A prospective, multicenter trial of complementary and alternative medicine (CAM) utilization by patients undergoing definitive breast radiotherapy

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Background: A substantial number of breast cancer (BC) pts use complementary and alternative medicines (CAM), but there is a paucity of data on CAM specifically during radiation therapy (RT). The purpose of this study was to prospectively assess the utilization of CAM during RT for BC pts.

Methods: 456 pts w/stage 0-III BC were accrued from 5 RT centers from 9/07-2/09. Participating MDs were advised not to discuss CAM. A validated survey instrument was administered during the last week of RT under guidance of a study nurse, which included demographics, details regarding types/doses/frequency of CAM and skin assessments by pt and nurse.

Results: 360 pts were eligible for analysis (79%); median age 57 yrs; stage 0-II, 91%; white race 89%; chemotherapy 39%; hormone therapy (HT) w/ RT, 26%; > college education, 59%. CAM was reported in 54% (n = 195), of which 72% reported programs/activities (i.e., Reiki, healing touch, visualization, etc.), and 66% oral/topical CAM. Only 16% reported counseling prior to starting CAM. CAM use did not differ by ethnicity, chemotherapy or stage (all p > 0.05), but correlated significantly with higher education level (p = 0.0001) and inversely correlated w/ HT/RT (p = 0.015). There was a trend towards CAM use in younger pts (p = 0.069). On MVA, education (RC: 1.859; OR: 6.417, 95% CI: 2.023, 20.357, p = 0.002) and HT/RT (RC: -0.530, OR: 0.589, 95% CI: 0.357, 0.970, p = 0.038) independently predicted for CAM use. Rationale for oral/topical: 32% “improve their chance of cure”; 24% “provide treatment-related symptom relief”. For programs/activities: 31% “relaxation/stress reduction”; 11% “reduces treatment-related symptoms”. Despite these beliefs, there were no significant differences between the perception of the pts to nursing skin assessment score as a function of CAM use (p = 0.497).

Conclusions: To our knowledge, this is the first and largest prospective study of CAM during RT for BC pts. Given the high prevalence of undocumented CAM use during RT, questions regarding CAM should be considered during consultation and weekly tx visits. A better understanding of CAM practices during RT will facilitate evaluation of potential interactions of CAM and RT for BC.

Structure of GATE-16, membrane transport modulator and mammalian ortholog of autophagocytosis factor Aut7p

The GATE-16 protein participates in intra-Golgi transport and can associate with the N-ethylmaleimide-sensitive fusion protein and with Golgi SNAREs. The yeast ortholog of GATE-16 is the autophagocytosis factor Aut7p. GATE-16 is also closely related to the GABA receptor-associated protein (GABARAP), which has been proposed to cluster neurotransmitter receptors by mediating interaction with the cytoskeleton, and to the light chain-3 subunit of the neuronal microtubule-associated protein complex. Here, we present the crystal structure of GATE-16 refined to 1.8 A resolution. GATE-16 contains a ubiquitin fold decorated by two additional N-terminal helices. Proteins with strong structural similarity but no detectable sequence homology to GATE-16 include Ras effectors that mediate diverse downstream functions, but each interacts with Ras by forming pseudo-continuous beta-sheets. The GATE-16 surface suggests that it binds its targets in a similar manner. Moreover, a second potential protein-protein interaction site on GATE-16 may explain the adapter activity observed for members of the GATE-16 family.

Crystal structure of the Sec18p N-terminal domain

Yeast Sec18p and its mammalian orthologue N-ethylmaleimide-sensitive fusion protein (NSF) are hexameric ATPases with a central role in vesicle trafficking. Aided by soluble adapter factors (SNAPs), Sec18p/NSF induces ATP-dependent disassembly of a complex of integral membrane proteins from the vesicle and target membranes (SNAP receptors). During the ATP hydrolysis cycle, the Sec18p/NSF homohexamer undergoes a large-scale conformational change involving repositioning of the most N terminal of the three domains of each protomer, a domain that is required for SNAP-mediated interaction with SNAP receptors. Whether an internal conformational change in the N-terminal domains accompanies their reorientation with respect to the rest of the hexamer remains to be addressed. We have determined the structure of the N-terminal domain from Sec18p by x-ray crystallography. The Sec18p N-terminal domain consists of two beta-sheet-rich subdomains connected by a short linker. A conserved basic cleft opposite the linker may constitute a SNAP-binding site. Despite structural variability in the linker region and in an adjacent loop, all three independent molecules in the crystal asymmetric unit have the identical subdomain interface, supporting the notion that this interface is a preferred packing arrangement. However, the linker flexibility allows for the possibility that other subdomain orientations may be sampled.

