ARTS mediates apoptosis and regeneration of the intestinal stem cell niche

Stem cells (SCs) play a pivotal role in fueling homeostasis and regeneration. While much focus has been given to self-renewal and differentiation pathways regulating SC fate, little is known regarding the specific mechanisms utilized for their elimination. Here, we report that the pro-apoptotic protein ARTS (a Septin4 isoform) is highly expressed in cells comprising the intestinal SC niche and that its deletion protects Lgr5⁺ and Paneth cells from undergoing apoptotic cell death. As a result, the Sept4/ARTS^−/− crypt displays augmented proliferation and, in culture, generates massive cystic-like organoids due to enhanced Wnt/β-catenin signaling. Importantly, Sept4/ARTS^−/− mice exhibit resistance against intestinal damage in a manner dependent upon Lgr5⁺ SCs. Finally, we show that ARTS interacts with XIAP in intestinal crypt cells and that deletion of XIAP can abrogate Sept4/ARTS^−/−-dependent phenotypes. Our results indicate that intestinal SCs utilize specific apoptotic proteins for their elimination, representing a unique target for regenerative medicine.

The mechanisms regulating intestinal stem cell elimination remain unclear. Here, the authors identify that the pro-apoptotic protein ARTS (a Septin4 isoform) interacts with XIAP in the intestinal stem cell niche to  regulate stem cell survival during intestinal homeostasis and regeneration.

Short Androgen Suppression and Radiation Dose Escalation for Intermediate- and High-Risk Localized Prostate Cancer: Results of EORTC Trial 22991

Purpose

Up to 30% of patients who undergo radiation for intermediate- or high-risk localized prostate cancer relapse biochemically within 5 years. We assessed if biochemical disease-free survival (DFS) is improved by adding 6 months of androgen suppression (AS; two injections of every-3-months depot of luteinizing hormone–releasing hormone agonist) to primary radiotherapy (RT) for intermediate- or high-risk localized prostate cancer.

Patients and Methods

A total of 819 patients staged: (1) cT1b-c, with prostate-specific antigen (PSA) ≥ 10 ng/mL or Gleason ≥ 7, or (2) cT2a (International Union Against Cancer TNM 1997), with no involvement of pelvic lymph nodes and no clinical evidence of metastatic spread, with PSA ≤ 50 ng/mL, were centrally randomized 1:1 to either RT or RT plus AS started on day 1 of RT. Centers opted for one dose (70, 74, or 78 Gy). Biochemical DFS, the primary end point, was defined from entry until PSA relapse (Phoenix criteria) and clinical relapse by imaging or death of any cause. The trial had 80% power to detect hazard ratio (HR), 0.714 by intent-to-treat analysis stratified by dose of RT at the two-sided α = 5%.

Results

The median patient age was 70 years. Among patients, 74.8% were intermediate risk and 24.8% were high risk. In the RT arm, 407 of 409 patients received RT; in the RT plus AS arm, 403 patients received RT plus AS and three patients received RT only. At 7.2 years median follow-up, RT plus AS significantly improved biochemical DFS (HR, 0.52; 95% CI, 0.41 to 0.66; P < .001, with 319 events), as well as clinical progression-free survival (205 events, HR, 0.63; 95% CI, 0.48 to 0.84; P = .001). In exploratory analysis, no statistically significant interaction between treatment effect and dose of RT could be evidenced (heterogeneity P = .79 and P = .66, for biochemical DFS and progression-free survival, respectively). Overall survival data are not mature yet.

Conclusion

Six months of concomitant and adjuvant AS improves biochemical and clinical DFS of intermediate- and high-risk cT1b-c to cT2a (with no involvement of pelvic lymph nodes and no clinical evidence of metastatic spread) prostatic carcinoma, treated by radiation.

Radiotherapy for Stage IIA seminoma: The Northern Israel Oncology Center Experience, 1971-2010

AIM

To evaluate treatment details, outcome, relapse rate and side-effects in Stage IIA seminoma irradiated and followed for a period of 39 years.

BACKGROUND

Seminoma is a very radiosensitive disease and radiation therapy alone is able to achieve long-term disease-free survival, even in advanced Stage disease. Due to the lack of long-term prospective studies, it is of value to follow patients and try to determine the appropriate volume to be irradiated and the dose which can achieve total cure with minimal acute and chronic side-effects.

PATIENTS AND METHODS

A retrospective review of 24 Stage IIA seminoma patients irradiated between 1971 and 2010 was performed. All patients underwent orchiectomy and meticulous clinical, biochemical and radiological staging.

RESULTS

Median age at diagnosis was 36 years and median follow-up was 84 months. A majority of patients received the "hockey-stick" irradiation schedule (para-aortic lymph nodes and hemi-pelvis) to a total dose of 2250-2500 cGy and a boost to radiologically involved nodes of 500-1000 cGy. Treatment was well-tolerated. Twenty-one (88%) patients are alive with no evidence of disease. Two patients died due to unknown causes, while one patient died due to head of the pancreas carcinoma, most probably radiation-induced.

CONCLUSIONS

In Stage II seminoma, radiotherapy can provide excellent results with low rates of toxicity. Reduction of total dose and size of fields without affecting the good results should be considered. Due to prolonged survival, awareness of second primary tumor is indicated.

