Qualitative results from a randomized pilot study of eHealth Mindful Movement and Breathing to improve gynecologic cancer surgery outcomes

PURPOSE

Improved management of pain and co-morbid symptoms (sleep disturbances, psychological distress) among women undergoing surgery for suspected gynecologic malignancies may reach a population vulnerable to chronic pain.

PARTICIPANTS

Women undergoing surgery for a suspected gynecologic malignancy.

METHOD

We conducted a pilot randomized controlled trial of eHealth Mindful Movement and Breathing (eMMB) compared to an empathic attention control (AC). Semi-structured interviews were conducted by telephone (n = 23), recorded, transcribed, coded, and analyzed using thematic analysis.

FINDINGS

Participants reported overall high acceptability such that all would recommend the study to others. Positive impacts of practicing eMMB included that it relieved tension, facilitated falling asleep, and decreased pain. Participants also reported high adherence to self-directed eMMB and AC writing practices and described facilitators and barriers to practicing.

CONCLUSIONS

This qualitative feedback will inform future research to assess the efficacy of eMMB for reducing pain and use of remotely-delivered interventions more broadly.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03681405.

HIPEC after neoadjuvant chemotherapy is associated with acceptable toxicity and favorable quality of life in newly diagnosed advanced ovarian cancer patients

OBJECTIVE

To evaluate toxicity, quality of life and PFS in patients with advanced ovarian cancer who underwent neoadjuvant chemotherapy (NAC) followed by CRS and HIPEC with carboplatin.

METHODS

Patients with stage IIIC or IVA epithelial ovarian cancer, who were not candidates for primary CRS, were enrolled in this phase two trial. Patients received 3-6 cycles of NAC with an IV carboplatin doublet followed by CRS with HIPEC (carboplatin 800 mg/m2 for 90 min). They were followed for at least 12 months to assess for adverse events, quality of life (QOL) and disease progression. QOL was measured using the Functional Assessment of Cancer Therapy-Ovarian (FACT-O) questionnaires prior to CRS and post-operatively at 6 weeks, 3 months, and 6 months after CRS.

RESULTS

Twenty patients were enrolled. HIPEC was completed successfully in all twenty patients, and there was no peri-operative mortality. Twelve (70.6%) patients experienced a grade 3 or 4 toxicity; most commonly anemia (59%), thrombocytopenia (29%), and hypokalemia (24%). There was no significant change between the pre-operative and postoperative 6 weeks, 3 month, and 6 month FACT-O, NTX, and AD scores. Nine (45%) patients have experienced disease recurrence to date. The median progression free survival in this cohort is 11.2 months (2.5-23.7 months).

CONCLUSION

The addition of HIPEC with carboplatin to interval CRS was well tolerated in patient population. Myelosuppression was the most common adverse event. CRS with HIPEC did not adversely impact these patients' QOL indices. The efficacy of this regimen should be further evaluated in a larger clinical trial.

Current management of adults receiving oral anti-cancer medications: A scoping review

PURPOSE

Oral anti-cancer medication (OAM) has revolutionised oncology care. Due to their potential toxicities and associated safety challenges ongoing assessment and monitoring is essential; currently generally performed in acute care settings. Internationally there exists a transformative vision to shift patient care from acute to primary care. A nurse-led integrated model of care could be developed for OAM patient management in primary care. The aim of this study was to examine international literature regarding current clinical management practices for assessment and monitoring of patients receiving OAM.

METHODS

Following PRISMA-ScR guidelines, databases MEDLINE, CINAHL and Web of Science were searched for English studies published between 2010 and 2020 using keywords: assessment, cancer, care, management, oral anticancer medications. Articles were screened and assessed for eligibility. From eligible studies, data were extracted to summarize, collate and make a narrative account of the findings.

RESULTS

2261 papers were reviewed, 14 met inclusion criteria. Three phases of management are reported: 1. Patient treatment plan development; 2. Patient education; 3. Patient monitoring. Within these phases seven specific stages of care were identified broadly representing the patient's journey: (1) treatment decision, (2) prescribing of OAM, (3) OAM dispensing and administration, (4) maximising patient safety (5) ongoing patient assessment (6) patient support (7) communication with other health-care professionals.

CONCLUSIONS

Despite a paucity of international literature, a dedicated OAM clinic was endorsed as a means to achieve improved care. Nurses and pharmacists were identified as being of particular importance especially in education and ongoing management of patients receiving OAMs.

Beyond Sedlis-A novel histology-specific nomogram for predicting cervical cancer recurrence risk: An NRG/GOG ancillary analysis

PURPOSE

The Sedlis criteria define risk factors for recurrence warranting post-hysterectomy radiation for early-stage cervical cancer; however, these factors were defined for squamous cell carcinoma (SCC) at an estimated recurrence risk of ≥30%. Our study evaluates and compares risk factors for recurrence for cervical SCC compared with adenocarcinoma (AC) and develops histology-specific nomograms to estimate risk of recurrence and guide adjuvant treatment.

