Localized Amyloidosis Involving Palatine Tonsils: A Case Report and Literature Review

Amyloidosis is a localized or systemic process where extracellular insoluble plasma protein fibers are deposited into tissues. Localized amyloidosis is rare and curable by surgical resection. While the head and neck region represents 19% of localized amyloidosis cases, only one other case of bilateral involvement of the pharyngeal tonsils has been published in the international literature. We report a case of asymptomatic amyloidosis isolated to the bilateral palatine tonsils and a cervical lymph node in a 59-year-old male. Systemic amyloidosis was ruled out through multidisciplinary consultation, and resection of the masses was performed. This represents the second reported case of bilateral tonsillar amyloidosis.

Abstract P3-09-02: Unhealthy lifestyle patterns are prevalent in unaffected BRCA mutation carriers & are associated with increased oxidative stress and telomere length alterations

The lifetime-risk of breast-cancer is greatly increased in women carrying a deleterious mutation in the BRCA1 or BRCA2 genes. Recently, there has been increased penetrance of BRCA1 and BRCA2 mutations which may be due to lifestyle influences.

There is a need to identify approaches to reduce the penetrance of BRCA 1/2 mutations. Understanding how modifiable lifestyle-factors affect cancer-risk in BRCA-mutation carriers may have implications for risk-reduction in this group. At the molecular level, oxidative-stress and telomere dysfunction are early events in cancer development and these processes may be considered surrogate markers of cancer-risk. It has been reported that BRCA-mutation carriers are more susceptible to these pro-carcinogenic processes that non-carriers.

The aim of this pilot study was to objectively measure lifestyle factors in unaffected BRCA-mutation carriers and to assess the impact of these lifestyle-factors on oxidative-stress profiles and telomere length.

Participants (n=75) were recruited from breast-cancer family-risk clinics and cancer-genetics clinics. Body-composition (BMI, waist-circumference), metabolic profiles and physical-activity (triaxial accelerometry) were measured for each participant. Serum levels of the oxidative-stress markers 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxo-DG) and 4-hydroxynonenal (4-HNE) were measured in a subset of participants (n=30) by ELISA. Telomere length was measured in a subset of participants (n=30) by quantitative PCR (qPCR).

Participants demonstrated poor adherence to physical-activity guidelines with 94% not reaching physical-activity levels recommended by the American College of Sports Medicine. The majority of participants were overweight (39%) or obese (32%) with 73% exhibiting abdominal obesity. 21% of participants had the metabolic syndrome (MetS) at the time of study enrolment with the majority of participants (80%) presenting with at least one feature of the MetS. Circulating levels of 8-oxo-DG did not appear to be affected by body composition or MetS status, however, serum levels of the lipid peroxidation marker 4-HNE were significantly higher in participants with the MetS (p < 0.0001). Correlation of serum 4-HNE levels with individual features of the MetS and related parameters revealed significant direct correlations with waist circumference (p = 0.02), number of features of MetS (p = 0.0007), insulin (p = 0.02) insulin resistance score (HOMA-IR) (p = 0.01), HBA1c (p = 0.006), glucose (p = 0.048) and triglycerides (p <0.0001). Age-adjusted telomere length was not influenced by anthropometric measurements or MetS status in this group. Moderate physical activity levels were inversely associated with age-adjusted telomere length; particularly, among post-menopausal participants (p =0.009).

This work has provided compelling evidence that in this cohort of BRCA-mutation carriers, unhealthy lifestyle-patterns are prevalent. In addition, these results suggest that the potential may exist to modify pro-carcinogenic processes in this cohort by modifying physical activity levels and targeting the metabolic syndrome and its component features lifestyle interventions and/or medication.The lifetime-risk of breast-cancer is greatly increased in women carrying a deleterious mutation in the BRCA1 or BRCA2 genes. Recently, there has been increased penetrance of BRCA1 and BRCA2 mutations which may be due to lifestyle influences.

There is a need to identify approaches to reduce the penetrance of BRCA 1/2 mutations. Understanding how modifiable lifestyle-factors affect cancer-risk in BRCA-mutation carriers may have implications for risk-reduction in this group. At the molecular level, oxidative-stress and telomere dysfunction are early events in cancer development and these processes may be considered surrogate markers of cancer-risk. It has been reported that BRCA-mutation carriers are more susceptible to these pro-carcinogenic processes that non-carriers.

The aim of this pilot study was to objectively measure lifestyle factors in unaffected BRCA-mutation carriers and to assess the impact of these lifestyle-factors on oxidative-stress profiles and telomere length.