Crystal structure of the N-terminal domain of the DnaB hexameric helicase

BACKGROUND

The hexameric helicase DnaB unwinds the DNA duplex at the Escherichia coli chromosome replication fork. Although the mechanism by which DnaB both couples ATP hydrolysis to translocation along DNA and denatures the duplex is unknown, a change in the quaternary structure of the protein involving dimerization of the N-terminal domain has been observed and may occur during the enzymatic cycle. This N-terminal domain is required both for interaction with other proteins in the primosome and for DnaB helicase activity. Knowledge of the structure of this domain may contribute to an understanding of its role in DnaB function.

RESULTS

We have determined the structure of the N-terminal domain of DnaB crystallographically. The structure is globular, highly helical and lacks a close structural relative in the database of known protein folds. Conserved residues and sites of dominant-negative mutations have structurally significant roles. Each asymmetric unit in the crystal contains two independent and identical copies of a dimer of the DnaB N-terminal domain.

CONCLUSIONS

The large-scale domain or subunit reorientation that is seen in DnaB by electron microscopy might result from the formation of a true twofold symmetric dimer of N-terminal domains, while maintaining a head-to-tail arrangement of C-terminal domains. The N-terminal domain of DnaB is the first region of a hexameric DNA replicative helicase to be visualized at high resolution. Comparison of this structure to the analogous region of the Rho RNA/DNA helicase indicates that the N-terminal domains of these hexameric helicases are structurally dissimilar.

The structural basis for terminator recognition by the Rho transcription termination factor

The E. coli Rho protein disengages newly transcribed RNA from its DNA template, helping terminate certain transcripts. We have determined the X-ray crystal structure of the RNA-binding domain of Rho complexed to an RNA ligand. Filters that screen both ligand size and chemical functionality line the primary nucleic acid-binding site, imparting sequence specificity to a generic single-stranded nucleic acid-binding fold and explaining the preference of Rho for cytosine-rich RNA. The crystal packing reveals two Rho domain protomers bound to a single RNA with a single base spacer, suggesting that the strong RNA-binding sites of Rho may arise from pairing of RNA-binding modules. Dimerization of symmetric subunits on an asymmetric ligand is developed as a model for allosteric control in the action of the intact Rho hexamer.

Quaternary changes in topoisomerase II may direct orthogonal movement of two DNA strands

Type II DNA topoisomerases mediate the passage of one DNA duplex through a transient break in another, an event essential for chromosome segregation and cell viability. The active sites of the type II topoisomerase dimer associate covalently with the DNA break-points and must separate by at least the width of the second DNA duplex to accommodate transport. A new structure of the Saccharomyces cerevisiae topoisomerase II DNA-binding and cleavage core suggests that in addition to conformational changes in the DNA-opening platform, a dramatic reorganization of accessory domains may occur during catalysis. These conformational differences have implications for both the DNA-breaking and duplex-transport events in the topo II reaction mechanism, suggest a mechanism by which two distinct drug-resistance loci interact, and illustrate the scope of structural changes in the cycling of molecular machines.

Structural similarities between topoisomerases that cleave one or both DNA strands

Type IA and type II DNA topoisomerases are distinguished by their ability to cleave one or two strands, respectively, of a DNA duplex. Both types have been proposed to use an "enzyme-bridging" mechanism, in which a break is formed in a DNA strand and a gap is opened between the broken pieces to allow passage of a second DNA strand or duplex segment. Although the type IA and type II topoisomerase structures appear overall quite different from one another, unexpected similarities between several structural elements suggest that members of the two subfamilies may use comparable mechanisms to bind and cleave DNA.

Structure of a murine leukemia virus receptor-binding glycoprotein at 2.0 angstrom resolution

An essential step in retrovirus infection is the binding of the virus to its receptor on a target cell. The structure of the receptor-binding domain of the envelope glycoprotein from Friend murine leukemia virus was determined to 2.0 angstrom resolution by x-ray crystallography. The core of the domain is an antiparallel beta sandwich, with two interstrand loops forming a helical subdomain atop the sandwich. The residues in the helical region, but not in the beta sandwich, are highly variable among mammalian C-type retroviruses with distinct tropisms, indicating that the helical subdomain determines the receptor specificity of the virus.

