A new tidal breathing measurement device detects bronchial obstruction during methacholine challenge test

PURPOSE

Bronchial hyperresponsiveness (BHR), a hallmark of bronchial asthma, is typically diagnosed through a methacholine inhalation test followed by spirometry, known as the methacholine challenge test (MCT). While spirometry relies on proper patients' cooperation and precise execution of forced breathing maneuvers, we conducted a comparative analysis with the portable nanomaterial-based sensing device, SenseGuard™, to non-intrusively assess tidal breathing parameters.

MATERIALS AND METHODS

In this prospective study, 37 adult participants with suspected asthma underwent sequential spirometry and SenseGuard™ measurements after inhaling increasing methacholine doses.

RESULTS

Among the 37 participants, 18 were MCT responders, 17 were non-responders and 2 were excluded due to uninterpretable data. The MCT responders exhibited a significant lung function difference when comparing the change from baseline to maximum response. This was evident through a notable decrease in forced expiratory volume in 1 ​s (FEV1) levels in spirometry, as well as in prominent changes in tidal breathing parameters as assessed by SenseGuard™, including the expiratory pause time (Trest) to total breath time (Ttot) ratio, and the expiratory time (Tex) to Ttot ratio. Notably, the ratios Trest/Ttot (∗p ​= ​0.02), Tex/Ttot (∗p ​= ​0.002), and inspiratory time (Tin) to Tex (∗p ​= ​0.04) identified MCT responders distinctly, corresponding to spirometry (∗p ​< ​0.0001).

CONCLUSIONS

This study demonstrates that tidal breathing assessment using SenseGuard™ device reliably detects clinically relevant changes of respiratory parameter during the MCT. It effectively distinguishes between responders and non-responders, with strong agreement to conventional spirometry-measured FEV1. This technology holds promise for monitoring clinical respiratory changes in bronchial asthma patients pending further studies.

Changes in tidal breathing biomarkers as indicators of treatment response in AECOPD patients in an acute care setting

PURPOSE

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a complication of COPD that typically necessitates intensified treatment and hospitalization. It is linked to higher morbidity, mortality and healthcare spending. Assessment of therapy response for AECOPD is difficult due to the variability of symptoms and limitations in current measures. Hence, there is a need for new biomarkers to aid in the management of AECOPD in acute care settings.

MATERIALS AND METHODS

Fifteen hospitalized AECOPD patients (GOLD 3-4) were enrolled in this study. Treatment response was assessed daily through clinical evaluations and by monitoring tidal breathing biomarkers (respiratory rate [RR], expiratory time [Tex], inspiratory time [Tin], expiratory pause [Trst], total breath time [Ttot]), using a novel, wearable nanosensor-based device (SenseGuard™).

RESULTS

Patients who showed significant clinical improvement had substantial changes in ΔTex/Ttot (+14%), ΔTrst/Ttot (-18%), and ΔTin/Tex (+0.09), whereas patients who showed mild or no clinical improvement had smaller changes (+5%, +3%, and -0.03, respectively). Linear regression between change in physician's assessment score and the median change in tidal breathing parameters was significant for Tin/Tex (R2 ​= ​0.449, ∗p ​= ​0.017), Tex/Ttot (R2 ​= ​0.556, ∗p ​= ​0.005) and Trst/Ttot (R2 ​= ​0.446, ∗p ​= ​0.018), while no significant regression was observed for RR, Tin/(Trst ​+ ​Tex) and Tin/Ttot.

CONCLUSIONS

Our study demonstrates the potential of the SenseGuard™ to monitor treatment response in AECOPD patients by measuring changes in tidal breathing biomarkers, which were shown to be associated with significant changes in the patients' respiratory condition as evaluated by physicians. However, further large-scale clinical studies are needed to confirm these findings.

Clinical Scores, Biomarkers and IT Tools in Lung Cancer Screening-Can an Integrated Approach Overcome Current Challenges?

As most lung cancer (LC) cases are still detected at advanced and incurable stages, there are increasing efforts to foster detection at earlier stages by low dose computed tomography (LDCT) based LC screening. In this scoping review, we describe current advances in candidate selection for screening (selection phase), technical aspects (screening), and probability evaluation of malignancy of CT-detected pulmonary nodules (PN management). Literature was non-systematically assessed and reviewed for suitability by the authors. For the selection phase, we describe current eligibility criteria for screening, along with their limitations and potential refinements through advanced clinical scores and biomarker assessments. For LC screening, we discuss how the accuracy of computerized tomography (CT) scan reading might be augmented by IT tools, helping radiologists to cope with increasing workloads. For PN management, we evaluate the precision of follow-up scans by semi-automatic volume measurements of CT-detected PN. Moreover, we present an integrative approach to evaluate the probability of PN malignancy to enable safe decisions on further management. As a clear limitation, additional validation studies are required for most innovative diagnostic approaches presented in this article, but the integration of clinical risk models, current imaging techniques, and advancing biomarker research has the potential to improve the LC screening performance generally.

Improved guideline adherence in oncology through clinical decision-support systems: still hindered by current health IT infrastructures?

PURPOSE OF REVIEW

Despite several efforts to enhance guideline adherence in cancer management, the rate of adherence remains often dissatisfactory in clinical routine. Clinical decision-support systems (CDSS) have been developed to support the management of cancer patients by providing evidence-based recommendations. In this review, we focus on both current evidence supporting the beneficial effects of CDSS on guideline adherence as well as technical and structural requirements for CDSS implementation in clinical routine.

RECENT FINDINGS

Some studies have demonstrated a significant improvement of guideline adherence by CDSSs in oncologic diseases such as breast cancer, colon cancer, cervical cancer, prostate cancer, and hepatocellular carcinoma as well as in the management of cancer pain. However, most of these studies were rather small and designs rather simple. One reason for this limited evidence might be that CDSSs are only occasionally implemented in clinical routine. The main limitations for a broader implementation might lie in the currently existing clinical data infrastructures that do not sufficiently allow CDSS interoperability as well as in some CDSS tools themselves, if handling is hampered by poor usability.

SUMMARY

In principle, CDSSs improve guideline adherence in clinical cancer management. However, there are some technical und structural obstacles to overcome to fully implement CDSSs in clinical routine.