Spermatocytic variant of classic seminoma: a report of five cases and a brief review of the literature

BACKGROUND

Spermatocytic seminoma is a rare testicular malignancy, appearing in the adult population. It has a good prognosis and a low rate of metastatic potential.

OBJECTIVES

We present five cases diagnosed and treated with radiotherapy at Rambam Health Care Campus in Haifa, Israel.

METHODS

Between 1974 and 1996, five patients with stage I spermatocytic seminoma were referred post-orchiectomy to the Northern Israel Oncology Center. All five patients presented with the typical pathological features of the spermatocytic variant of classic seminoma, and all were staged clinically and radiologically.

RESULTS

Mean age at diagnosis was 44 years (range 30-58 years). Main symptoms included a palpable testicular mass and/or testicular enlargement. Mean duration of symptoms was 9 months (range 0.5-24 months). Three patients were irradiated to the para-aortic/ipsilateral iliacal lymph nodes (mean total dose 2,500 cGy), one patient with 4,000 cGy. One patient was irradiated to the bilateral iliacal lymph nodes (2,600 cGy). With a median follow-up of 15 years, four patients are alive with no evidence of disease or severe late side effects. One patient developed severe lymphedema and symptomatic peripheral vascular disease, stage IIA prostate carcinoma (hormonal and brachytherapy treatment) and a non-secretory hypophyseal adenoma (surgically removed); he died at the age of 75 due to severe peripheral vascular and coronary heart disease with no evidence of his first or second primaries.

CONCLUSIONS

Prognosis is excellent and does not differ from classic seminoma. As in the accumulated experience in early-stage, low-risk classic seminoma, we suggest surveillance as the preferred policy.

Tolerance of the vaginal vault to high-dose rate brachytherapy and concomitant chemo-pelvic irradiation: Long-term perspective

AIM/BACKGROUND

We sought to determine the tolerance level and complication rates of the vaginal vault to combined high-dose-rate intra-cavitary brachytherapy with concomitant chemo-radiotherapy.

PATIENTS AND METHODS

A retrospective review of medical records of all the patients who received definitive chemo-radiotherapy for cervical cancer between 1998 and 2002 was undertaken. The records were reviewed for doses and for radiation-associated early and late sequelae of the vagina, rectum and bladder. Cumulative biological effective dose was calculated for two reference vaginal surface points.

RESULTS

Fifty patients were included. Average age at diagnosis was 54 years. Median follow-up was 59 months. There were no recorded instances of acute grade IV toxicity. Maximal high-dose-rate vaginal surface dose (upper central point) was 103 Gy, and maximal brachytherapy lateral surface dose was 70 Gy. Maximal cumulative biological effective dose for the lateral surface reference point was 465.5 Gy3, and the maximal cumulative biological effective dose for the superior reference point was 878.6 Gy3. There were no cases of vaginal necrosis or fistulas, and no cases of grade IV late vaginal, rectal or bladder toxicity. No correlation was found between the maximal vaginal surface dose and vaginal, rectal or bladder toxicity.

CONCLUSIONS

The maximal surface HDR brachytherapy dose of 103 Gy and the maximal cBED of 878.6 Gy3 were not associated with fistula or necrosis or other grade 3-4 vaginal complications. Concomitant chemo-radiotherapy, including pelvic radiotherapy and high-dose-rate intracavitary brachytherapy, is relatively safe for cervical cancer patients.

Platinum-based Chemotherapy in Primary Advanced Seminoma-a Retrospective Analysis: Treatment Results at the Northern Israel Oncology Center (1989-2010)

OBJECTIVE

Over the past 30 years, great strides have been made in the treatment of disseminated testicular tumors. Despite the low number of patients and the rarity of studies concerning primary advanced seminoma, the efficacy of chemotherapy is clear, mainly 3-4-cisplatin-based chemotherapy. Aiming to contribute to the understanding and implementation of proper chemotherapeutic management in advanced seminoma patients, we retrospectively summarized our experience with 26 patients who were referred for platinum-based chemotherapy, post-orchiectomy to the Northern Israel Oncology Center between 1989 and 2010. Response rate, side effects, and long-term outcome were investigated.

METHODS

Before chemotherapy, meticulous staging was done, including tumor markers (B-human chorionic gonadotropin (B-HCG), alpha-fetoprotein (AFP), and lactic dehydrogenase (LDH)), and abdominal and pelvic computerized tomography (CT) scans were carried out.

RESULTS

All 26 treated patients achieved complete remission, clinically and symptomatically, with normalization of their CT scans. At a median follow-up of 120 months (range, 24-268 months) all patients are alive, without evidence of recurrent disease. One patient whose disease recurred twice achieved a third complete remission following salvage treatment with high-dose chemotherapy and autologous peripheral stem cell transplantation. Another patient, who preferred surveillance, relapsed abdominally after 9 months but achieved long-standing complete remission with cisplatin-based chemotherapy. Both these patients are alive with no evidence of disease. Three patients recovered uneventfully from bleomycin-induced pneumonitis.

CONCLUSIONS

Advanced seminoma is a highly curable disease using platinum-based chemotherapy. Our study confirms the efficacy and safety of cisplatin-based chemotherapy in the treatment of advanced seminoma.

Anaplastic variant of classical seminoma of the testis: northern Israel oncology center experience and brief review of literature

OBJECTIVES

There are only sporadic reports on the clinical behavior and appropriate treatment of anaplastic seminoma. This retrospective study summarizes our experience with the anaplastic variant of classical (typical) seminoma.

