Left Pulmonary Artery from the Ascending Aorta: A Case Report and Review of Published Cases

The left pulmonary artery arising from the ascending aorta is an infrequent finding. It may be found isolated or with intracardiac anomalies. We present a new case of the left pulmonary artery arising from the ascending aorta and pool these findings with those of previously reported cases. Associated cardiac, extracardiac, and syndromic findings are discussed along with the implications of these in the evaluation and management of this condition.

Does using anatomical models improve patient satisfaction in orthopaedic consenting? Single-blinded randomised controlled trial

BACKGROUND

Patient satisfaction in consenting is a major pillar of clinical governance and healthcare quality assessment. The purpose was to observe the effect of using 3D anatomical models of knee and shoulder joints on patient satisfaction during informed consent in the largest single-blinded randomised controlled trial in this field.

METHODS

52 patients undergoing elective knee or shoulder surgery were randomised into two groups when being consented. The intervention group (n = 26) was shown an anatomical model of the knee/shoulder joint while the control group (n = 26) was given only a verbal explanation without a model. Patients rated their satisfaction on the validated Medical Interview Satisfaction Scale (MISS-26) questionnaire. Semi-structured interviews were analysed for specific themes to determine key factors that influenced patient satisfaction. The mean score ±SD were calculated with significance set at p < 0.05.

RESULTS

There was a significant difference in the overall satisfaction between the control and intervention cohorts (MISS-26 score 4.33 [86.6%] ± 0.646 vs 4.70 [94.0%] ± 0.335 respectively, 7.4% improvement, 8.5% difference, p = 0.01). Behavioural criteria showed a 13% increase in satisfaction (p = 0.02). Semi-structured interviews determined that the factors influencing satisfaction included the surgeon's interpersonal manner, the use of the visual aid and seeing the consultant surgeon in clinic. All patients in the intervention cohort identified factors contributing to their satisfaction, whereas a fifth of the control cohort claimed nothing at all made them feel satisfied.

CONCLUSION

Anatomical models as visual aids significantly increased patient satisfaction during the consenting process and played an integral part of the surgeon's explanation. Patients exposed to anatomical models also claimed to be more satisfied with the surgeon's inter-personal skills. This study recommends the use of anatomical models, which are both cost-effective and easily implementable, during explanation and consent for orthopaedic procedures.

Inhaled calcium salts inhibit tobacco smoke-induced inflammation by modulating expression of chemokines and cytokines

Tobacco smoke-induced lung inflammation in patients with chronic obstructive pulmonary disease (COPD) worsens with disease progression and acute exacerbations caused by respiratory infections. Chronic therapies to manage COPD center on bronchodilators to improve lung function and inhaled corticosteroids (ICS) to help reduce the risk of exacerbations. Novel therapies are needed that reduce the underlying inflammation associated with COPD and the inflammation resulting from respiratory infections that worsen disease. The lung is lined with airway surface liquid (ASL), a rheologically active material that provides an innate defense for the airway against inhaled particulate and is continuously cleared from the airways by mucociliary clearance. The rheological properties of the ASL can be altered by changes in airway hydration and by cations, such as calcium, that interact with electronegative glycoproteins. The effect of inhaled salts on inflammation resulting from tobacco smoke exposure was studied to determine if cations could be used to alter the properties of the ASL and reduce inflammation. Inhaled calcium salts, but not sodium or magnesium salts, reduced cellular inflammation and key chemokines and cytokines that were induced by tobacco smoke exposure. Similar anti-inflammatory effects of calcium salts were observed using in vitro cultures of human monocyte derived macrophages and human bronchial epithelial cells. The data suggest that inhaled calcium salts may act broadly on both biophysical and biological pathways to reduce pulmonary inflammation.

Abstract P5-13-01: Effects of a 16-week combined aerobic and resistance exercise intervention on metabolic syndrome in overweight/Obese Hispanic breast cancer survivors

Purpose. Metabolic syndrome (MetS) is associated with increased risk of cardiovascular disease, type 2 diabetes, and possibly cancer recurrence, and is higher in breast cancer survivors than age-matched postmenopausal women. Further, MetS is 1.5 times more prevalent in Hispanic women (&gt;40 years of age) than in non-Hispanic Whites and African Americans, thereby increasing the need to attenuate MetS in Hispanic breast cancer survivors (HBCS). This study examined the effects of a 16-week combined aerobic and resistance exercise intervention on MetS in overweight and obese HBCS.

Methods. This pre-planned sub-analysis included 60 sedentary HBCS (BMI325 kg/m2) from our larger MetS trial. HBCS were randomized to the exercise intervention (EXE; n=30) or usual care (UC; n=30). The EXE group participated in 3 supervised exercise sessions per week for 16 weeks. Aerobic exercise was performed at 65-85% heart rate maximum for ˜30 minutes. Resistance exercise was performed in circuit-fashion with 3 sets of 10-15 repetitions including upper and lower body exercises at 65-85% 1-repetition maximum. The UC group was asked not to increase their current exercise levels during the study period. Participants were tested for MetS (blood pressure, waist circumference, fasting blood glucose, HDL-C, and triglycerides) at baseline, within one week following the 16-week study period, and at 12-week follow-up for the EXE group only. Fasting blood samples were used to measure glucose, HDL-C, and triglycerides. Waist circumference was measured at the midpoint between the lower margin of the last palpable rib and the top of the iliac crest using a fabric tape measure. Blood pressure was measured with an automated sphygmomanometer. Body composition was assessed via dual energy X-ray absorptiometry.

Results. At baseline, 82% (overall and by group) of the HBCS met the criteria for MetS. There were no significant group differences in the MetS variables between the EXE and UC groups at baseline (p&gt;0.01). Post-intervention, all MetS components were significantly lower in the EXE group than the UC group (p&lt;0.01) and only 15% of participants in the EXE group met the criteria for MetS, representing a 67% absolute decrease. This is in comparison to 84% of participants in the UC group. Body fat mass decreased by 10% during the 16-week EXE period, compared to a 2% increase in the UC group (p&lt;0.01). MetS changes remained significantly improved in the EXE group when fat mass was included as a covariate in the statistical model. At the follow-up assessment in the EXE group, all MetS variables remained significantly improved compared to baseline (p&lt;0.01) and were not significantly different post-intervention (p&gt;0.25) despite slight increases (&lt;2%) in waist circumference and triglyceride levels.