METHODS

We performed an ancillary analysis of GOG 49, 92, and 141, and included stage I patients who were surgically managed and received no neoadjuvant/adjuvant therapy. Multivariable Cox proportional hazards models were used to evaluate independent risk factors for recurrence by histology and to generate prognostic histology-specific nomograms for 3-year recurrence risk.

RESULTS

We identified 715 patients with SCC and 105 with AC; 20% with SCC and 17% with AC recurred. For SCC, lymphvascular space invasion (LVSI: HR 1.58, CI 1.12-2.22), tumor size (TS ≥4 cm: HR 2.67, CI 1.67-4.29), and depth of invasion (DOI; middle 1/3, HR 4.31, CI 1.81-10.26; deep 1/3, HR 7.05, CI 2.99-16.64) were associated with recurrence. For AC, only TS ≥4 cm, was associated with recurrence (HR 4.69, CI 1.25-17.63). For both histologies, there was an interaction effect between TS and LVSI. For those with SCC, DOI was most associated with recurrence (16% risk); for AC, TS conferred a 15% risk with negative LVSI versus a 25% risk with positive LVSI.

CONCLUSIONS

Current treatment standards are based on the Sedlis criteria, specifically derived from data on SCC. However, risk factors for recurrence differ for squamous cell and adenocarcinoma of the cervix. Histology-specific nomograms accurately and linearly represent risk of recurrence for both SCC and AC tumors and may provide a more contemporary and tailored tool for clinicians to base adjuvant treatment recommendations to their patients with cervical cancer.

Preoperative Circulating Lymphocyte and Monocyte Counts Correlate with Patient Outcomes in Type I and Type II Endometrial Cancer

Tumor-associated macrophages and tumor-infiltrating lymphocytes are associated with survival in solid malignancies. Given the physiological link to peripheral immune cell counts, we evaluated if peripheral immune cell counts were predictors of outcomes in endometrial cancer. A retrospective study was completed for endometrial cancer cases between 2000 and 2010. Kaplan-Meier, bivariate, and multivariable Cox proportion hazard analyses were performed examining the relations between survival and peripheral immune cell counts. Three hundred ten patients were identified. In bivariate analyses, high monocyte counts (> 0.7 × 10⁹ cells/L) trended with decreased progression free survival (PFS) (p = 0.10) and poorer overall survival (OS) (p = 0.16). By contrast, high lymphocyte level (> 1.5 × 10⁹ cells/L) was associated with improved PFS (p = 0.008) and OS (p = 0.006). These findings were consistent for type I and type II endometrial cancers. In a multivariable Cox model, high monocyte level was associated with a greater risk of disease recurrence (hazard ratio (HR) = 1.63, p < 0.035). Other significant predictors of recurrence were age, non-endometrioid histology, and the presence of lymph vascular space invasion (LVSI). In a multivariable Cox model, high lymphocyte count trended with a lower risk of death (HR = 0.66, p = 0.07). Age, surgical stage, non-endometrioid histology, and LVSI were also associated with death in this model. In this sample of endometrial cancer patients, we found that high preoperative lymphocyte counts were associated with improved overall improved survival. High monocyte counts were associated with poorer disease-free survival outcomes. Further studies that focused on understanding tumor-antagonizing and pro-tumoral effects of lymphocytes and monocytes, respectively, in endometrial cancer are recommended.

Serum Calcium and Serum Albumin Are Biomarkers That Can Discriminate Malignant from Benign Pelvic Masses

BACKGROUND

Biomarkers that aid in the differential diagnosis of malignant pelvic masses from benign ones prior to surgery are needed in order to triage women with malignant masses to appropriate specialist care. Because high albumin-adjusted serum calcium predicted ovarian cancer among women without evidence of disease, we hypothesized that it might predict cancer among women with pelvic masses that were evident radiographically.

METHODS

We studied a cohort of 514 women with pelvic masses who underwent resection at Wake Forest University Baptist Medical Center from July 2009 through June 2013. We divided patients into a "training" set, to identify associations in the data, and a "testing" set, to confirm them. Data were obtained from medical records. A best fit model was selected using the Akaike Information Criterion.

RESULTS

Albumin-adjusted serum calcium was significantly higher in women with malignant versus benign masses (P = 0.0004). High normocalcemia, i.e., an albumin-adjusted serum calcium ≥ 10 mg/dL, occurred in 53% of women with malignant tumors versus 12% of benign tumors. High normocalcemia was associated with an approximately 14-fold increased risk of malignancy. The best fit model (Overa) included albumin, calcium, and nonlinear terms. Overa achieved an area under the curve of 0.83 with a sensitivity of 72% and specificity of 83%, a positive predictive value of 71% and a negative predictive value of 85%.