Participants (n=75) were recruited from breast-cancer family-risk clinics and cancer-genetics clinics. Body-composition (BMI, waist-circumference), metabolic profiles and physical-activity (triaxial accelerometry) were measured for each participant. Serum levels of the oxidative-stress markers 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxo-DG) and 4-hydroxynonenal (4-HNE) were measured in a subset of participants (n=30) by ELISA. Telomere length was measured in a subset of participants (n=30) by quantitative PCR (qPCR).

Participants demonstrated poor adherence to physical-activity guidelines with 94% not reaching physical-activity levels recommended by the American College of Sports Medicine. The majority of participants were overweight (39%) or obese (32%) with 73% exhibiting abdominal obesity. 21% of participants had the metabolic syndrome (MetS) at the time of study enrolment with the majority of participants (80%) presenting with at least one feature of the MetS. Circulating levels of 8-oxo-DG did not appear to be affected by body composition or MetS status, however, serum levels of the lipid peroxidation marker 4-HNE were significantly higher in participants with the MetS (p < 0.0001). Correlation of serum 4-HNE levels with individual features of the MetS and related parameters revealed significant direct correlations with waist circumference (p = 0.02), number of features of MetS (p = 0.0007), insulin (p = 0.02) insulin resistance score (HOMA-IR) (p = 0.01), HBA1c (p = 0.006), glucose (p = 0.048) and triglycerides (p <0.0001). Age-adjusted telomere length was not influenced by anthropometric measurements or MetS status in this group. Moderate physical activity levels were inversely associated with age-adjusted telomere length; particularly, among post-menopausal participants (p =0.009).

This work has provided compelling evidence that in this cohort of BRCA-mutation carriers, unhealthy lifestyle-patterns are prevalent. In addition, these results suggest that the potential may exist to modify pro-carcinogenic processes in this cohort by modifying physical activity levels and targeting the metabolic syndrome and its component features lifestyle interventions and/or medication.

Citation Format: McGarrigle SA, Guinan EM, Hussey J, O'Sullivan J, Boyle T, Hanhauser Y, Al-azawi D, Kennedy MJ, Gallagher DJ, Connolly EM. Unhealthy lifestyle patterns are prevalent in unaffected BRCA mutation carriers & are associated with increased oxidative stress and telomere length alterations [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-09-02.

Breast cancer detection among Irish BRCA1 & BRCA2 mutation carriers: a population-based study

BACKGROUND

High-risk breast cancer screening for BRCA1/2 mutation carriers with clinical breast exam, mammography and MRI has reported sensitivity of 100 %, but BRCA1/2 mutation carriers still present with interval cancers.

AIMS

We investigated the presentation and screening patterns of an Irish cohort of BRCA1/2 mutation carriers with breast cancer.

MATERIALS AND METHODS

BRCA1/2 mutation carriers with breast cancer were identified in this retrospective cohort study. Records were reviewed for BRCA1/2 mutation status, demographics, screening regimen, screening modality, stage and histology at diagnosis.

RESULTS

Fifty-three cases of breast cancer were diagnosed between 1968 and 2010 among 60 Irish hereditary breast ovarian cancer (HBOC) families. In 50 of 53 women, the diagnosis of breast cancer predated the identification of BRCA1/2 mutations. Breast cancer detection method was identified in 47 % of patients (n = 25): 80 % (n = 20) by clinical breast exam (CBE), 12 % by mammography (n = 3), 8 % by MRI (n = 2). Fourteen women (26 %) developed a second breast cancer. Ten of these patients (71 %) were involved in regular screening; 50 % were detected by screening mammography, 20 % by MRI and 30 % by CBE alone. Six patients (43 %) had a change in morphology from first to second breast cancers. There was no change in hormone receptor status between first and second breast cancers.

CONCLUSION

In this cohort of Irish BRCA1/2 mutation carriers, compliance with screening was inconsistent. There was a 30 % incidence of interval cancers occurring in women in high-risk screening. Preventive surgery may be a more effective risk reduction strategy for certain high-risk women.

Genetic testing and interpretive complexity: a BRCA1 gene mutation example

Diagnosis and interpretation of hereditary breast cancer can be a complex and challenging dilemma. Advances in genetic testing have resulted in guidelines for clinical evaluation and recommendations. Here, we present a case of one family with multiple cases of early-onset breast cancer, some due to a familial BRCA1 mutation but others unrelated to this pathogenic E143X nonsense mutation. In this case report, we highlight the complexities associated with adhering strictly to guidelines and highlight the need for clinical experience in when to deviate from recommended protocols.