METHODS

Between 1986 and 2006, seven anaplastic seminoma patients were staged and treated at the Northern Israel Oncology Center. Staging procedures included meticulous physical and neurological examinations, complete blood count, full biochemistry profile, specific tumor markers, testicular ultrasound, and other radiological measures. All patients underwent inguinal orchiectomy and were staged properly. Six patients had stage I disease, and one patient had stage IIA disease. Patients were irradiated with doses ranging from 2,500 to 3,000 cGy, and the stage IIA patient received an additional 1,000 cGy boost to radiographically involved lymph nodes.

RESULTS

After a mean follow-up of 11 years, six patients are alive with no evidence of disease. One patient died due to an unknown, non-oncological, cause, unrelated to his previous testicular tumor, while in complete remission.

CONCLUSIONS

Despite the low patient numbers and the retrospective nature of our study, it can be concluded that radiotherapy treatment for early-stage anaplastic seminoma patients might achieve the same excellent survival as for classical seminoma. However, the general consensus achieved through large-scale studies suggests that active surveillance should be offered to all stage I seminoma patients, regardless of the pathologic variant.

Hippocampal-sparing whole-brain radiotherapy using Elekta equipment

The purpose of this study was to evaluate the feasibility of hippocampal‐sparing whole‐brain radiotherapy (HS WBRT) using the Elekta Infinity linear accelerator and Monaco treatment planning system (TPS). Ten treatment plans were created for HS‐WBRT to a dose of 30 Gy (10 fractions). RTOG 0933 recommendations were applied for treatment planning. Intensity‐modulated radiotherapy (IMRT) plans for the Elekta Infinity linear accelerator were created using Monaco 3.1 TPS‐based on a nine‐field arrangement and step‐and‐shoot delivery method. Plan evaluation was performed using D2% and D98% for the whole‐brain PTV (defined as whole brain excluding hippocampus avoidance region), D100% and maximum dose to the hippocampus, and maximum dose to optic nerves and chiasm. Homogeneity index (HI) defined as (D2%−D98%)/Dmedian was used to quantify dose homogeneity in the PTV. The whole‐brain PTV D2% mean value was 37.28 Gy (range 36.95–37.49 Gy), and D98% mean value was 25.37 Gy (range 25.40–25.89 Gy). The hippocampus D100% mean value was 8.37 Gy (range 7.48–8.97 Gy) and the hippocampus maximum dose mean value was 14.35 Gy (range 13.48–15.40 Gy). The maximum dose to optic nerves and optic chiasm for all patients did not exceed 37.50 Gy. HI mean value was 0.36 (range 0.34–0.37). Mean number of segments was 105 (range 88–122) and mean number of monitor units was 1724 (range 1622–1914). Gamma evaluation showed that all plans passed 3%, 3 mm criteria with more than 99% of the measured points. These results indicate that Elekta equipment (Elekta Infinity linac and Monaco TPS) can be used for HS WBRT planning according to compliance criteria defined by the RTOG 0933 protocol.

PACS numbers: 87.55D, 87.55 –v, 87.55 de

Primary signet-ring cell adenocarcinoma of the uterine cervix: case report and review of the literature

Signet-ring cell adenocarcinoma is a rare subtype of the uterine cervix; thus there are no guidelines and the prognosis is unknown. There seems to be a significant role for reporting the treatment and outcome of this rare disease in order to establish guidelines and to assist in decision-making. However, treatment should be tailored to each patient according to clinical status and disease stage. Excluding extra-genital origin is mandatory, as it will change treatment management considerably.

Effect of Chinese herbal therapy on breast cancer adenocarcinoma cell lines

Despite the widespread use of medicinal herbs to prevent and treat many diseases, including cancer, there are insufficient scientific data on the safety and efficacy of the majority of herbal therapies. The aim of this study was to assess the effect of a unique Chinese herbal therapy (CHT) from controlled manufactured concentrated powders, on an in vitro model of breast cancer. Three breast adenocarcinoma cell lines (MDA-231, MDA-453, T47D) were exposed to CHT for 72 h. Cell viability was assessed by XTT (sodium 3'-[1-(phenylaminocarbonyl)-3, 4-tetra zolium]-bis(4-methoxy-6-nitro) benzene sulphonic acid hydrate) assay. Apoptosis and cell cycle stage were determined by fluorescence-activated cell sorting (FACS) analysis. CHT decreased cell survival in a dose-dependent manner in all tested cell lines. FACS analysis of treated and non-treated T47D cells demonstrated that the inhibitory effect of CHT was associated with an increase in apoptosis. A randomized clinical trial is currently underway to investigate CHT as supplementary therapy for breast cancer patients receiving chemotherapy.

Nuclear and Cytoplasmic Expression of ErbB-4 in Prostate Cancer

Purpose

To evaluate cytoplasmic and nuclear ErbB-4 expression in prostate cancer specimens and its association with outcome.

Basic procedures

Specimens of 50 prostate cancer patients were investigated for ErbB-4 overexpression using immunohistochemistry staining. Cytoplasmic and nuclear staining was graded as 0–3 according to its intensity. The prognostic parameters were tumor stage, PSA level, Gleason score, probability of positive lymph nodes (Partin's tables and Roach equation), and 5-year disease free survival (Kattan nomogram).

