Utilization of antineoplastic therapy (ANT) in advanced cancer patients admitted to an acute palliative care unit (APCU) at a comprehensive cancer center

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Background: Cancer patients admitted to a palliative care unit generally have a poor prognosis. The role of ANT (chemotherapy and targeted agents) in these patients is unclear. We examined the frequency, trends, factors and survival associated with ANT use in hospitalized patients who required an APCU stay. Methods: All patients admitted to APCU between September 1, 2003 and August 31, 2008 were included. Demographics, cancer diagnosis and ANTs utilization from day of hospitalization to discharge, and survival information were retrieved retrospectively. Results: 2604 cancer patients had the following characteristics: median age 59 (range 18–101), male 51%, hematologic malignancy 11%, median hospital stay 11 (Q1-Q3 8–17) days, median APCU stay 7 (Q1-Q3 4–10) days and median survival 22 days. During hospitalization, 393 patients (15%) received ANTs, including chemotherapy (N=297, 11%) and targeted therapy (N=155, 6%). No significant change in frequency of ANTs was detected over the 5 year period. Multivariate logistic regression analysis ( Table ) revealed that younger age, cancer primaries and longer admissions were associated with ANT use. Patients with hematologic malignancies received more chemotherapy (38% vs. 8%, p<0.001) and targeted agents (18% vs. 4%, p<0.001) compared to patients with solid tumors. ANT use was associated with longer overall survival in univariate analysis (median 25 days vs. 21 days, p=0.001); however, this was no longer significant in multivariate Cox regression analysis. Conclusions: The use of ANT during hospitalization that included an APCU stay was limited to a highly selected group of patients, and did not increase overtime. ANT use was associated with younger age, specific cancer primaries, longer admissions, and no significant improvement in survival. The APCU at our cancer center facilitates simultaneous care where patients access palliative care while on ANT. [Table: see text]

No significant financial relationships to disclose.

Use of CA9 gene single nucleotide polymorphisms to predict prognosis and treatment response of metastatic renal cell carcinoma

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Background: Carbonic anhydrase 9 gene (CA9) is located in a prognostically relevant chromosomal area on chromosome 9p and is encoding for one of the most significant protein markers in metastatic renal cell carcinoma (MRCC), CAIX. In contrast to CAIX protein, however, no efforts have been made to date to study CA9 gene in metastatic RCC. Here, we test the hypotheses that single nucleotide polymorphisms (SNPs) and mutations of the CA9 gene are associated with CAIX expression, response to immunotherapy and survival. Methods: Genomic DNA was extracted from frozen tumor samples of 54 patients with clear cell MRCC. All exons of the CA9 gene were PCR-amplified and sequenced. The antibody M75 was used to evaluate CAIX protein expression immunohistochemically. Statistical associations of CA9 gene status and CAIX protein expression with response to IL-2 based immunotherapy and overall survival were assessed with chi-square tests, t-tests, Kaplan-Meier survival estimates and Cox proportional hazards regression models. Results: CA9 reference SNP (rs) 2071676 was found in 59%, rs12553173 in 15%, rs3829078 in 11% and rs1048638 in 33% of the patients. The deletion c.376del393 was observed in two patients. CAIX expression was high (>85%) in 65% of the patients. None of the SNPs was significantly associated with CAIX expression. Patients with the C allele variant of rs12553173 had improved median survival (27.3 vs. 13.6 months, p = 0.0431) and a greater likelihood of response to IL-2 (57% vs. 22%, p = 0.081) Likewise, high CAIX expression was associated with longer median survival (25.5 vs. 8.5 months, p < 0.0001) and a greater IL-2 response rate (37% vs. 8%, p = 0.070). In a multivariate Cox model, both C allele variant of CA9 SNP rs12553173 and CAIX expression were retained as independent prognostic factors. Conclusions: CA9 SNPs are frequently found in patients with MRCC. The C allele variant of rs12553173 is associated with improved overall survival and a greater likelihood of response to IL-2. CA9 rs12553173 and CAIX are both independent prognostic factors of overall survival and complementary in predicting prognosis of MRCC.

No significant financial relationships to disclose.