CONCLUSIONS

A model using serum calcium and serum albumin to predict malignancy in women with pelvic masses has high sensitivity and is economical.

IMPACT

Our model can help triage women with ovarian cancer to appropriate surgical care.

Xanthogranulomatous Oophoritis Presenting as an Adnexal Mass and Bowel Obstruction. A Case Report

BACKGROUND

Xanthogranulomatous inflammation of the female genital tract is a rare entity. When the gynecological organs are affected, it is particularly unusual for xanthogranulomataus inflammation to involve only the ovary.

CASE

A 45-year-old woman with an intrauterine device, long-term exposure to nicotine, and hyperlipidemia presented with an adnexal mass and bowel obstruction. She underwent 2 exploratory laparotomies, ureteral stent placement, left salpingooophorectomy, and rectosigmoid resection with end colostomy. Pathology revealed xanthogranulomatous oophoritis without involvement of the associated fallopian tube.

CONCLUSION

The synergistic effects of intrauterine device use, abnormal lipid levels, and long-term nicotine exposure may have contributed to the development of this patient's condition. Knowledge of xanthogranulomatous inflammation is essential to avoid misdiagnosis of malignancy and excessive surgical intervention.

Abstract 1090: Type 2 endometrial cancer is associated with an M1 subtype, tumor associated macrophage polarization in the stromal compartment

Objectives: The more aggressive behavior of type 2 than type 1 endometrial cancers may be due to differences in their tumor microenvironments. In other solid cancers, tumor associated macrophages (TAMs) play a pivotal role in orchestrating the microenvironment. TAMs differentially polarize into M1 or M2 macrophages with distinct cytokine secretion patterns and actions. The aim of our work is to characterize the density, subtype and distribution of TAMs in endometrial hyperplasia and cancer.

Methods: Five patients with complex atypical hyperplasia (hyperplasia), 5 patients with grade 1, non-invasive endometrioid adenocarcinoma (type 1) and 5 patients with uterine papillary serous carcinoma (type 2) were included. Formalin-fixed, paraffin-embedded sections from each specimen were stained with anti-CD68 and anti-CD163 monoclonal antibodies as markers for total TAMs and M2 TAMs, respectively. M1 macrophages were estimated by subtraction of CD163+ from CD68+ densities. Macrophages were counted at 40x magnification in 10 fields per slide by 4 observers. Repeated measure models, accounting for intra- and inter-observer correlation were contstructed and the compound symmetry covariance method was used to determine the relationship between macrophages and cancer. To establish an in vitro model, immortalized histiocytic lymphoma (U937) cells were differentiated to macrophages and treated with LPS to induce a M1 phenotype. Supernatants were applied to Cytokine C1000 microarray (RayBiotech) to screen for differentially expressed cytokines.

Results: The correlation between the 4 observers was robust (r=0.71). Most TAMs were located in the stromal (mean=41.0/field) compared to epithelial (mean=11.0) or luminal (mean=11.6) compartments (p&lt;0.0001). The mean total TAM density was highest in patients with type 2 cancers (mean=90.1/field), followed by type 1 cancers (mean=51.4) and hyperplasias (mean=41.1, p&lt;0.0001). The calculated density of M1 macrophages was higher in type 2 cancers (mean=71.7) compared to type 1 cancers (mean =36.4, p&lt;0.0001). This difference was only observed in the stromal compartment (p&lt;0.0001). In the in vitro M1 macrophage model, ENA-78, a neutrophil chemo-attractant, and IL-6 were expressed at the highest concentrations.

Conclusions: Type 2 cancers have nearly twice the TAM density of type 1 cancers. This difference is due to M1 macrophage predominance in the stroma of type 2 cancers. We postulate that cytokines produced by M1 TAMs within the tumor stroma contribute to the aggressive biology of these cancers. Future experiments will determine how well the in vitro model mimics M1 TAMs in the tumor microenvironment.

Citation Format: Michael G. Kelly, Antonio M.C. Francisco, Adela Cimic, Anne Wofford, Nora Fitzgerald, Jie Yu, Robert N. Taylor. Type 2 endometrial cancer is associated with an M1 subtype, tumor associated macrophage polarization in the stromal compartment. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 1090. doi:10.1158/1538-7445.AM2014-1090

Intercalibrating classifications of ecological status: Europe's quest for common management objectives for aquatic ecosystems

Halting and reversing the deterioration of aquatic ecosystems requires concerted action across state boundaries and administrative barriers. However, the achievement of common management objectives is jeopardised by different national quality targets and ambitions. The European Water Framework Directive requires that quality classifications are harmonised via an intercalibration exercise, ensuring a consistent level of ambition in the protection and restoration of surface water bodies across the Member States of the European Union. We outline the key principles of the intercalibration methodology, review the achievements of intercalibration and discuss its benefits and drawbacks. Less than half of the required intercalibration has been completed, mostly due to a lack of national assessment methods. The process has fostered a scientific debate on ecological classification with important implications for environmental management. Despite a significant level of statistical abstraction, intercalibration yielded a fundamental and unified vision of what constitutes good ecology across Europe, in principle ensuring greater parity in the funds invested to achieve good ecological status.