Main findings

Overexpression of ErbB-4 (≥1) was detected in 30 (60%) patients and overexpression using cytoplasmic and nuclear staining was ≥2 in 19 (38%) and 17 (34%) patients, respectively. In only one third of the specimens was there any similarity between the 2 types of staining. Advanced tumor stage, high pretreatment PSA levels and high Gleason scores were evenly distributed among the patients with low (≤1) and intermediate/high (≥2) ErbB-4 expression. The probability of lymph node involvement and 5-year disease free survival were similar in both types of staining.

Principal conclusions

ErbB-4 was overexpressed (cytoplasmic and nuclear staining) in approximately one third of prostate cancer patients. The rate of similarity between the 2 staining types was only 33%: overexpression was evenly distributed among intermediate/high and low risk prostate cancer patients with both staining methods.

ErbB1–4 expression in prostate cancer patients and its correlation to patients’ ethnicity and outcome

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Background: ErbB family is involved in both cancer progression and treatment response in solid tumors. Few inconclusive studies reported on ErbB over-expression in prostate cancer. We investigated ErbB1–4 expression in prostate cancer patients and its correlation to patients ethnicity and outcome. Methods: ErbB expression was evaluated by immunohistochemistry of prostate cancer specimen using polyclonal antibody (Santa Cruz, CA). The staining was recorded as negative (0/+1), moderately positive (+2) and highly positive (+3). Kattan nomogram was used to predict 5-yr progression-free probability, assuming that all patients received external beam radiation therapy (a total dose of 78 Gy) and hormonal manipulation. Origin was counted in all 43 patients: Ashkenazic patients were defined as those who immigrated from East/West Europe or North America and Sephardic patients - from Middle East and North Africa. Results: ErbB1 (+2/+3) was over-expressed in 12 and 7 patients for a total of 19/43 (44%). ErbB2 over-expression (+2/+3) was not found in all patients. ErbB3 over-expression of +2 was seen in 2 patients and none had +3 (2/43, 5%). ErbB4 over-expression (+2/+3) was seen in 5 and 11 patients for a total of 16/43 (37%). 22 patients were Ashkenazic and 21 - Sephardic. ErbB1 over-expression in Ashkenazic and Sephardic groups was 9/22 (41%) and 10/21 (48%). ErbB4 over-expression in the two groups was 7/22 (32%) and 9/21 (43%). Kattan score of <80 was seen in 20/43 and <60 in 7/43 patients. ErbB1 over-expression was noted in 11/20 and in 4/7 patients. ErbB4 over-expression was seen in 7/20 and in 4/7 patients. In both ErbB1 and ErbB4 over-expression and Kattan nomogram of <80 and <60 the Sephardic ethnicity dominated-7/11 (64%), 3/4 (75%), 5/7 (71%) and 3/4 (75%). Conclusions: ErbB1 and ErbB4 over-expression is presented in 43% and 37% patients while ErbB3 was over-expressed in 5%; no over-expression of ErbB2 was observed. Ashkenazic and Sephardic ethnicity were evenly distributed in the over-expressed ErbB1 and ErbB4 patients. However, a tendency to a worse prognosis, based on Kattan nomogram, was seen in over-expressed ErbB1 and ErbB4 patients from Sephardic ethnicity. Further studies on ethnicity and ErbB prevalence and prognosis are warranted.

No significant financial relationships to disclose.

Curcumin synergistically potentiates the growth inhibitory and pro-apoptotic effects of celecoxib in pancreatic adenocarcinoma cells

BACKGROUND AND AIM

Adenocarcinoma of the Pancreas is a leading cause of cancer-related mortality, accounting for an estimated 30,000 deaths per year in the United States. Multiple studies have indicated that specific cyclooxygenase-2 (COX-2) inhibitors may serve in the prevention and treatment of a variety of malignancies including pancreatic adenocarcinoma. Recent studies had shown that the long-term use of high concentration of COX-2 inhibitors is not toxic free and may be limited due to serious gastrointestinal and cardiovascular side effects. The chemopreventive efficacy of the phytochemical, curcumin has been demonstrated in several in vitro and animal models. In this study we investigated whether curcumin potentiates the growth inhibition effect of a COX-2 inhibitor (celecoxib, Pfizer, NY, USA) in human pancreatic cancer cells.

METHODS

P-34 (expressing high levels of COX-2), and MIAPaCa (expressing low levels of COX-2) and Panc-1 (no expression of COX-2) evaluated cell lines were exposed to different concentrations of celecoxib (0-40 microM), curcumin (0-20 microM) and their combination. Cell viability was by XTT assay. Apoptosis was assessed by flow cytometry and COX-2 expression was measured by Western blotting analysis.

RESULTS

In P-34 cells, curcumin synergistically potentiated the inhibitory effect of celecoxib on cell growth. The growth inhibition was associated with inhibition of proliferation and induction of apoptosis. Western blot analysis showed that COX-2 expression was down-regulated by the combination therapy.

CONCLUSION

Curcumin synergistically augments the growth inhibition inserted by celecoxib in pancreatic cancer cells expressing COX-2. The synergistic effect was mediated through inhibition of COX-2. This may enable the use of celecoxib at lower and safer concentrations and may pave the way for a more effective treatment in this devastating disease.

Establishment and Characterization of a Pancreatic Carcinoma Cell Line Derived from Malignant Pleural Effusion

BACKGROUND/AIMS

A novel cell line, designated p34, was developed from the malignant pleural effusion of a patient with carcinoma of pancreas. The objective of this work was to characterize this cell line.

