vitro to enhance doxorubicin induced apoptosis. Using the BWH dediffentiated liposarcoma xenograft model we have shown that sequential therapy with doxorubicin (D) followed 1 hour later by flavopiridol (F) is superior to doxorubicin alone (p=0.006). Single agent flavopiridol was also active in this xenograft model, but less so than the combination. Methods: We have commenced an ongoing phase I study of the combination of D and F on the basis of this preclinical data in soft tissue sarcoma with fixed dose D (60 mg/m2), followed 1 hour later by escalating doses of F (40–70 mg/m2) administered over one hour, every 3 weeks. Standard phase I eligibility criteria apply. No prior anthracycline therapy is allowed. At 300 mg/m2 D, dexrazoxane is added to D F. Patients with responsive or stable disease after cumulative D dose of 600mg/m2 can receive single agent flavopiridol. Results: Median characteristics of 7 evaluable patients: age 52 (31–65), KPS 80% (70–90), 3 males / 4 females, 0 prior regimens (range 0–2). The combination has been well-tolerated, with no dose limiting toxicity (DLT) yet. There has been 1 grade 3 bleed in the setting of progressive disease and 1 grade 4 neutropenia without fever. Grade 1 and 2 diarrhea, related to flavopiridol have been observed. Pharmacokinetic (PK) studies are ongoing. We have observed no partial responses (PR). Prolonged stable disease (SD) has been seen in 3 patients for 6, 6 and 11 months. Two patients with SD have liposarcoma. One patient with liposarcoma continues on single agent flavopiridol with stable disease after having reached the prescribed limit of D of 600 mg/m2. Conclusions: The combination of doxorubicin and flavopiridol is safe, with no unexpected toxicities. Disease stabilization in STS has been observed. This appears to be an encouraging combination in liposarcoma and is consistent with our preclinical model. Flavopiridol dose escalation is continuing.

No significant financial relationships to disclose.

The effects of cholinergic and dopaminergic antagonists on nicotine-induced cerebral neurotransmitter changes

In a continuing study of nicotine-induced mechanisms in brain areas associated with cognitive processes, the effects of cholinergic and dopaminergic antagonists on nicotine-induced changes in dopamine, norepinephrine, and serotonin were examined. These effects were measured via in vivo microdialysis in the dorsal and ventral hippocampus and in the prefrontal and medial temporal cortex of conscious, freely moving, adult male rats. Nicotine (0.3 mg/kg, free base) was administered subcutaneously and the antagonists were infused locally via the microdialysis probe. Nicotine alone induced an increase of dopamine and its metabolites in all areas, an increase of norepinephrine in the cortex, and an increase of the norepinephrine metabolite 4-hydroxy-3-methoxy-phenylglycol in all areas. Serotonin was decreased in the hippocampus and increased in the cortex. Nicotine-induced dopamine increases were inhibited by nicotinic (mecamylamine 100 microM, methyllycaconitine 500 microM), muscarinic (atropine 100 microM), and dopaminergic D1 (SCH23390 100 microM) and D2 (eticlopride 100 microM) antagonists, in the hippocampal and cortical areas. In the hippocampal areas, these antagonists had less significant effect on norepinephrine and serotonin. However, in the cortical areas, all antagonists inhibited the nicotine-induced increase of serotonin to varying degrees; and some, primarily nicotinic and dopamine D1 antagonists, inhibited the induced increase of norepinephrine. In the hippocampal and cortical areas, the mechanisms of nicotine-induced dopamine increase seem to be similar, but the mechanisms seem to be different for noradrenergic and serotonergic systems, as shown by the fact that nicotine induces no change in norepinephrine and a decrease in serotonin in the hippocampus, while it induces an increase in both in the cortex. Nicotine-induced dopamine release seems to be mediated, in part locally, by nicotinic and muscarinic receptors on dopaminergic cells. In contrast, nicotine's effect on norepinephrine and serotonin is at least partially mediated by initial changes at other than local sites, and through different receptors. Thus, the effects of nicotine and the mechanisms involved differ for different neurotransmitters and in different brain areas.

Neo-adjuvant chemotherapy for primary high-grade extremity soft tissue sarcoma

BACKGROUND

The purpose of this study was to retrospectively analyze the relationship between neo-adjuvant chemotherapy (NAC) and outcome in patients with high-grade extremity sarcomas.

