Surveillance of Sentinel Node-Positive Melanoma Patients with Reasons for Exclusion from MSLT-II: Multi-Institutional Propensity Score Matched Analysis

BACKGROUND

In sentinel lymph node (SLN)-positive melanoma, two randomized trials demonstrated equivalent melanoma-specific survival with nodal surveillance vs completion lymph node dissection (CLND). Patients with microsatellites, extranodal extension (ENE) in the SLN, or >3 positive SLNs constitute a high-risk group largely excluded from the randomized trials, for whom appropriate management remains unknown.

STUDY DESIGN

SLN-positive patients with any of the three high-risk features were identified from an international cohort. CLND patients were matched 1:1 with surveillance patients using propensity scores. Risk of any-site recurrence, SLN-basin-only recurrence, and melanoma-specific mortality were compared.

RESULTS

Among 1,154 SLN-positive patients, 166 had ENE, microsatellites, and/or >3 positive SLN. At 18.5 months median follow-up, 49% had recurrence (vs 26% in patients without high-risk features, p < 0.01). Among high-risk patients, 52 (31%) underwent CLND and 114 (69%) received surveillance. Fifty-one CLND patients were matched to 51 surveillance patients. The matched cohort was balanced on tumor, nodal, and adjuvant treatment factors. There were no significant differences in any-site recurrence (CLND 49%, surveillance 45%, p = 0.99), SLN-basin-only recurrence (CLND 6%, surveillance 14%, p = 0.20), or melanoma-specific mortality (CLND 14%, surveillance 12%, p = 0.86).

CONCLUSIONS

SLN-positive patients with microsatellites, ENE, or >3 positive SLN constitute a high-risk group with a 2-fold greater recurrence risk. For those managed with nodal surveillance, SLN-basin recurrences were more frequent, but all-site recurrence and melanoma-specific mortality were comparable to patients treated with CLND. Most recurrences were outside the SLN-basin, supporting use of nodal surveillance for SLN-positive patients with microsatellites, ENE, and/or >3 positive SLN.

Birth Control in Clinical Trials: Industry Survey of Current Use Practices, Governance, and Monitoring

The Health and Environmental Sciences Institute (HESI) Developmental and Reproductive Toxicology Technical Committee sponsored a pharmaceutical industry survey on current industry practices for contraception use during clinical trials. The objectives of the survey were to improve our understanding of the current industry practices for contraception requirements in clinical trials, the governance processes set up to promote consistency and/or compliance with contraception requirements, and the effectiveness of current contraception practices in preventing pregnancies during clinical trials. Opportunities for improvements in current practices were also considered. The survey results from 12 pharmaceutical companies identified significant variability among companies with regard to contraception practices and governance during clinical trials. This variability was due primarily to differences in definitions, areas of scientific uncertainty or misunderstanding, and differences in company approaches to enrollment in clinical trials. The survey also revealed that few companies collected data in a manner that would allow a retrospective understanding of the reasons for failure of birth control during clinical trials. In this article, suggestions are made for topics where regulatory guidance or scientific publications could facilitate best practice. These include provisions for a pragmatic definition of women of childbearing potential, guidance on how animal data can influence the requirements for male and female birth control, evidence-based guidance on birth control and pregnancy testing regimes suitable for low- and high-risk situations, plus practical methods to ascertain the risk of drug-drug interactions with hormonal contraceptives.

Ultrasonographic features of pseudotumorous form of ascariasis

We report the ultrasonographic findings of a 60 year old woman with pseudotumorous form of ascariasis. Real-time ultrasonographic examination using a curved array transducer revealed grossly thickened small bowel loops, multiple small circular deposits throughout the peritoneal cavity, and a moderate amount of ascites. The English literature on the different forms of abdominal ascariasis is reviewed. Specific signs, which include the 'strip' sign, the 'four-lines', 'inner tube', or 'double tube' sign, the 'bull's eye' or 'target' sign, a 'worm mass' or 'spaghetti-like' appearance, and the 'zig-zag' sign can be present in any form of abdominal ascariasis, as they represent the image of the Ascaris worms visualized under ultrasonographic examination. However, the non-specific signs are not peculiar to A. lumbricoides infections, but are results of secondary changes due to A. lumbricoides infections in the corresponding organs.