Implant brachytherapy: a novel treatment for recurrent orbital rhabdomyosarcoma

BACKGROUND

Orbital rhabdomyosarcoma is the most common primary malignancy of the orbit in childhood. Tumor resection and exenteration were the preferred treatment modalities for rhabdomyosarcoma. In the past 20 years, however, combined local radiation and systemic chemotherapy have shown excellent survival results. Tumor recurrence after any of the aforementioned therapies is almost always fatal. We have developed a novel treatment for recurrent disease that has resulted in long-term survival for three patients.

METHODS

Three patients with recurrent orbital rhabdomyosarcoma were previously treated with primary radiation and chemotherapy. At the time of recurrence, exenteration and localized brachytherapy were performed. An individually molded poly(methylmethacrylate) (Lucite; E. I. du Pont de Nemours & Co., Wilmington, Del.) device loaded with radioactive iodine seeds delivered localized high-dose radiation, 6000 cGy over 6 days, to the orbit without irradiating the brain.

RESULTS

All patients are alive and free of disease with follow-up ranging from 4 years and 4 months to 8 years and 4 months.

CONCLUSION

A novel technique of delivering localized radiation to the orbit of three children with recurrent orbital rhabdomyosarcoma appears curative.

Molecular basis of familial hypercholesterolaemia from structure of LDL receptor module

The low-density lipoprotein receptor (LDLR) is responsible for the uptake of cholesterol-containing lipoprotein particles into cells. The amino-terminal region of LDLR, which consists of seven tandemly repeated, approximately 40-amino-acid, cysteine-rich modules (LDL-A modules), mediates binding to lipoproteins. LDL-A modules are biologically ubiquitous domains, found in over 100 proteins in the sequence database. The structure of ligand-binding repeat 5 (LR5) of the LDLR, determined to 1.7 A resolution by X-ray crystallography and presented here, contains a calcium ion coordinated by acidic residues that lie at the carboxy-terminal end of the domain and are conserved among LDL-A modules. Naturally occurring point mutations found in patients with the disease familial hypercholesterolaemia alter residues that directly coordinate Ca2+ or that serve as scaffolding residues of LR5.

Core structure of gp41 from the HIV envelope glycoprotein

The envelope glycoprotein of human immunodeficiency virus type 1 (HIV-1) consists of a complex of gp120 and gp41. gp120 determines viral tropism by binding to target-cell receptors, while gp41 mediates fusion between viral and cellular membranes. Previous studies identified an alpha-helical domain within gp41 composed of a trimer of two interacting peptides. The crystal structure of this complex, composed of the peptides N36 and C34, is a six-helical bundle. Three N36 helices form an interior, parallel coiled-coil trimer, while three C34 helices pack in an oblique, antiparallel manner into highly conserved, hydrophobic grooves on the surface of this trimer. This structure shows striking similarity to the low-pH-induced conformation of influenza hemagglutinin and likely represents the core of fusion-active gp41. Avenues for the design/discovery of small-molecule inhibitors of HIV infection are directly suggested by this structure.

Retrovirus envelope domain at 1.7 angstrom resolution

We report the crystal structure of an extraviral segment of a retrovirus envelope protein, the Moloney murine leukemia virus (MoMuLV) transmembrane (TM) subunit. This segment, which comprises a region of the MoMuLV TM protein analogous to that contained within the X-ray crystal structure of low-pH converted influenza hemagglutinin, contains a trimeric coiled coil, with a hydrophobic cluster at its base and a strand that packs in an antiparallel orientation against the coiled coil. This structure gives the first high-resolution insight into the retrovirus surface and serves as a model for a wide range of viral fusion proteins; key residues in this structure are conserved among C- and D-type retroviruses and the filovirus ebola.

Dissection of a retrovirus envelope protein reveals structural similarity to influenza hemagglutinin

BACKGROUND

The amino-acid sequences of retroviral envelope proteins contain a '4-3 hydrophobic repeat', with hydrophobic amino acids spaced every four and then every three residues, characteristic of sequences that form coiled coils. The 4-3 hydrophobic repeat is located in the transmembrane subunit (TM) of the retroviral envelope protein, adjacent to the fusion peptide, a region that inserts into the host bilayer during the membrane-fusion process. A 4-3 hydrophobic repeat region in an analogous position of the influenza hemagglutinin protein is recruited to extend a three-stranded coiled coil during the conformational change to the fusion-competent state. To determine the conformation of the retroviral TM subunit and the role of the 4-3 hydrophobic repeat, we constructed soluble peptide models of the envelope protein of Moloney murine leukemia virus (MMLV).