Radiation Exposure During Uterine Fibroid Embolization (UFE): A Confounder-Controlled Comparison Between a State-of-the-Art Angiography Unit and a Conventional Angiography unit

PURPOSE

To compare radiation exposure of a state-of-the-art and a conventional angiography unit in patients undergoing uterine fibroid embolization (UFE).

MATERIALS AND METHODS

Between January 2009 and December 2016, 286 patients underwent UFE in our Interdisciplinary Fibroid Center. The inclusion criteria for this retrospective analysis were first-time transarterial embolization for symptomatic fibroids, bilateral embolization, procedures applying a state-of-the-art (Group 1) or a conventional angiography unit (Group 2), and bilateral technical success with an adequate embolization endpoint after the injection of microspheres. Study endpoints included radiation exposure, major complications, morphological success (MRI), and clinical success (questionnaire on quality-of-life). Propensity score matching controlled for confounders.

RESULTS

The inclusion criteria were met by 58 (Group 1) and 177 (Group 2) patients. After propensity score matching, there was no significant difference between Group 1 (n = 46) and Group 2 (n = 92) regarding age, body-mass index, volume of the dominant fibroid and the uterus, fluoroscopy time, and amount of embolic agent (p ≥ 0.10 each). The dose-area product was significantly lower in Group 1 than in Group 2 (1159.0 cGycm² vs. 3123.5 cGycm²; p < 0.001), while major complication rates (both groups 0 %) and dominant fibroid devascularization (both groups 100 %) were equal (p > 0.99). There were no significant differences between both groups regarding shrinkage of the dominant fibroid and the uterus and no relevant differences regarding patient-reported quality-of-life.

CONCLUSION

A state-of-the-art angiography unit has the potential to reduce radiation exposure in patients undergoing UFE without increasing the risk of major complications and with comparably high morphological and clinical success.

KEY POINTS

· A state-of-the-art angiography unit potentially reduces radiation exposure in patients undergoing UFE.. · Reduced radiation exposure does not seem to negatively influence the rate of major complications.. · Reduced exposure does not seem to negatively affect morphological and clinical success..

CITATION FORMAT

· Sommer C, Voigt W, Oliger MK et al. Radiation Exposure During Uterine Fibroid Embolization (UFE): A Confounder-Controlled Comparison Between a State-of-the-Art Angiography Unit and a Conventional Angiography unit. Fortschr Röntgenstr 2018; 190: 250 - 258.

Efficacy of targeted drugs in germ cell cancer cell lines with differential cisplatin sensitivity

Testicular germ cell tumors (TGCTs) are the most common malignancies in men between the age of 15 and 35. Although cisplatin-based chemotherapy is highly effective in advanced disease, approximately 20% of patients have an unfavorable prognosis due to primary or acquired cisplatin resistance. For these patients, new therapeutic options are urgently needed. In numerous tumor entities, combinations of monoclonal antibodies or kinase inhibitors with chemotherapy exerted promising preclinical or clinical results, which have led to new treatment concepts. This prompted us to investigate the activity of different targeted agents alone or in combination with cisplatin in a panel of TGCT cell lines.

From diagnosis to therapy in lung cancer: management of CT detected pulmonary nodules, a summary of the 2015 Chinese-German Lung Cancer Expert Panel

The first Chinese-German Lung Cancer Expert Panel was held in November 2015 one day after the 7th Chinese-German Lung Cancer Forum, Shanghai. The intention of the meeting was to discuss strategies for the diagnosis and treatment of lung cancer within the context of lung cancer screening. Improved risk classification criteria and novel imaging approaches for screening populations are highly required as more than half of lung cancer cases are false positive during the initial screening round if the National Lung Screening Trial (NLST) demographic criteria [≥30 pack years (PY) of cigarettes, age ≥55 years] are applied. Moreover, if the NLST criteria are applied to the Chinese population a high number of lung cancer patients are not diagnosed due to non-smoking related risk factors in China. The primary goal in the evaluation of pulmonary nodules (PN) is to determine whether they are malignant or benign. Volumetric based screening concepts such as investigated in the Dutch-Belgian randomized lung cancer screening trial (NELSON) seem to achieve higher specificity. Chest CT is the best imaging technique to identify the origin and location of the nodule since 20% of suspected PN found on chest X-ray turn out to be non-pulmonary lesions. Moreover, novel state-of-the-art CT systems can reduce the radiation dose for lung cancer screening acquisitions down to a level of 0.1 mSv with improved image quality to novel reconstruction techniques and thus reduce concerns related to chest CT as the primary screening technology. The aim of the first part of this manuscript was to summarize the current status of novel diagnostic techniques used for lung cancer screening and minimally invasive treatment techniques for progressive PNs that were discussed during the first Chinese-German Lung Cancer. This part should serve as an educational part for the readership of the techniques that were discussed during the Expert Panel. The second part summarizes the consensus recommendations that were interdisciplinary discussed by the Expert Panel.

'Act on oncology' as a new comprehensive approach to assess prostate cancer centres--method description and results of a pilot study

Background

Multidisciplinary care of prostate cancer is increasingly offered in specialised cancer centres. It requires the optimisation of medical and operational processes and the integration of the different medical and non-medical stakeholders.

Objective

To develop a standardised operational process assessment tool basing on the capability maturity model integration (CMMI) able to implement multidisciplinary care and improve process quality and efficiency.

Design, Setting, and Participants

Information for model development was derived from medical experts, clinical guidelines, best practice elements of renowned cancer centres, and scientific literature. Data were organised in a hierarchically structured model, consisting of 5 categories, 30 key process areas, 172 requirements, and more than 1500 criteria. Compliance with requirements was assessed through structured on-site surveys covering all relevant clinical and management processes. Comparison with best practice standards allowed to recommend improvements. ‘Act On Oncology’(AoO) was applied in a pilot study on a prostate cancer unit in Europe.

Results and Limitations

Several best practice elements such as multidisciplinary clinics or advanced organisational measures for patient scheduling were observed. Substantial opportunities were found in other areas such as centre management and infrastructure. As first improvements the evaluated centre administration described and formalised the organisation of the prostate cancer unit with defined personnel assignments and clinical activities and a formal agreement is being worked on to have structured access to First-Aid Posts.

Conclusions

In the pilot study, the AoO approach was feasible to identify opportunities for process improvements. Measures were derived that might increase the operational process quality and efficiency.