METHOD

The in vitro studies included karyotype analysis, immunohistochemistry, XTT cell proliferation assay, analysis of the cell cycle by FACS and cell sensitivity to chemotherapeutic drugs and irradiation. Subcutaneous and intra-spleen inoculations into nude mice were carried out to study the tumorigenicity and the metastatic tendency of this cell line.

RESULTS

The p34 cell line showed typical morphological characteristics of epithelial pancreatic tumor cells. The cells were hyperdiploid with a modal number of 48, and had two markers, deletion in the short arm of chromosome 2 and duplication of the short arm of chromosome 8. The doubling time was 16 h. Subcutaneous inoculation of the cells into nude mice yielded 100% tumorigenicity, and intra-spleen inoculation resulted in extensive intra-abdominal spread. The antiproliferative effect of chemotherapy (gemcitabine, cisplatin, taxol and vinorelbine), chemopreventive agents (celecoxib and curcumin) and radiotherapy showed dose-dependent cytotoxicity.

CONCLUSIONS

This p34 cell line can be used as a new model for studying various aspects of the biology of human pancreatic cancer and potential treatment approaches for the disease.

Correlation of toxicity with pharmacokinetics of pegylated liposomal doxorubicin (Doxil) in metastatic breast carcinoma

BACKGROUND

Doxil (ALZA Corp., Mountain View, CA) is a formulation of doxorubicin in polyethylene-glycol coated liposomes with a prolonged circulation time and unique toxicity profile. As yet, the effect of the dose schedule on toxicity and the correlation of toxicity with pharmacokinetics have not been directly addressed.

METHODS

The objectives of this study were to examine the toxicity profile and pharmacokinetics of various dose schedules of Doxil in a group of patients with metastatic breast carcinoma (MBC) previously treated with chemotherapy. Forty-five patients received a total of 268 courses of Doxil (median per patient, 5; range, 1-19). Six dose schedules were investigated: 35 mg/m2 every 3 weeks (11 patients), 45 mg/m(2) every 3 weeks (5 patients), 50 mg/m(2) every 4 weeks (5 patients), 60 mg/m(2) every 4 weeks (6 patients), 65 mg/m(2) every 5 weeks (6 patients), and 70 mg/m(2) every 6 weeks (12 patients). Doxil pharmacokinetics was examined in 24 of these patients at the dose levels of 35, 45, 60, and 70 mg/m(2).

RESULTS

Stomatitis was dose related, with higher incidence and severity at doses of 60-70 mg/m(2). Skin toxicity in the form of palmar-plantar erythrodysesthesia (PPE) developed usually after two or more courses of treatment and was schedule dependent with shorter dosing intervals leading to increased frequency and severity of skin manifestations. Myelosuppression, mainly as leukopenia/neutropenia, was dose dependent but mild and uncomplicated in most cases. Hair loss was infrequent (< 7%) and always of limited extent. Despite high cumulative doses up to 1500 mg/m(2), cardiac toxicity was observed in only 1 patient who received prior mitoxantrone and mediastinal radiotherapy. Objective responses, improvements, and durable stabilizations were observed in 9, 6, and 14 patients, respectively, indicating significant antitumor activity of Doxil in previously treated MBC patients. Doxil pharmacokinetics was well described by a monoexponential elimination curve with a long T(1/2) (median, 79 hours), a slow clearance (median, 40 mL/hour), and a small volume of distribution (median, 3.9 L). Cmax (peak plasma concentration) and AUC (area under the concentration*time curve) increased linearly with dose with a statistically significant correlation. Correlation analysis of dose and pharmacokinetic parameters with Doxil toxicites revealed that stomatitis grade and leukocyte nadir were correlated strongly with dose and Cmax, and weakly with AUC, whereas PPE grade was correlated significantly with only 1 parameter, T(1/2).

CONCLUSIONS

The toxicity of Doxil is dose and schedule dependent and well correlated with pharmacokinetic parameters. Pharmacokinetic guidance of Doxil dosing may be a useful tool.

Continuous interleukin-2 infusion combined with cyclophosphamide- based combination chemotherapy in the treatment of hemato-oncological malignancies. Results of a phase I-II study

The combination of a cyclophosphamide (CTX)-based chemotherapy regimen and interleukin-2 (IL-2) has been shown to provide synergistic effects against malignancy in animal models. We therefore conducted a phase I-II trial combining CTX-based combination chemotherapy or CTX alone with high-dose IL-2 in patients with advanced and refractory malignant disease. Fifteen patients with hemato-oncological malignancies (malignant lymphoma 8, multiple myeloma 3, solid tumor 2, leukemia 2) were enrolled in the study. Continuous high-dose IL-2 infusion was shown to be safely administered, starting as soon as recovery of white blood cell count. All patients developed rebound lymphocytosis 24-48 h after termination of IL-2 infusion. Although grade IV toxicity was observed in 5 patients (7 episodes), all side effects completely subsided. Triple chemotherapy (CTX, etoposide and Ara-C) seemed rather toxic (in this group of heavily treated patients) while CTX alone was well tolerated. Four out of 13 (31%) evaluable patients had partial response and another patient (7%) had stabilization of disease progression lasting 2-8 months. Our conclusion is that the combination of CTX and continuous infusion of IL-2 is feasible and should be investigated in patients with various malignant neoplasms.