Acute palliative care unit in a comprehensive cancer center (CCC): Financial and clinical outcomes

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Background: Acute palliative care units (APCU) in CCCs improves symptom control for advanced cancer patients and supports their families. However, these services are not available in the majority of cancer centers. Concerns regarding financial reimbursements represent a major barrier for establishing APCUs. The purpose of this study is to report the clinical outcomes and compare the financial outcomes of our APCU as compared to other services at our CCC. Methods: We reviewed all admissions to the APCU over the last 5 fiscal years for demographic information, length of stay, discharges, survival, hospital billings and collection of charges, and compared these to the rest of the institution. Results: 2,510 unique patients were admitted to the APCU. Median age was 59 years (19–101) and 51% were female. The median length of stay in APCU was 8 days (Q1-Q3 6–10). Median survival of patients discharged home, to health care facilities and hospice were 53, 22, and 13 days, respectively (p<0.001, log rank test), with 6 month survival of 20%, 4%, and 2%, respectively. Professional collections ranged from 42–47% of charges for APCU, vs. 32–38% for rest of the CCC and were stable over the 5 year period. Hospital collections were 47–51% of charges for APCU, vs. 55–57% for the rest of the CCC. The payer mix included commercial 1155 (46%), Medicare 755 (30%), Medicaid 126 (5%), mixed 127 (5%), indigent 198 (8%), and others 149 (6%). Conclusions: The ACPU has reimbursement outcomes consistent with the American acute care model and comparable to the rest of the CCC for last 5 years. The APCU is as viable as any other clinical programs in our institution. Further research is needed to investigate possible reasons for lack of APCU in cancer centers.

No significant financial relationships to disclose.

Treatment experience of subsequent complications after Roux-en-Y biliojejunostomy

PURPOSE

Roux-en-Y biliojejunostomy has been frequently used in the management of benign biliary disease. The aim of this study was to summarize one institute's experiences in prevention and management of subsequent complications of Roux-en-Y biliojejunostomy.

METHODS

A retrospective analysis was carried out for patients who underwent reoperation after Roux-en-Y biliojejunostomy from February 1990 through June 2004. Operation history, laboratory test data before the last operation, and images were collected.

RESULTS

Sixty-one patients, aged 36-60 years and with a 3.5-year average operation interval, were involved in the study. Anastomotic stricture (47, 80.3%), recurrent calculi (36, 60.7%), and biliary tract infection (all) were the most common complications after Roux-en-Y biliojejunostomy. Other complications (such as calculi of the intrahepatic duct or intrahepatic duct stricture, malformed or twisted jejunum loop, too long or too short proximal jejunum, disappearance of the normal form of anastomosis, and adhesion of the intestinal loop) were also detected by laparotomy.

CONCLUSION

Calculus, stricture, and infection arise as a result of each other. Lessening of the anastomotic stricture, fluent drainage of the distal jejunum below the anastomosis, and relieving pressure of gastrointestinal tract are pivotal in decreasing subsequent complications after Roux-en-Y biliojejunostomy.

Influence of Borneol on In Vitro Corneal Permeability and on In Vivo and In Vitro Corneal Toxicity

This study examined whether borneol could enhance corneal drug permeability. Model drugs containing either synthetic or natural borneol were co-administered to isolated intact or de-epithelialized rabbit corneas and the apparent permeability coefficients were measured. Draize tests in rabbits and levels of isolated intact rabbit corneal hydration were used to measure in vivo and in vitro toxicity, respectively. Synthetic borneol (0.1%) increased corneal penetration of the lipophilic agents, indomethacin and dexamethasone, by 1.23 and 2.40, respectively, and of the hydrophilic agents, ofloxacin, ribavirin and tobramycin, by 1.87, 2.80 and 3.89, respectively. For natural borneol, the corresponding fold increases were 1.67, 2.00, 2.15, 2.18 and 3.39, respectively. Removing the epithelium attenuated the penetration-enhancing effects of borneol. Borneol (0.1%) did not damage corneal tissue. The ability of borneol to enhance drug penetration through the outer corneal layer, particularly for highly-hydrophilic drugs, suggests that further clinical investigation may be warranted.

Characterization of a new HLA-C allele in a Chinese family by sequence-based typing: HLA-Cw*0348

The novel human leukocyte antigen (HLA)-Cw*0348 allele was identified by sequence-based typing in a Chinese family. This allele shows that the sequences of exons 1-3 of HLA-Cw*0348 are identical to those of HLA-Cw*030401 except for a nucleotide substitution that changes CCG to CTG at codon 57, resulting in an amino acid change from Pro to Leu in the protein, and this is a unique nucleotide change among the HLA-C alleles, suggesting a point mutation mechanism. The extended haplotype carrying the new allele was deduced from the family group typing and defined as A*110101, B*1301, Cw*0348, DRB1*0405, and DQB1*0402.

PI3K/Akt mediates expression of TNF-alpha mRNA and activation of NF-kappaB in calyculin A-treated primary osteoblasts

OBJECTIVE

The effect of calyculin A (CA), a serine/threonine protein phosphatase inhibitor, on tumor necrosis factor-alpha (TNF-alpha) in primary osteoblasts was investigated to determine whether protein phosphatases could affect primary osteoblasts and if so which signaling pathways would be involved.