Conclusion. This is one of few exercise trials in minority BCS and the first study to target MetS with exercise in HBCS. This 16-week supervised combined aerobic and resistance exercise intervention reduced MetS in sedentary, overweight and obese HBCS. Reductions in MetS components were maintained after completion of the intervention, suggesting the benefits of the intervention on MetS were sustainable in the absence of a supervised intervention.

Citation Format: Dieli-Conwright CM, Sami N, Lee K, Spicer D, Buchanan TA, Demark-Wahnefried W, Courneya K, Tripathy D, Mortimer J. Effects of a 16-week combined aerobic and resistance exercise intervention on metabolic syndrome in overweight/Obese Hispanic breast cancer survivors [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-13-01.

White matter apoptosis is increased by delayed hypothermia and rewarming in a neonatal piglet model of hypoxic ischemic encephalopathy

Therapeutic hypothermia is widely used to treat neonatal hypoxic ischemic (HI) brain injuries. However, potentially deleterious effects of delaying the induction of hypothermia and of rewarming on white matter injury remain unclear. We used a piglet model of HI to assess the effects of delayed hypothermia and rewarming on white matter apoptosis. Piglets underwent HI injury or sham surgery followed by normothermic or hypothermic recovery at 2h. Hypothermic groups were divided into those with no rewarming, slow rewarming at 0.5°C/h, or rapid rewarming at 4°C/h. Apoptotic cells in the subcortical white matter of the motor gyrus, corpus callosum, lateral olfactory tract, and internal capsule at 29h were identified morphologically and counted by hematoxylin & eosin staining. Cell death was verified by terminal deoxynucleotidyl transferase (TdT) dUTP nick end labeling (TUNEL) assay. White matter neurons were also counted, and apoptotic cells were immunophenotyped with the oligodendrocyte marker 2',3'-cyclic-nucleotide 3'-phosphodiesterase (CNPase). Hypothermia, slow rewarming, and rapid rewarming increased apoptosis in the subcortical white matter relative to normothermia (p<0.05). The number of white matter neurons was not lower in groups with more apoptosis after hypothermia or rapid rewarming, indicating that the apoptosis occurred among glial cells. Hypothermic piglets had more apoptosis in the lateral olfactory tract than those that were rewarmed (p<0.05). The promotion of apoptosis by hypothermia and rewarming in these regions was independent of HI. In the corpus callosum, HI piglets had more apoptosis than shams after normothermia, slow rewarming, and rapid rewarming (p<0.05). Many apoptotic cells were myelinating oligodendrocytes identified by CNPase positivity. Our results indicate that delaying the induction of hypothermia and rewarming are associated with white matter apoptosis in a piglet model of HI; in some regions these temperature effects are independent of HI. Vulnerable cells include myelinating oligodendrocytes. This study identifies a deleterious effect of therapeutic hypothermia in the developing brain.

Anatomy of common atrioventricular junction with complex associated lesions

The essence of the lesion increasingly described as atrioventricular septal defect is the presence of a common atrioventricular junction. In most instances, the common junction is itself shared in more or less equal fashion between the cardiac chambers, producing the so-called balanced arrangement, which can be considered the default option. Complexity can be produced at various levels within this standard lesion. The most complex malformations are seen in the setting of visceral heterotaxy. Greatest complexity is seen with right isomerism. This always includes totally anomalous pulmonary venous connection, even when the pulmonary veins return to the heart. Still further complexity is often added by the presence of pulmonary stenosis or atresia. Imbalance can involve either the atrial or ventricular chambers. Imbalance at atrial level produces one form of double outlet atrium, but typically with balanced ventricles. Ventricular imbalance represents spectrums extending either to double inlet left or right ventricle through a common atrioventricular valve. Complexity at the level of the ventriculoarterial junctions is seen in the form of abnormal ventriculoarterial connections, notably tetralogy of Fallot or double outlet right ventricle. In these settings, the superior bridging leaflet is free-floating. Hypoplasia of the left atrioventricular valve is part of right ventricular dominance and is often associated with the so-called parachute malformation. Dual orifice is also a problem. In both these lesions, the zone of apposition between the bridging leaflets is the effective inlet to the left ventricle.

Anomalous pulmonary venous connections and related anomalies: nomenclature, embryology, anatomy, and morphology

This article combines material from three complementary overviews presented in the Symposium on Pulmonary Venous Anomalies during the Joint Meeting of the World Society for Pediatric and Congenital Heart Surgery and Sociedad Latina de Cardiologia y Cirugia Cardiovascular Pediátrica in Lima, Peru. We discuss the embryologic basis for nomenclature, the hierarchical diagnostic categories, and the important anatomic and morphologic characteristics of anomalous pulmonary venous connections. The anatomic descriptions help to guide an understandable and sensible approach to the diagnosis and surgical management of these various disorders.

Clinico-morphological correlations in the categorization of holes between the ventricles

Controversy still exists in the categorization of holes between the ventricles, although they are the most common congenital cardiac malformation. Advanced imaging techniques such as three-dimensional echocardiography and computed tomographic angiography offer superb anatomical details of these defects. In this review, we have sought to collate the features highlighted in different categorizations and identify their similarities, but also emphasize their differences. We hope that an analysis of this type, now achievable during life, using advanced imaging, might lead to the appearance of a unified system for diagnosis and description of holes between the ventricles.

Abstract P2-02-04: MRI Findings and Outcomes in an Underserved Breast Cancer Population Screened with BRCA Testing

Background: Patients with breast cancer and a familial risk and/or BRCA 1 or 2 mutations are at high risk of contralateral breast cancer and ipsilateral recurrence. While MRI screening is recommended for patients with BRCA mutations, and MRI staging for breast cancer is being increasingly used, the outcomes of such testing are not well described, especially in underserved populations. At Los Angeles County Hospital (LAC) for the last 3 years, we have enacted a program of genetic counseling and testing based standard guidelines as well as MRI evaluation of all patients newly diagnosed with breast cancer. LAC serves a population that includes a high number of indigent patients, primarily Hispanic (60%) and Asian (15%). Methods: We undertook a retrospective evaluation of all patients seen at LAC from March 2008 to March 2010 who underwent genetic counseling/testing and MRI as preoperative assessment for histologically documented breast cancer or followup after cancer treatment. IRB approval was obtained to extract data for this analysis. Demographic information along with clinical presentation, MRI and mammography results, additional imaging results, biopsy and surgical procedure and corresponding pathology data were obtained through the review of electronic medical records and clinic charts.