Germline single nucleotide polymorphisms associated with response of urothelial carcinoma to platinum-based therapy: the role of the host

BACKGROUND

Variations in urothelial carcinoma (UC) response to platinum chemotherapy are common and frequently attributed to genetic and epigenetic variations of somatic DNA. We hypothesized that variations in germline DNA may contribute to UC chemosensitivity.

PATIENTS AND METHODS

DNA from 210 UC patients treated with platinum-based chemotherapy was genotyped for 80 single nucleotide polymorphisms (SNPs). Logistic regression was used to examine the association between SNPs and response, and a multivariable predictive model was created. Significant SNPs were combined to form a SNP score predicting response. Eleven UC cell lines were genotyped as validation.

RESULTS

Six SNPs were significantly associated with 101 complete or partial responses (48%). Four SNPs retained independence association and were incorporated into a response prediction model. Each additional risk allele was associated with a nearly 50% decrease in odds of response [odds ratio (OR) = 0.51, 95% confidence interval 0.39-0.65, P = 1.05 × 10(-7)). The bootstrap-adjusted area under the curves of this model was greater than clinical prognostic factors alone (0.78 versus 0.64). The SNP score showed a positive trend with chemosensitivity in cell lines (P = 0.115).

CONCLUSIONS

Genetic variants associated with response of UC to platinum-based therapy were identified in germline DNA. A model using these genetic variants may predict response to chemotherapy better than clinical factors alone.

Advantages and challenges of using physics curricula as a model for reforming an undergraduate biology course

We report on the development of a life sciences curriculum, targeted to undergraduate students, which was modeled after a commercially available physics curriculum and based on aspects of how people learn. Our paper describes the collaborative development process and necessary modifications required to apply a physics pedagogical model in a life sciences context. While some approaches were easily adapted, others provided significant challenges. Among these challenges were: representations of energy, introducing definitions, the placement of Scientists' Ideas, and the replicability of data. In modifying the curriculum to address these challenges, we have come to see them as speaking to deeper differences between the disciplines, namely that introductory physics--for example, Newton's laws, magnetism, light--is a science of pairwise interaction, while introductory biology--for example, photosynthesis, evolution, cycling of matter in ecosystems--is a science of linked processes, and we suggest that this is how the two disciplines are presented in introductory classes. We illustrate this tension through an analysis of our adaptations of the physics curriculum for instruction on the cycling of matter and energy; we show that modifications of the physics curriculum to address the biological framework promotes strong gains in student understanding of these topics, as evidenced by analysis of student work.

Multivariate analysis of MLH1 c.1664T>C (p.Leu555Pro) mismatch repair gene variant demonstrates its pathogenicity

Genetic testing of an Irish kindred identified an exonic nucleotide substitution c.1664T>C (p.Leu555Pro) in the MLH1 mismatch repair (MMR) gene. This previously unreported variant is classified as a "variant of uncertain significance" (VUS). Immunohistochemical (IHC) analysis and microsatellite instability (MSI) studies, genetic testing, a literature and online MMR mutation database review, in silico phenotype prediction tools, and an in vitro MMR activity assay were used to study the clinical significance of this variant. The MLH1 c.1664T>C (p.Leu555Pro) VUS co-segregated with three cases of classic Lynch syndrome-associated malignancies over two generations, with consistent loss of MLH1 and PMS2 protein expression on IHC, and evidence of the MSI-High mutator phenotype. The leucine at position 555 is well conserved across a number of species, and this novel variant has not been reported as a normal polymorphism in the general population. In silico and in vitro analyses suggest that this variant may have a deleterious effect on the MLH1 protein and abrogate MMR activity. Evidence from clinical, histological, immunohistochemical, and molecular genetic data suggests that MLH1 c.1664T>C (p.Leu555Pro) is likely to be the pathogenic cause of Lynch syndrome in this family.

Breast cancer in Irish families with Lynch syndrome

413

Background: Breast cancer is not a recognised malignant manifestation of Lynch Syndrome which includes colorectal, endometrial, gastric, ovarian and upper urinary tract tumours. In this study we report the prevalence of breast cancer in Irish Lynch Syndrome families and determine immunohistochemical expression of mismatch repair proteins (MMR) in available breast cancer tissue.

Methods: Breast cancer prevalence was determined among Lynch Syndrome kindreds from two institutions in Ireland, and a genotype phenotype correlation was investigated. One kindred was omitted due to the presence of a biallelic MMR and BRCA1 mutation. The clinicopathological data that was collected on breast cancer cases included age of onset, morphology, and hormone receptor status. Immunohistochemical staining was performed for MLH1, MSH2, MSH6, and PMS2 on all available breast cancer tissue from affected individuals.