RESULTS

The region of the MMLV TM protein external to the lipid envelope (the ectodomain) contains a stably folded, trimeric, protease-resistant core. As predicted, an alpha-helical segment spans the 4-3 repeat. A cysteine-rich region carboxy-terminal to the 4-3 repeat confers a dramatic increase in stability and displays a unique disulfide bonding pattern.

CONCLUSIONS

Our results demonstrate that the MMLV TM subunit can fold into a stable and distinct species in the absence of the receptor-binding 'surface' co-subunit (SU) of the envelope complex. As the SU subunit is readily shed from the surface of the virus, we conclude that the TM subunit structure forms the core of the MMLV membrane-fusion machinery, and that this structure, like the fusion-active conformation of influenza hemagglutinin, contains a three-stranded coiled coil adjacent to the fusion peptide.

Effects of beam modifiers and immobilization devices on the dose in the build-up region

PURPOSE

To analyze the effect that immobilization devices used in conjunction with beam modifiers may have on the dose to the skin and build-up region.

METHODS AND MATERIALS

Central axis depth dose measurements were made in a polystyrene phantom in the build-up regions using the 6 and 15 MV photon beams, at two different source-to-phantom distances, and various field sizes. The effects of acrylic blocking trays, lead wedges, and cerrobend blocks were assessed in conjunction with the enhancement of dose in the build-up region due to immobilizing devices using plaster and thermoplastic casting materials of different thicknesses.

RESULTS

For the 6 MV photons, solid (3 mm) thermoplastic casting material was found to have the greatest effect on surface dose: for a 12 x 12 cm field we measured 79% of maximum dose when treating through the material versus 22% of maximum dose when no beam modifiers or immobilization devices are used. Measurements were also made to evaluate the effect of the immobilization of patients receiving three-dimensional conformal treatments using a 15 MV photon beam.

CONCLUSIONS

The relevance of these results to treatments in the pelvis, breast, and head and neck regions is discussed. For 6 MV beams, special consideration should be given if the need arises to treat through the immobilization device, as unacceptable skin reactions may result.

Crystal structure of transcription factor E47: E-box recognition by a basic region helix-loop-helix dimer

A large group of transcription factors regulating cell growth and differentiation share a dimeric alpha-helical DNA-binding domain termed the basic region helix-loop-helix (bHLH). bHLH proteins associate as homodimers and heterodimers having distinctive DNA-binding activities and transcriptional activities that are central to the regulated differentiation of a number of tissues. Some of the bHLH residues specifying these activities have been identified, but a full understanding of their function has awaited further structural information. We report here the crystal structure of the transcription factor E47 bHLH domain bound to DNA. The bHLH of E47 is a parallel, four-helix bundle with structural features that distinguish it from the bHLH-zipper protein Max. The E47 dimer makes nonequivalent contacts to each half of the -CACCTG- binding site. Sequence discrimination at the center of the E box may result from interaction with both the DNA bases and the phosphodiester backbone.

The effect of setup uncertainties on the treatment of nasopharynx cancer

PURPOSE

As radiation treatment techniques become more complicated, the need to understand the effect of uncertainties on dose distributions increases. This study investigates the effect of positional uncertainities for patients with nasopharynx carcinoma treated with a multiple field conformal boost technique. Three dimensional setup errors were measured for six patients and the effect on patient dose was evaluated using dose volume histograms.

METHODS AND MATERIALS

A method is presented for determining 3-dimensional translational and rotational setup errors by identifying anatomical landmarks on two treatment field images and their corresponding simulation images. Measurements were made on a daily basis for six patients undergoing conformal treatment.

RESULTS

The average magnitude of the translational errors was between 1.5 and 3 mm while the average distance between simulation and treatment isocenters was 5 mm. Both systematic and random setup errors were observed. Dose volume histograms incorporating these uncertainties for standard parallel opposed and conformal techniques were generated for patients experiencing random and systematic setup errors.

CONCLUSION

The data imply that positional uncertainties effect the daily dose distributions for target and critical structures differently and that the effect may be treatment technique dependent. These results demonstrate the need to measure setup uncertainties for all sites and to develop techniques for incorporating dose uncertainties in treatment plans.