PATIENTS AND METHODS

Inclusion criteria were high-grade, deep, >5 cm extremity soft tissue sarcomas. Patients diagnosed between 1990 and 2001 were treated with surgery only (n=282) or NAC containing doxorubicin/ifosfamide/mesna (AIM) (n=74). The stratified Cox proportional hazards model was used to test the effect of NAC on disease-specific survival and recurrence while adjusting for known prognostic factors.

RESULTS

NAC was associated with improved disease-specific survival for this cohort of patients (P=0.02). This overall improvement appears to be driven by the benefit of NAC on disease-specific survival for patient with tumors >10 cm. The 3-year disease-specific survival for tumors >10 cm was 0.62 (95% CI: 0.53-0.71) for patients not receiving NAC and 0.83 (95% CI: 0.72-0.95) for patients receiving NAC.

CONCLUSION

NAC with AIM was associated with a significant improvement in disease-specific survival in patients with high-grade extremity soft tissue sarcomas >10 cm. These data emphasize the need for further prospective clinical studies of neo-adjuvant or adjuvant chemotherapy for patients with large high-grade extremity sarcomas.

Extracellular matrix proteins and matrix metalloproteinases differ between various right and left ventricular sites in end-stage cardiomyopathies

This study was undertaken to investigate whether there might be differences in the distribution of extracellular matrix (ECM) proteins and matrix metalloproteinases (MMPs), depending on their specific sites within the heart. We investigated 33 explanted human hearts, 15 with dilated cardiomyopathy (DCM) and 18 with ischemic cardiomyopathy (ICM). Transmural samples from the right ventricle, the interventricular septum and the left ventricle, either from near the apex or from near the base were taken from every heart. Frozen sections were processed for connective tissue staining and immunohistochemistry for collagens type I, III, IV, laminin and fibronectin, as well as MMP-1, -2 and -9. Volume densities of laminin in ICM as well as of fibronectin and collagen types I and IV in DCM showed significant differences between right and left ventricular sites. The volume densities of matrix proteins usually did not reveal significant differences among the three left ventricular sites tested in both DCM and ICM. MMPs partly showed differences between the right and the left ventricular myocardium. These results suggest that the distributions of ECM proteins and MMPs differ between the two ventricles in both end-stage DCM and ICM. This gives rise to the hypothesis that a specific pattern of ECM degradation exists in the right and left ventricular myocardium.

Regional Heterogeneity of Nicotine Effects on Neurotransmitters in Rat Brains in vivo at Low Doses

In our recent studies on nicotine-induced changes in neurotransmitters in brain areas associated with cognitive function using a nicotine dose of 0.5 mg/kg administered subcutaneously to conscious freely moving rats, we found changes in dopamine, norepinephrine, and serotonin, and their metabolites, in the areas examined. For the present report we examined changes in these neurotransmitters following administration of lower nicotine doses, to test regional differences in nicotine response and possible threshold levels for some effects of nicotine. The doses used were 0.15 mg/kg and 0.03 mg/kg nicotine administered subcutaneously. Nicotine levels in the brain reached peak values in less than 10 min and decreased with a half-life of about 60 min (0.15 mg/kg) or 30 min (0.03 mg/kg) to values below detection limits (1 ng/g), by the later time points of the 0.03 mg/kg experiments. Nicotine-induced dopamine (DA) increase (and increase in DA metabolites) and decrease in 5-HT levels at 0.15 mg/kg were significant in the cortex, less so in the hippocampus. Norepinephrine (NE) increase at 0.15 mg/ kg was much less significant than found previously at 0.5 mg/kg. At a low nicotine dose (0.03 mg/kg), the significant changes observed were a decrease in 5-HT in the hippocampus and small increases of DA and NE in the prefrontal cortex and of NE in the medial temporal cortex. In the nucleus accumbens DA, NE, and 5-HT and their metabolites in the ventral tegmental area, mostly DA and metabolites were increased. We conclude that in areas of cognitive function nicotine-induced DA changes are more concentration dependent than changes in NE or 5-HT, and that there are regional differences in neurotransmitter changes induced by nicotine, with NE changes detectable only in the cortex and 5-HT changes only in the hippocampus at a low nicotine dose, indicating significant regional variation in sensitivity to nicotine-induced neurotransmitter changes in brain areas associated with cognitive function. The decrease in 5-HT shows that nicotine also has indirect effects caused by neurotransmitters released by nicotine. The effects of a low nicotine dose are more significant in areas of reward function, indicating differences in sensitivity between cognitive and reward functions.

