The prognostic importance of triple negative breast cancer: A population based study in India

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Background: Triple-negative (ER-negative, PR-negative, HER2/neu negative) breast cancer has distinct clinical and pathologic features, and is a clinical problem because of its typically high grade, relatively poor prognosis, aggressive behavior and lack of targeted therapies leaving chemotherapy as the mainstay of treatment. This study envisaged to analyse the influence of triple negativity status on survival and disease free survival in prospective cohort of breast cancer patients. Methods: Breast tumors of 215 women aged 30–75, diagnosed from 2004 were tested for ER, PR and HER2 positivity by immunohistochemistry and correlated with clinical outcomes such as recurrence, disease free survival and overall survival using Kaplan Meiers Survival analysis and Coxs regression analysis. The study cohort was followed up for 60 months or until death whichever was earlier. Results: Triple negativity significantly influenced disease free survival (46 ± 3, 41, 52) vs. non triple negative cohort (mean ± SE; 95%CI, 37 ± 2; 32, 40) and log rank = 2.1, p = 0.04. However triple negativity did not influence overall survival in months (56 ± 0; 55, 56) vs. non triple negative cohort (43 ± 1; 42, 45), (log rank = 1.78, p = 0.16). However, the mean disease free survival was (45 ± 7; 32, 58) months for patients >40 years age vs (37 ± 4; 33, 39) for patients < 40 years of age (log rank = 2.87, p =0.02). Stage of disease, node status, grade and menopausal status did not influence disease free survival significantly. However, Cox regression analysis did not predict significant effects of triple negativity on overall survival or disease free survival when controlled for confounding factors such as age, node status, stage etc Conclusions: Our observations suggest that triple negativity can significantly affect progression of breast cancer in Indian breast cancer patients and longer follow up is necessary (10 years) to determine its effects on survival.

No significant financial relationships to disclose.

Ossifying luteinized thecoma of the ovary with endometrial adenocarcinoma

Luteinized thecomas are one of the sex cord stromal tumors of the ovary rarely undergoing ossification. We report a case of a 66-year-old post-menopausal female with the chief complaint of uterine bleeding of 7 months duration. Endometrial curettage performed showed features of endometrial adenocarcinoma. Follow-up total abdominal hysterectomy revealed bilateral luteinized thecomas of the ovary, one of which had undergone massive ossification converting the ovary into a bone. True bone formation in ovarian tumors is rare. This case is the second in the literature of osseous metaplasia in an ovarian luteinized thecoma, with the association of endometrial adenocarcinoma suggesting its functional status.

Neurodevelopmental outcome of infants with meconium aspiration syndrome: report of a study and literature review

There is a paucity of information on long-term outcome of infants who have suffered from meconium aspiration syndrome (MAS) in the neonatal period. We analyzed long-term developmental outcome data of 35 infants who were admitted to the neonatal intensive care unit (NICU) at the University of Illinois Hospital at Chicago (UICMC) with a diagnosis of MAS, and we reviewed the literature pertinent to the subject. The objective of the study was to assess the neurodevelopment status of MAS infants and compare the possible effects of different variables that are known to affect the later developmental outcome. The variables included mode of delivery, APGAR score, cord pH, mode of treatment, and neurological findings during the course of NICU. The infants were enrolled in the developmental follow-up program (DFUP) after discharge from the nursery for assessment of long-term developmental status and neurodevelopmental outcome. In order to assess the impact of the treatment on long-term outcome and compare our findings with previously published reports, we also reviewed the previously published literature on neurodevelopment outcome of infants treated for MAS (with different modalities) during the last three decades. Total of 35 infants with a diagnosis of MAS admitted to the NICU at UICMC were followed in the DFUP clinic for 3 years during January 1999 to September 2001. The medical records of these infants were reviewed for the mode of delivery, APGAR score, birth weight (BW), gestational age, mode of treatment during the neonatal period, and neurodevelopment status. 19/35 (54%) infants were delivered vaginally, 16/35 (46%) by cesarean section (C-section). All were treated in the delivery room using the standard resuscitation protocol. Following initial resuscitation, all except three required intubation and ventilation for varying duration. One infant required inhaled nitric oxide therapy, and two required extracorporeal membrane oxygenation treatment. Subsequent to discharge, the infants were evaluated in the clinic at 2 months of age, and then every 4 months up to 3 years. The developmental assessment of mental development index (MDI), psychomotor development index (PDI), and behavior rating scale (BRS) were obtained using the Bayley II infant motor scale, and neurodevelopment evaluation was performed using the Amiel-Tison technique. Speech evaluation was performed in infants >18 months using the Rossetti Infant-Toddler language scale. Infants were considered normal when MDI and PDI scores were >85 to 110; mildly delayed when scores were >70 to 84; and severely delayed if the scores were <69. In addition, neurological evaluation also confirmed the disability. The report is based on the final analysis of 29 infants. Data of six infants were not included in the final analysis because of incomplete information. The mean BW of the infants was 3269+/-671 g; mean gestational age was 39.5+/-3.1 weeks. The median APGAR score at 1' was 4, and at 5' was 6. Out of 29, 11 (38%) infants were normal. Out of 29, 2 infants (7%) had cerebral palsy (CP) and 4 (14%) had severe delay at 12 months of age. Out of 29, 2 who were neurologically disabled had PDI <69. Out of 29, 12 (41%) had mild delay in speech. No statistical difference in neurodevelopment was found in infants born vaginally or by C-section. Our findings show poor outcome (CP and global delay) in 21% of infants who suffered MAS, even though the majority of the infants (26/29) responded to conventional ventilator support alone. No difference was found in the outcome of infants between NSVD vs C-section delivery. These findings suggest that infants with the diagnosis of MAS manifest later neurodevelopmental delays, even if they respond well to conventional treatment. This abstract was presented at the Society for Pediatric Research Annual Meeting, 2000.