Prospective Assessment of an innovative test for prostate cancer screening using the VITA process model framework

Healthcare innovations are crucial for enhancing patient treatment and a high-quality healthcare system. However, bringing new technologies, methods and procedures into the healthcare market is challenging. Enormous amounts of financial, personnel and organizational resources are required with no upfront certainty for the medical and economic benefit. A new and innovative approach uses interdisciplinary medical, technical and economic expertise to forecast effects of healthcare innovations already at the early research and concept phase of an idea and before major investments are made. A process model framework was developed to operationalize this structured assessment of healthcare innovations. The Visionary Iterative Tailored Approach (VITA) is based on conceptual modeling, simulation and health economics evaluation. Its application for the prospective assessment of an innovative prostate cancer screening is presented.

Economic constraints - the growing challenge for Western breast cancer centers

Breast cancer care in Western countries has reached a considerable level of quality and standardization, which has contributed to the decline in breast cancer mortality. Certified Breast Cancer Centers (BCC) represent an important element of this development. Related to changes in reimbursement and growing costs, BCC face economic constraints which ultimately could endanger the achievements of the past. Thus, BCC have to optimize their care strategies from an economic perspective, particularly by increasing efficiency but also by adapting their service portfolio. This could result in competitive advantages and additional revenue by increasing case numbers and extra charges to patients. Furthermore, an intensification of collaboration with the outpatient sector resulting in an integrated and managed 'trans-sectoral' care approach which could allow to shift unprofitable procedures to the outpatient sector - in the sense of a win-win situation for both sectors and without loss of care quality - seems reasonable. Structured and specialized consulting approaches can further be a lever to fulfill economic requirements in order to avoid cuts in medical care quality for the sake of a balanced budget. In this review, economic constraints of BCC with a focus on the German healthcare system and potential approaches to ameliorate these financial burdens are being discussed.

Chemotherapy-induced diarrhea: pathophysiology, frequency and guideline-based management

Diarrhea is one of the main drawbacks for cancer patients. Possible etiologies could be radiotherapy, chemotherapeutic agents, decreased physical performance, graft versus host disease and infections. Chemotherapy-induced diarrhea (CID) is a common problem, especially in patients with advanced cancer. The incidence of CID has been reported to be as high as 50-80% of treated patients (≥30% CTC grade 3-5), especially with 5-fluorouracil bolus or some combination therapies of irinotecan and fluoropyrimidines (IFL, XELIRI). Regardless of the molecular targeted approach of tyrosine kinase inhibitors and antibodies, diarrhea is a common side effect in up to 60% of patients with up to 10% having severe diarrhea. Furthermore, the underlying pathophysiology is still under investigation. Despite the number of clinical trials evaluating therapeutic or prophylactic measures in CID, there are just three drugs recommended in current guidelines: loperamide, deodorized tincture of opium and octreotide. Newer strategies and more effective agents are being developed to reduce the morbidity and mortality associated with CID. Recent research focusing on the prophylactic use of antibiotics, budesonide, probiotics or activated charcoal still have to define the role of these drugs in the routine clinical setting. Whereas therapeutic management and clinical work-up of patients presenting with diarrhea after chemotherapy are rather well defined, prediction and prevention of CID is an evolving field. Current research focuses on establishing predictive factors for CID like uridine diphosphate glucuronosyltransferase-1A1 polymorphisms for irinotecan or dihydropyrimidine-dehydrogenase insufficiency for fluoropyrimidines.

Fermented wheat germ extract--nutritional supplement or anticancer drug?

Background

Fermented wheat germ extract (FWGE) is a multisubstance composition and, besides others, contains 2-methoxy benzoquinone and 2, 6-dimethoxy benzoquinone which are likely to exert some of its biological effects. FWGE interferes with anaerobic glycolysis, pentose cycle and ribonucleotide reductase. It has significant antiproliferative effects and kills tumor cells by the induction of apoptosis via the caspase-poly [ADP-ribose] polymerase-pathway. FWGE interacts synergistically with a variety of different anticancer drugs and exerted antimetastatic properties in mouse models. In addition, FWGE modulates immune response by downregulation of MHC-I complex and the induction of TNF-α and various interleukins. Data in the F-344 rat model provide evidence for a colon cancer preventing effect of FWGE.

Clinical data from a randomized phase II trial in melanoma patients indicate a significant benefit for patients treated with dacarbazine in combination with FWGE in terms of progression free survival (PFS) and overall survival (OS). Similarly, data from studies in colorectal cancer suggested a benefit of FWGE treatment. Besides extension of OS and PFS, FWGE improved the quality of life in several studies.

Conclusion

In conclusion, available data so far, justify the use of FWGE as a non-prescription medical nutriment for cancer patients. Further randomized, controlled and large scale clinical studies are mandatory, to further clarify the value of FWGE as a drug component of future chemotherapy regimens.

Promising cytotoxic activity profile of fermented wheat germ extract (Avemar®) in human cancer cell lines

Fermented wheat germ extract (FWGE) is currently used as nutrition supplement for cancer patients. Limited recent data suggest antiproliferative, antimetastatic and immunological effects which were at least in part exerted by two quinones, 2-methoxy benzoquinone and 2,6-dimethoxybenzquinone as ingredients of FWGE. These activity data prompted us to further evaluate the in vitro antiproliferative activity of FWGE alone or in combination with the commonly used cytotoxic drugs 5-FU, oxaliplatin or irinotecan in a broad spectrum of human tumor cell lines. We used the sulforhodamine B assay to determine dose response relationships and IC₅₀-values were calculated using the Hill equation. Drug interaction of simultaneous and sequential drug exposure was estimated using the model of Drewinko and potential clinical activity was assessed by the model of relative antitumor activity (RAA). Apoptosis was detected by DNA gel electrophoresis.

FWGE induced apoptosis and exerted significant antitumor activity in a broad spectrum of 32 human cancer cell lines. The highest activity was found in neuroblastoma cell lines with an average IC₅₀ of 0.042 mg/ml. Furthermore, IC₅₀-range was very narrow ranging from 0.3 mg/ml to 0.54 mg/ml in 8 colon cancer cell lines. At combination experiments in colon cancer cell lines when FWGE was simultaneously applied with either 5-FU, oxaliplatin or irinotecan we observed additive to synergistic drug interaction, particularly for 5-FU. At sequential drug exposure with 5-FU and FWGE the observed synergism was abolished.