Results: The distribution of MMR mutations seen in 16 pedigrees was as follows; MLH1 (n=5), MSH2 (7), MSH6 (3), PMS2 (1). Sixty cases of colorectal cancer and 14 cases of endometrial cancer were seen. Seven breast cancers (5 invasive ductal and 2 invasive lobular cancers) and 1 case of ductal carcinoma in situ were reported in 7 pedigrees. This compared with 4 cases of prostate cancer. Six MSH2 mutations and 1 MSH6 mutation were identified in the 7 Lynch syndrome kindreds. Median age of breast cancer diagnosis was 49 years (range 38-57). Hormone receptor status is available on 3 breast cancer cases at time of abstract submission; all were ER positive and HER 2 negative. All cases had grade 2 or 3 tumours. Final results of immunohistochemistry for mismatch repair protein expression on breast cancer samples are pending and will be reported at the meeting. One breast cancer has been tested to date and demonstrated loss of MSH2 protein expression in an individual carrying an MSH2 mutation.

Conclusions: Breast cancer occurred at an early age and was more common than prostate cancer in Irish Lynch Syndrome pedigrees. All reported breast cancer cases were in kindreds with MSH2 or MSH6 mutations. Enhanced breast cancer screening may be warranted in certain Lynch Syndrome kindreds.

Phase II trial of gemcitabine, carboplatin, and bevacizumab in chemotherapy-naive patients (Pts) with advanced/metastatic urothelial carcinoma (UC)

248

Background: Effective treatment for pts with advanced UC unfit to receive cisplatin-based therapy remains an unmet need. A recent phase III study showed limited benefit of gemcitabine-carboplatin (GC) alone (median OS 9.3 months) (DeSantis ASCO 2010). We recently identified the VEGF-axis as a viable pathway for UC treatment (JCO 2010;Mar 10). We propose that bevacizumab, a monoclonal antibody against VEGFR, may be safely added to GC and improve time to progression (TTP) in pts with advanced UC.

Methods: Primary endpoints (N=47 planned enrollment) were median TTP, to test an improvement of 50% over a 4.8 months median TTP seen with GC alone (Urology 2004;64:479), and safety. Secondary endpoints were response rate (RR) and overall survival (OS). Pts first received a single dose of bevacizumab 10 mg/kg. 2 weeks later they received 6 cycles of gemcitabine 1,000 mg/m2 on day(D) 1 and D 8, and both carboplatin AUC 4.5 and bevacizumab 15 mg/kg on D1 every 21 days. Pts who achieved at least stable disease were eligible to receive maintenance bevacizumab at 15 mg/kg q21 days for 18 additional doses. Restaging evaluations were performed after every 3 cycles of therapy.

Results: 51 pts (37 M, 14 F; median age 67 (Range 42-83)) were enrolled from 6/06 to 6/10. Primary tumor sites include bladder (31), renal pelvis (17) and ureter (2). 38 pts (74.5%) had visceral disease including lung (22), liver (13), bone (9) and adrenal (2). 13 pts had LN only disease. 46 of 51 pts were evaluable for response rate (RR) and TTP, 51 for toxicity. RR by RECIST was 46% (21 pts; PR 18, CR 3). 12 achieved stable disease; 1 too early to assess. Responses by MSKCC Risk Scores of 0, 1 and 2 were seen in 8/11(73%), 10/29 (35%), and 3/6 (50%) pts, respectively. 39% of pts had grade 3/4 toxicity, notably vascular thromboembolic events (VTE) in 18%.

Conclusions: Bevacizumab can be safely added to GC in the treatment of advanced UC. The 16% VTE rate is similar to the 17% rate seen at MSKCC with GC alone. (JCO 2009;27:15s). Addition of bevacizumab does not improve the RR seen with GC alone in phase II and III studies (Bellmunt Eur J Cancer 2001; DeSantis ASCO 2010). Analysis of bevacizumab's impact on TTP and OS is ongoing and will be updated.

[Table: see text]

Clinical outcomes in patients age 40 or younger at diagnosis of synchonous metastatic colorectal cancer

531

Background: The impact of age ≤ 40 at diagnosis of colorectal cancer on outcome is unclear. The higher incidence of tumor microsatellite instability (MSI) in young patients may confound the estimation of survival in this population due to the more favorable biology associated with MSI cancers.

Methods: All pts diagnosed with metastatic colorectal adenocarcinoma at ≤ 40 years old between Jan 2000-Jan 2010 were identified from the institutional database with prior IRB approval. Clinical and pathology records were reviewed. Only patients with synchronous metastases at presentation were included. Immunohistochemistry for DNA mismatch repair proteins (MMR) was performed in 40 pts of whom 5 had loss of MMR and were excluded from the analysis.