Comparative subchronic oral toxicity of sulphite and acetaldehyde hydroxysulphonate in rats

A subchronic oral toxicity study of sodium metabisulphite and acetaldehyde hydroxysulphonate was conducted in normal and sulphite oxidase-deficient rats. At the highest dose level (350 mg SO2 equiv./kg body weight/day for 3 wk followed by 175 mg SO2 equiv./kg body weight/day for 5 wk of either compound), gastric lesions were noted histologically in both normal and sulphite oxidase-deficient rats. The lesions were more severe and more frequently encountered in the sulphite oxidase-deficient rats. The no-effect level for Na2S2O5 was 70 mg SO2 equiv./kg body weight/day in both normal and sulphite oxidase-deficient rats. Liver lesions were noted in rats treated with acetaldehyde hydroxysulphonate. These lesions may possibly be attributable to the effects of free acetaldehyde. The no-effect level for acetaldehyde hydroxysulphonate was 7 mg SO2 equiv./kg body weight/day for sulphite oxidase-deficient rats and 70 mg SO2 equiv./kg body weight/day for normal rats. Increased urinary excretion of sulphite was noted in sulphite oxidase-deficient rats whether or not they were given exogenous sulphites. An increase in urinary sulphite levels in sulphite oxidase-deficient rats was observed after dosing with acetaldehyde hydroxy-sulphonate. These findings suggest that acetaldehyde hydroxysulphonate is metabolized to acetaldehyde and free sulphite.

Inhibition of in vivo histamine metabolism in rats by foodborne and pharmacologic inhibitors of diamine oxidase, histamine N-methyltransferase, and monoamine oxidase

When [14C]histamine was administered orally to rats, an average of 80% of the administered radioactivity was recovered in the urine at the end of 24 hr. About 10% of the total dose was excreted via the feces. Analysis of 4-hr urine samples found imidazoleacetic acid to be the predominant metabolite (60.6%), with N tau-methylimidazoleacetic acid (8.6%), N tau-methylhistamine (7.3%), and N-acetylhistamine (4.5%) to be the minor metabolites. Histamine metabolism was inhibited by simultaneous oral administration of aminoguanidine, isoniazid, quinacrine, cadaverine, putrescine, tyramine, and beta-phenylethylamine. The administration of inhibitors resulted in an increased amount of unmetabolized histamine and a decreased amount of metabolites reaching the urine. Pharmacologic inhibitors were found to be more potent and have a longer duration of action than foodborne ones. The inhibitors could potentiate food poisoning caused by histamine by inhibiting its metabolism.

Reversed-phase ion-pair high-performance liquid chromatographic procedure for determination of histamine and its metabolites in rat urine

A reversed-phase ion-pair high-performance liquid chromatographic procedure for quantitative determination of histamine and its metabolites in rat urine is described. This method allows simultaneous analysis of five major histamine metabolites. Good separations were obtained by using 1-pentanesulfonic acid as the ion-pair reagent. A gradient elution program was used; the total elution time was less than 22 min. Linear standard curves with high correlation coefficients were obtained. This procedure has the advantage of requiring little sample preparation time and handling, and therefore maximizes the recovery of metabolites.

High pressure liquid chromatographic determination of putrefactive amines in foods

A high pressure liquid chromatographic (HPLC) procedure is described for determining the following putrefactive amines: histamine, tyramine, putrescine, cadaverine, tryptamine, and beta-phenylethylamine. The amines were extracted from tuna or cheese with methanol. Further cleanup was performed by sequential extractions with butanol and HCl. The acid extract was dried, and residues were derivatized with dansyl chloride. HPLC separations were performed on an Ultrasphere-ODS column at 33 degrees C. A gradient elution program was used; the total elution time was less than 17 min. Linear standard curves with high correlation coefficients were obtained. The procedure allowed good recoveries of histamine, tyramine, putrescine, and cadaverine; recoveries of tryptamine and beta-phenylethylamine were lower but constant. With this method, some swiss cheese samples were found to contain considerable amounts of histamine, tyramine, putrescine, cadaverine, and beta-phenylethylamine. Canned tuna samples had very low levels of these amines. Since the presence of amines at high levels has been associated with tuna decomposition, this method may be useful in identifying decomposed fish.