Results: A total of 90 patients had both genetic testing and MRI reports available. The median age of all tested patients was 41 years. Ethnicity was 78% Hispanic, 9% Asian, 7% African American, 2% Caucasian and 4% other. BRCA mutation was seen in 20 cases (22%), 12 BRCA-1, 8 BRCA-2, 4 variants of unknown significance, and 66 had no mutation. Breast mass or other symptoms were the mode of detection in 89% of the overall cohort, and 81% in mutation carriers. The index lesion was visible on MRI in 78% and by mammogram in 82% of all patients. Ipsilateral MRI showed 7 abnormal non-index findings in 6 patients (7%); 6 of 7 lesions biopsied showed cancer. In the contralateral breast, 7 abnormalities were noted on MRI, but only 5 were amenable to biopsy as 2 could not be visualized by any means on follow up, and 1 showed cancer. Interestingly, only one of the 13 patients with abnormal findings carried a mutation (BRCA-1) and this patient did not have cancer on contralateral lesion biopsy. Mastectomy was performed in 91% and 78% of patients with and without mutation. Conclusions: Screening, counseling and testing for BRCA mutations is feasible in an underserved population, with a 22% mutation identification rate. MRI detected 5 non-index ipsilateral cancers and one contralateral cancer among 90 patients, with none of the detected cancers among the 20 mutation carriers. While MRI staging may be effective at detecting additional cancers in this underserved and high familial risk population, this appears to be independent of BRCA status.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-02-04.

Report From The International Society for Nomenclature of Paediatric and Congenital Heart Disease

Tremendous progress has been made in the field of pediatric heart disease over the past 30 years. Although survival after heart surgery in children has improved dramatically, complications still occur, and optimization of outcomes for all patients remains a challenge. To improve outcomes, collaborative efforts are required and ultimately depend on the possibility of using a common language when discussing pediatric and congenital heart disease. Such a universal language has been developed and named the International Pediatric and Congenital Cardiac Code (IPCCC). To make the IPCCC more universally understood, efforts are under way to link the IPCCC to pictures and videos. The Archiving Working Group is an organization composed of leaders within the international pediatric cardiac medical community and part of the International Society for Nomenclature of Paediatric and Congenital Heart Disease ( www.ipccc.net ). Its purpose is to illustrate, with representative images of all types and formats, the pertinent aspects of cardiac diseases that affect neonates, infants, children, and adults with congenital heart disease, using the codes and definitions associated with the IPCCC as the organizational backbone. The Archiving Working Group certifies and links images and videos to the appropriate term and definition in the IPCCC. These images and videos are then displayed in an electronic format on the Internet. The purpose of this publication is to report the recent progress made by the Archiving Working Group in establishing an Internet-based, image encyclopedia that is based on the standards of the IPCCC.

Magnetic Resonance Imaging quantification of breast density in BRCA carriers following gonadotropin releasing hormone agonist (GnRHA)-based hormonal chemoprevention

1506

Background: Breast tissue density limits the usefulness of mammography as a surveillance tool in young women. Breast Magnetic Resonance Imaging (MRI) provides high tissue contrast and three-dimensional structural information not impaired by high breast density. We developed a volumetric “MR density” measure of breast structural composition that may be complementary to mammographic breast density. We tested this MR density measure in unaffected women with known high risk of breast cancer due to a BRCA gene mutation (or empiric risk > 30% lifetime), who were recruited in a phase II trial to study the effects of a hormonal chemoprevention regimen. Methods: Nine premenopausal high-risk women age 21 to 48 were treated with intranasal GnRHA (deslorelin), low-dose estradiol, and testosterone daily for 10 months. All patients underwent one contrast-enhanced breast MRI exam before and after treatment. We measured MR density as the ratio of fibroglandular tissue volume to total volume of the breast, at both time points. Our technique involved the semi-automated delineation of the breast and the automated segmentation of fibroglandular from adipose tissue. An “MR index” was also defined to quantify partial voluming effects due to the presence of adipose/fibroglandular edges in the MR data. Results: Eight out of nine patients showed a reduction in MR density (p = 0.026) with treatment. Three patients had less than 5% MR density at baseline, making it difficult to quantitate a change with treatment. All of the remaining six patients had reduced MR density after treatment (mean reduction 35.5%; p = 0.035). Conclusions: We have demonstrated the use of breast MR density as a robust volumetric quantitative measure of breast tissue composition. Our findings suggest that MR could be used to measure hormonal chemoprevention effects in BRCA carriers.

[Table: see text]

Polymorphisms of DNA-repair genes associated with clinical outcome in metastatic breast cancer (MBC) patients treated with gemcitabine/cisplatin (GC) (California Cancer Consortium)