Results: 185 pts were identified; median age at diagnosis was 36 years (range 18–40) Primary site was in the right colon in 50 cases (27%). All pts received at least one line of systemic chemotherapy. For pts receiving systemic therapy median survival was 23.4 months and for those receiving hepatic arterial infusion (HAI) plus systemic the median survival was 48.2 months. Median survival for those who underwent liver resection (78 pts) was 54.6 months. Other factors such as race, post partum and KRAS mutation impacted on survival as shown below.

Conclusions: Overall survival in this cohort of young pts is similar to that observed in clinical trials of modern combination therapy for metastatic CRC. African American race, presence of a KRAS mutation, and presentation following pregnancy may be associated with reduced survival in this group.

[Table: see text]

No significant financial relationships to disclose.

Survival in epithelial ovarian cancer: a multivariate analysis incorporating BRCA mutation status and platinum sensitivity

BACKGROUND

Patients with BRCA-associated ovarian cancer (OC) have a survival advantage over those with sporadic OC. To further explore this, we examined the impact of prognostic factors on disease-free survival (DFS) and overall survival (OS) in patients with known BRCA mutation status.

PATIENTS AND METHODS

We reviewed stage III-IV OC patients treated at our institution between 1 December 1996 and 30 September 2006 and also tested on protocol for BRCA mutations. Impact on DFS and OS was determined by Kaplan-Meier analysis and a Cox proportional hazards model.

RESULTS

Of the 110 patients, 36 had deleterious BRCA mutations [BRCA (+)] and 74 were BRCA wild type [BRCA(-)]. Thirty-one of 36 (86%) BRCA (+) and 60 of 74 (81%) BRCA (-) patients were platinum sensitive (P = 0.60). Median OS was longer for BRCA (+) patients (not reached versus 67.8 months; P = 0.02), but DFS was similar (26.9 versus 24.0, P = 0.3). On multivariate analysis, OS correlated with primary platinum sensitivity [HR = 0.15; 95% CI (confidence interval) 0.06-0.34] and BRCA (+) mutation status (HR = 0.33; 95% CI 0.12-0.86).

CONCLUSIONS

BRCA mutation status predicted OS independent of primary platinum sensitivity, suggesting that underlying tumor biology contributes to disease outcome and may be worthy of consideration in future clinical trial design.

A phase II study of sunitinib on a continuous dosing schedule in patients (pts) with relapsed or refractory urothelial carcinoma (UC)

5072

Background: Suntinib has demonstrated activity in the second-line setting for pts with advanced UC when administered on a 4 week on/2 week off schedule. This study was designed to evaluate an alternative 37.5 mg/day continuous dosing schedule for sunitinib in the same setting. Methods: The primary objectives of this single institution phase II study of sunitinib in pts with UC who have failed prior chemotherapy were: 1) to determine the response rate (by RECIST); and 2) to evaluate toxicity. Secondary endpoints include: 1) correlation of response and toxicity with HIF and mTOR pathway marker expression; and 2) phamacokinetics. Pts may not have received >4 prior cytotoxic agents. Pts received sunitinib 37.5 mg/day continuous dosing.. Response was assessed after each of the initial 4 cycles and every other cycle thereafter. A minimax 2-stage design was used (maximal 32 pts). Results: 31 pts (21 M, 10 F) with a median age of 68 yrs and median KPS of 90 were enrolled between 10/15/07 and 12/18/08. Primary sites included bladder (28), and renal pelvis (3). Prior therapy included 1 pt with 1 drug, 19 pts with 2, 7 with 3 and 4 with 4. 25 pts had visceral metastases and 6 pts had lymph node only metastases. 25 pts were evaluable for response after completing at least 1 cycle. One pt achieved PR, 12 pts had SD, 12 had PD, 2 are too early to assess for response, and 4 patients did not complete cycle 1 (2 related to toxicity, and 2 related to non-treatment-related deaths). Radiographic regression was seen in liver, lung, soft tissue and lymph nodes. With a median follow up of 4 months, median progression free survival was 2 months (95% CI, 1 - 4 months) and median overall survival was 7 months (95% CI, 4 months - not achieved). Clinically significant toxicity (Grade 3/4) included: abdominal pain (1), anorexia (1), diarrhea (1), fatigue (4), hand and foot syndrome (2), hemorrhage (2), hypertension (2), mucositis (2), thrombosis (2), and emesis (1). Conclusions: Sunitinib has modest activity when administered on a 37.5 mg continuous dosing schedule to patients with relapsed or refractory UC with a similar toxicity profile to the 50 mg in the 4 /2 schedule. Upcoming trials will evaluate sunitinib in combination with standard chemotherapy in pts with UC.