Large cell neuroendocrine carcinoma of the cervix: prognostic factors and survival advantage with platinum chemotherapy

OBJECTIVE

Large cell neuroendocrine carcinoma of the cervix (LCNEC) is a rare cervical neoplasm associated with poor survival. Our objective was to identify treatments associated with improved survival.

METHODS

Relevant data were abstracted from an English literature MEDLINE search, SEER database, and a patient treated at our institution. Multivariate analysis was performed by generating Cox proportional hazard ratios.

RESULTS

We identified 62 patients with LCNEC: 49 cases from the English literature, 12 patients in the SEER database and our patient. Out of the 62 women, median age was 37 (range, 21-75). FIGO stage was as follows: 58% had stage I disease, 16% had stage II, 2% had stage III, 8% had stage IV disease and 16% had no stage documented. Of all patients, 73% underwent primary surgery, 4.7% underwent primary radiation, 4.7% underwent chemotherapy, 8% had chemoradiation, and 9.6% had no primary treatment. Of all patients, 58% died of disease, 26% had no evidence of disease, 3% were alive with disease, and 13% had no survival data. The overall median survival was 16.5 months (0.5-151 months). Median overall survival for stage I, II, III, and IV cancers was 19, 17, 3, and 1.5 months, respectively. In a multivariate analysis, earlier stage (p<0.00001) and the addition of chemotherapy (p=0.04) were associated with improved survival. Both platinum agents (p=0.034) and platinum and etoposide together (p=0.027) were associated with improved survival.

CONCLUSIONS

Perioperative chemotherapy, in particular platinum with or without etoposide, improves survival in the rare LCNEC.

The discovery of an orally efficacious positive allosteric modulator of the calcium sensing receptor containing a dibenzylamine core

The discovery of a series of novel and orally efficacious type II calcimimetics, developed from the lead compound 1, is described herein. Compound 22 suppressed plasma PTH levels relative to vehicle when dosed orally in a rat pharmacodynamic model.

Oxime derivatives related to AP18: Agonists and antagonists of the TRPA1 receptor

AP18 1 was recently disclosed as an antagonist of the TRPA1 receptor by the research group of Patapoutian. However, no detailed structure-activity relationships around 1 have been disclosed. Thus, a small number of oximes related to AP18 were examined in order to characterize the determinants of TRPA1 activity. Congeners of AP18 were found to possess both agonist and antagonist activity, suggesting that AP18 may behave as a covalent antagonist of the TRPA1 ion-channel.

Quality of life and inflammation in exacerbations of bronchiectasis

Patients with bronchiectasis often have impaired quality of life (QoL), which deteriorates with exacerbations. The aim of this study was to investigate changes in QoL and how these were influenced by changes in airway physiology and inflammation in patients with bronchiectasis before and after resolution of an exacerbation. Sputum induction and a QoL questionnaire were undertaken on the first day, day 14, and 4 weeks after completion of intravenous antibiotics (day 42). Eighteen patients (12 female) were recruited, median (IQ range) age of 54 (47–60) years. There was a trend towards an improvement in lung function from visit 1 to visit 2, but this was not statistically significant. C-reactive protein (CRP) [mean (SEM)] reduced between visit 1 and visit 2 [55.4 (21.5) vs 9.4 (3.1) mg/L, P = 0.03] but did not increase significantly on visit 3 [44.4 (32.9) mg/L, P = 0.27]. The median (interquartile range) sputum cell count (×106 cells/g of sputum) decreased from visit 1 to visit 2 [21.6 (11.8–37.6)–13.3 (6.7–22.9) × 106 cells/g, respectively, P = 0.008] and increased from visit 2 to visit 3 [26.3 (14.1–33.6) × 106 cells/g, P = 0.03]. All soluble markers of inflammation significantly reduced from visit 1 to visit 2 but increased on visit 3 with the exception of TNF-α. Regarding QoL, three of the four domains (dyspnoea, emotional, mastery) significantly improved from visit 1 to visit 2 but did not change between visit 2 and visit 3. The improvements in QoL scores could not be explained by the improvements in lung function or inflammatory markers.