675

Background: DNA repair enzymes may play an important role in determining efficacy of chemotherapy in MBC. In particular, GC combination therapy may be dependent on activity of DNA repair enzymes in host cells, since cisplatin acts by inducing DNA damage. Cancer cells with increased DNA repair capacity may be resistant to GC, and specific genes may be responsible for this increased repair capacity. We examined whether polymorphisms in genes related to DNA repair were associated with clinical outcome in MBC patients treated with GC, enrolled in a parent phase II clinical trial (Ph II-14 A & B). Methods: Fifty-five patients with MBC were evaluated. Patients received the following regimen: 25 mg/m2 cisplatin on days 1–4; 1000 mg/m2 gemcitabine on days 2 and 8 of 21-day cycle. Thirteen polymorphisms in 10 cancer-related genes were tested for association with overall survival, time to tumor progression, and tumor response using a PCR RFLP based assay. Results: Of 55 patients evaluated, there were 17 responders (31%) and 33 non-responders (60%). Five patients (9%) inevaluable for response. Of 33 non-responders, 15 had stable disease, 18 had progressive disease. Median survival: 11.7 months with median follow-up 32.4 months for 4 patients alive at time of analysis. Median progression-free survival: 4.2 months. XPD Lys751Gln polymorphism was associated with overall survival and time to tumor progression (p=0.0003, p=0.006, respectively, log-rank test). Thirty-five patients carried Lys/Lys genotype, of which 29% resopnded. Fourteen patients carried Lys/Gln genotype, of which 54% resopnded. Five patients carried Gln/Gln genotype, with no responders. XRCC3 Thr241Met polymorphism was associated with time to tumor progression and tumor response (p=0.03, p=0.002, respectively). Eighteen patients had Met/Met genotype, of which 47% responded. Twenty-six patients had heterozygous genotype, of which 17% responded. Five patients had homozygous Thr/Thr, of which 100% responded. Conclusions: Our results suggest that polymorphisms in DNA repair genes XPD and XRCC3 may be important markers in predicting clinical outcome in MBC patients treated with GC. Supported by the following NCI grant: N01 CM1701.

[Table: see text]

Three-dimensional echocardiography: research toy or clinical tool?

Conventional 2D echocardiography is an excellent qualitative imaging method, but its use for quantitation is limited by test-retest reproducibility of image planes. The increasing sophistication of medical treatments for left ventricular dysfunction, hypertension and valvular heart disease has created the need for accurate and reproducible measurements of chamber dimensions. Similarly, improvements in valve repair and catheter-based interventions for valve lesions and septal defects have created the need for better visualisation of cardiac structures. The use of 31) echocardiography may decrease variability both in the quality and interpretation of complex pathology among investigators. Three-dimensional echocardiography is achieved by using a 3D spatial registration device with a conventional 21) scanner, or by using a high-speed, phased-array real-time scanner. The latter are still developmental, so that the technique currently requires use of a 21) scanner, combined with a 31) spatial coordinate system, which may be external or internal to the scanning transducer. An external system permits data acquired from several cardiac windows to be integrated and reconstructed. Image reconstruction is performed using a wire-frame model or surface rendering. Wire-frame models are formed by manual or automatic connection of boundary data points; this approach uses fewer data points than rendering, can be rapidly processed and is sufficient for quantitative analysis. Surface-rendering uses lighting and shading applied to a wire-frame model to produce a realistic 31) display, which may be useful for surgical planning and increasing understanding of anatomic relations. Three-dimensional echocardiography yields more accurate measurements of ventricular volume and function, as well as new measurements such as infarct area. With increased reproducibility and reliability, 3D echocardiography may well prove to be the essential tool required for the serial follow up of left ventricular mass and volume.

Splenogonadal fusion-limb defect "syndrome" and associated malformations

Two types of splenogonadal fusion (SGF) have been proposed. In the continuous type the spleen is connected to the gonad, and often it is associated with limb defects and other anomalies such as micrognathia, microglossia, anal atresia, and hypoplastic lungs. Associated abnormalities are lower in the discontinuous type of SGF, where there is fusion between the gonad and accessory splenic tissue, without connection with the normal spleen. The cause of SGF and SGF with limb defects (SGFLD) is unknown. On the basis of associated orofacial limb abnormalities, some authors have suggested that SGFLD may be related to the Hanhart complex. Others have noted the overlap between SGFLD and femoral-facial syndrome (FFS). We consider SGFLD a developmental field defect that originates during blastogenesis. Although the cause is unknown, the earlier its action, the more severe the involvement resulting in SGFLD; later action may result only in SGF.

Delayed presentation of compartment syndrome following gastrocnemius tear

The authors describe a case of acute compartment syndrome occurring twenty days following a tear of gastrocnemius. To their knowledge, this is the only such case reported where the onset of compartment syndrome was so long since of index injury.

Application of tissue Doppler to interpretation of dobutamine echocardiography and comparison with quantitative coronary angiography

The main limitation of dobutamine echocardiography (DE) is its subjective interpretation. We sought to reduce the need for expert interpretation by developing a quantitative approach to DE using myocardial Doppler velocity (MDV) in 242 patients undergoing DE. In 128 patients with a normal dobutamine echocardiogram, the normal range was designed to give a specificity of 80%. The accuracy of this range was investigated in 114 consecutive patients who underwent coronary angiography within 2 months of DE. A standard dobutamine echocardiographic protocol was used, with MDV gathered from color tissue Doppler at rest and peak stress. Wall motion at these stages was scored by experienced observers using a 16-segment model and MDV was measured off-line. Sensitivity and specificity of wall motion scoring and MDV were obtained by comparison with angiographic evidence of disease, defined as stenosis > 50% of the coronary artery diameter. The normal range in tethered segments (septum, anteroseptum, and inferior) was > or = 7 cm/s in the basal segments and > or = 5 cm/s in the midsegments. In the free wall (anterior, lateral, and posterior), the cutoff was > or = 6 cm/s in the base and > or = 4 cm/s in the midventricle. Of 114 patients undergoing angiography, 84 (75%) had significant stenoses, and the sensitivity of wall motion scoring and MDV were 88% and 83%, respectively, with specificities of 81% and 72% (p = NS). The accuracy was similar overall (86% vs 80%), as well as in each vascular territory. These data suggest that a fully quantitative interpretation of DE using site-specific normal ranges of tissue Doppler, which account for regional variations of base-apex function, is feasible and equivalent in accuracy to expert wall motion scoring.