[Table: see text]

Detection of circulating tumor cells in patients with urothelial cancer

BACKGROUND

Approximately 50% of patients with metastatic urothelial cancer (UC) respond to chemotherapy and several months of therapy is required to assess for radiographic response. Blood-based biomarkers may identify patients in whom a specific therapy provides clinical benefit, and this study sought to characterize circulating tumor cells (CTCs) in patients with metastatic UC.

PATIENTS AND METHODS

Peripheral blood from patients with metastatic UC was evaluated for CTCs using the CellSearch system. We assessed for associations between CTC counts and the number and sites of metastatic disease.

RESULTS

CTC evaluations were carried out in 33 patients with metastatic UC. Fourteen of 33 patients (44%; 95% confidence interval 27% to 59%) had a positive assay (range 0-87 cells/7.5 ml of blood) with 10 patients (31%) having five or more CTCs. A significantly higher number of CTCs was seen in patients with two or more sites of metastases compared with those with less than one or one site of metastases (3.5 versus 0, P = 0.04).

CONCLUSIONS

CTCs, detected by antibody capture technology, are present in 44% of patients with metastatic UC. Higher numbers of CTCs are seen in patients with a greater number of metastatic sites. One-third of patients have five or more CTCs providing a potential early marker to monitor response to chemotherapy.

Phase II study of sunitinib in patients (pts) with relapsed or refractory urothelial carcinoma (UC)

5080

Background: Second-line chemotherapy has limited activity in advanced UC. Pre-clinical evidence demonstrates an important role for angiogenesis in UC biology, thus supporting this study of the novel VEGF targeted agent, sunitinib, in pts with UC. Methods: The primary objectives of this single institution phase II trial of sunitinib in pts with UC who have failed prior chemotherapy are: 1) to determine the response rate (RECIST); and 2) to evaluate toxicity. Prior therapy is restricted to = 4 chemotherapy drugs. Pts receive sunitinib 50 mg orally daily for 4 weeks followed by 2 weeks off (one cycle). Response is assessed after each of the initial 4 cycles and every other cycle thereafter. The Simon 2-stage design requires = 2 responses in the first 21 pts to proceed to maximal accrual of 41 evaluable pts. Results: 21 pts (19 male, 2 female) with median age of 64 yrs (39–76) and median KPS of 80 (70–90) were enrolled between 9/15/06 and 1/4/07. Primary tumor sites include bladder (14 pts), ureter/renal pelvis (6 pts) and urethra (1). Prior therapy included 10 pts with 2 drugs, 9 with 3 and 2 with 4. 14 pts have metastatic visceral disease [lung (11), liver (8) and bone (1)], and 7 pts have only lymph node metastases. To date, 15 pts are evaluable for radiographic response after completing at least one cycle of therapy; 6 pts are too early for response assessment. One pt experienced a treatment-related death. Responses include: 1 PR seen after cycle 1 and confirmed after cycle 2, 8 with SD (range -29% to +16% change compared to baseline) and 6 with POD. Radiographic regression has been observed in liver, lung, soft tissue and lymph node metastases. Clinically significant toxicity (Grade 3/4) includes: hematuria (n= 1 pt, 2 events in a bladder primary), mucositis (2 pts), thrombocytopenia (2 pts), infection (1), stomatitis (1), fatigue (1), rash (1), diarrhea (1), and abdominal pain (1). Conclusions: Sunitinib has clinical activity in pts with advanced UC. Accrual is ongoing to define further the level of activity, the duration of response, and the time to progression.

[Table: see text]

Wilms’ tumour in adults: a case report and review of the literature

BACKGROUND

Wilms' tumour is a very rare adult malignancy representing 1% of adult renal tumours. It is however the most common renal tumour of childhood, and adult patients are treated in accordance with paediatric protocols.

AIM

To review modern day management of adult Wilms' tumour.

METHODS

We report a case of adult Wilms' tumour and discuss the management including the use of newer treatment modalities.

RESULTS

Following diagnostic nephrectomy, our patient was treated with chemotherapy in accordance with North American paediatric protocols and PET scanning was used to diagnose early relapse.

CONCLUSION

In the absence of randomised controlled data, central reporting of cases of adult Wilms' Tumour may help improve management. The incorporation of newer chemotherapeutic agents, high-dose therapy and PET scanning into treatment protocols should improve outcome for these patients.

Universal precautions--do Irish anaesthetists comply?

