Tumor heterogeneity in anal cancer assessed with diffusion-weighted (DW) and T2-weighted MRI: Potential biomarker of treatment outcome

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Background: Despite advances in the management of anal squamous cell carcinoma (ASCC), roughly 25% of patients undergoing chemoradiotherapy (CRT) will experience a disease recurrence. Currently, there is no validated way to predict treatment failure and guidance on the timing of follow-up scans differs. This study was carried out to assess the role of statistical and fractal heterogeneity parameters from pre-treatment and early post-CRT T2- and diffusion-weighted MR in predicting disease outcome. Methods: Baseline and follow-up MR scans from patients with histologically proven non-metastatic ASCC undergoing radical CRT were included in this study. T2-W and DWI MR images were analyzed by two readers, blinded to clinical data. Statistical and fractal heterogeneity parameters were derived using in-house software. Results: 40 patients were included in the final analysis. Follow-up MRI scan was performed at a median of 15 weeks from the start of radiotherapy. 31/40 patients achieved a radiological complete response (CR) and a further 7/40 partial response (PR). Median follow-up was 34.5 months. During the course of follow-up, 12 patients experienced disease recurrence (30%). Radiological CR was not significantly associated with disease outcome. First order statistical heterogeneity analysis demonstrated a significantly lower ROI Skewness (median -0.05±0.49 vs 0.45±1.04 p=0.01) on baseline T2-W imaging as well as lower ROI Entropy (3.95±0.46 vs 4.45±0.49, p=0.01) and higher ROI Energy (0.07±0.03 vs 0.03±0.03, p=0.01) on follow-up T2-W imaging in subjects who experienced disease recurrence. In these patients T2-W Homogeneity derived from Grey-Level Co-occurrence Matrices (GLCM) was lower at baseline (0.41±0.12 vs 0.58 ±0.15 p=0.02) and associated with a higher T2-W Sum Average (median 35±7 vs median 29±7 p=0.01), whereas T2-W Contrast and ADC Correlation derived from GLCM were lower on follow-up imaging (30±11 vs 38 ±35, p=0.01 and 0.77±0.12 vs 0.88±0.12 p=0.04, respectively). Conclusions: First order statistical and fractal heterogeneity analysis of baseline and early post CRT MR scans in patients with ASCC might have a role in predicting long-term disease outcome.

The Clinical Utility of the Test of Playfulness

Occupational therapists' increased focus on play as an occupation has created a need for play assessments that reflect this perspective. This study examined the clinical utility of the recently developed Test of Playfulness (ToP) (Bundy, 1997a) when used with children with disabilities. Changes in the participant's views of the child, the therapy goals, and the intervention plans after using the ToP were explored. Fourteen paediatric occupational therapists assessed children using the ToP, completed a clinical utility questionnaire and attended a focus group. Participants found the ToP easy to administer and score, however some found interpreting the results difficult. The ToP highlights the interactions between the child, activity and environment, and illustrates the child's strengths in his/her role as a player. The results suggest the ToP is a useful tool for assessing playfulness. Additional education and research is needed to provide further direction for intervention and incorporation into practice.

Rectal tumour volume (GTV) delineation using T2-weighted and diffusion-weighted MRI: Implications for radiotherapy planning

PURPOSE

To compare the rectal tumour gross target volume (GTV) delineated on T2 weighted (T2W MRI) and diffusion weighted MRI (DWI) images by two different observers and to assess if agreement is improved by DWI.

MATERIAL AND METHODS

27 consecutive patients (15 male, range 27.1-88.8 years, mean 66.9 years) underwent 1.5T MRI prior to chemoradiation (45Gy in 25 fractions; oral capecitabine 850mg/m(2)), including axial T2W MRI (TR=6600ms, TE=90ms) and DWI (TR=3000ms, TE=77ms, b=0, 100, 800s/mm(2)). 3D tumour volume (cm(3)) was measured by volume of interest (VOI) analysis by two independent readers for the T2W MRI and b800 DWI axial images, and the T2W MRI and DWI volumes compared using Mann-Whitney test. Observer agreement was assessed using Bland-Altman statistics. Significance was at 5%.