Pharmacokinetic and pharmacodynamic evaluation of the glycinamide ribonucleotide formyltransferase inhibitor AG2034

Glycinamide ribonucleotide formyltransferase (GARFT) is a component of the de novo purine synthesis pathway. AG2034 is a specific inhibitor of GARFT that was designed based on the GARFT crystal structure. In conjunction with Phase I studies at four clinical centers in the United States and United Kingdom, AG2034 pharmacology was evaluated in 54 patients receiving 1-11 mg/m2 AG2034 as a 2-5 min injection. Blood samples were obtained just prior to and 5, 15, 30, and 45 min, and 1, 1.5, 2, 4, 6, 8, 12, 24, 48, 72, and 96 h after bolus injection during course 1. Limited sampling was also performed on course 3. Plasma AG2034 was measured using a sensitive and reproducible ELISA assay. AG2034 demonstrated a trimodal elimination pattern over 24 h, with median half-life (t(1/2))alpha = 8.7 min, t(1/2)beta = 72.6 min, and t(1/2)gamma = 364.2 min. AG2034 systemic clearance ranged from 9.4-144.5 ml/min/m2, and volume of distribution was 1.2-7.6 liters/m2. Course 1 AG2034 area under the concentration versus time curve (AUC) had a linear relationship with dose (r(s) = 0.86). Accumulation of AG2034 was evident, because course 3 AUC was higher than course 1 in 23 of 23 evaluable patients, but was not associated with an increase in erythrocyte AG2034. AG2034 systemic exposure had an impact on toxicity, because course 1 and course 3 AG2034 AUCs were significantly higher for patients with grade III/IV toxicity than patients with less than grade II toxicity (P < 0.001 and P = 0.001 for course 1 and course 3, respectively). This study demonstrates rapid systemic clearance of AG2034 and suggests pharmacokinetic approaches that may minimize patient toxicity and aid the development of this interesting class of anticancer agents.

Preoperative paclitaxel and radiotherapy for locally advanced breast cancer: surgical aspects

INTRODUCTION

Approximately 15% of breast cancer patients present with large tumors that involve the skin, the chest wall, or the regional lymph nodes. Multimodality therapy is required, to provide the best chance for long-term survival. We have developed a regimen of paclitaxel, with concomitant radiation, as a primary therapy in patients with locally advanced breast cancer.

METHODS

Eligible patients had locally advanced breast cancer (stage IIB or III). After obtaining informed consent, patients received paclitaxel (30 mg/m2 during 1 hour) twice per week for 8 weeks and radiotherapy to 45 Gy (25 fractions, at 180 cGy/fraction, to the breast and regional nodes). Patients then underwent modified radical mastectomy followed by postoperative polychemotherapy.

RESULTS

Twenty-nine patients were enrolled. Of these, 28 were assessable for clinical response and toxicity, and 27 were assessable for pathological response. Objective clinical response was achieved in 89%. At the time of surgery, 33% had no or minimal microscopic residual disease. Chemoradiation-related acute toxicity was limited; however, surgical complications occurred in 41% of patients.

CONCLUSIONS

Preoperative paclitaxel with radiotherapy is well tolerated and provides significant pathological response, in up to 33% of patients with locally advanced breast cancer, but with a significant postoperative morbidity rate.

Concurrent paclitaxel and radiation therapy for breast cancer

Few studies have evaluated the role of concurrent chemoradiation therapy in the management of locally advanced breast cancer. The availability of radiosensitizing chemotherapeutic agents that are effective in breast cancer and the encouraging results achieved by concurrent chemoradiation in other malignancies have prompted us to investigate this approach. Paclitaxel is a promising agent for use with concurrent radiotherapy because of its single-agent efficacy profile and its radiosensitizing effects. A clinical protocol of preoperative paclitaxel and radiation in locally advanced breast cancer is ongoing at our institution to test feasibility, measure pathologic response at mastectomy, and explore association of pathologic response with molecular tumor markers. Initially, the study was designed to test weekly paclitaxel at a dose of 60 mg/m2 during radiation therapy, delivered 5 days a week at 200 cGy fractions to a total dose of 50 Gy over 5 weeks. Due to severe skin toxicity in the first two patients, the protocol was amended to change the scheduling of paclitaxel to 30 mg/m2 twice weekly and to reduce the radiation to 180 cGy fractions to a total dose of 45 Gy, delivered 5 days a week over 5 weeks. Presently, 13 patients have been accrued; preliminary data indicate good tolerance to twice-weekly paclitaxel, and four of eight evaluable patients have achieved pathologic response (one patient who received the weekly regimen and three who received the twice-weekly regimen). In addition, sequential fine-needle aspirations of palpable breast cancers were obtained in patients enrolled in a parallel study of preoperative single-agent paclitaxel (200 mg/m2 every 2 weeks, for a total of four cycles before breast surgery). Preliminary results suggest that a steep increase in the mitotic index occurs during the first day after paclitaxel administration and plateaus between the second and the third day, then decreases to pretreatment values. The peak apoptotic index occurs at approximately 72 hours after paclitaxel administration and decreases at approximately 98 hours. These initial findings suggest that twice-weekly dosing of paclitaxel may optimize recruitment of cells into the G2/M phase of the cell cycle, the most radiosensitive phase.

Seckel-like syndrome in three siblings

Seckel syndrome has been described as the prototype of the primordial bird-headed type of dwarfism. Since Seckel originally defined the disorder, less than 60 cases have been reported. In addition to the characteristic craniofacial dysmorphism and skeletal defects, abnormalities have been described in the cardiovascular, hematopoietic, endocrine, and central nervous systems. This pleiotropy has implied genetic heterogeneity and prompted reviews of previously reported cases of Seckel syndrome. As a result, the characteristic diagnostic features of Seckel syndrome have been highly debated. Although deletions in chromosome 2q have been described, to date, no genetic defect has been defined. We report three cases of Seckel-like syndrome in siblings from nonconsanguinous Caucasian parents. In addition to the typical Seckel phenotypic features, all three cases were characterized by severe hydrocephalus. We review the literature and propose that there is a spectrum of Seckel conditions that share some common key features, but also demonstrate a wide range of phenotypic features.

Rabbit urethral regeneration using small intestinal submucosa onlay grafts

OBJECTIVES

To determine if small intestinal submucosa (SIS) can evoke urethral regeneration.

METHODS

Twenty male white New Zealand rabbits were assigned to one of three experimental groups. Group 1 (n = 4) underwent simple urethrotomy and closure. Group 2 (n = 8), a second control group, underwent an onlay urethroplasty with a graft of full-thickness preputial skin from the host rabbit. Group 3 (n = 8) underwent an onlay urethroplasty with an SIS graft.