Regulation of IKKbeta by miR-199a affects NF-kappaB activity in ovarian cancer cells

Cancer progression is an abnormal form of tissue repair characterized by chronic inflammation. IkappaB kinase-beta (IKKbeta) required for nuclear factor-kappaB (NF-kappaB) activation plays a critical role in this process. Using EOC cells isolated from malignant ovarian cancer ascites and solid tumors, we identified IKKbeta as a major factor promoting a functional TLR-MyD88-NF-kappaB pathway that confers to EOC cell the capacity to constitutively secrete proinflammatory/protumor cytokines and therefore promoting tumor progression and chemoresistance. Furthermore, we describe for the first time the identification of the microRNA hsa-miR-199a as a regulator of IKKbeta expression. Our study describes the property of ovarian cancer cells to enhance the inflammatory microenvironment as a result of the expression of an active IKKbeta pathway. Identification of these markers in patients' tumor samples may facilitate the adequate selection of treatment and open new venues for the development of effective therapy for chemoresistant ovarian cancers.

Carcinosarcoma of the ovary

The objective of this study was to evaluate the treatment and outcome in patients with ovarian carcinosarcoma. The Tumor Board Registry was reviewed for patients with ovarian carcinosarcoma treated at our institution from June 1993 to December 2004. The medical records were retrospectively analyzed with emphasis on cytoreduction, cytotoxic regimens, progression-free interval, and survival. Twenty-two patients were identified. All but two presented with advanced stage disease. The median survival for the entire cohort was 38 months. Median survival was 46 months for 18 optimally debulked (<1 cm) patients and 27 months for four suboptimally debulked (>1 cm) patients. Six patients were treated with optimal cytoreduction and adjuvant cisplatin (40 mg/m(2)x 1 day) and ifosfamide (1200 mg/m(2)/day x 4 days) every 28 days. Median progression-free interval in the cisplatin and ifosfamide group was 13 months, and median survival was 51 months. The combination of carboplatin (AUC 5) and taxol (175 mg/m(2)) every 21 days was administered to four patients as first-line chemotherapy following optimal cytoreduction. In the carboplatin and taxol group, median progression-free interval was 6 months and median survival was 38 months. The difference in survival between the cisplatin and ifosfamide group and the carboplatin and taxol group was not statistically significant (P= 0.48). In conclusion, patients with ovarian carcinosarcoma usually present with advanced stage disease. Treatment consists of optimal cytoreduction and chemotherapy. The most effective cytotoxic regimen remains to be determined. First-line cisplatin and ifosfamide or carboplatin and taxol can achieve survival rates observed in epithelial ovarian cancer.

Neoadjuvant chemotherapy lessens surgical morbidity in advanced ovarian cancer and leads to improved survival in stage IV disease

OBJECTIVES

To compare the survival and peri-operative morbidities of patients with advanced epithelial ovarian cancer (EOC, stage IIIC and IV) who were treated with primary debulking surgery (PDS) followed by adjuvant platinum-based chemotherapy, or neoadjuvant chemotherapy followed by cytoreductive surgery (NAC).

METHODS

172 patients with advanced EOC diagnosed at YNHH (1998-2005) were retrospectively reviewed. 109 patients were treated with PDS and 63 patients were treated with NAC [37 received carboplatin/paclitaxel (CP), 26 received carboplatin/cyclophosphamide (CC)].

RESULTS

NAC patients had significantly less intra-operative blood loss, operating time, units of transfusion, and shorter hospital stay (p<0.05). Optimal cytoreduction was achieved in 95% NAC patients, versus 71% of PDS group (p<0.001). Three patients in the NAC group (5%) versus 27 patients (25%) in the PDS group required aggressive surgery in addition to standard cytoreduction. Within the NAC group, overall survival (OS) is improved in patients who received CP compared to CC (83 vs. 26 months, p=0.008). Patients with extra-abdominal disease who received CP as NAC had improved progression-free survival (PFS) and OS when compared to the PDS group with stage IV disease (15 vs. 9 months, p=0.015; 31 vs. 20 months, p=0.032, respectively).

CONCLUSION

This study demonstrates that NAC is associated with less peri-operative morbidity, less need for further aggressive surgery, and similar survival. Additionally, in patients with extra-abdominal disease, NAC is associated with an improved PFS and OS. Therapy with platinum and taxane should be the treatment of choice in NAC.

Inflammatory bowel disease and the lung: is there a link between surgery and bronchiectasis?

PURPOSE

One-third of patients with inflammatory bowel disease (IBD) has extracolonic manifestations. Inflammatory bowel-associated pulmonary disease is one of the less commonly recognized and more recently described manifestations. Here, we report the experience of our patients with inflammatory bowel-associated bronchiectasis.

METHODS

A retrospective analysis of case notes of patients with IBD and respiratory manifestations was undertaken. Relevant demographic, clinical, radiological, and pulmonary physiology laboratory results were reviewed.

RESULTS

Ten patients with IBD and bronchiectasis were identified. Eight developed respiratory symptoms after surgery for IBD. Five of the ten had ulcerative colitis. Their lung function abnormality is mild to moderate in severity. Small airways disease (forced expiratory flow between 25-75% is <50%) was evident in seven of the ten patients.

