Mediastinal lymph node clearance after docetaxel-cisplatin neoadjuvant chemotherapy is prognostic of survival in patients with stage IIIA pN2 non-small-cell lung cancer: a multicenter phase II trial

PURPOSE

A multicenter, phase II trial investigated the efficacy and toxicity of neoadjuvant docetaxel-cisplatin in locally advanced non-small-cell lung cancer (NSCLC) and examined prognostic factors for patients not benefiting from surgery.

PATIENTS AND METHODS

Ninety patients with previously untreated, potentially operable stage IIIA (mediastinoscopically pN2) NSCLC received three cycles of docetaxel 85 mg/m2 day 1 plus cisplatin 40 mg/m2 days 1 and 2, with subsequent surgical resection.

RESULTS

Administered dose-intensities were docetaxel 85 mg/m2/3 weeks (range, 53 to 96) and cisplatin 95 mg/m2/3 weeks (range, 0 to 104). The 265 cycles were well tolerated, and the overall response rate was 66% (95% confidence interval [CI], 55% to 75%). Seventy-five patients underwent tumor resection with positive resection margin and involvement of the uppermost mediastinal lymph node in 16% and 35% of patients, respectively (perioperative mortality, 3%; morbidity, 17%). Pathologic complete response occurred in 19% of patients with tumor resection. In patients with tumor resection, downstaging to N0-1 at surgery was prognostic and significantly prolonged event-free survival (EFS) and overall survival (OS; P =.0001). At median follow-up of 32 months, the median EFS and OS were 14.8 months (range, 2.4 to 53.4) and 33 months (range, 2.4 to 53.4), respectively. Local relapse occurred in 27% of patients with tumor resection, with distant metastases in 37%. Multivariate analyses identified mediastinal clearance (hazard ratio, 0.22; P =.0003) and complete resection (hazard ratio, 0.26; P =.0006) as strongly prognostic for increased survival.

CONCLUSION

Neoadjuvant docetaxel-cisplatin is effective and tolerable in stage IIIA pN2 NSCLC. Resection is recommended only for patients with mediastinal downstaging after chemotherapy.

A review of the incorporation of complementary and alternative medicine by mainstream physicians

BACKGROUND

Studies suggest that between 30% and 50% of the adult population in industrialized nations use some form of complementary and/or alternative medicine (CAM) to prevent or treat a variety of health-related problems.

METHOD

A comprehensive literature search identified 25 surveys conducted between 1982 and 1995 that examined the practices and beliefs of conventional physicians with regard to 5 of the more prominent CAM therapies: acupuncture, chiropractic, homeopathy, herbal medicine, and massage. Six studies were excluded owing to their methodological limitations.

RESULTS

Across surveys, acupuncture had the highest rate of physician referral (43%) among the 5 CAM therapies, followed by chiropractic (40%) and massage (21%). Rates of CAM practice by conventional physicians varied from a low of 9% for homeopathy to a high of 19% for chiropractic and massage therapy. Approximately half of the surveyed physicians believed in the efficacy of acupuncture (51%), chiropractic (53%), and massage (48%), while fewer believed in the value of homeopathy (26%) and herbal approaches (13%).

CONCLUSIONS

This review suggests that large numbers of physicians are either referring to or practicing some of the more prominent and well-known forms of CAM and that many physicians believe that these therapies are useful or efficacious. These data vary considerably across surveys, most likely because of regional differences and sampling methods, suggesting the need for more rigorous surveys using national, representative samples. Finally, outcomes studies are needed so that physicians can make decisions about the use of CAM based on scientific evidence of efficacy rather than on regional economics and cultural norms.

Tumor cells in blood shed from the surgical field

OBJECTIVES

To analyze blood shed from the surgical field during oncologic surgery for tumor cells and to assess functional characteristics of these cells.

DESIGN AND PATIENTS

Series of 61 patients with cancer who underwent surgery for an abdominal, orthopedic, urological, gynecological, or head and neck malignant tumor, and blinded comparison with 15 patients with benign diseases undergoing surgery.

SETTING

A 500-bed tumor center and a tertiary care hospital.