RESULTS

All eight SIS onlay grafts promoted regeneration of the normal rabbit epithelium supported by a well-vascularized collagen and smooth muscle backing. Preputial free onlay grafts maintained a keratinizing squamous cell epithelium with a poor supportive backing, which resulted in the formation of urethral diverticulum.

CONCLUSIONS

SIS onlay patch grafts for urethroplasty promote rabbit urethral regeneration.

Rat mesangial cells express two unique isoforms of laminin which modulate mesangial cell phenotype

Rat mesangial cells express two unique isoforms of laminin which can be modulated by culture medium composition. To define further the nature of laminin expressed by cultured rat mesangial cells, synthesis of individual laminin chains, as well as their trimeric association, was examined. Based on data from Northern analysis of mRNA expression, immunoblots, immunofluorescence staining and radioimmunoprecipitation of biosynthetically labeled proteins, mesangial cells express laminin beta1, beta2, and gamma1 chains. Mesangial cells do not express laminin alpha1 or alpha2. MC produce a unique alpha chain, designated alpha'm. These laminin chains assemble into two major isoforms. One contains alpha'mbeta1gamma1, co-precipitates with entactin and is assembled into the fibrillar extracellular matrix. The second isoform contains alpha'mbeta2 and a presumed gamma chain that migrates in gel slightly ahead of gamma1. The beta2-containing isoform is concentrated in punctate sites on the cell surface. In addition, mesangial cells display different phenotypes when plated on laminin-1 (alpha1beta1gamma1), as compared to purified beta2. An LRE-containing peptide of laminin beta2 serves as an attachment site for mesangial cells and is sufficient to induce the phenotype observed with intact beta2. These data suggest that laminin isoform expression plays an important role in mesangial cell phenotype and function.

Preoperative 5-fluorouracil and radiation therapy for locally advanced breast cancer

BACKGROUND

Fifteen percent of breast cancer patients present with large tumors involving skin or chest wall. Often, surgery with primary wound closure is impossible. We used neoadjuvant chemoradiation in locally advanced breast cancer patients, in hopes of increasing resectability.

METHODS

Eligible patients had locally advanced breast cancer deemed unresectable with primary wound closure. Patients received 8 weeks of infusional 5-fluorouracil (5-FU) 200 mg/m2 per day and radiation therapy to 50 Gy. Patients rendered resectable underwent modified radical mastectomy (MRM) followed up by chemotherapy.

RESULTS

Of 30 evaluable patients, 73% had an objective clinical response. All were able to undergo MRM with primary wound closure; 63% had residual disease, 20% had minimal microscopic disease, and 17% had complete pathologic response. Treatment-related toxicity was minimal. Surgical morbidity was not increased.

CONCLUSIONS

Infusional 5-FU with concomitant radiotherapy is well tolerated and effective at producing shrinkage in the majority of patients, converting inoperable breast cancer to easily resectable disease.

Original p53 status predicts for pathological response in locally advanced breast cancer patients treated preoperatively with continuous infusion 5-fluorouracil and radiation therapy

PURPOSE/OBJECTIVE

1) To test feasibility of preoperative continuous infusion (c.i.) 5-Fluorouracil (5-FU) and radiation (RT) in locally advanced breast cancer. 2) To study clinical and pathological response rates of 5-FU and radiation. 3) To attempt preliminary correlations between biological probes and pathological response.

METHODS AND MATERIALS

Previously untreated, locally advanced breast cancer patients were eligible: only patients who presented with T3/T4 tumors that could not be resected with primary wound closure were eligible, while inflammatory breast cancer patients were excluded. The protocol consisted of preoperative c.i. infusion 5-FU, 200 mg/m2/day with radiotherapy, 50 Gy at 2 Gy fractions to the breast and regional nodes. At mastectomy, pathological findings were classified based on persistence of invasive cancer: pathological complete response (pCR) = no residual invasive cells in the breast and axillary contents; pathological partial response (pPR) = presence of microscopic foci of invasive cells in either the breast or nodal specimens; no pathological response (pNR) = pathological persistence of tumor. For each patient pretreatment breast cancer biopsies were analyzed by immunohistochemistry for nuclear grade, ER/PR hormonal receptors, her2/neu and p53 overexpression.

RESULTS

Thirty-five women have completed the protocol and are available for analysis. 5-FU was interrupted during radiation in 10 of 35 patients because of oral mucositis in 8 patients, cellulitis in 1, and patient choice in another. Objective clinical response rate before mastectomy was 71% (25 of 35 patients): 4 CR, 21 PR. However, in all 35 patients tumor response was sufficient to make them resectable with primary wound closure. Accordingly, all patients underwent modified radical mastectomy: primary wound closure was achieved in all patients. At mastectomy there were 7 pCR (20%), 5 pPR (14%) and the remaining 23 patients (66%) had pathological persistence of cancer (pNR). Variables analyzed as potential predictors for pathological response (pPR and pCR) were: initial TNM clinical stage, clinical response, nuclear grade, hormonal receptor status, p53 overexpression, and Her2/neu overexpression in the pretreatment tumor biopsy. Only initial p53 status (lack of overexpression at immunohistochemistry) significantly correlated with achievement of a pathological response to this regimen (p = 0.010).

CONCLUSION

The combination of c.i. 5-FU and radiation was well tolerated and generated objective clinical responses in 71% of the patients. With the limitation of the small sample size, the complete pathological response achieved (20%) compares favorably with that reported in other series of neoadjuvant therapy for similar stage breast cancer. These preliminary data suggest that initial p53 status predicts for pathological response (pPR and pCR) to the combination of c.i. 5-FU and radiotherapy in locally advanced breast cancer.