Taken together, FWGE exerts significant antitumor activity in our tumor model. Simultaneous drug exposure with FWGE and 5-FU, oxaliplatin or irinotecan yielded in additive to synergistic drug interaction. However, sequential drug exposure of 5-FU and FWGE in colon cancer cell lines appeared to be schedule-dependent (5-FU may precede FWGE).

Further evaluation of FWGE as a candidate for clinical combination drug regimens appeared to be warranted.

Magnetic resonance imaging of intramuscular metastases

OBJECTIVE

The aim of the present study was to analyse magnetic resonance findings of intramuscular metastases (IM) in a relatively large series.

MATERIALS AND METHODS

From January 2000 to January 2010, 28 patients (207 metastases) were retrospectively identified in the radiological database of the Martin-Luther-University. Several different scanning protocols were used depending on the localisation of IM. In 12 patients diffusion-weighted (DW) images were obtained with a multi-shot SE-EPI sequence. Apparent diffusion coefficient (ADC) maps were also calculated. Furthermore, fusion images were manually generated between the DW and half-Fourier acquisition single-shot turbo spin echo (HASTE) images.

RESULTS

On T2-weighted images, 97% of the recognised IM were hyperintense in comparison to unaffected musculature, and 3% were mixed iso- to hyperintense. On T1-weighted images most IM (91%) were homogeneously isointense in comparison to muscle tissue, whereas 4% were hypointense, and 5% lightly hyperintense. ADC maps were calculated for 91 metastases ranging from 0.99 to 4.00 mm(2)s(-1) (mean value 1.99 ± 0.66). ADC values of low (<1.5) signal intensity (SI) were identified in 26%, moderate SI (from 1.5 to 3.0) in 68%, and high SI (>3.0) in 6%. Of the IM that were investigated with contrast medium, 88.5% showed marked enhancement. It was homogeneous in 88% and heterogenous in 6%. Rim enhancement with central low attenuation was seen in 6%. There was no difference in enhancement characteristics with respect to ADC values or fusion patterns. Peritumoral enhancement was identified in 2.4%.

CONCLUSION

Magnetic resonance features of muscle metastases are relatively typical and consist of round or oval intramuscular masses with well-defined margins, marked enhancement, low or moderate ADC values, and moderate to high signal intensity on fusion images.

Sequential X-irradiation induced acquired resistance to oxaliplatin but increased sensitivity to cisplatin in two human teratoma cell lines in vitro

Cisplatin (CDDP) and oxaliplatin (OXA-P) are potential therapeutic drugs in the treatment of testicular cancer. However, the emergence of drug resistance has been documented not only in patients after chemotherapy but also subsequently to fractionated X-irradiation. Specific radiation-induced biochemical alterations may play a role in the observed resistance. Since irradiation influences the cellular responses to chemotherapy, this study investigated changes in the expression of key proteins in the regulation of DNA repair and apoptosis subsequent to sequential irradiation.

MATERIALS AND METHODS

Logarithmically growing human teratocarcinoma cell lines 2101 EP and H 12.1 were irradiated (10 fractions of 4 Gy in vitro) to establish the sub-lines 2101 EP/DXR-10 and H 12.1/DXR-10. Radiosensitivity was assayed using a clonogenic survival assay. Drug response was assayed using a sulforhodamine B assay. Expression of p53, PARP, hMSH2 and Fas was detected by Western blotting.

RESULTS

Both DXR-10 sub-lines showed a significant increase in sensitivity towards CDDP as compared to their parental cell line, however, there was a concomitant increase in resistance against OXA-P. No significant changes in radiosensitivity between parental and DXR-10 cell lines were observed. In addition, there was an up-regulation of PARP, p53, hMSH2 and Fas in the DXR-10 sub-lines, implicating induced damage tolerance and repair mechanisms following irradiation.

CONCLUSION

These results suggest that radiation preceding chemotherapy might induce resistance to subsequent chemotherapy with oxaliplatin but not to cisplatin. This is a novel observation and, if confirmed, particularly in other tumor types, may have clinical implications.

Safety and efficacy of weekly 5-fluorouracil/folinic acid/oxaliplatin/irinotecan in the first-line treatment of gastrointestinal cancer

BACKGROUND

Standard chemotherapy for patients with metastatic colorectal cancer (mCRC) or gastric cancer (GC) consists of two-drug, usually fluoropyrimidine-based, combinations, with or without the addition of biological agents. Studies of triple-drug regimens combining 5-fluorouracil (5-FU)/folinic acid (FA) with both oxaliplatin and irinotecan have shown promising efficacy in studies of patients with mCRC or GC. However, improved efficacy has often been achieved at the expense of high rates of grade 3 or 4 toxicities such as neutropenia and diarrhoea, occasionally even resulting in toxic deaths.

OBJECTIVE/METHODS

We performed a phase II study of previously untreated patients with mCRC or GC to assess the safety and efficacy of our 5-fluorouracil/folinic acid/oxaliplatin/irinotecan (FUFOXIRI) regimen with weekly administration of irinotecan 70 mg/m(2), oxaliplatin 50 mg/m(2), FA 500 mg/m(2) and 5-FU 2000 mg/m(2) on days 1, 8, 15 and 22, repeated from day 36.

RESULTS

A total of 22 patients were enrolled, 11 each with mCRC and GC receiving a median of four cycles per patient. The FUFOXIRI regimen was generally well tolerated with no toxic deaths, neutropenic fever or grade 4 toxicities. Most common grade 3 side effects were diarrhoea and neutropenia each affecting 24% of patients. Dose reductions due to toxicity were performed in 48% of all and 60% of patients having received at least two cycles of FUFOXIRI. The overall response rate was 46% (all partial responses), 55% and 36% for patients with mCRC and GC, respectively. Median progression-free survival for all patients, mCRC and GC patients was 9.5, 10.0 and 8.0 months, respectively. The median overall survival for all patients was 16.5, 18.0 and 15.0 months for patients with mCRC and GC, respectively.

CONCLUSION

These data show excellent tolerance and efficacy of the FUFOXIRI regimen in both mCRC and GC. Therefore, FUFOXIRI is a promising backbone for future studies incorporating biologic 'targeted' agents for the treatment of gastrointestinal cancers.