RESULTS

Artefacts precluded DWI analysis in 1 patient. In the remaining 26 patients evaluated, median (range) T2W MRI MRI and DWI (b=800s/mm(2)) 3D GTVin cm(3) were 33.97 (4.44-199.8) and 31.38 (2.43-228), respectively, for Reader One and 43.78 (7.57-267.7) and 42.45 (3.68-251) for Reader Two. T2W MRI GTVs were slightly larger but not statistically different from DWI volumes: p=0.52 Reader One; p=0.92 Reader Two. Interobserver mean difference (95% limits of agreement) for T2W MRI and DWI GTVs were -9.84 (-54.96 to +35.28) cm(3) and -14.79 (-54.01 to +24.43) cm(3) respectively.

CONCLUSION

Smaller DWI volumes may result from better tumour conspicuity but overall observer agreement is not improved by DWI.

Mitomycin or cisplatin chemoradiation with or without maintenance chemotherapy for treatment of squamous-cell carcinoma of the anus (ACT II): a randomised, phase 3, open-label, 2 × 2 factorial trial

BACKGROUND

Chemoradiation became the standard of care for anal cancer after the ACT I trial. However, only two-thirds of patients achieved local control, with 5-year survival of 50%; therefore, better treatments are needed. We investigated whether replacing mitomycin with cisplatin in chemoradiation improves response, and whether maintenance chemotherapy after chemoradiation improves survival.

METHODS

In this 2 × 2 factorial trial, we enrolled patients with histologically confirmed squamous-cell carcinoma of the anus without metastatic disease from 59 centres in the UK. Patients were randomly assigned to one of four groups, to receive either mitomycin (12 mg/m(2) on day 1) or cisplatin (60 mg/m(2) on days 1 and 29), with fluorouracil (1000 mg/m(2) per day on days 1-4 and 29-32) and radiotherapy (50.4 Gy in 28 daily fractions); with or without two courses of maintenance chemotherapy (fluorouracil and cisplatin at weeks 11 and 14). The random allocation was generated by computer and patients assigned by telephone. Randomisation was done by minimisation and stratified by tumour site, T and N stage, sex, age, and renal function. Neither patients nor investigators were masked to assignment. Primary endpoints were complete response at 26 weeks and acute toxic effects (for chemoradiation), and progression-free survival (for maintenance). The primary analyses were done by intention to treat. This study is registered at controlled-trials.com, number 26715889.

FINDINGS

We enrolled 940 patients: 472 were assigned to mitomycin, of whom 246 were assigned to no maintenance, 226 to maintenance; 468 were assigned to cisplatin, of whom 246 were assigned to no maintenance, 222 to maintenance. Median follow-up was 5.1 years (IQR 3.9-6.9). 391 of 432 (90.5%) patients in the mitomycin group versus 386 of 431 (89.6%) in the cisplatin group had a complete response at 26 weeks (difference -0.9%, 95% CI -4.9 to 3.1; p=0.64). Overall, toxic effects were similar in each group (334/472 [71%] for mitomycin vs 337/468 [72%] for cisplatin). The most common grade 3-4 toxic effects were skin (228/472 [48%] vs 222/468 [47%]), pain (122/472 [26%] vs 135/468 [29%]), haematological (124/472 [26%] vs 73/468 [16%]), and gastrointestinal (75/472 [16%] vs 85/468 [18%]). 3-year progression-free survival was 74% (95% CI 69-77; maintenance) versus 73% (95% CI 68-77; no maintenance; hazard ratio 0.95, 95% CI 0.75-1.21; p=0.70).

INTERPRETATION

The results of our trial--the largest in anal cancer to date--show that fluorouracil and mitomycin with 50.4 Gy radiotherapy in 28 daily fractions should remain standard practice in the UK.

FUNDING

Cancer Research UK.