Diabetes induces changes in glomerular development and laminin-beta 2 (s-laminin) expression

Offspring of diabetic mothers have developmental renal abnormalities; thus, we investigated the effects of the diabetic milieu on kidney development. Four groups of host rats, including insulin-deficient and insulin-treated streptozotocin-induced diabetic rats, normal controls, and insulin-treated nondiabetic rats, were prepared. After 38 days, rats received ocular implants of E14 fetal rat kidneys. Nine days later the fetal kidney grafts were harvested for analysis of glomerular development and expression of fibronectin, laminin, laminin-beta 2, and alpha-smooth muscle actin and m170, two additional markers of mesangial maturation. The rate of glomerular maturation was delayed in grafts placed in hyperglycemic, insulin-deficient diabetic rats. These glomeruli contained few mesangial cells or matrix, and laminin-beta 2 expression was reduced as compared with controls. Mesangial expression of alpha-smooth muscle actin and m170 was not detected. In contrast, grafts placed in insulin-treated diabetic animals had increased numbers of mesangial cells and expanded mesangial matrix. The content of laminin-beta 2 and expression of m170 and alpha-smooth muscle actin were also increased in these grafts. These data show that hyperglycemia and insulin status influence laminin isoform expression and play important roles in mesangial development.

Cardioprotection with dexrazoxane for doxorubicin-containing therapy in advanced breast cancer

PURPOSE

To determine the cardioprotective effect of dexrazoxane (DZR) used in a doxorubicin-based combination therapy in advanced breast cancer.

PATIENTS AND METHODS

Between November 1988 and January 1991, 534 patients with advanced breast cancer were randomized to two multicenter, double-blind studies (088001 and 088006). Patients received fluorouracil, doxorubicin, and cyclophosphamide (FAC) with either DZR (DZR-to-doxorubicin ratio, 10:1) or placebo (PLA) every 3 weeks and were monitored with serial multiplegated acquisition (MUGA) scans.

RESULTS

The hazards ratio (HR) of PLA to DZR for a cardiac event, which was predefined ejection fraction changes or congestive heart failure (CHF), was 2.63 (95% confidence interval [CI], 1.61 to 4.27; P < .001) for 088001 and 2.00 (95% CI, 1.01 to 3.96; P = .038) for 088006. The objective response rates for 088001 were 46.8% for DZR and 60.5% for PLA, a difference of 14% (95% CI, -25% to -2%; P = .019), and for 088006 were 53.7% for DZR and 49.3% for PLA, a difference of 4% (95% CI, -13% to 22%; P = .63). Time to progression and survival were not significantly different between treatment arms in either study. Toxicities on the DZR arms included lower granulocyte and platelet counts at nadir (P = .009 and P = .004, respectively) and more pain on injection (P = .001), with no difference in the rates of fever, infection, or hemorrhage.

CONCLUSION

DZR had a significant cardioprotective effect as measured by noninvasive testing and clinical CHF. One of the two studies (088001) showed a lower response rate with DZR, but time to progression and survival were not significantly different. DZR is the first agent shown to reduce cardiotoxicity from doxorubicin.

Insulin-like growth factor I (IGF-I) induces unique effects in the cytoskeleton of cultured rat glomerular mesangial cells

Resident glomerular mesangial cells (MCs) have complex cytoskeletal organizations that maintain functional and structural integrity. The ability of cells to replicate, coordinate movement, change shape, and interact with contiguous cells or extracellular matrix depends on cytoskeletal organization. MCs synthesize insulin-like growth factor (IGF-I), express IGF-I receptors, and respond to IGF-I with increased proliferation. We noted that IGF-I treatment of mesangial cells was associated with a change in morphology. Therefore, these studies were undertaken to define specific IGF-I-mediated changes in cytoskeletal protein organization. Rat MCs were propagated from birth in culture without supplemental insulin. Quiescent, subconfluent cultures were treated with IGF-I (100 nM) for 1 hr. Rearrangements in f-actin, alpha-smooth muscle actin, beta-actin, vimentin, and vinculin were seen by fluorescence microscopy. As the cytoskeleton rearranged, alpha-smooth muscle actin dissociated from the f-actin bundles and beta-actin became polymerized under the leading lamellar edge. Ultrastructural changes were consistent with increased membrane turnover and metabolic activity. The normally sessile mesangial cell was induced by IGF-I to express a wound-healing phenotype characterized by movement and increased pinocytosis. These changes are different from those induced by insulin and have important implications for mesangial cell function.

Phase I and pharmacokinetic study of oral UFT, a combination of the 5-fluorouracil prodrug tegafur and uracil

UFT is an oral preparation combining the 5-fluorouracil (FU) prodrug tegafur (FT) and uracil (U) in a 1:4 ratio, which is commercially available in Japan for the treatment of breast and gastrointestinal cancers. We sought to determine the tolerance of daily oral UFT and to relate this tolerance to the pharmacokinetics of FT and/or the derived FU, while exploring the possibility of circadian FU kinetics contributing to the results. A 28-day schedule followed by 2 weeks rest was began at the initial level of 300 mg/m2/day administered either at 8 a.m. or at 6 p.m. At the following level, 400 mg/m2/day patients were randomly assigned to a split-dose administration or to the above single, timed dose administration. Intolerance to single dosing was clearly demonstrated, and only the split dosing was advanced to 500 mg/m2/day. When this level proved too toxic, 400 mg/m2 was studied further on a 7 a.m., 3 p.m., and 11 p.m. (every 8 h) schedule. Pharmacology was determined on selected patients. In the single dose administration, areas under the curves of FU were higher following p.m. dosing, although substantial interpatient variation was present. Toxicities (diarrhea and neutropenia) were more severe in patients receiving the drug in single daily doses. We conclude that the kinetics of FT are saturable, with disproportionate increases in area under the curve (and toxicities) as dose levels are increased. With divided dosing, tolerance improves. UFT at a dose of 400 mg/m2/day administered as three divided doses (every 8 h) is suitable for Phase II studies, although toxicity requiring cessation of drug administration prior to completion of 28-day cycles will occur in some patients.

Sonohysterographic imaging of the endometrial cavity

Vaginal ultrasound is the most effective method of imaging the contents of the true pelvis in the female. Saline influsion sonohysterography (SIS) is a simple refinement of the standard vaginal sonographic exam. Here, we briefly describe and demonstrate our use of this latter technique.