The regulatory gene, hXBP-1, and its target, HLA-DRA, utilize both common and distinct regulatory elements and protein complexes

hXBP-1 is a transcription factor of the leucine zipper (b-zip) family important in the expression of the class II major histocompatibility complex gene, DRA. Studies with mouse-human hybrids have mapped hXBP-1 hybridizing fragments to human chromosomes 5 and 22 and the frequent detection of two mRNA transcripts suggested that hXBP-1 may be a member of a small gene family. To analyze the structure and regulation of hXBP-1 further, cosmid clones from both chromosomes were isolated. Mapping and sequence analyses reveal that chromosome 22 contains the functional hXBP-1 gene while chromosome 5 contains a processed pseudogene. hXBP-1 promoter analysis has revealed that cis-active elements within the 5'-untranslated region of hXBP-1 are essential for full promoter activity. One such element, hX2, is identical to the hXBP-1 target sequence in the DRA promoter. Mutagenesis of the hX2 site substantially decreases promoter activity. This element interacts with four distinct protein complexes in mature B cells and cross-competition experiments show that two of these complexes (complex 1 and complex 4) also interact with the hXBP-1 target sequence (X2) from the DRA promoter. The similarities of the hXBP-1 promoter and of the DRA promoter (the gene that the hXBP-1 protein regulates) are further emphasized by the fact that a Y box element is located 3' of both hX2 and X2.

Choroidal melanoma responses after brachytherapy treatment

Serial ultrasonic measurements performed on 85 melanoma patients who were treated with radioactive plaques and followed for up to 141 months revealed that no 2 patients had identical patterns of change. Eighty-two of the patients were categorized into one of four patterns after treatment: Type D (decrease in height, 57 patients), Type S (same height, 12 patients), Type I (increase in height, 9 patients), and Type RG (tumour regrowth, 4 patients). The calculated mean total change in tumor height for Type D was 1.92 mm at 6 months, 2.58 mm at 12 months, 2.97 mm at 24 months and 3.61 mm at 48 months. For Type I, the mean total change in tumor height was 0.80 mm at 6 months, 0.95 mm at 12 months, 2.28 mm at 24 months, and 3.0 mm at 48 months.

A reappraisal of the role of prophylactic cranial irradiation in limited small cell lung cancer

The use of prophylactic cranial irradiation in limited stage small cell lung cancer remains controversial. Prospective trials have demonstrated that PCI can reduce central nervous system relapse rates, but the impact on survival remains questionable except for the possible evidence of a beneficial effect for long term survivors. With higher rates of thoracic control now obtainable with hyperfractionated radiation and concomitant chemotherapy, it becomes important to analyze the benefit of PCI in that setting. Before 1982, we included PCI in the management of all patients with limited stage small cell lung cancer; thereafter, we discontinued its use. This report compares the outcome of the two treatment approaches and addresses the role of PCI among patients who achieve durable local control. There were 36 limited stage small cell lung cancer patients treated with PCI from 1979-1982 and 26 patients treated without PCI from 1985-1989. Induction chemotherapy was followed in both groups by thoracic irradiation (45 Gy). The PCI patients received 30 Gy to the whole brain in 10 fractions. Both groups received maintenance chemotherapy. Of complete responders, brain failure was the first failure in 18% (4/22) of PCI (+) versus 45% (10/22) of PCI (-) (p = .04). Survival at 2 years was 42% for PCI (+) versus 13% for PCI (-) (p less than .05). When the analysis was limited to those patients permanently controlled in the thorax; there were 25% (4/16) brain failures PCI (+) versus 70% (7/10) PCI (-) (p = .03). For this same subset the 2-year survival was 56% PCI (+) versus 14% PCI (-) (p less than .05). There were no 5 year survivors without PCI compared to 38% (6/16) with PCI. These data suggest that PCI appears to be effective in enhancing survival of patients who achieve durable thoracic control. Prospective trials are necessary to evaluate the use of PCI combined with therapeutic regimens with a documented ability to achieve high rates of sustained control of thoracic disease.