Immunogenicity and safety of an indigenously developed DTPw hepatitis B combination vaccine in Indian infants

OBJECTIVE

To evaluate the safety and immunogenicity of an indigenous hepatitis B, diphtheria, tetanus and B. pertussis tetravalent vaccine (Shantetra) in comparison with Tritanrix HBTM in healthy Indian infants.

DESIGN

Multicentric, randomized, single blind intention-to-treat study with 12-18 weeks of follow up period.

SETTING

5 out patient departments at tertiary care referral centers across India.

PARTICIPANTS

151 infants were randomized in a 2:1 ratio to recruit 101 in the Shantetra and 50 in the Tritanrix HBTM groups respectively. A total of 136 subjects completed the study. No patients were withdrawn from the study due to any adverse effects.

INTERVENTIONS

Recruited subjects were randomized to receive three doses of either of the two DTPw-Hepatitis B combination vaccines as per the EPI schedule.

MAIN OUTCOME MEASURES

Monitoring the humoral immune response (seroconversion rates) induced by each antigenic component three to six weeks after the last dose of vaccine in both the groups.

RESULTS

Seroprotective immune response was observed in 98.9% subjects for diphtheria, tetanus and hepatitis B components in the Shantetra group as compared to 95.5% subjects in the Tritanrix HB group. Anti pertussis antibody response was seen in 89% and 91.1% in the Shantetra and Tritanrix HB groups, respectively. The commonly observed adverse events in both the groups were, pain at injection site, mild fever and transient crying.

CONCLUSION

The safety and immunogenicity of indigenously developed DTPwHepatitis B combination vaccine was demonstrated in the present study.

The Chitinase A from the baculovirus AcMNPV enhances resistance to both fungi and herbivorous pests in tobacco

Biotechnology has allowed the development of novel strategies to obtain plants that are more resistant to pests, fungal pathogens and other agents of biotic stress. The obvious advantages of having genotypes with multiple beneficial traits have recently fostered the development of gene pyramiding strategies, but less attention has been given to the study of genes that can increase resistance to different types of harmful organisms. Here we report that a recombinant Chitinase A protein of the Autographa californica nuclear polyhedrosis virus (AcMNPV) has both antifungal and insecticide properties in vitro. Transgenic tobacco plants expressing an active ChiA protein showed reduced damages caused by fungal pathogens and lepidopteran larvae, while did not have an effect on aphid populations. To our knowledge, this is the first report on the characterisation and expression in plants of a single gene that increases resistance against herbivorous pests and fungal pathogens and not affecting non-target insects. The implications and the potential of the ChiA gene for plant molecular breeding and biotechnology are discussed.