[Evolving role of radiation therapy in nonmalignant disorders]

Various nonmalignant disorders have traditionally been treated with radiation therapy. It has almost completely been discontinued due to reports of secondary malignancy. During the past 15 years there has been an evolving role for radiation therapy in various nonmalignant disorders such as meningioma, A-V malformation, prevention of vascular restenosis and heterotopic bone formation. Appropriate follow-up of such patients for diagnosis of secondary malignancy is recommended. Radiation therapy should be carefully considered in diseases not successfully treated with conventional means.

Should soybean agglutinin purging be performed in breast cancer patients undergoing autologous stem cell transplantation? A retrospective analysis of 48 patients

High-dose chemotherapy (HDC) followed by autologous stem cell transplantation (ASCT) has gained an increasing role in the treatment of high-risk Stage II-III and/or metastatic breast cancer patients. Several investigators reported on a high rate of tumor cells contaminating the bone marrow and peripheral blood stem cell collection. Nevertheless, the clinical implication of reinfusion of tumor cells with the stem cells to the relapse rate is still uncertain. In this retrospective analysis we compare the outcome and the toxicity of 29 patients with high-risk Stage II-III and 19 metastatic breast cancer patients who underwent HDC with ASCT. Thirteen patients underwent transplant with soybean agglutinin (SBA)-purged graft, while 35 consecutive patients received unmanipulated graft. Engraftment was significantly faster for the nonpurged transplant. No differences in disease-free survival, freedom from relapse, or overall survival were noted in both groups during a median follow up time of 14 months. We conclude that tumor cell purging using SBA in breast cancer patients is not warranted. New purging methods are needed to assess the role of tumor cell purging in breast cancer patients.

Mucosal melanoma following autologous stem cell transplantation for non-Hodgkin's lymphoma (NHL)

The incidence of secondary malignancy following autologous stem cell transplantation (ASCT) is increasing. We describe a patient with stage IVB Hodgkin's disease who developed primary amelanotic malignant melanoma of the tongue 18 months following autologous stem cell transplantation. She was treated by partial glossectomy and supra-omohyoid neck dissection followed by cytokine-mediated immunotherapy. Malignant melanoma of the skin is a frequent secondary solid tumor seen in patients undergoing stem cell transplantation. However, mucosal melanoma which is rare by itself (0.2-8%) has never been reported in NHL patients following ASCT. Early diagnosis and initiation of combined local and systemic treatments including immuno-therapy may improve the outcome of this rare but lethal complication.

Direct clinical comparison of ultrasound and radiative electromagnetic hyperthermia applicators in the same tumours

Hyperthermia in conjunction with radiation therapy is a promising method for the treatment of superficially or eccentrically located recurrent or advanced primary malignant tumours. The external hyperthermia applicators most commonly used are radiative electromagnetic (including microwave) or ultrasound devices. Each type of device has its own limitations. The aim was to evaluate the temperature distributions obtained as well as the acute and subacute toxicities in patients that were treated with both radiative radiative electromagnetic and ultrasound applicators to the same tumours. Thirty-nine patients treated to 41 hyperthermia fields for a total of 197 hyperthermia treatments were analysed. Thermal parameter include mean, Tmax, mean Tave, mean Tmin, T50, T90, %T > 43.5 degrees C and %T < 41 degrees C. Acute toxicities including pain in field, referred pain, blister/ulceration, positional discomfort and subacute toxicities (occurring with 24 h of treatment) were determined for each type of hyperthermia applicator. Although there were increased acute toxicities (in-field or referred pain) associated with the ultrasound treatments no significant differences between the two methods of heating were observed in temperature distributions or subacute toxicities. We conclude that there is no generally preferred method of heating superficially or eccentrically located tumours and the type of applicator should be selected on a tumour-size and site-specific basis.

Treatment of early-stage gastric lymphoma

The treatment of early-stage gastric lymphoma is controversial. This retrospective analysis reports on the outcome of 24 patients treated in our institution during the past 25 years. Fourteen patients had stage IEA, one patient had IEB, six patients IIEA1, and three patients had stage IIEA2 non-Hodgkin's lymphoma (NHL). Diffuse large cell intermediate-grade NHL was diagnosed in 17 patients, diffuse small cleaved cell in three patients, and diffuse mixed large and small cell lymphosarcoma, low-grade B-cell lymphoma, and unclassified lymphoma in one patient each. Fourteen patients underwent surgery, 21 had radiation therapy (XRT), and 10 patients received chemotherapy. Surgery + XRT were given to 7 patients, surgery + XRT + chemo and XRT alone were delivered to five patients each, and XRT + chemotherapy were employed in four patients. Surgery alone was the initial treatment in two patients and chemotherapy alone was given to one patient. Following treatment 22/24 achieved a complete response. During a mean follow-up period of 77.6 months (range 1-285), five patients relapsed. At 10 years, the actuarial survival of the 15 patients with stage I disease was 57.4% and for stage II it was 51.9% (Gehan P-value 0.33). Freedom from relapse (FFR) was 60.7% and 58.3%, respectively (P-value 0.56). No significant statistical differences in terms of survival and FFR were noted in patients treated with surgery, chemotherapy, or XRT. The outcome of patients treated with triple-modality therapy was similar to those treated with double-modality therapy and to patients treated with XRT alone. Gender, age, presenting symptoms, depth of tumor through the gastric wall, and stage were not statistically significant for prediction of either survival or FFR. Both surgery + XRT and chemotherapy + XRT are effective in the treatment of early-stage gastric disease. XRT alone is equally effective as two or three modality treatments in the subset of patients with early-stage gastric lymphoma. However, the low number of patients treated with various approaches over a long period precludes a firm conclusion. Until prospective randomized studies are initiated, management programs should be individually tailored.