Chemotherapy with paclitaxel and gemcitabine in progressive medullary and thyroid carcinoma of the follicular epithelium

Nine patients (mean age 53) with metastasizing, progressive, medullary (MTC), thyroid carcinoma and progressive, nonradioiodine accumulating thyroid carcinoma of the follicular epithelium (follicular carcinoma, FTC and papillary carcinoma, PTC) were treated with a combination of paclitaxel and gemcitabine between 2004 and 2006. Tumors were histologically classified as follicular in 5 patients (56%), as papillary in 2 patients (22%), and medullary in 2 patients (22%). Paclitaxel (90-100 mg/m (2)) and gemcitabine (1,000 mg/m (2)) were applied for two, three, or 6 cycles every three weeks, depending on response and side effects. The effect of therapy was evaluated by radiographic imaging (CT images) and [(18)F]FDG-PET. All patients with papillary, follicular, or medullary thyroid carcinoma had continuous progression during restaging 14.8+/-8.8 weeks after initiation of chemotherapy, including one patient with stable disease after 3 cycles, but continuous progression after 6 cycles of chemotherapy. Paclitaxel and gemcitabine are not a valid chemotherapy option, in particular in patients with progressive, nonradioiodine-accumulating follicular thyroid carcinoma, who were already treated by other chemotherapeutic agents.

Activity of mTOR-Inhibitor Rad001 (everolimus) in differentiated and anaplastic thyroid cancer cell lines

e14608

Background: Recent data suggest that aberrant activation of PIK3/AKT-pathway and mTOR are involved in the development of thyroid cancer, particularly of anaplastic (ATC) and follicular (FTC) subtype. Therefore, mTOR could be a potential treatment target in thyroid cancer. Methods: To asses the potential role of mTOR as target for the treatment of thyroid cancer, two human ATC cell lines SW1736 and 8505C, the papillary thyroid cancer (PTC) cell line BCPAP and the FTC cell line FTC133 were exposed for 96h to increasing concentrations of the mTOR inhibitor RAD001 (Everolimus, kindly provided by Novartis, Switzerland). For combination experiments 10 nM of RAD001 were combined with increasing concentrations of either doxorubicin (DOX) or cisplatin (CDDP) continuously. Cytotoxicity was measured using the sulforhodamine B assay. IC50-values were calculated with Sigma Plot (Jandel Scientific) and drug interaction was determined by the model of Drewinko. Results: The observed IC50-values of RAD001 were 1nM (FTC133), 10 nM (BCPAP), 1000 nM (SW1736) and 9400 nM (8505C). In contrast to the pronounced differences in sensitivity as assessed on the basis of IC50, a growth inhibitory effect ≥ 25 % was seen in all cell lines at a concentration of 1 nM of RAD001. IC50 for CDDP ranged from 1,3–4,8 μM and for DOX from 8–40 nM. Combination of 10 nM RAD001 with either DOX or CDDP resulted in additive drug interaction with the exception in cell line 8505C where significant synergy was found for the combination with CDDP. Conclusion: RAD001 exerted interesting preclinical activity in two differentiated thyroid cancer cell lines. Mainly additive drug interaction in thyroid cancer cell lines was observed for combinations with CDDP and DOX. Mechanistic investigations are underway and will be presented at the meeting. At least for differentiated thyroid cancer mTOR-inhibition appeared promising, further evaluation in thyroid cancer seems warranted.

No significant financial relationships to disclose.

Severe thrombocytosis and anemia associated with celiac disease in a young female patient: a case report

INTRODUCTION

Platelet counts exceeding 1.000 x 103/microl are usually considered secondary to another cause, particularly to chronic myeloproliferative disease (CMPD). Reactive thrombocytosis due to iron deficiency rarely exceeds platelet counts of 700 x 103/microl.

CASE PRESENTATION

Here we report the case of a young woman presenting with clinical signs of severe anemia. Laboratory findings confirmed an iron-deficiency anemia associated with severe thrombocytosis of 1703 x 103/microl. Macroscopic gastrointestinal and genitourinary tract bleeding was excluded. The excessive elevation of platelets, slightly elevated lactate dehydrogenase and slightly elevated leukocytes along with the absence of other inflammation parameters raised the suspicion of an underlying hematological disease. However, bone marrow evaluation could not prove the suspected diagnosis of a CMPD, especially essential thrombocythemia (ET). In the further clinical course the platelet count returned to normal after raising the hemoglobin to a level close to normal range with erythrocyte transfusion, and normalization of serum iron and decline of erythropoietin. Finally, following small bowel biopsy, despite the absence of typical clinical signs, celiac disease was diagnosed. After discharge from hospital the patient was commenced on a gluten-free diet and her hemoglobin almost completely normalized in the further follow-up period.

CONCLUSION

This case illustrates the rare constellation of an extreme thrombocytosis most likely secondary to iron deficiency due to celiac disease. This represents, to the best of the authors' knowledge, the highest reported platelet count coincident with iron deficiency. A potential mechanism for the association of iron-deficiency anemia and thrombocytosis is discussed. Even in the presence of 'atypically' high platelets one should consider the possibility of reactive thrombocytosis. Extreme thrombocytosis could emerge in the case of iron deficiency secondary to celiac disease.

Safety and efficacy of a triple antiemetic combination with the NK-1 antagonist aprepitant (APR) in high (HEC), moderate (MEC) and high dose chemotherapy (HDC) in multiple day chemotherapy (MDC)