MAIN OUTCOME MEASURES

Tumor cells were isolated from intraoperatively salvaged and washed blood by density gradient centrifugation. They were identified in cytospin specimens by their content of cytokeratins and nucleolar organizer regions with a sensitivity of 10 cells in 500 mL of blood. Clonogenicity was tested in a cell colony assay; invasiveness, in Boyden chambers; and tumorigenicity, in nude mice.

RESULTS

In 57 of 61 patients, tumor cells were detected in the blood shed during oncologic surgery. They demonstrated proliferation capacity, invasiveness, and tumorigenicity. The total number of tumor cells identified ranged from 1 x 10(1) to 7 x 10(6), with no close correlation to the amount of blood loss. Circulating tumor cells were demonstrated in only 26% of these patients and in small numbers.

CONCLUSIONS

Malignant cells identified regularly in the blood shed during tumor surgery and different from circulating tumor cells are of concern, since at the surgical site they may cause local tumor recurrence, or in the salvaged blood they may cause hematogenic metastasis after retransfusion. Therefore, the contraindication of intraoperative autotransfusion in tumor surgery is strongly supported, and a review of surgical procedures and adjuvant therapy may be indicated, as the passage of the identified cells to the shed blood is yet unknown.

Prognostic factors affecting long-term outcomes in patients with resected stage IIIA pN2 non-small-cell lung cancer: 5-year follow-up of a phase II study

The aim was to investigate the efficacy of neoadjuvant docetaxel-cisplatin and identify prognostic factors for outcome in locally advanced stage IIIA (pN2 by mediastinoscopy) non-small-cell lung cancer (NSCLC) patients. In all, 75 patients (from 90 enrolled) underwent tumour resection after three 3-week cycles of docetaxel 85 mg m-2 (day 1) plus cisplatin 40 or 50 mg m-2 (days 1 and 2). Therapy was well tolerated (overall grade 3 toxicity occurred in 48% patients; no grade 4 nonhaematological toxicity was reported), with no observed late toxicities. Median overall survival (OS) and event-free survival (EFS) times were 35 and 15 months, respectively, in the 75 patients who underwent surgery; corresponding figures for all 90 patients enrolled were 28 and 12 months. At 3 years after initiating trial therapy, 27 out of 75 patients (36%) were alive and tumour free. At 5-year follow-up, 60 and 65% of patients had local relapse and distant metastases, respectively. The most common sites of distant metastases were the lung (24%) and brain (17%). Factors associated with OS, EFS and risk of local relapse and distant metastases were complete tumour resection and chemotherapy activity (clinical response, pathologic response, mediastinal downstaging). Neoadjuvant docetaxel-cisplatin was effective and tolerable in stage IIIA pN2 NSCLC, with chemotherapy contributing significantly to outcomes.

Strong expression of foreign genes following direct injection into fish muscle

We report here for the first time direct injection of genes into fish muscle in vivo. Plasmids used contain either SV40 early promoter, rabbit beta-cardiac myosin heavy chain promoter, human MxA promoter or an artificial promoter, fused to a chloramphenicol acetyltransferase (CAT) or beta-galactosidase reporter gene. CAT assays revealed that most gene constructs were highly expressed. Histochemical analysis showed that beta-galactosidase was strongly expressed at the site of injection within muscle fibres. This method provides an excellent system for testing expression of gene constructs, including those of mammalian origin, in fish muscle in vivo and has the potential for fish vaccination.

Prevalidation of a new in vitro reconstituted human cornea model to assess the eye irritating potential of chemicals

This multicentre study aimed at evaluating the reliability (reproducibility) and relevance (predictivity) of a new commercially available human corneal epithelial (HCE) model (SkinEthic Laboratories, Nice, France) to assess acute ocular irritation. A prevalidation approach (protocol optimisation, transfer and performance) was followed and at each of the four participating laboratories, 20 coded reference chemicals, covering the whole range of irritancy, were tested. The compounds were applied topically to the HCE cultures and the level of cytotoxicity (tissue viability and histological analysis) was determined. Once a standardised protocol was established, a high level of reproducibility between the laboratories was observed. In order to assess the capability of the HCE model to discriminate between irritants (I) and non-irritants (NI), a classification prediction model (PM) was defined based on a viability cut-off value of 60%. The obtained in vitro classifications were compared with different in vivo classifications (e.g. Globally Harmonised System) which were calculated from individual rabbit data described in the ECETOC data bank. Although an overall concordance of 80% was obtained (sensitivity = 100% and specificity = 56%), the predictivity of the HCE model substantially increased when other sources of in vivo and in vitro data were taken into account.