Radiation Therapy in Epidemic, Aids-Related Kaposi's Sarcoma in Southern Africa

Aims and background

Acquired Immunodeficiency Syndrome (AIDS) associated Kaposi's Sarcoma (EKS) is widely spread in the Southern African Region. No large studies concerning the role of radiation therapy in the Southern African variant of EKS have been reported to date.

Methods

Over a 10 year period (1982-1992) 25 patients with EKS (disseminated skin involvement) were treated primarily with radiation therapy at the Johannesburg General Hospital. Radiation fields were individually tailored to the extent of the disease. Total administered doses ranged between 8-12 Gy (single fraction) to 24-30 Gy fractionated over 2-3 weeks.

Results

Overall response and symptomatic relief rates were 72% and 80%, respectively. Toxicity was mild and manageable.

Conclusions

Our retrospective analysis supports the use of radiation therapy for the Southern African type of EKS.

Thermometry of interstitial hyperthermia given as an adjuvant to brachytherapy for the treatment of carcinoma of the prostate

PURPOSE

Recurrence in the prostatic gland remains a significant problem in the management of locally advanced prostatic cancer. Transperineal thermobrachytherapy has been utilized in an attempt to improve local tumor control. The purpose of this study was to quantitate the temperature distributions obtained in carcinoma of the prostate treated with interstitial radiofrequency-induced hyperthermia given in conjunction with 192Ir brachytherapy in a Phase I study.

METHODS AND MATERIALS

From 1987 until 1992, 36 patients (5 with locally recurrent, 15 with Stage B, and 16 Stage C prostate cancers) were treated with interstitial brachytherapy implants supplemented with radiofrequency-induced hyperthermia. An array of 7-32 stainless steel trocar electrodes (outer diameter = 1.5 mm, interelectrode spacing = 8 mm) were implanted into the prostate gland through a perineal approach utilizing a specially designed template. Each trocar was electrically insulated along the length which traversed surrounding normal tissues. One to three additional plastic catheters were implanted for automated temperature mapping. Thirty-four of these procedures were performed following lymph node sampling. However, the last two removable interstitial hyperthermic prostate implants were done by the transperineal route under ultrasound guidance. A hyperthermia treatment (goal of 43 degrees C for 45 minutes) was given immediately prior to the insertion and immediately following the removal of the 192Ir. A computer-controlled radiofrequency-based generator (freq. 0.5 MHz) implementing electrode multiplexing was used to induce and maintain elevated temperatures.

RESULTS

Transient local pain was the most common treatment limiting factor. The average values of the measured minimum, mean, and maximum temperatures were 38.9 degrees C, 41.9 degrees C, and 45.7 degrees C in tumor, and 37.7 degrees C, 39.8 degrees C, and 42.9 degrees C in surrounding normal tissue, respectively. The percentages of mapped temperatures exceeding 41 degrees C, 42 degrees C, and 43 degrees C were 67%, 46%, and 27% in tumor, and 26%, 11%, and 4% in normal surrounding tissue, respectively.

CONCLUSION

From this study we conclude that heterogeneous temperature distributions were induced in the prostate; significant normal tissue protection was realized in part through the selective insulation of sections of each electrode; and interstitial radiofrequency-induced hyperthermia of the prostate is feasible and well tolerated, with further technical developments warranted.

Prognostic factors in metastatic malignant melanoma treated with combined radiation therapy and hyperthermia

From May 1981 to September 1991, 38 patients with metastatic malignant melanoma were treated with combined radiation therapy and hyperthermia to a total of 97 hyperthermia treatment fields. Prior treatments to these sites included surgery (31 patients, 76 fields), chemotherapy (18 patients, 54 fields), immunotherapy (14 patients, 42 fields) and radiation therapy (7 patients, 13 hyperthermia fields). Hyperthermia was given to fields located in the head and neck region, trunk and extremities in 30, 45 and 22 cases, respectively. Nodular-diffuse tumours were present in 86 fields while 11 fields were treated for microscopic residual tumour deposits. Concurrent radiation therapy was given in 180-400 cGy per fraction, 2-5 times per week for a mean total dose of 4098 cGy per field. Hyperthermia treatments were delivered using either microwave or ultrasound devices (286 and 48 treatments, respectively) with a mean (range) of 3.4 (1-14) hyperthermia treatments per field for a mean (range) of 43 (10-70) min per field. Patients (n = 34; 84 fields) were available for follow-up for a mean (range) of 14.6 (0.4-82.5) months. At 3 weeks post-treatment, 34 fields had complete, ongoing, or partial responses; 39 fields had no response; and there were no recurrences in the 11 fields treated for microscopic residual disease. Local control was maintained in 31% (26/84) fields with a mean follow-up of 14.6 months. At 36 months, five patients remained alive with complete control of their treated local disease. Statistical analyses revealed that patients with soft tissue metastases only, who were older at the time of hyperthermia, had a longer time between initial diagnosis and hyperthermia treatment, received a higher dose of radiation, had no previous chemotherapy, and had small tumour volumes, had a higher initial response. Multivariate analyses revealed that the three-covariate model including time interval between initial diagnosis and hyperthermia treatment, previous chemotherapy, and metastases to soft tissue only, best predicted response. The results of the investigation support the continued study of combined radiation therapy and hyperthermia treatments for selected patients with metastatic melanoma, and indicate that long-term survival can occasionally be obtained with this approach.