The expression of tomato prosystemin gene in tobacco plants highly affects host proteomic repertoire

Systemin, an octadecapeptide isolated from tomato, is a primary signal molecule involved in the local and systemic responses to pest attack, elicited by activation of a set of defence genes. It derives from processing of prosystemin, a prohormone of almost 200 amino acids. Prosystemin orthologues have been found in other Solanaceae species but not in tobacco, where are present hydroxyproline-rich peptides functionally but not structurally related to tomato systemin. Molecular events leading to the release of signalling peptides from protein precursors are unknown in plants; the occurrence of a family of signal molecules suggests that initiation of wound response may involve different processing mechanisms. It has been previously shown that the protein product from an engineered tomato prosystemin gene is processed in tobacco, thus suggesting that the components responsible for its post-translational modifications are present in this species. By analyzing analysing the proteome repertoire of transformed tobacco plant leaves with 2-DE, here we demonstrate that the constitutive expression of the tomato prosystemin gene highly affected host protein synthesis. In particular, engineered plants showed a number of differentially synthesized proteins that were identified by PMF MALDI-TOF and microLC-ESI-IT-MS/MS experiments as polypeptide species involved in protection from pathogens and oxidative stress, or in carbon/energy metabolism. Significant differences in over-produced proteins were observed with respect to previous data reported on systemin-engineered tomato plants. Our results strongly support the need of using proteomic approaches during systematic analysis of plant tissues to investigate the principle of substantial equivalence in transgenic plants expressing a transgene coding for a signalling molecule.

Psychiatric morbidity in HIV-infected children

After the introduction of antiretroviral therapy, HIV infection in children has been transformed from an acute to a chronic illness. The number of HIV-infected children has also increased in recent years. The routes of transmission and clinical manifestation of HIV infection in children are unique and different from those of adults. There are a number of biological, psychological and social factors associated with HIV-infected child that may predispose him/her to develop psychiatric illness. However, there are very few studies on psychiatric morbidity in HIV-infected children. In the existing studies, a number of psychiatric illnesses including: depression, anxiety, disruptive disorders and hyperactive disorders have been observed in HIV-infected children. A number of variables have a bearing on psychiatric morbidity, including experience and expression of physical illness as well as adherence to medications. The physician dealing with HIV-infected children should be aware of the psychological manifestations so that appropriate interventions and referral may be made as needed.

Impact on overall survival of primary tumor extirpation in breast cancer patients who present with stage IV disease

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Background: Limited data exists regarding optimal local therapy for patients who present with stage IV breast cancer with an intact primary tumor. Two retrospective series, from the National Cancer Data Base and the Geneva Cancer Registry, showed that surgery may improve overall survival in these patients. Our institutional experience demonstrated improved metastatic progression-free survival after a median follow-up of 32.1 months but did not show a survival benefit at short term follow-up. We evaluated the impact of local control on overall (OS) and disease-specific survival (DSS) in this population after a longer follow-up interval to determine if a survival benefit could be demonstrated from local surgical treatment for selected patients with stage IV breast cancer. Methods: We reviewed the records of all patients at our institution who presented from 1997–2002 with stage IV disease with an intact primary tumor. OS and DSS were estimated by the Kaplan-Meier method. The log-rank test was used to compare the difference in survival between surgical and non-surgical patients. Multivariate statistical analysis was performed using the Cox proportional hazards model. Results: Of 220 patients identified with stage IV disease with an intact primary tumor, 80 (36%) underwent surgical resection of the primary tumor; 39 (49%) had segmental mastectomy and 41 (51%) had a total mastectomy. There were 140 (64%) patients who did not undergo surgery. The median follow-up duration from time of presentation to our institution was 58.6 months and the median OS time after presentation was 45.8 months. After adjustment for covariates, surgery was associated with improved OS (p=0.03) and DSS (p=0.04) compared to the non-surgical group. Conclusions: With a median follow-up time of 58.6 months, patients who presented with stage IV breast cancer with an intact primary tumor treated surgically had significantly improved OS and DSS compared to patients who did not undergo surgery. Our findings may be limited by a selection bias. Therefore, we feel that the issue of surgical intervention for the primary tumor in stage IV breast cancer patients deserves to be carefully studied in a well-designed, prospective, multi-center trial.

No significant financial relationships to disclose.

Demographics, clinical profile, management, and outcome of retinoblastoma in a tertiary care center in southern India