Blood irradiation for intraoperative autotransfusion in cancer surgery: demonstration of efficient elimination of contaminating tumor cells

BACKGROUND

Intraoperative blood salvage is contraindicated in cancer surgery because of contaminating tumor cells and the risk of systemic dissemination. On the basis of the radiosensitivity of cancer cells, irradiation of salvaged blood with 50 Gy is proposed as a way to allow return of salvaged blood.

STUDY DESIGN AND METHODS

Elimination of tumor cells by blood irradiation was studied in vitro with cells from 10 cell lines and from 14 tumor preparations after their addition to red cells in high numbers, or with blood shed during cancer surgery. Before and after gamma radiation, tumor cells were isolated by density gradient centrifugation and tested for their proliferative capacity in a cell colony assay. DNA metabolism was analyzed by incorporation of 5' bromodesoxyuridine.

RESULTS

Survival curves of cells from various tumors confirmed D0 (the dose required to reduce the fraction of surviving cells to 37 percent of the original value) values in the range of 1.2 to 2.2 Gy. After irradiation of tumor cell-contaminated blood with 50 Gy, no cell colony formation was observed, which indicates a reduction rate exceeding 10 log. Irradiated cancer cells showed viability, but no residual DNA metabolism.

CONCLUSION

The level of inactivation by a 50-Gy dose far exceeds that needed to inactivate the number of proliferating tumor cells observed or expected in wound blood. These results provide the experimental basis for the clinical application of blood irradiation for intraoperative blood salvage in cancer surgery.

Oxidative stability of chilled pork chops following long term freeze storage

Colour stability and development of lipid oxidation were followed during chill storage for 6 days of chops from M. Longissimus dorsi produced from pigs with high (6.3) and low (5.5) ultimate pH (pH(u)). The chops from the same individual pigs were either chill stored at 2 days post-mortem or after frozen storage for 30 months (pre-frozen). Initial redness, measured as tristimulus parameter a(*), was lower for pre-frozen chops than for fresh chops. Chops with the high pH(u) had a stable a(*)-value during chill storage, while chops with the low pH(u) showed a rapidly decreasing a(*)-value both for fresh and pre-frozen chops. In contrast, initial lipid oxidation, measured as TBARS, was similar for pre-frozen and fresh chops prior to chill storage for both the high and the low pH(u) meat but developed most significantly in pre-frozen, low pH(u) meat. Individual differences in colour stability and development of lipid oxidation between pigs were notable for pre-frozen low pH(u) meat and need to be considered in quality control since meat from single pigs otherwise might give problems.

Incidence of registered visual impairment in the Nordic child population

A collaborative, population based, prospective register study on the incidence of visual impairment in children during the year 1993 was carried out in five Nordic countries with a total population of 17 million inhabitants. The child population was 3.8 million individuals aged 0-17 years. The following variables were taken into account: nationality, age, sex, diagnoses, aetiology, degree of visual impairment, and additional impairments. Classification routines from an earlier prevalence study were used. The present study included 304 children corresponding to an incidence of notification of 8/100,000 children, varying from 5.7 to 11.1 in the five countries. Fifty per cent of the visually impaired children were reported before they were 3 years of age. In approximately 45% of the children, visual impairment was due to various brain disorders, with cerebral amblyopia and secondary optic atrophy as the two leading causes. The relative impact of retinopathy of prematurity had decreased from the third most frequent cause (10%) in the prevalence study to seventh place (4%) in the incidence study. Two thirds of the children had additional impairments and these children also suffered from the most severe visual impairments. Among aetiological factors the majority (64%) were prenatal. The overall male:female ratio of 1.4:1 was identical to the sex ratio of the prevalence study.