Nicotine-induced changes in neurotransmitter levels in brain areas associated with cognitive function

Nicotine, one of the most widespread drugs of abuse, has long been shown to impact areas of the brain involved in addiction and reward. Recent research, however, has begun to explore the positive effects that nicotine may have on learning and memory. The mechanisms by which nicotine interacts with areas of cognitive function are relatively unknown. Therefore, this paper is part of an ongoing study to evaluate regional effects of nicotine enhancement of cognitive function. Nicotine-induced changes in the levels of three neurotransmitters, dopamine (DA), serotonin (5-HT), norepinepherine (NE), their metabolites, homovanillic acid (HVA), dihydroxyphenylacetic acid (DOPAC), 5-hydroxyindoleacetic acid (5-HIAA), and their precursor, L-DOPA, were evaluated in the ventral and dorsal hippocampus (VH and DH), prefrontal and medial temporal cortex (PFC and MTC), and the ventral tegmental area (VTA) using in vivo microdialysis in awake, freely moving, male Sprague-Dawley rats. The animals were treated with acute nicotine (0.5 mg/kg, s.c.) halfway through the 300-min experimental period. The reuptake blockers, desipramine (100 microM) and fluoxetine (30 microM), were given to increase the levels of NE and 5-HT so that they could be detected. Overall, a nicotine-induced DA increase was found in some areas, and this increase was potentiated by desipramine and fluoxetine. The two DA metabolites, HVA and DOPAC, increased in all the areas throughout the experiments, both with and without the inhibitors, indicating a rapid metabolism of the released DA. The increase in these metabolites was greater than the increase in DA. 5-HT was increased in the DH, MTC, and VTA in the presence of fluoxetine; its metabolite, 5-HIAA, was increased in the presence and absence of fluoxetine. Except in the VTA, NE levels increased to a similar extent with desipramine and fluoxetine. Overall, nicotine appeared to increase the release and turnover of these three neurotransmitters, which was indicated by significant increases in their metabolites. Furthermore, DA, and especially HVA and DOPAC, increased for the 150 min following nicotine administration; 5-HT and NE changes were shorter in duration. As gas chromatography experiments showed that nicotine levels in the brain decreased by 75% after 150 min, this may indicate that DA is more susceptible to lower levels of nicotine than 5-HT or NE. In conclusion, acute nicotine administration caused alterations in the levels of DA, 5-HT, and NE, and in the metabolism of DA and 5-HT, in brain areas that are involved in cognitive processes.

Circulating angiogenic factor levels correlate with extent of disease and risk of recurrence in patients with soft tissue sarcoma

BACKGROUND

Tumor angiogenesis, or new blood vessel formation, is regulated by a balance between pro-angiogenic factors such as vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF), and anti-angiogenic factors such as endostatin.

PATIENTS AND METHODS

To investigate this angiogenic balance in soft tissue sarcomas (STS), blood samples were collected from 76 STS patients and 15 healthy controls, and analyzed for VEGF, bFGF and endostatin using quantitative enzyme-linked immunosorbent assays (ELISA).

RESULTS

Forty-one patients (54%) had primary tumors, 20 (26%) had local recurrences and 15 (20%) had metastatic disease with or without local disease. Levels of all three angiogenic factors were highly variable in STS patients. Mean levels of VEGF and bFGF were 12 and 14 times higher, respectively, in patients compared with controls (P<0.0001). VEGF levels correlated with size of tumor, with the highest levels found in tumors >10 cm in size. Patients with metastases had endostatin levels 45% lower than patients without metastases (P=0.047). In 54 patients who underwent resection of primary disease or local recurrence, low pre-operative bFGF level was associated with a higher risk of subsequent recurrence (P=0.044).

CONCLUSIONS

STS secrete widely variable levels of angiogenic factors, and levels of specific factors may correlate with extent of disease, predict risk of recurrence and possibly guide the use of anti-angiogenic agents.