19545

Background: 5-HT3 receptor antagonists (RA) plus dexamethasone (DEX) has been shown to induce 55–57% complete responses from emesis during the 4–5 days of cisplatin chemotherapy. The role of aprepitant in MDC remains to be defined. The antiemetic triple combination of a NK-1-RA, 5-HT3-RA and dexamethasone has not been formally investigated in more than one day chemotherapy. Methods: In this retrospective study, pts. with MDC received APR 125 mg d1, 80 mg consecutive days, granisetron (GRAN) 2 mg daily and DEX 8 mg daily for prevention of acute CINV and APR 80 mg and DEX 8 mg for 2 days for delayed CINV. Endpoints were complete response (CR, no vomiting & no use of rescue therapy) in the acute, delayed and overall phase. Results: Of 103 pts. (f/m 21/82 pts.; median age 40.6y) with various types of cancers 41 pts. (39.8%) received HEC, 44 (42.8%) MEC, and 18 pts. (17.4%) HDC. Median duration of CTX was 3.42 days (HEC 3.9 d). The most frequent regimens were ICE (35%), PEB (14.6%), I3VA (10.7%), MAID (4.9%) and IEV (5.9%). Toxicity: Singultus was reported in 6.8% and loss of appetite in 25.5%. Elevation (CTC grade 1–2) of transaminase/AP/bilirubin and creatinine were seen in comparison to pretreatment values in 15.6%/6.8%/21.1% and 7.8% of all pts.. Efficacy: Acute/delayed/overall CR in HEC was 68.3%/70.7%/63.4%, in MEC 77.3%/84.1%/77.3% and in HDC 77.8%/61.6%/55.6%. Risk factor analysis revealed that pretreatment anxiety increased the risk of vomiting significantly (p= 0.008). Conclusions: Toxicity seems not to be increased by the multiple day treatment of APR (5–7 days) in comparison to the usually used 3-day APR regimen. The CR in the acute and delayed phase in patients receiving HEC was superior to the results reported in the literature with the combination of a 5-HT3 RA and DEX. The CR in the delayed phase in MEC was better than reported by Warr et al. where pts. receiving only one day of MEC and APR mono in the delayed phase. This might be due to the combination of APR/DEX in the delayed phase in our study. These promising results have to be confirmed in a prospective randomized trial.

No significant financial relationships to disclose.

Human Chorionic Gonadotropin-Induced Hyperthyroidism in Germ Cell Cancer – a Case Presentation and Review of the Literature

BACKGROUND

Human chorionic gonadotropin (hCG)-induced hyperthyroidism represents a rare paraneoplastic syndrome in hCG-secreting testicular cancer. In most cases, this hyperthyroidism remains subclinical. hCG belongs to the family of glycoprotein hormones with structural homology to thyroid- stimulating hormone (TSH). The thyrotropic potency and thereby the degree of cross reactivity of hCG is determined by several factors, such as content of sialic acid or lack of the C-terminal tail. In the absence of clinical signs of hyperthyroidism, treatment usually consists of specific antitumor therapy which will result in normalization of thyroid function if hCG declines. Where there are clinical signs of hyperthyroidism, overlapping thyreostatic treatment is recommended.

CASE REPORT

Here, we report of a young man presenting biochemical signs of hyperthyroidism without clinical signs at the time of diagnosis of non-seminomatous germ cell cancer. Beta-hCG initially exceeded 1,000,000 IU/ml and declined close to normal at the end of cancer treatment. Concomitantly, thyroid hormones returned to the normal range without any thyreostatic therapy. We observed a significant correlation of neta-hCG and thyroid hormones in linear regression analysis (r2 = 0.98, p< 0.05). A concise overview of potential mechanisms of hCG-induced hyperthyroidism in germ cell cancer but also in pregnancy is given and the case discussed according to the cited literature.

Monoterpenes as drug shuttles: cytotoxic (6-aminomethylnicotinate)dichloridoplatinum(II) complexes with potential to overcome cisplatin resistance

(6-Aminomethylnicotinate)dichloridoplatinum(II) complexes 4 esterified with terpene alcohols were tested on a panel of five human tumor cell lines. While they were accumulated in all cell lines more readily than cisplatin (CDDP), their cytotoxicities were tumor-specific and structure-dependent. Cell lines known to feature elevated levels of antiapoptotic, ion-channel-affecting proteins or otherwise impaired caspase-9 activation responded better to 4 than to CDDP, e.g., the HL-60 leukemia to the fenchyl and bornyl derivatives 4a,b at an IC90 < or = 10 microM. The (-)-menthyl complex 4g was far better accumulated and more efficacious in CDDP-resistant 1411HP male germ cell tumor cells than in the congenerous CDDP-sensitive H12.1 cell line. 4g also broke the CDDP resistance of 518A2 melanoma cells. Cell decay in each case was apoptotic as to TUNEL and Annexin V fluorescence assays. Some complexes 4 seem to positively modulate the permeability of the cell membrane and of blocked mitochondrial anion channels.

A meta-analysis comparing the efficacy of four 5-HT3-receptor antagonists for acute chemotherapy-induced emesis

GOALS OF WORK

Comparing antiemetic efficacy of different 5-HT(3)-receptor antagonists (5-HT(3)RAs) is difficult due to inter-study variability. Therefore, a meta-analysis was performed to comparatively evaluate dolasetron, granisetron, ondansetron and tropisetron for acute chemotherapy-induced nausea and vomiting (CINV).

PATIENTS AND METHODS

Comparisons between 5-HT(3)RAs were based on 44 randomized studies (including 12,343 patients) identified by MEDLINE, CANCERLIT or EMBASE searches and subcategorized by chemotherapy type (cisplatin- or non-cisplatin-based).

MAIN RESULTS

When all studies were combined, granisetron was equivalent to ondansetron (n = 27), and showed an advantage vs tropisetron (p = 0.018; n = 12). Ondansetron vs tropisetron (n = 11) and ondansetron vs dolasetron (n = 3) revealed equivalence in each comparison. An advantage for 3 mg granisetron vs 8 mg ondansetron was found in non-cisplatin-based studies (p = 0.015; n = 6). Overall equivalence was seen between ondansetron, 24 or 32 mg, and granisetron, 2 or 3 mg, for all studies (n = 13). There was a possible advantage for higher (24 or 32 mg) vs lower (8 mg) ondansetron dose regimens with cisplatin-based trials (n = 6). No differences were seen between 3 and 1 mg granisetron doses (n = 6).

CONCLUSIONS

Efficacy of 5-HT(3)RAs for preventing CINV following cisplatin- and non-cisplatin-based chemotherapy is comparable, with the exception of granisetron vs tropisetron. Some differences were noted in dosing subanalyses.

Epidermal growth factor receptor tyrosine kinase inhibitors: present and future role in gastrointestinal cancer treatment: a review

BACKGROUND

Despite advances in conventional and targeted anticancer therapy, the prognosis remains poor for many patients with solid tumors. Ongoing research into the molecular basis of malignant disease, however, has yielded many novel agents with potential activity, including the epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs).