Modulation of p53 and MDM2 activity by novel interaction with Ras-GAP binding proteins (G3BP)

Inactivation of the p53 tumor suppressor pathway is a critical step in human tumorigenesis. In addition to mutations, p53 can be functionally silenced through its increased degradation, inhibition of its transcriptional activity and/or its inappropriate subcellular localization. Using a proteomic approach, we have found that members of the Ras network of proteins, Ras-GTPase activating protein-SH3-domain-binding proteins 1 and 2 (G3BP1 and 2), bind to p53 in vitro and in vivo. Our data show that expression of G3BPs leads to the redistribution of p53 from the nucleus to the cytoplasm. The G3BP2 isoform additionally associated with murine double minute 2 (MDM2), a negative regulator of p53. G3BP2 expression resulted in significant reduction in MDM2-mediated p53 ubiquitylation and degradation. Interestingly, MDM2 was also stabilized in G3BP2-expressing cells and its ability to ubiquitylate itself was compromised. Accordingly, short hairpin RNA (shRNA)-mediated knockdown of G3BP2 caused a reduction in MDM2 protein levels. Furthermore, expression of shRNA targeting either G3BP1 or G3BP2 in human cancer cell lines resulted in marked upregulation of p53 levels and activity. Our results suggest that both G3BP isoforms may act as negative regulators of p53.

Popliteal fossa neural blockade as the sole anesthetic technique for outpatient foot and ankle surgery

Foot and ankle operations are being performed with greater frequency as outpatient procedures. Although the surgical procedure remains the same whether the operation is done in an inpatient or an outpatient setting, the anesthesia and postoperative analgesia are greatly affected when patients must be discharged soon after their operation. We have evaluated a regional anesthetic technique which blocks the sciatic nerve in the popliteal fossa and the saphenous nerve block at the knee. This was the sole anesthetic technique for both the operation and the immediate postoperative period. This technique appears to have several advantages: 1) Excellent anesthesia during the operation and for about ten hours postoperatively; 2) Use of a proximal calf tourniquet, and 3) Absence of systemic or local complications as might be seen with general, spinal or epidural anesthesia.

Dynamics of central nervous activation during motor imagination

Central nervous processes of sensorimotor and behaviour control are prerequisites of skills and motor performance. Eight students (Ss) in sports were tested during motor imagination. They were requested to imagine their own movements when swimming over a distance of 100 m (sitting in a resting position, without any real or imitated movements). Electroencephalograms (EEG), heart rate (HR), skin conductance (SC), and respiration rate (RR) were recorded before, during and after one series of 3 periods of mental training (MT). HR, RR and SC increased during MT. The highest level of SC can be found at the beginning of the first period of imagination. Mean alpha-frequency of the EEG over the left occipital and precentral area in all Ss was higher during MT. The degree of these changes varied during the 3 imagination periods.

Behavioural and developmental effects of butylated hydroxytoluene dosed to rats in utero and in the lactation period

Butylated hydroxytoluene (BHT) 500 mg/kg body wt/day was given in the diet to Fo-rats from 6 weeks of age to weaning of the F1-generation (growth period to age 19 week, gestation period and lactation period) and subsequent to F1-animals until 21 days of age. Body weight of F0-animals was recorded, and the influence on the F1-generation was investigated applying crossfostering. Mortality, litter size, weight gain and some developmental events as well as tests for auditory and visual function and locomotor coordination in the F1-generation were recorded. The applied dose of BHT exerted a significant adverse effect on body weight in both F0 and F1-animals and on several developmental parameters in F1-animals. The effects arose during the lactation period.

The cost of dementia in Denmark: the Odense Study

In a population-based study of dementia, the cost of care for 245 demented elderly and 490 controls matched by age and gender was estimated. Dementia of Alzheimer's type was diagnosed according to the NINCDS-ADRDA criteria, and vascular dementia and other types of dementia were diagnosed according to the DSM-IIIR criteria. Severity of dementia was determined by the Clinical Dementia Rating scale. The annual cost of medical care, domestic care, home help, nursing home and special equipment for nondemented patients was DKK 22,000 per person while the cost for very mildly, mildly, moderately and severely demented patients was DKK 49,000, DKK 93,000, DKK 138,000 and DKK 206,000, respectively. Except for very mild dementia the cost did not differ between elderly who suffer from Alzheimer's disease and those with other types of dementia. The net cost of dementia is the difference in cost between those with dementia and the matched controls and amounts on average to DKK 77,000 per person per year. However, priority setting cannot be based on the cost of dementia per se, but only on the cost of a specific dementia intervention compared to its health benefit.