20011

Background: Retinoblastoma is the most common malignant intraocular tumor in children. The estimated incidence of retinoblastoma in India is about 2,000 a year. However, there is scant data on the clinical manifestations and outcome of retinoblastoma in India. Methods: In this retrospective case series, the medical records of 460 consecutive cases of retinoblastoma from January 1990 to December 2004 were analyzed for demographics, clinical profile, treatment and outcome (survival, organ and function salvage). Results: An integrated Ocular Oncology Service was established at the treatment center in the year 2000 and a specialized Children’s Eye Cancer Center was founded in 2004. The annual referral increased from <20 a year before 2000 to 38 in 2000, and 120 in 2005. Two hundred and six (45%) patients were economically underprivileged. A majority (303, 66%) presented <3 years of age. There were 277 (60%) males. Although 188 (41%) were bilateral, family history was forthcoming in only 19 (4%). Of 648 involved eyes, 531 (82%) eyes were symptomatic. Leucocoria (71%) was the most common symptom, followed by visual loss (12%), eyelid edema or proptosis (7%), squint (6%), pain (2%), redness (2%), enlarged eyeball (2%), or shrunken eyeball (1%). The tumor was intraocular in 609 (94%) eyes while 39 (6%) were extraocular. Enucleation was the most common primary treatment for intraocular retinoblastoma (236 of 451, 52%), followed by chemoreduction coupled with focal therapy (26%), focal therapy alone (11%), external beam radiation (55) or chemotherapy alone (4%). Histopathologic risk factors predictive of metastasis were found in 152 of 277 (55%) eyes that underwent enucleation. Chemoreduction with focal therapy resulted in eye and vision salvage in 109 of 118 (92%). At the final follow-up (minimum 24 months), 434 (94%) were alive and well. Conclusions: Retinoblastoma has excellent prognosis for survival, eye salvage and vision salvage with the current management modalities. An integrated approach involving a team of a pediatric oncologist and an ocular oncologist at a comprehensive tertiary care center may augment referrals and help implement systematic treatment strategies.

No significant financial relationships to disclose.

Anti-leukemia activity of histone deacetylase (HDAC) inhibitor LBH589 involves depletion of EZH2 and DNA methyltransferase (DNMT) 1 through disruption of their chaperone association with heat shock protein (hsp) 90

10501

Background: LBH589 is a hydroxamate pan-HDAC inhibitor (HA-HDI) that also inhibits HDAC6, which induces acetylation of hsp90 and hsp70. This inhibits the ATP binding and chaperone function of hsp90. We recently reported that treatment with LBH589 depletes the levels of the polycomb repressive complex (PRC) 2 proteins EZH (enhancer of zeste homolog) 2, Suz12 and EED in AML cells. Since EZH2 has been shown to interact with and modulate the DNA methyltransferase activity of DNMT1, which affects its binding to the EZH2-targeted gene promoters, we determined the effects of LBH589 on the levels and interaction between EZH2 and DNMT1 in the CML blast crisis (CML-BC) K562 and LAMA-84 cells as well as in primary AML samples. Methods: Following exposure to 20 to 100 nM of LBH589 for 8 and 24 hours. immunoprecipitation and/or immunoblot analyses were performed to determine hsp90 binding and levels of DNMT1 and EZH2, as well as induction of JunB and loss of clonogenic survival of leukemia cells. Results: Treatment with LBH589 disrupted the chaperone association of DNMT1 and EZH2 with hsp90, resulting in polyubiquitylation and proteasomal degradation of DNMT1. Similar findings were also noted following treatment of leukemia cells with the hsp90 inhibitor, 17-DMAG. DNMT1 depletion by LBH589 was associated with induction of JunB in cultured and primary leukemia cells, which was further enhanced by co-treatment with decitabine. Consistent with this, methylation specific PCR analysis demonstrated increased demethylation of the JunB promoter. Co-treatment with decitabine and LBH589 or DMAG inhibited colony growth of the leukemia cells significantly more than treatment with either agent alone (p<0.05). Conclusions: These findings indicate that in addition to mediating histone acetylation and demethylation, LBH589 treatment induces epigenetic DNA demethylation by targeted depletion of EZH2 and DNMT1 in human leukemia cells. These results support the rationale for testing novel anti- leukemia combinations for epigenetic targeting that include LBH589, decitabine and/or histone methyltransferase inhibitors.

No significant financial relationships to disclose.

BRCA1a has antitumor activity in TN breast, ovarian and prostate cancers

Breast cancer gene 1 (BRCA1) mutations predispose women to breast and ovarian cancers and men to increased risks for prostate cancer. We have previously showed BRCA1 splice variant BRCA1a/p110 to induce apoptosis of human breast cancer cells. In the current study, stable expression of BRCA1a/p110 resulted in inhibition of growth of estrogen receptor (ER)-positive and triple-negative (TN) human breast, ovarian, prostate and colon cancer cells and mouse fibroblast cells. Similar to wild-type BRCA1, only those cells with wild-type Rb were sensitive to BRCA1a-induced growth suppression and the status of p53 did not affect the ability of BRCA1a to suppress growth of tumor cells. BRCA1a also significantly inhibited tumor mass in nude mice bearing human CAL-51 TN breast cancer, ES-2 ovarian cancer and PC-3 prostate cancer xenografts. These results suggest that the majority of exon 11 sequences (residues 263-1365) are not required for the tumor suppressor function of BRCA1 proteins. This is the first report demonstrating antitumor activity of BRCA1a in human ER-positive and TN breast, hormone-independent ovarian and prostate cancer cells. Currently, there are no effective treatments against TN breast cancers and results from these studies will provide new treatments for one of the biggest needs in breast cancer research.