DESIGN

This review summarizes current clinical data for EGFR-TKIs as monotherapy or in combination with 5-fluorouracil/leucovorin, irinotecan, or oxaliplatin, focusing on the rapidly developing area of colorectal, gastroesophageal, and pancreatic cancers.

RESULTS

EGFR-TKIs have limited but valuable activity as monotherapy in non-small cell lung cancer patients who have received prior anticancer treatment. The potential for application as a single agent in colorectal, gastroesophageal, and pancreatic cancers has yet to be demonstrated conclusively and deserves further investigation, especially as second- or third-line therapy. In combination with oxaliplatin-based regimens and 5-fluorouracil/leucovorin-based regimens, TKIs have shown benefits, suggesting that there may be a synergistic effect with chemotherapy. However, combinations with irinotecan-based regimens have been limited by toxicities.

CONCLUSIONS

EGFR-TKIs show benefits when used in combination with chemotherapy, and the favorable toxicity profiles observed suggest that these may be of value in frail or elderly patients.

[Chemotherapy induced-vomiting--a practical guide for prevention and therapy]

Nausea and vomiting are considered as two of the most distressing side effects of chemotherapy. The frequency of nausea and vomiting depends primarily on the emetogenic potential of the chemotherapeutic agents used. With the introduction of the neurokinin-1-receptor-antagonists in combination with 5-HT(3) receptor-antagonists and steroid approximately 70-90 % of patients receiving highly emetogenic chemotherapy can be protected from emesis. Here, the most recent developments in the antiemetic therapy including the latest guidelines for antiemetic prophylaxis are described.

Enterobacterial autoinducer of growth enhances shiga toxin production by enterohemorrhagic Escherichia coli

The addition of the enterobacterial autoinducer of growth to nutrient-poor minimal medium markedly accelerated the exponential growth rates of strains of enterohemorrhagic Escherichia coli but had little or no effect on maximal cell densities in stationary phase. Growth in the presence of the autoinducer resulted in an approximately twofold enhancement in Shiga toxin production.

C-reactive protein is a strong independent predictor of death in type 2 diabetes: association with multiple facets of the metabolic syndrome

INTRODUCTION

It has been suggested that atherosclerotic vascular disease is a chronic inflammatory process. The aim of this study was to investigate the importance of C-reactive protein (CRP) as a cardiovascular risk marker and predictor of death, as well as its relation to other factors of the metabolic syndrome in a cohort of type 2 diabetic patients at high risk of severe macrovascular complications.

MATERIAL AND METHODS

592 patients, aged 55 to 74 years (311 men, 281 women), with signs and symptoms of circulation deficits were examined by duplex ultrasound for suspected cerebrovascular and peripheral arterial disease and followed over a period of 5 years. At baseline, 292 patients of the total group had type 2 diabetes (49.3%). Ischemic heart disease was present in 40.2%, internal carotid stenosis in 21.9% and peripheral arterial disease in 39.7% of the subjects.

RESULTS

During the observation period, 104 patients had died, 72 (69.2%) due to cardiovascular causes. Non-fatal myocardial infarction occurred in 39 patients (7.4%), non-fatal stroke in 70 patients (13.3%) and amputations because of gangrene were unavoidable in 24 patients (4.6%). In Cox regression analysis, CRP was the strongest predictor of death and cardiovascular death in the total cohort (RR 3.7 [95% CI 1.86-7.50] and 5.4 [2.13-13.76]), as well as in the type 2 diabetic subgroup (RR 3.3 [1.27-8.70] and 5.4 [1.44-20.0]). In contrast neither the traditional cardiovascular risk factors nor the data of diabetic metabolic control were able to improve prediction. CRP was correlated positively with plasma levels of triglycerides (r=0.19, p=0.002), C-peptide (r=0.21, p=0.004), postprandial glucose (r=0.17, p=0.009), albuminuria (r=0.16, p=0.020), and inversely with HDL cholesterol (r=-0.20, p=0.002) in type 2 diabetic patients.

CONCLUSIONS

CRP seems to be a better predictor of death and cardiovascular events than traditional risk factors or parameters of metabolic control in type 2 diabetic patients at high risk for cardiovascular endpoints. Additionally, CRP is associated with several facets of the metabolic syndrome.

Loss of Oct-3/4 Expression in Embryonal Carcinoma Cells Is Associated with Induction of Cisplatin Resistance

Although the majority of testicular germ cell tumors (TGCTs) are curable by cisplatin-based chemotherapy, in a few cases, the occurrence of cisplatin resistance results in a poor outcome. The biological basis of this differential cisplatin sensitivity in TGCTs remains largely unexplained. Embryonal carcinoma (EC) cells represent the presumptive tumor stem cells in nonseminomatous TGCTs and are known to express the embryonal transcription factor Oct-3/4 and to be hypersensitive to cisplatin. In the present study, we analyzed TGCT cell lines and nude mouse xenografts showing differential cisplatin sensitivity. Here we demonstrate that a lack of expression of Oct-3/4 in TGCT cells is associated with a higher apoptotic threshold and cisplatin resistance which is accompanied by an impaired caspase-9 activation, reduced caspase-3 activity and altered p53 accumulation. We were able to induce loss of Oct-3/4 in a cisplatin-sensitive EC cell line resulting in a secondary cisplatin-resistant cell type with retained EC cell characteristics and changes in apoptotic signaling identical to those in primary resistant cells. Furthermore, we show that EC cells are retained in their undifferentiated state by Oct-3/4 and that a complete and ultimate loss of Oct-3/4 followed by an early differentiation step is necessary to establish the cisplatin-resistant state. Our data suggest that loss of Oct-3/4 expression leads to induction of a higher apoptotic threshold and to cisplatin resistance in EC cells of nonseminomatous TGCTs. We hypothesize that in refractory TGCTs the original tumor stem cell population of Oct-3/4-positive, cisplatin-sensitive EC cells could be replaced by an Oct-3/4-negative, resistant population in a selection process. In contrast, the presence of the Oct-3/4-positive, highly sensitive EC cells as the tumor stem cell component in most TGCTs could explain the general high chemosensitivity and curability of these tumors.