Induction of nodular sclerosis by insulin in rat mesangial cells in vitro: studies of collagen

These studies evaluated the contribution of insulin to the development of the abnormal mesangial matrix that characterizes diabetic nephropathy and is common to mesangial cells in culture. Glomeruli were isolated from a single rat and divided into two aliquots. In one set (SI-MC), the insulin contained in the medium was only that contributed by the fetal calf serum (20%). For the other set, the tissue culture medium was supplemented with 1 microM insulin (SI+MC). Mesangial cell outgrowths from each condition were isolated, cloned, and propagated. At passage 4, mesangial cells were characterized by morphology and cell markers, and compared in terms of composition and appearance of the secreted extracellular matrix. SI-MC grew in nests of cells surrounded by a thin layer of matrix that was rich in collagen IV. In contrast, mesangial cells supplemented with insulin aggregated into macroscopic "hillocks" rich in collagens I and III as described previously. Insulin (1 microM) or IGF-I (0.1 microM) was subsequently added to the medium of SI-MC. Insulin, but not IGF-I, induced a change in culture morphology and collagen accumulation characteristic of SI+MC. In contrast to SI+MC, SI-MC express insulin receptors and at physiologic concentrations insulin is a more potent stimulator of MC proliferation than is IGF-I. Insulin-induced changes in the collagenous composition of the accumulated ECM were directionally correlated with the rate of collagen I synthesis measured by biosynthetic labeling experiments and collagens III and IV as determined by ELISA. These data demonstrate that insulin alters the phenotype of mesangial cells in culture and their expression of interstitial and basement membrane collagens. These observations implicate insulin as a factor in the pathogenesis of mesangial matrix accumulation in diabetic nephropathy. Furthermore, a method for culturing mesangial cells that accumulate an extracellular matrix that is similar in composition to normal mesangial matrix provides a new model system for future studies of mesangial cell biology.

Depot leuprolide acetate with estrogen and progestin add-back for long-term treatment of premenstrual syndrome

OBJECTIVE

To test the effectiveness and safety of long-term depot leuprolide acetate (GnRH-a) plus estrogen and progestin add-back therapy in the treatment of moderate and severe premenstrual syndrome (PMS).

DESIGN

A prospective trial with each patient serving as her own control.

SETTING

University teaching hospital.

PARTICIPANTS

Ten women with regular menstrual cycles complaining of moderate to severe PMS. Premenstrual syndrome was diagnosed when symptoms increased > or = 25% during the luteal phase.

TREATMENT

Four-week cycles of IM injections of placebo or GnRH-a with all patients receiving saline (placebo), the first cycle followed by 12 cycles of GnRH-a, 7.5 mg. Conjugated equine estrogen (0.625 mg/d) was started Monday through Saturday within the first cycle and increased as needed. Medroxyprogesterone acetate (MPA), 10 mg/d, was taken orally for 10 days after 4, 8, and 12 cycles of GnRH-a therapy.

MAIN OUTCOME MEASURES

Changes in three symptom categories (water retention, pain, and psychological function), serum levels of total cholesterol and HDL, HDL-2, and LDL cholesterol, E2, and estrone. Endometrial biopsy was obtained 1 day after the end of the 12th GnRH-a cycle, and bone density was assessed using quantitative computer tomography at the end of the 12th GnRH-a cycle.

RESULTS

During treatment, there was a significant decrease compared with baseline and placebo in all three symptom categories. There were no significant changes in lipids. Endometrial biopsies revealed progestational changes with no evidence of hyperplasia. Quantitative computer tomography bone density dropped 3.7 on average compared with baseline after 12 months of treatment, but this was not statistically significant.

CONCLUSION

Gonadotropin-releasing hormone agonist therapy with hormonal add-back therapy is effective in treating PMS symptoms with progressive improvement over a 12-month period. This therapy prevents changes in lipids and adequately protects the endometrium with the addition of MPA every 4th cycle. Quantitative computer tomography bone density dropped at 12 months; further examination of bone changes is necessary.

Insulin induces a change in extracellular matrix glycoproteins synthesized by rat mesangial cells in culture

Extracellular matrix (ECM) accumulation within the glomerular mesangium is a hallmark of progressive forms of renal disease. We recently succeeded in propagating mesangial cells (MC) from the time of explant without supplemental insulin which exhibit a matrix profile analogous to normal mesangium in vivo. We used these cells to characterize insulin-induced changes in biosynthesis and accumulation of three important matrix glycoproteins, laminin, fibronectin, and thrombospondin. Two clones of MC derived from glomeruli from a single rat were compared. MC grown in the absence of supplemental insulin (SI-MC) assemble a matrix rich in fibronectin with much smaller accumulations of laminin and thrombospondin. In comparison, MC (SI+MC) grown chronically in the presence of 1 microM insulin have a greatly expanded ECM that immunostains less intensely with antibodies to fibronectin, but, it contains significant accumulations of laminin and thrombospondin. Following metabolic labeling of secreted proteins with 35S-methionine, total protein synthesis was measured, and specific ECM components were identified and quantitated by immunoprecipitation, SDS-PAGE and autoradiography. The rate of total protein synthesis was increased by 50% in SI+MC as compared to SI-MC, yet, individual proteins were increased or decreased. The rate of synthesis of fibronectin was decreased and the rate of synthesis of laminin and thrombospondin was increased by insulin. These changes were directionally correlated with the net accumulation of these proteins as shown by immunostaining. In addition to an increase in laminin synthesis, insulin treatment induced a change in the isoform of laminin expressed.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of flutamide in hormone-refractory metastatic prostate cancer

In a recent intergroup study under the auspices of the National Cancer Institute, 603 eligible patients with newly diagnosed disseminated adenocarcinoma of the prostate were prospectively randomized in a double-blinded clinical trial to receive either a gonadotropin-releasing hormone analogue (leuprolide) and a nonsteroidal antiandrogen (flutamide) or leuprolide and placebo. Of the 603 eligible patients, 300 were in the leuprolide and placebo arm and 303 were in the leuprolide and flutamide arm. At the time of disease progression, the code was broken: Those patients in the placebo arm were given the opportunity to receive flutamide, and the patients in the flutamide arm were treated at their physician's discretion. There was no survival time distribution difference, based on survival measured from the progression data, between the patients who were received flutamide after progression and those who were treated at their physician's discretion after progression. Furthermore, the addition of flutamide to leuprolide at the time of disease progression resulted in a survival-time distribution that is similar to other treatments of hormone-refractory prostate cancer.