Systemin regulates both systemic and volatile signaling in tomato plants

The prevailing reaction of plants to pest attack is the activation of various defense mechanisms. In tomato, several studies indicate that an 18 amino acid (aa) peptide, called systemin, is a primary signal for the systemic induction of direct resistance against plant-chewing pests, and that the transgenic expression of the prosystemin gene (encoding the 200 aa systemin precursor) activates genes involved in the plant response to herbivores. By using a combination of behavioral, chemical, and gene expression analyses, we report that systemin enhances the production of bioactive volatile compounds, increases plant attractivity towards parasitiod wasps, and activates genes involved in volatile production. Our data imply that systemin is involved in the systemic activation of indirect defense in tomato, and we conclude that a single gene controls the systemic activation of coordinated and associated responses against pests.

The birth of a specialty: the first ten thousand patients of an old age psychiatry service

BACKGROUND

Old age psychiatry as a clinical specialty emerged in the 1970s and modern, open-access multidisciplinary services started in the mid-1980s in South London. There are few accounts of referrals to old age psychiatry services and no quantitative accounts of the referral patterns to such teams. We report on the first 10,000 patients newly referred to the first such service in the world.

METHODS

Observational study on routinely gathered data on age, gender, referral source, discipline of team member involved, diagnosis and duration of contact. Data validation was by iterative feedback to clinicians.

RESULTS

Ten thousand patients were referred between December 1983 and March 2000. Missing data rates were low. The overall referral rate was 21.0 per 1000 population over 65 per annum, with the highest rate in those 85+ years old, in whom there was a marked rise over time. The rise in referral rate compensated for a decline in the population over 65 so that the numbers of referrals rose. Although there was a rise in the rate of referral of people with an organic diagnosis over time, this was not statistically significant. Organic patients constituted 50-60% of referrals but had shorter contact times than functional ones. Cause for concern included a low rate of referral from care homes, and a high proportion of possibly inappropriate referrals from medical and general psychiatry services. We were pleased to see no excess of such referrals from open-access sources, confirming earlier work.

CONCLUSIONS

Descriptive data on referrals and workload of the first open-access multidisciplinary old age psychiatry service have generated cause for both celebration and concern.

Glycogen synthase kinase 3 inhibition improves insulin-stimulated glucose metabolism but not hypertension in high-fat-fed C57BL/6J mice

AIMS/HYPOTHESIS

In the current study, the effect of a highly specific peptide inhibitor of glycogen synthase kinase 3 (GSK3) (L803-mts) on glucose metabolism and BP was examined in a high-fat (HF) fed mouse model of diabetes.

METHODS

C57/BL6J mice were placed on an HF diet for 3 months and treated with L803-mts for 20 days, following which glucose metabolism was examined by euglycaemic-hyperinsulinaemic clamp studies. BP and heart rate were measured by radio-telemetry.

RESULTS

The HF mice were obese, with impaired glucose tolerance and high plasma insulin and leptin levels. L803-mts treatment significantly reduced the insulin levels and doubled the glucose infusion rate required to maintain a euglycaemic condition in the HF+L803-mts group compared with the HF group. Insulin failed to suppress the endogenous glucose production rate in the HF group while decreasing it by 75% in the HF+L803-mts group, accompanied by increased liver glycogen synthase activity and net hepatic glycogen synthesis. GSK3 inhibition also reduced peripheral insulin resistance. Plasma glucose disappearance rate increased by 60% in the HF+L803-mts group compared with the HF group. In addition, glucose uptake in heart and gastrocnemius muscle was markedly improved. Although mean arterial pressure increased following the HF diet, it did not change significantly during the 12 days of L803-mts treatment.

CONCLUSIONS/INTERPRETATION

These studies demonstrate that GSK3 inhibition improved hepatic and peripheral insulin resistance in a mouse model of HF-induced diabetes, but it failed to have an effect on BP. GSK3 may represent an important therapeutic target for insulin resistance.