Cobalt60 plaques in recurrent retinoblastoma

Cobalt60 plaque irradiation is one treatment option for patients with recurrent retinoblastoma following conventional external beam irradiation (ERT). Tumorocidal doses can be delivered without excessive risk of normal tissue injury. In patients not considered candidates for xenon arc or cryotherapy, 60Co is an alternative to enucleation. Between 1968 and 1987, 85 patients were treated with 60Co plaques, 72 of whom had failed prior ERT. Age at diagnosis ranged from 1 week to 4 years. There are 37 males and 35 females. Seventy-one patients had bilateral disease and one had unilateral. Three patients had both eyes plaqued. Prior ERT ranged from 30 to 70 Gy (mean 4200 Gy). Time from initial therapy to failure ranged from 13 to 60 months. Cobalt plaques of 10 mm, 15 mm, or 10 x 15 mm were used depending on tumor size and location. Dose prescribed to the apex of the tumor ranged from 30 to 50 Gy (median 40 Gy) given over 3 to 8 days. Twelve patients had two plaque applications; three patients had three plaque applications. All patients were followed with routine ophthalmoscopic examinations. Follow-up ranged from 2 to 22 years (mean 8.7). Seven patients died of metastatic disease; 10 patients developed non-ocular second tumors. Thirty patients required enucleation. Twenty-two patients had clear tumor progression, two patients had radiation complications, and six patients had a combination of tumor growth and complications. Cobalt60 can salvage eyes in retinoblastoma patients failing ERT. Currently, we are using I125 in an attempt to spare normal ocular tissue and reduce subsequent complications.

Intraoperative brachytherapy alone for incomplete resected recurrent rectal cancer

In order to determine the impact of intraoperative brachytherapy alone in patients with recurrent rectal cancer who, due to prior pelvic radiation therapy, were ineligible to receive further external beam pelvic radiation, we retrospectively reviewed the records of 36 patients with recurrent rectal cancer who had gross residual disease remaining in the pelvis following biopsy alone or subtotal resection. The median follow-up was 24 months (6-81 months). The median survival was 27 months and the 4 year actuarial survival was 25%. There was a suggestion of lower survival in patients who underwent biopsy alone compared with those who underwent a subtotal resection (21% vs. 34%). The local failure (LF) rate was 22% as the only site of failure and 44% as a component of failure. There was a lower but non-significant LF rate in patients who underwent subtotal resection vs. biopsy alone (33% vs. 66%) and those with an 125I implant volume of less than 40 cm3 vs. greater than or equal to 40 cm3 (39% vs. 100%). Four patients (11%) developed treatment-related severe complications (without evidence of LF). Our data suggest that, although it is not clear that intraoperative brachytherapy impacts on the ultimate survival rate in this group of patients, it does offer reasonable local control with acceptable morbidity. Since local control, in and of itself is an important endpoint in the treatment of rectal cancer, we continue to recommend brachytherapy as part of an overall aggressive approach in patients who are unable to receive pelvic radiation therapy.

Retinoblastoma. The long-term appearance of radiated intraocular tumors

A retrospective analysis of 50 patients with retinoblastoma was undertaken to determine the appearance of intraocular retinoblastoma that had received external beam radiation a minimum of 10 years previously. Of the 91 tumors found in 59 eyes, 76 (84%) continued to be ophthalmoscopically visible after 10 years. The most common ophthalmoscopic appearance was a Type III regression pattern. The type of radiation regression pattern correlated with the pretreatment volume of the tumor. The largest tumors (mean, 10.0 disc diameter [dd]) became Type I regression patterns, whereas the smallest tumors (mean, 1.0 dd) completely disappeared. This represents the first long-term follow-up of the intraocular status of radiated retinoblastoma.

Changes in height of choroidal melanomas after plaque therapy

Serial ultrasonic measurements of 82 uveal melanomas treated with brachytherapy plaques (cobalt-60 and iodine-125) and followed up for up to 141 months revealed that no two patients had identical patterns of change. The mean absolute change in tumour height after treatment was 1.8 mm at six months, 5.6 mm at 48 months for large tumours, and 0.9 and 1.9 mm for medium sized tumours. Eighty of the 82 patients fell into one of three patterns of response: 57 patients had a decrease in height after treatment (type D), 13 patients had the same height after treatment (type S), and 10 patients had a progressive increase in height (type I). Life table comparison showed no correlation between survival and location of tumour, sex of patient, size of tumour when treated, or laterality. There was a slight correlation between age and survival. Patients older than 60 died more frequently from metastatic melanoma than those under 60 (p = 0.06). Life table analysis showed a significant correlation between tumour regression type and survival. At 48 months the best cumulative probability of survival was in patients with type D (88% alive) compared with those of type I (34% alive, p = 0.0004).