CONCLUSIONS

This preliminary study supports an association between surgery for IBD and development of symptomatic lung disease, particularly bronchiectasis, in susceptible patients. The pulmonary manifestations of IBD in some patients may only become clinically significant after surgery and the withdrawal of medical treatment.

Atypical presentations of carboplatin hypersensitivity reactions: Characterization and management in patients with gynecologic malignancies

OBJECTIVES

Carboplatin skin testing (ST) can help identify patients with platinum hypersensitivity (PH), however, we have encountered patients who do not immediately test positive yet exhibit subtle or delayed allergy symptoms prior to PH. We describe the "atypical platinum reactions" (APH) of 14 patients and our experience with skin testing and desensitization.

METHODS

Retrospective chart review was performed on carboplatin-treated patients. Patients with +ST, PH or APH were offered desensitization, and the number of successful additional treatments was recorded.

RESULTS

A total of 73 ST were administered to patients receiving their >6th carboplatin cycle. 19 +ST and 10 PH with -ST were identified. 14 APH were identified including delayed +ST conversions and allergy symptoms. The median onset and duration of symptoms after treatment were 6 and 3.5 days respectively. 12 APH patients had ST on their next cycle, seven of which were immediately positive. ST was positive in 36% of those tested, resulting in a negative predictive value of 76%. The median number of carboplatin cycles received prior to ST conversion, PH or APH was eight. 29% of patients with a +ST, PH, or APH had a prior history of systemic allergic reaction to other medications or allergens. Desensitization and dose escalation were successful in 14/20 patients (70%) for an average of 1.9 cycles/patient.

CONCLUSIONS

ST will not identify all patients with carboplatin-associated reactions. Careful questioning regarding symptoms in between chemotherapeutic cycles may identify patients who will benefit from desensitization, allowing continuation of treatment and prevention of life-threatening adverse events.

TLR-4 signaling promotes tumor growth and paclitaxel chemoresistance in ovarian cancer

Evidence suggests that an inflammatory profile of cytokines and chemokines persisting at a particular site would lead to the development of a chronic disease. Recent studies implicate bacterial infection as one possible link between inflammation and carcinogenesis; however, the crucial molecular pathways involved remain unknown. We hypothesized that one possible upstream signaling pathway leading to inflammation in carcinogenesis may be mediated by Toll-like receptors (TLR). We describe for the first time an adaptive mechanism acquired by ovarian cancer cells that allows them to promote a proinflammatory environment and develop chemoresistance. We propose that the TLR-4-MyD88 signaling pathway may be a risk factor for developing cancer and may represent a novel target for the development of biomodulators. Our work explains how bacterial products, such as lipopolysaccharide, can promote, directly from the tumor, the production of proinflammatory cytokines and the enhancement of tumor survival. In addition, we provide new evidence that links TLR-4 signaling, inflammation, and chemoresistance in ovarian cancer cells.

Malignant Transformation of Myomas: Myth or Reality?

The possibility that a fibroid may actually be a smooth muscle tumor of uncertain malignant potential or a leiomyosarcoma often dictates the clinical management of rapidly growing fibroids. This article provides a clinicopathologic background regarding uterine leiomyosarcomas and answers common questions that obstetricians and gynecologists have about the management of rapidly growing fibroids and leiomyosarcoma. The clinician must be aware that the infrequent occurrence of uterine leiomyosarcomas makes it difficult to establish absolutely firm recommendations for the diagnosis and management of this disease, particularly with regard to fertility preservation. Nevertheless, this article addresses major issues that a clinician might face in the evaluation of a smooth muscle tumor of the uterus that clinically may be malignant.

Improved survival in surgical stage I patients with uterine papillary serous carcinoma (UPSC) treated with adjuvant platinum-based chemotherapy

OBJECTIVE

Uterine papillary serous carcinoma (UPSC) is an aggressive form of endometrial cancer characterized by a high recurrence rate and a poor prognosis. Prior studies evaluating treatment of UPSC have been limited by small numbers of patients and inclusion of partially staged patients. The purpose of this study was to evaluate the efficacy of adjuvant platinum-based chemotherapy and vaginal cuff radiation in a large cohort of surgical stage I UPSC patients.

METHODS

We retrospectively reviewed 74 stage I patients with UPSC who underwent complete surgical staging at our institution between 1987 and 2004.