Activation processes during mental practice in stroke patients

In healthy subjects, mental practice is known to improve motor performance. It is also known to be accompanied by a higher central nervous activity. Since such effects seem to be desirable for rehabilitation, we investigated the possibility of detecting changes in central nervous activity by means of EEG in stroke patients, and whether these changes were similar to those observed in healthy subjects. 12 left-sided hemiplegic patients who underwent a specific post-stroke rehabilitation treatment were requested to perform a simple arm movement sequence. In the following mental practice period the patients were requested to image the same sequence without any real movement. EEG background activity was recorded during rest and imagination periods. After the calculation of z-transformed power values within the theta, alpha, and beta-1 band, differences between rest and imagination periods were evaluated for their significance. Stroke patients show significant decreases of theta, alpha, as well as beta-1 power during mental practice in comparison to the rest period. These changes are similar to those obtained in healthy subjects. Theta power decreases in central and parietal leads. Central alpha power diminishes only during imagination of the contralateral arm. This phenomenon as well as the decrease of beta-1 power in central derivation were also obtained during real motor performance and might indicate an activation of the sensorimotor cortex. In accordance with the hypothesis of internal feedback mechanisms, this activation is a necessary prerequisite for motor learning during mental practice.

Visual impairment in Nordic children. I. Nordic registers and prevalence data

A Nordic study group of ophthalmologists, NORDSYN, has compiled data from registers in Denmark, Finland, Iceland and Norway of 2527 visually impaired children. Each record contains the following information: sex, year of birth, year of registration, classification of visual impairment, ocular diagnosis, systemic diagnosis, aetiology and evt. additional impairments. The ocular diagnoses were compiled into groups, and coding systems for aetiology and additional impairment were developed. The sex distribution revealed a dominance of males compared to the general population at the same age. Cases with non-genetic aetiology showed--through to a lesser extent--the same relative preponderance of males. The diseases in males caused by x-linked genetic factors do, therefore, not fully explain the sex distribution observed in the study. The national prevalences for registration of childhood blindness (WHO-definition: best corrected visual acuity in the best eye less than 3/60 or visual field less than 10 degrees around fixation for the ages 0-15 years) are per 100,000 child-population aged 0-15 years: Denmark 41, Finland 15, Iceland 19 and Norway 15. The differences are primarily presumed to be due to varying efficiency in registration. The proportion of visually impaired children with an additional mobility, hearing or mental impairment is between one-third and one-half of the national materials, thus indicating the need for interdisciplinary tracing of and care for the visually impaired child. This study documents the need of uniform routines for data classification of visually impaired children. The quality of the data in the present study calls for caution in the interpretation of the prevalence estimates. Incidence studies are being prepared to obtain information on whether the amount and causes of visual impairment in children with or without multiple impairments are changing.

Levetiracetam compared to phenytoin for the prevention of postoperative seizures after craniotomy for intracranial tumours in patients without epilepsy

Anticonvulsant drugs are frequently given after craniotomy. Phenytoin (PHT) is the most commonly used agent; levetiracetam (LEV) is a new anticonvulsant drug with fewer side effects. To compare the incidence of seizures in patients receiving either prophylactic PHT or LEV perioperatively, 971 patients undergoing a craniotomy were analysed retrospectively during a 2-year period. PHT was used routinely and LEV was administered when PHT was contraindicated. Seizures documented during the first 7 days after craniotomy were considered. A total of 235 patients were treated with an antiepileptic drug: 81 patients received LEV, and 154 patients, PHT. Two patients receiving LEV (2.5%) and seven receiving PHT (4.5%) had a seizure despite this treatment. No patient had a documented side effect or drug interaction. The data show that LEV may be an alternative option in patients with contraindications to PHT.