Remote afterloading intraluminal brachytherapy in the treatment of rectal, rectosigmoid, and anal cancer: a feasibility study

From 1981 to 1986, 28 patients (27 evaluable) were treated with intraluminal brachytherapy (ILBT) using a remote afterloading technique for persistent or recurrent anal, rectal and rectosigmoid cancers. Eighty-nine percent underwent previous surgery for colorectal cancer. Seventy-seven percent of the patients received external beam irradiation (ERT) as a part of the present treatment. Intraluminal brachytherapy was given with a 2 cm diameter cylinder and the dose per fraction ranged from 440 cGy to 840 cGy at 0.5 cm from the surface of the cylinder. Follow-up ranged from 1 to 74 months with a median of 12 months. Patients were divided into two groups. Group I consisted of 15 patients receiving elective ILBT; Group II: 13 patients with recurrent disease. Seventy-one percent of the patients in Group I and 39% of the patients in Group II achieved local control. The majority of patients tolerated treatment well with only transient reactions. However, three patients (11%) developed grade 3 (G3) complications requiring surgical intervention. Eight patients developed moderate complications--grade 2 (G2)--requiring only conservative treatment. This study has identified several factors which appear to influence the risk of developing complications with this combined treatment, using remote afterloading apparatus, among which are technique of previous external beam irradiation, treatment length, anatomical location, intraluminal brachytherapy fractionation, and total cumulative dose (ERT + ILBT). This experience suggests that intraluminal brachytherapy appears to be an acceptable form of treatment, as a boost to external beam radiation therapy, in the management of rectal and colorectal cancers.

New intraoperative brachytherapy techniques for positive or close surgical margins

Tumors attached or adjacent to critical structures can often not be completely resected or resected with adequate surgical margins. Sites involving major blood vessels, the paravertebral spaces, or critical abdominal structures often present technical difficulties for standard brachytherapy procedures using I-125 or Ir-192 implants. These techniques allow for a high-dose delivery to the tumor bed with minimal normal tissue toxicity. A relatively simple and accurate method is described using I-125 seeds in Vicryl suture threaded through Gelfoam. These permanent implant procedures with radioactive I-125 seeds effectively treat small residual tumors or suspicious margins where standard brachytherapy techniques may be unsatisfactory and technically difficult to perform.

Potentiation of immunosuppressive effects of cyclosporin A by 1 alpha,25-dihydroxyvitamin D3

Both cyclosporin A (CsA) and 1 alpha,25-dihydroxyvitamin D3 (vitamin D3) inhibit T-cell functions. Because CsA has a dose-related systemic toxicity, there is a need for approaches by which the dosage of CsA could be reduced while maintaining the required immunosuppression. Therefore, we examined for any potentiating effect of vitamin D3 on CsA-induced suppression of T cell functions in vitro. Peripheral blood mononuclear cells were stimulated with phytohemagglutinin in the presence or absence of various concentrations of CsA (1.6-13.2 micrograms/ml) or vitamin D3 (10(-10)-10(-7) M) or both together and [3H]thymidine incorporation (TdR), interleukin 2 (IL-2) production, IL-2 receptor (IL-2R) expression, and the response to exogenous recombinant IL-2 (rIL-2) on TdR were measured. IL-2 production was measured on CTLL cell line and IL-2R expression with anti-Tac monoclonal antibody using FACScan. There was a dose-dependent inhibition of TdR, IL-2 production, and IL-2R expression by CsA. Vitamin D3 inhibited TdR and IL-2 production in a dose-dependent manner but had no significant (P greater than 0.1) effect on IL-2R expression. Recombinant IL-2 had no effect on CsA-induced inhibition of TdR, whereas rIL-2 completely reversed the vitamin D3-induced inhibition of TdR. A significantly (P less than 0.05) increased inhibition of TdR and IL-2 production was observed when two agents were used together as compared to expected inhibition by the addition of each agent separately. A consistent synergism was observed between all concentrations of CsA used and vitamin D3 (10(-8) and 10(-7) M). This study shows that the potentiation of immunosuppressive effects of CsA by vitamin D3 could be used as an approach to reduce the dosage of CsA in clinical use without compromising immunosuppression, thus preventing or minimizing the dose-related toxic effects of CsA.