RESULTS

Stage IA patients were divided into two groups: patients with no cancer in the hysterectomy specimen (defined as no residual uterine disease) and patients with cancer in the hysterectomy specimen (defined as residual uterine disease). Stage IA patients with no residual uterine disease had no recurrences, regardless of adjuvant therapy (n = 12). Stage IA patients with residual uterine disease who were treated with platinum-based chemotherapy had no recurrences (n = 7). However, 6 of 14 (43%) stage IA patients with residual uterine disease who did not receive chemotherapy recurred. The 15 patients with stage IB UPSC who received platinum-based chemotherapy had no recurrences but 10 of the 13 (77%) stage IB patients who did not receive chemotherapy recurred. One of the 7 patients with stage IC UPSC who received platinum-based chemotherapy recurred and 4 of the 5 (80%) stage IC patients who did not receive chemotherapy recurred. Overall platinum-based chemotherapy was associated with improved disease-free survival (P < 0.01) and improved overall survival (P < 0.05) in patients with stage I UPSC. None of the 43 patients who received radiation to the vaginal cuff recurred locally, but 6 of the 31 (19%) patients who were not treated with vaginal radiation recurred at the cuff.

CONCLUSIONS

Platinum-based chemotherapy improves the disease-free and overall survival of patients with stage I UPSC and vaginal cuff radiation provides local control. Stage IA UPSC patients with no residual uterine disease can be observed but concomitant platinum-based chemotherapy and vaginal cuff radiation (referred to as chemoradiation) should be offered to all other stage I UPSC patients.

Synthesis and biological evaluation of benzodioxanylpiperazine derivatives as potent serotonin 5-HT(1A) antagonists: the discovery of Lecozotan

A series of benzodioxanylpiperazine derivatives possessing a 4-aryl amide substituent was prepared and evaluated for 5-HT(1A) affinity and functional antagonist activity in vitro and in vivo. All of the compounds in this series possessed high affinity for the human 5-HT(1A) receptor and many displayed potent antagonist activity in vitro and varying degrees of intrinsic activity in vivo. Compound 11c (Lecozotan) was selected for further development and is currently in clinical trials.

Melanocortin subtype-4 receptor agonists containing a piperazine core with substituted aryl sulfonamides

The biological activity for a set of melanocortin-4 receptor (MC4R) agonists containing a piperazine core with an ortho-substituted aryl sulfonamide is described. Compounds from this set had binding and functional activities at MC4R less than 30 nM. The most selective compound in this series was >25,000-fold more potent at MC4R than MC3R, and 490-fold more potent at MC4R than MC5R. This compound also reduced food intake after oral dosing at 25, 50, and 100 mg kg(-1) in fasted mice.

Discovery of Potent, Orally Available Vanilloid Receptor-1 Antagonists. Structure−Activity Relationship of N-Aryl Cinnamides

The vanilloid receptor-1 (TRPV1 or VR1) is a member of the transient receptor potential (TRP) family of ion channels and plays a role in regulating the function of sensory nerves. A growing body of evidence demonstrates the therapeutic potential of TRPV1 modulators, particularly in the management of pain. As a result of our screening efforts, we identified (E)-3-(4-tert-butylphenyl)-N-(2,3-dihydrobenzo[b][1,4]dioxin-6-yl)acrylamide (1), an antagonist that blocks the capsaicin-induced and pH-induced uptake of (45)Ca(2+) in TRPV1-expressing Chinese hamster ovary cells with IC(50) values of 17 +/- 5 and 150 +/- 80 nM, respectively. In this report, we describe the synthesis and structure-activity relationship of a series of N-aryl cinnamides, the most potent of which (49a and 49b) exhibit good oral bioavailability in rats (F(oral) = 39% and 17%, respectively).

Patients with uterine papillary serous cancers may benefit from adjuvant platinum-based chemoradiation

OBJECTIVE

The coexistence of minimal uterine disease and extrauterine metastases is common in patients with uterine papillary serous carcinoma (UPSC). Only complete surgical staging accurately depicts the extent of this disease. The purpose of this study was to evaluate different therapeutic options in surgically staged patients.

METHODS

We retrospectively reviewed all patients with UPSC histologically limited in the uterus to the endometrium treated at our institution between 1987 and 2002.

RESULTS

Twenty-three (45%) cases were International Federation of Gynecology and Obstetrics (FIGO) stage IA, seven (15%) were stage IIIA, one (2%) was stage IIIC, and nine (18%) stage IV. Additionally, 11 of these 51 patients (21%) were diagnosed with two cancers: a stage IA UPSC and concomitant advanced stage serous cancer of the ovary, fallopian tube, or peritoneum. Stage IA patients with no cancer in the hysterectomy specimen (defined as no residual uterine disease) had no recurrences (n = 10) regardless of treatment. There was a trend toward increased survival in stage IA patients with residual uterine disease who were treated with chemoradiation (concomitant vaginal brachytherapy and platinum-based chemotherapy). There were no recurrences in patients with locoregional disease (stages IA-IIIA) who received chemoradiation. All patients with advanced stage UPSC (stage IIIC or IV or two primary cancers) did poorly regardless of treatment.

CONCLUSION

Our findings suggest that stage IA patients with no residual uterine disease may be observed. Stage IA patients with residual uterine disease may benefit from chemoradiation. More effective treatment needs to be identified for advanced stage UPSC.