Potential activity of paclitaxel, vinorelbine and gemcitabine in anaplastic thyroid carcinoma

Anaplastic thyroid carcinoma (ATC) has a rapidly fatal course in the mostly elderly patients with a median survival after diagnosis of 4-12 months. Activity of commonly used chemotherapy (doxorubicin) is low, thus more active compounds need to be introduced into the therapeutic concept of ATC. Recently, based on preclinical data Ain et al. conducted a clinical phase II study with paclitaxel 96 h infusion in ATC achieving a promising response rate of 53%. To further improve therapeutic options in ATC, we evaluated the activity of topotecan, oxaliplatin, vinorelbine, gemcitabine and paclitaxel in comparision to cisplatin and doxorubicin (1 and 96 h drug exposure) alone or in combination in the ATC cell lines SW1736 and 8505C. IC50 values were determined by the sulforhodamine B assay, potential clinical activity was estimated by relative antitumor activity (RAA) and drug interaction was analyzed using a parametric response surface approach (Greco model) of the Loewe additivity. Duration of drug effect was estimated by regrowth kinetics. We found paclitaxel, vinorelbine and gemcitabine active in ATC with RAA (1 h drug exposure) ranging from 86 to 454, 15 to 17 and 31 to 140, respectively. The activity of doxorubicin and cisplatin was moderate with RAA ranging from 1.4 to 2.2 and 0.2 to 0.3, respectively. Combined drug exposure of gemcitabine/paclitaxel and gemcitabine/vinorelbine was synergistic with a Loewe index > 0. However, these results did not reach statistical significance with p > 0.05. At clinically relevant drug concentrations paclitaxel, gemcitabine and vinorelbine but not oxaliplatin exerted a sustained growth inhibition after cessation of drug exposure for the complete assay time of 15 days. In conclusion, paclitaxel, gemcitabine and vinorelbine but not topotecan or oxaliplatin appeared to be active in anaplastic thyroid carcinoma based on RAA or growth delay at clinically relevant drug concentrations. Combinations of vinorelbine/gemcitabine and paclitaxel/gemcitabine exerted a trend to synergy. Thus, further evaluation of paclitaxel, vinorelbine and gemcitabine alone or in combination with ATC seems warranted.

Preclinical Evaluation of ZD1839 Alone or in Combination with Oxaliplatin in a Panel of Human Tumor Cell Lines – Implications for Clinical Use

BACKGROUND

Preclinical studies have suggested antitumor activity of an epidermal growth factor (EGF)-receptor targeted therapy with selective tyrosine kinase inhibitors alone or in combination with conventional cytostatic drugs. However, in non-small cell lung cancer (NSCLC), addition of ZD1839 (Iressa) to combination chemotherapy did not improve the therapeutic outcome. Thus, further work is necessary to define factors predicting outcome of combination therapy.

MATERIALS AND METHODS

In the present study, the activity of ZD1839 alone or in combination with oxaliplatin (Eloxatin) was evaluated in 12 human cancer cell lines including colon, testicular, anaplastic thyroid and epidermoid carcinoma cells.

RESULTS

The EGF-receptor protein was overexpressed in line A431 (epidermoid carcinoma) and near the minimum detection limit in all other cell lines. The single agent activity of ZD1839 was highest in cell line A431. In the other cell lines, it was lower and appeared to be independent of EGF-receptor expression levels. The relative antitumor activity (RAA) was low (RAA = 1). Combined exposure to oxaliplatin and ZD1839 (IC30) resulted in significant synergy in 4 out of 6 colorectal cancer (CRC) cell lines and significant antagonism in 4 out of 6 non-colorectal cancer cell lines. Continuous exposure to ZD1839 (IC30) induced a marked G1-phase arrest and dephosphorylation of EGF-receptor in A431, whereas no significant cell cycle perturbation could be detected in the low-expression cell lines. Other factors than cell cycle perturbation seem to determine the mode of drug interaction between oxaliplatin and ZD1839.

CONCLUSION

Based on RAA, the single agent activity of ZD1839 in the investigated cell line panel appeared to be low. Combined exposure to ZD1839 and oxaliplatin exerted synergy in colorectal cancer cell lines, warranting further evaluation in this type of cancer. However, based on the observed antagonism in non-colorectal cancer cell lines, combined treatment with ZD1839 and oxaliplatin is not recommended for other types of cancer. Further research is necessary to identify factors which determine the nature of drug interaction in different tumor types including CRC and lung cancer.

Catecholate receptor proteins in Salmonella enterica: role in virulence and implications for vaccine development

Three outer membrane proteins of Salmonella enterica serovar Typhimurium function as catecholate siderophore receptors. IroN promotes uptake of enterobactin, salmochelins and 2,3-dihydroxybenzoylserine, FepA transports enterobactin and 2,3-dihydroxybenzoylserine, and Cir is a receptor for 2,3-dihydroxybenzoylserine. In addition, all three proteins are required for l-norepinephrine-facilitated iron uptake from transferrin as judged by failure of a fepA iroN cir triple mutant to grow in serum-containing medium in the presence of l-norepinephrine. Moreover, pre-treatment of mice with l-norepinephrine resulted in enhanced systemic spread of the parental strain, but had no effect on the fepA iroN cir mutant. Inoculation of mice with the triple mutant, which is significantly attenuated, elicited a significant protective effect against subsequent challenge with the parental strain.

Sulforhodamine B assay and chemosensitivity

The sulforhodamine B (SRB) assay was developed by Skehan and colleagues to measure drug-induced cytotoxicity and cell proliferation for large-scale drug-screening applications. Its principle is based on the ability of the protein dye sulforhodamine B to bind electrostatically and pH dependent on protein basic amino acid residues of trichloroacetic acid-fixed cells. Under mild acidic conditions it binds to and under mild basic conditions it can be extracted from cells and solubilized for measurement. Results of the SRB assay were linear with cell number and cellular protein measured at cellular densities ranging from 1 to 200% of confluence. Its sensitivity is comparable with that of several fluorescence assays and superior to that of Lowry or Bradford. The signal-to-noise ratio is favorable and the resolution is 1000-2000 cells/well. It performed similarly compared to other cytotoxicity assays such as MTT or clonogenic assay. The SRB assay possesses a colorimetric end point and is nondestructive and indefinitely stable. These practical advances make the SRB assay an appropriate and sensitive assay to measure drug-induced cytotoxicity even at large-scale application.