BACKGROUND

Anaesthetists are at high risk from blood-borne pathogens. Universal Precautions (UP) include the routine use of appropriate barrier precautions and techniques to reduce the likelihood of exposure to blood, body fluids and tissues that may contain pathogens. The compliance of Irish anaesthetists with these precautions has not been studied.

AIM

To study the attitudes of Irish anaesthetists to Universal Precautions.

METHOD

A postal questionnaire was sent to 210 anaesthetists currently practising in Ireland. The questionnaire was based on a model used in Australia and New Zealand.

RESULTS

There was a 50% response rate to the survey. Only 15% of respondents had taken a risk history from a patient in the preceding four weeks. Resheathing of needles was commonplace. The effectiveness of hepatitis B immunisation was rarely checked and only 66% of respondents believe implementation of Universal Precautions to be practical.

CONCLUSION

Irish anaesthetists comply poorly with Universal Precautions.

Synthesis of highly potent second-generation taxoids through effective kinetic resolution coupling of racemic beta-lactams with baccatins

A series of highly potent second-generation taxoids bearing a 2-methylprop-1-enyl or a 2-methylpropyl group at C-3' with modifications at the C-2, C-10, and C-14 positions was synthesized through the coupling of racemic cis-beta-lactams with properly protected/modified baccatin and 14-OH-baccatin. A high level of kinetic resolution was observed for all cases examined. The observed highly efficient enantiomer differentiation is ascribed to the markedly different chiral environment between the (+)- and (-)-beta-lactams in their approach to the chiral framework of the enantiopure lithium alkoxide of a baccatin in the ring-opening coupling process. It was also observed that substantially higher selectivity was achieved when 14-OH-baccatin-1,14-carbonate was used. Analysis of the transition state models revealed that the repulsive interactions between the 3-TIPS group of a (-)-beta-lactam with 1, 14-carbonate group of the baccatin substantially increases the asymmetric bias in the kinetic resolution process, favoring the reaction of a (+)-beta-lactam, which leads to the observed excellent selectivity.

Phosphorylation is required for alteration of kv1.5 K(+) channel function by the Kvbeta1.3 subunit

The Kv1.5 K(+) channel is functionally altered by coassembly with the Kvbeta1.3 subunit, which induces fast inactivation and a hyperpolarizing shift in the activation curve. Here we examine kinase regulation of Kv1.5/Kvbeta1.3 interaction after coexpression in human embryonic kidney 293 cells. The protein kinase C inhibitor calphostin C (3 microM) removed the fast inactivation (66 +/- 1.9 versus 11 +/- 0.25%, steady state/peak current) and the beta-induced hyperpolarizing voltage shift in the activation midpoint (V(1/2)) (-21.9 +/- 1.4 versus -4.3 +/- 2.0 mV). Calphostin C had no effect on Kv1.5 alone with respect to inactivation kinetics and V(1/2). Okadaic acid, but not the inactive derivative, blunted both calphostin C effects (V(1/2) = -17.6 +/- 2.2 mV, 38 +/- 1.8% inactivation), consistent with dephosphorylation being required for calphostin C action. Calphostin C also removed the fast inactivation (57 +/- 2.6 versus 16 +/- 0.6%) and the shift in V(1/2) (-22.1 +/- 1.4 versus -2.1 +/- 2.0 mV) conferred onto Kv1.5 by the Kvbeta1.2 subunit, which shares only C terminus sequence identity with Kvbeta1. 3. In contrast, modulation of Kv1.5 by the Kvbeta2.1 subunit was unaffected by calphostin C. These data suggest that Kvbeta1.2 and Kvbeta1.3 subunit modification of Kv1.5 inactivation and voltage sensitivity require phosphorylation by protein kinase C or a related kinase.

Distinct domains of the voltage-gated K+ channel Kv beta 1.3 beta-subunit affect voltage-dependent gating

The Kvbeta1.3 subunit confers a voltage-dependent, partial inactivation (time constant = 5.76 +/- 0.14 ms at +50 mV), an enhanced slow inactivation, a hyperpolarizing shift in the activation midpoint, and an increase in the deactivation time constant of the Kv1.5 delayed rectifier. Removal of the first 10 amino acids from Kvbeta1.3 eliminated the effects on fast and slow inactivation but not the voltage shift in activation. Addition of the first 87 amino acids of Kvbeta1.3 to the amino terminus of Kv1.5 reconstituted fast and slow inactivation without altering the midpoint of activation. Although an internal pore mutation that alters quinidine block (V512A) did not affect Kvbeta1.3-mediated inactivation, a mutation of the external mouth of the pore (R485Y) increased the extent of fast inactivation while preventing the enhancement of slow inactivation. These data suggest that 1) Kvbeta1.3-mediated effects involve at least two distinct domains of this beta-subunit, 2) inactivation involves open channel block that is allosterically linked to the external pore, and 3) the Kvbeta1.3-induced shift in the activation midpoint is functionally distinct from inactivation.