MATERIALS AND METHODS

Primary osteoblasts were prepared from newborn rat calvaria. Cells were treated with 1 nM CA for different time periods. The expressions of TNF-alpha and GAPDH mRNA were determined by RT-PCR. Cell extracts were subjected to SDS-PAGE and the activation of Akt and NF-kappaB were analyzed by western blotting.

RESULTS

Calyculin A-treatment markedly increased the expression of TNF-alpha mRNA and enhanced the phosphorylation level of Akt (Ser473) in these cells. Pretreatment with the PI3K inhibitor LY294002 suppressed the increase in TNF-alpha mRNA expression and the phosphorylation of Akt in response to CA. Western blot analysis showed that CA stimulated the phosphorylation and nuclear translocation of NF-kappaB in primary osteoblasts, and these responses were blocked by pretreatment with LY294002.

CONCLUSION

Calyculin A elicits activation of PI3K/Akt pathway which leads to expression of TNF-alpha mRNA and activation of NF-kappaB. This NF-kappaB activation involves both phosphorylation and nuclear translocation of NF-kappaB.

Soft-hydrothermal processing of red cedar bedding reduces its induction of cytochrome P450 in mouse liver

Red cedar-derived bedding materials cause changes in cytochrome P450-dependent microsomal enzyme systems in laboratory animals. We examined the effect of essential oil of red cedar (EORC), as well as the effect of bedding from which it had been removed, on the hepatic expression cytochrome P450s in mice. EORC was obtained from liquid extracts of red cedar bedding by a soft-hydrothermal process and was administered orally to mice. Between days 1 and 2 after administration, hepatic P450s were significantly induced as follows: CYP3As, 7.1×; CYP1As, 1.6×; CYP2E1, 1.5×; CYP2Cs, 1.6×. A housing study of mice indicated that red cedar bedding increased the levels of these P450s in mouse liver, whereas mice housed in cedar bedding from which EORC had been removed (ST-cedar bedding) showed significantly lower levels of P450s, especially CYP3As, CYP1As and CYP2E1. Soft-hydrothermal processing partially removed many components of EORC. In particular, several volatile sesquiterpenes, naphthalene-derived aromatics and 4,4-dimethyl-13α-androst-5-ene were decreased in the ST-cedar bedding, suggesting that these may be responsible for P450 induction. This study demonstrated that the removal of these volatile compounds by soft-hydrothermal processing can decrease the hepatic P450-inducing effect of red cedar bedding.

Evaluation of endoscopic-ultrasound-guided celiac ganglion irradiation with iodine-125 seeds: a pilot study in a porcine model

BACKGROUND AND STUDY AIMS

Implantation of iodine-125 ( (125)I) seeds under the guidance of endoscopic ultrasonography (EUS) has been proved to be a safe alternative treatment option for advanced pancreatic cancer. The main purpose of this study was to evaluate the feasibility and safety of EUS-guided radiation of the celiac ganglia with (125)I seeds in a porcine model.

METHODS

Twelve domestic pigs were randomly divided into three groups. The pigs in group A had blank seeds implanted, and groups B and C had 0.4 mCi and 0.8 mCi (125)I seeds implanted, respectively. Enhanced CT scan and 3-D vascular remodeling were used to check the location of the seeds. All animals were killed and celiac ganglia were checked at 14 and at 60 days after procedure. Necrosis and apoptosis in celiac ganglia and adjacent vessels and organs were also observed.

RESULTS

EUS-guided implantations of (125)I seeds in celiac plexus were successful at first procedure in 10 animals. The remaining two animals were implanted successfully the next day. No severe complications occurred in any animal and no damage was found in the surrounding organs. At day 60 after operation, the apoptotic index in the ganglia was 0.53 in the 0.4 mCi group and 0.94 in the 0.8 mCi group. No apoptotic cells were found in the control group implanted with blank seeds. Damage to vessels and surrounding organs by radioactive seeds was observed in only one pig at each time point.

CONCLUSION

EUS-guided implantation of (125)I seeds beside the celiac ganglia is a safe procedure and can induce apoptosis of local neurons. This new method may lead to an alternative treatment for pain accompanying pancreatic diseases in human.

Identification of a new HLA-B*40 allele, HLA-B*4081, in a Chinese individual

A novel human leukocyte antigen (HLA)-B*40 allele, officially named B*4081, was identified during routine high-resolution sequence-based typing in a Chinese potential hematopoietic stem cell transplantation donor. The HLA-B*4081 allele shows one nucleotide difference from B*400101 in exon 2 at nucleotide position 124 where G-->C (codon 18 GGG-->CGG) resulting in a coding change, 18Gly is changed to Arg, this is a unique nucleotide change among the HLA class I alleles, suggesting a point mutation mechanism.