Stanford 3D hyperthermia treatment planning system. Technical review and clinical summary

In the field of deep regional hyperthermia cancer therapy the Sigma 60 applicator of the BSD-2000 Hyperthermia System is one of the most widely used devices. This device employs four independent sources of radiofrequency electromagnetic energy to heat tumour sites deep within the body. The difficulty in determining the input parameters for the four sources has motivated the development of a computer-based three-dimensional (3D) treatment planning system. The Stanford 3D Hyperthermia Treatment Planning System has been in clinical use at Stanford Medical Center for the past 2 years. It utilizes a patient-specific, three-dimensional computer simulation to determine safe and effective power deposition plans. An optimization programme for the selection of the amplitudes, phases and frequency for the sources has been developed and used in the clinic. Examples of the application of the treatment planning for hyperthermia treatment of pulmonary, pelvic, and mediastinal tumours are presented. Methods for quantifying the relative effectiveness of various treatment plans are reviewed.

Persistent and/or late complications of combined radiation therapy and hyperthermia

Persistent and/or late complications were analysed in 64 patients (183 fields) that were treated with combined hyperthermia and radiation therapy for advanced, recurrent or metastatic cancer. The incidence and type of complications were evaluated over a minimum follow-up period of 2 years from the onset of treatment (mean 38.7 months; range 24-82.5 months). The primary malignancies included: breast (39), melanomas (6), adenoid cystic carcinomas of salivary glands (4), prostate (4), soft tissue sarcomas (3), squamous cell carcinoma of head and neck (3), lymphomas (3), transitional cell carcinoma of bladder (1) and basal cell carcinoma of the skin (1). The persistent complications noted included induration and fibrosis (39 hyperthermia fields, 22 patients), ulceration at the site of prior tumour (three patients, three fields), and ulceration in normal tissue (one patient, one field). Brachial plexopathy developed in one patient treated for recurrent breast cancer, but she had active disease at that time. A squamous cell carcinoma of the skin developed within the treatment field in a breast cancer patient. Radionecrosis of the mandible was seen in one patient treated for a floor of the mouth cancer, and osteomyelitis with septic arthritis developed in one patient treated for a soft tissue sarcoma of the thigh. Univariate logistic regression analyses of pretreatment and radiation-hyperthermia treatment parameters revealed that maximal tumour temperature had a borderline significant correlation with the development of complications (p = 0.07). Multivariate analyses of the pretreatment and treatment parameters revealed the best-two-covariate model to predict complications included mean maximal tumour temperature and tumour type (macroscopic tumours had greater incidence of complications than for microscopic residual disease). The rate and type of persistent and/or late complications seen following combined radiation and hyperthermia did not appear to dramatically differ from those that would be anticipated from irradiation alone in this patient population, with the exception of an increased incidence of areas of induration and tumour necrosis.

Cancer metastatic to the penis: treatment with hyperthermia and radiation therapy and review of the literature

Metastatic cancer to the penis is rare, its optimum treatment remains poorly defined and the outcome of patients with such metastases is poor. Hyperthermia in conjunction with radiation therapy has been shown to be an effective modality in the treatment of locally advanced or recurrent cancer and hyperthermia alone is under evaluation in treating benign disorders, such as hypertrophy of the prostate. Recently, 4 patients with symptomatic metastatic lesions to the penis (3 had primary prostatic cancer and 1 had rectal cancer) were treated with radiation therapy and hyperthermia. Treatment was well tolerated except for pain during hyperthermia, which limited the temperatures that could be obtained. All of the patients improved symptomatically, 1 achieved a complete response and 2 had partial responses. No significant complications were noted. Symptomatic control was maintained in all patients for the duration of their survival. This limited series suggests the possible role of local hyperthermia as an adjunct to radiation therapy in the treatment of metastases to the penis.

Peripheral neuropathy and myonecrosis following hyperthermia and radiation therapy for recurrent prostatic cancer: correlation of damage with predicted SAR pattern

During the past 10 years, numerous phase I-II studies were conducted and provided clinical experience with combined radiation therapy and hyperthermia treatments. Among the rare complications reported in these combined radiation therapy-hyperthermia trials were myonecrosis and peripheral neuropathy which were felt, mainly on a clinical basis, to be caused by local heat damage. Recently, such complications were noted in two patients with recurrent prostatic cancer treated in our department with radiation therapy combined with deep regional hyperthermia delivered by the Sigma-60 applicator of the BSD 2000 hyperthermia system (Salt Lake City, UT, USA). Analysis of the results of three-dimensional modelling of the SAR (specific absorption rate, W/kg) pattern in these patients indicated high SAR at the sites of the complications. Pretreatment three-dimensional modelling or other methods of predicting potential areas of high power deposition may have a role for future hyperthermia treatment planning aiding in the prevention of possible local heat damage and providing improved delivery of heat to the target volume.