Brain metastases from ovarian cancer

Brain metastasis from ovarian carcinoma is a relatively rare phenomenon. At NYU Medical Center five patients were treated for this entity from 1982 to 1985. The stage at presentation ranged from stage I to stage III, and all patients had received or were receiving chemotherapy. Two patients had active disease elsewhere at diagnosis of brain metastasis, but three patients were otherwise NED. Three patients had solitary cerebellar disease, and two patients had multiple lesions. All patients were treated with whole brain radiotherapy to 3,000 cGy, with neurological improvement in three of the five patients. The central nervous system may need special consideration for prophylactic treatment in those patients with ovarian cancer who receive adjuvant chemotherapy.

[Trial of systematization of the therapeutic approach to digestive behavior disorders]

The aim of this work is to propose a therapeutic model for eating disorders. Among various techniques, emphasis is focused on the importance of the cognitive treatment for in and out patients' eating disorders.

The amino acid sequence of the NH2-terminal portion of rat and human vitamin D binding protein: evidence for a high degree of homology between rat and human vitamin D binding protein

We determined the amino terminal sequence of rat and human vitamin D binding protein (VDBP). The sequences of the two proteins are: Rat VDBP: LeuGluArgGlyArgAspTyrGluLysAspLysValCysGlnGluLeuSerThrLeuGlyLys Human VDBP: LeuGluArgGlyArgAspTyrGluLysAsnLysValCysLysGluPheSerHisLeuGlyLys AspAspPhe GluAspPhe There are 19 matches out of a total of 24 residues sequenced giving a percent match/length of 79.2%. Differences in the composition of the two proteins at residue 10, 14, 16, and 22 can be accounted for by single base changes in the the gene for the proteins. The difference (Thr----His) at residue 18 requires a change in two bases in the respective genes. We conclude that the sequence of the amino terminus of rat and human VDBP is similar with a high degree of homology between the two proteins. Vitamin D sterols, such as 25-hydroxyvitamin D3, 24,25-dihydroxyvitamin D3, and 25,26-dihydroxyvitamin D3, are bound with high affinity by a plasma alpha-globulin - VDBP, also known as group-specific component (Gc). Other vitamin D sterols, such as 1,25-dihydroxyvitamin D3 and vitamin D3 itself, are bound to this protein with a lesser affinity. VDBP also binds actin with high affinity. Its role in vitamin D physiology is unclear, although it may play a role in the bioavailability of different D sterols. Svasti et al. have shown that human group specific component (Gc) exists as different isoforms that have rapid or slow mobility on gel electrophoresis. The different human Gc isoforms have similar NH2-terminal and COOH-terminal amino acid sequences. The difference in the mobility of the various isoforms is due to post-translational modification of the protein by various carbohydrate residues; treatment of the protein with neuraminidase results in the conversion of the different isoforms to a single isoform. The amino acid sequence of the amino terminus of rat VDBP is not known. Recently, Cooke reported preliminary data from the analysis of cDNA clones showing that rat and human VDBP are partially homologous and that rat and human VDBP exhibit homology with rat and human albumin and alpha-fetoprotein. The NH2-terminal sequence of the rat VDBP, however, has not been reported. In order to learn more about the nature of the NH2-terminal sequence of human and rat VDBP, we isolated these proteins in relatively pure form and determined the NH2-terminal amino acid sequence of both of them.(ABSTRACT TRUNCATED AT 400 WORDS)

Radiotherapeutic prophylaxis of estrogen-induced gynecomastia: a study of late sequela

Radiation therapy is an effective means of preventing the development of hormone-induced gynecomastia in men with cancer of the prostate. The efficacy and morbidity of this type of radiation was studied in a retrospective analysis of 87 patients referred for treatment from 1972 to 1982. Patients receiving DES as treatment for prostate carcinoma were treated with irradiation to the breast tissue. Patients were treated with 4 MV, 60Co superficial X rays. Doses range from 1200 to 1500 cGy in 3 fractions. The majority of patients had satisfactory results in terms of prevention of gynecomastia and mammalgia. There were few acute reactions noted and no evidence of long term sequela.

[Systematized treatment of patients hospitalized with anorexia nervosa]

In-patients with anorexia nervosa are generally treated by two behavioral techniques such as desensitization and operant conditioning. In this work, functional analysis enables a better clinical description of the disorders allowing more specific therapeutic measures. Three patients have been treated according to this procedure. Return to normal of many behavior disorders like quantitative and qualitative restriction of food intake, vomiting and bulimia, has been confirmed by self evaluating measurement. The authors discuss the persistence of body image disturbances, and the need for the association of a cognitive approach.