Biomechanical analysis of nonreamed tibial intramedullary nailing after simulated transverse fracture and fibulectomy

A tibial shaft fracture model was created to study the effects of an intramedullary nail and partial fibulectomy on fracture loading. Cadaveric lower extremities were instrumented with strain gages and subjected to biomechanical testing. A nonreamed nail was inserted into each tibia using only the proximal locking screws. Each specimen was tested under six conditions: intact tibia; intact tibia with nail; fractured tibia with nail removed and fibula intact; fractured tibia with nail and fibula intact; fractured tibia with nail and partial fibulectomy; and fractured tibia with partial fibulectomy and nail removed. In the intact tibia the anterior cortices were in relative tension compared with the posterior cortex. After transverse fracture this relative tension was increased. Inserting the nail after fracture significantly increased anteromedial and anterolateral compressive strains and decreased posterior strains. Performing a partial fibulectomy in the fractured tibia with a nail had no significant effect on the strain patterns. These results confirm the relative anterior tension present in the intact tibia and demonstrate an increase in this anterior tension following transverse fracture. Performing a partial fibulectomy or inserting an intramedullary nail increased anterior compressive loading. This loading alteration may be responsible for the clinical success seen using these treatment methods.

Orthopedic manifestations of acute pediatric leukemia

The variety and distribution of skeletal lesions in children with acute lymphoblastic leukemia is rarely seen in other diseases. Skeletal radiographic changes that can occur in a child with acute leukemia include diffuse osteopenia, metaphyseal bands, periosteal new bone formation, geographic osteolysis, osteosclerosis, mixed osteolysis and sclerosis, and permeative destruction. It is important for orthopedic surgeons to recognize the skeletal manifestations of acute leukemia of childhood because the physician who initially evaluates the child will often be an orthopedic surgeon, and a delay in diagnosis has an adverse affect on survival.

Pediatric chance fracture

A flexion-distraction injury of the first lumbar vertebrae (Chance fracture) in a child 4 years and 3 months old is discussed and the literature reviewed. Chance features are uncommon in children. This injury is seldom accompanied by a neurological deficit. Recommended treatment consists of early bed rest followed by the application of a hyperextension Risser cast.

Prophylaxis against vitamin D deficiency in the elderly by regular sunlight exposure

The effects of regular sunlight exposure on levels of vitamin D metabolites and on other indices of calcium metabolism have been studied in elderly rest-home residents. Fifteen subjects who formerly went outdoors very infrequently were studied over a 4-week period while spending 0, 15 or 30 minutes daily sitting on the rest-home verandah. During this time, levels of 25-hydroxyvitamin D [25(OH)D] rose by 7.4 +/- 1.2 (s.e.m.) microgram/1 in the group spending 30 minutes per day outdoors (P less than 0.005) and there was a smaller but nonsignificant increase in the 15 minutes per day group also. Serum 1,25 (OH)2D levels did not change during the study but serum ionized calcium and alkaline phosphatase showed small, but significant, decreases. Intestinal strontium absorption increased in both treatment groups (P less than 0.05), indicating a similar change in calcium absorption. It is concluded that 30 minutes spent outdoors each day leads to a substantial increase in 25(OH)D levels in elderly subjects and that this has significant effects upon other indices of calcium metabolism. This regimen provides a safe and inexpensive method for the prevention of osteomalacia in frail elderly subjects.

Renal hamartoma (angiomyolipoma) with spontaneous rupture during pregnancy

A 25-year-old pregnant patient at term with spontaneous rupture of the kidney and massive retroperitoneal hemorrhage from a renal hamartoma is described. A discussion of the case and a brief review of the literature on this rare tumor is included.

A new tetracycline minocycline compared with ampicillin in general practice

A new tetracycline (minocycline) and ampicillin were compared in the treatment of 217 adults with common infections seen in general practice. Minocycline had an overall clinical effectiveness comparable with ampicillin, though minocycline was more frequently prescribed for suspected staphylococcal infections with satisfactory results in 25 (26). Minocycline was significantly more effective in vitro against common pathogenic organisms than ampicillin. All strains of staphyloccocci isolated were sensitive to minocycline while 15 (27) were resistant to ampicillin. Minocycline and ampicillin were no different in the occurrence of mild side effects. Dizziness was troublesome for 23 (127) patients on minocycline and resulted in four patients discontinuing treatment.