Synthesis of novel melanocortin 4 receptor agonists and antagonists containing a succinamide core

A novel series of piperazines appended to a succinamide backbone were synthesized and found to have a high affinity for the melanocortin-4 receptor (IC(50)s ranging from <0.1 to 200 nM). Both agonists and antagonists of MC4R were prepared by modifying the groups attached to the right-hand side of the succinamide. This series also exhibits a high level of selectivity (up to 7000-fold) over mouse MC1R and human MC3R.

Design of a new peptidomimetic agonist for the melanocortin receptors based on the solution structure of the peptide ligand, Ac-Nle-cyclo[Asp-Pro-DPhe-Arg-Trp-Lys]-NH(2)

The solution structure of a potent melanocortin receptor agonist, Ac-Nle-cyclo[Asp-Pro-DPhe-Arg-Trp-Lys]-NH(2) (1) was calculated using distance restraints determined from 1H NMR spectroscopy. Eight of the lowest energy conformations from this study were used to identify non-peptide cores that mimic the spatial arrangement of the critical tripeptide region, DPhe-Arg-Trp, found in 1. From these studies, compound 2a, containing the cis-cyclohexyl core, was identified as a functional agonist of the melanocortin-4 receptor (MC4R) with an IC(50) and EC(50) below 10 nM. Compound 2a also showed 36- and 7-fold selectivity over MC3R and MC1R, respectively, in the binding assays. Subtle changes in cyclohexane stereochemistry and removal of functional groups led to analogues with lower affinity for the MC receptors.

Structure-activity relationship of (1-aryl-2-piperazinylethyl)piperazines: antagonists for the AGRP/melanocortin receptor binding

Agouti-related protein (AGRP) is an endogenous antagonist of the melanocortin action.(1) In the hypothalamus, melanocortin peptide agonists act as satiety-inducing factors that mediate their action through the melanocortin-4 receptor (MC4R) whereas AGRP is an opposing orexigenic agent. Novel inhibitors of the AGRP/MC4 binding based on (piperazinylethyl)piperazines were prepared, and their structure-activity relationship was established.

Pseudodextrocardia in bronchiectasis

Bronchiectasis is a chronic inflammatory pulmonary disorder characterized by chronic productive cough, recurrent bronchial sepsis and haemoptysis, with airflow obstruction and progressive tissue destruction. Kartagener's syndrome, associated with dysfunctional cilia, sinusitis and situs inversus, is a rare cause of bronchiectasis (Marwah and Sharman, 1995). This article reports two cases where patients had been erroneously diagnosed as having Kartagener's syndrome based on misinterpretations of chest radiographs.

Admissions with chronic obstructive pulmonary disease after publication of national guidelines

BACKGROUND

The British Thoracic Society (BTS) published guidelines on managing acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in 1997.

AIM

To audit admissions with AECOPD and to see how well these guidelines were adhered to. Methods All patients admitted were identified and 50 selected for audit.

RESULTS

The mean age was 72 years and 52% were female. Admission C reactive protein (CRP) and white cell count (WCC) were 49 (12.7) mg/l and 10.97 (0.64) x 10(9)/l respectively. Six were acidotic and 16 hypercapnoeic. Median length of stay (LOS) was six days. Twenty-one fulfilled admission criteria. Thirty-seven had > or = 2 Anthonisen criteria. Nine had spirometry performed. Correlations were seen between appropriateness of admission score and pH (r=-0.41, p=0.01) and LOS (r=-0.43, p=0.002) and between Anthonisen criteria score and age (r=0.33, p=0.018). Symptom score correlated with PaO2 (r=-0.38, p=0.02), LOS (r=0.27, p=0.06) and age (r=0.38, p=0.007). LOS correlated with PaCO2 (r=0.33, p=0.04).

CONCLUSION

Admissions are chiefly comprised of an ill, elderly population. Careful adherence to guidelines could result in fewer admissions.

Use of similarity measures for quality control of benthic diatom samples

A method for evaluating the similarity of replicate benthic diatom samples based on the Bray-Curtis similarity measure is described. This technique may be useful as part of quality control procedures where objective performance measures are required. Levels of similarity > 60% typically indicate good agreement between the primary analyst and auditor. However, an evaluation of 57 comparisons indicated that achievable levels of similarity were dependent upon the species diversity of the sample, with samples with high species diversity typically having lower levels of similarity than samples with low species diversity. Whilst a threshold value of 60% is adequate for most samples, a stiffer threshold of 70% should be applied to samples with very low levels of diversity.

1,2,5-Thiadiazole derivatives are potent and selective ligands at human 5-HT1A receptors

Amino acid derivatives of 1,2,5-thiadiazol-3-yl-piperazine related to (+)-WAY-100135 and WAY-100635 are potent 5-HT1A receptor agonists and antagonists, which have selective affinity for 5-HT1A receptors versus alpha1 and dopamine (D2, D3, and D4) receptors.