The Defect Structure of Yttria Stabilized Zirconia

We present results of EXAFS and computer simulation studies of the defect structure of yttria-stabilised zirconia. The results are analysed in terms of dopant-vacancy association models for this phase.

Small cell carcinoma of the anus: a case report

Small cell carcinoma of the anus is a very rare but aggressive tumour. We present a case of a 60-year old lady with small cell carcinoma of the anus. She had no metastatic disease on presentation. She had chemotherapy and radiotherapy but developed distant metastasis after completion of treatment. Immunohistochemistry is required to make a diagnosis. Chemotherapy remains the mainstay of treatment for small cell carcinoma of the anus with or without metastatic disease. Radiotherapy is for local control and relief of symptoms.

Serological survey for antibodies to Leptospira in dogs and raccoons in Washington State

A high number of reported canine leptospirosis cases occurred in Washington State from 2004 to 2006. This prompted a serosurvey of healthy dogs from around the state to determine the distribution of exposure risk and to provide insight into serovar epidemiology in the region. In addition, a convenience sample of sera from injured raccoons was also tested, and clinical serological data from the Washington Animal Disease Diagnostic Laboratory were examined. The proportion of dogs with an antibody titre (>or=1:100) to any serovar was 27/158 (17.1%, 95% CI 11.6-23.9), and that proportion among raccoons was 22/115 (19.1%, 95% CI 12.4-27.5) suggesting that the potential for exposure in Washington state is not uncommon. The most frequently detected serovars in healthy dogs were Autumnalis, Icterohemorrhagiae and Canicola, in clinical canine samples Autumnalis, Bratislava and Pomona were more frequent and in sick or injured raccoons Autumnalis, and Pomona were most frequently detected. Clinical canine serology demonstrated a late summer-fall seasonality that was consistent with other reports. An outbreak of canine leptospirosis occurred during 2004-2006 and was located primarily in western Washington counties, as were three reported human cases in 2005. Canine leptospirosis surveillance is an important tool for detecting human risk of exposure and may provide insights into which serovars are currently of clinical importance.

Greenhouse gas emissions from New Zealand agriculture: issues, perspectives and industry response

The prosperity of New Zealand (NZ) rests to a large extent on agriculture. Although our total greenhouse gas (GHG) emissions are unusually small for a developed nation, agricultural emissions make up almost half of the total emissions from NZ. Emissions from NZ agriculture have been rising at close to 1% a year since 1990 and by 2010, the midpoint of the first commitment period of the Kyoto Protocol, they are projected to be 7.2 Mt per year higher than the 1990 baseline. This excess has a potential cost of over NZ$0.5 billion. Despite the continued rise in absolute emissions, emissions intensity, the amount of GHG produced per unit of food produced, has been dropping and the emissions intensity of NZ agriculture goods compares favourably with that of other developed nations. The NZ agricultural sector has actively engaged in the search for cost-effective mitigation solutions and, in partnership with the government, has funded research through the Pastoral Greenhouse Gas Research Consortium (PGGRC). The PGGRC has been in existence since 2002 and has invested NZ$16 million in research into reducing methane and nitrous oxide emissions from pastoral agriculture. The structure of this research funding body, its objectives, achievements and future challenges are briefly outlined.

Docetaxel, cisplatin, and fluorouracil; docetaxel and cisplatin; and epirubicin, cisplatin, and fluorouracil as systemic treatment for advanced gastric carcinoma: a randomized phase II trial of the Swiss Group for Clinical Cancer Research

PURPOSE

This randomized phase II trial evaluated two docetaxel-based regimens to see which would be most promising according to overall response rate (ORR) for comparison in a phase III trial with epirubicin-cisplatin-fluorouracil (ECF) as first-line advanced gastric cancer therapy.

PATIENTS AND METHODS

Chemotherapy-naïve patients with measurable unresectable and/or metastatic gastric carcinoma, a performance status <or= 1, and adequate hematologic, hepatic, and renal function randomly received <or= eight 3-weekly cycles of ECF (epirubicin 50 mg/m(2) on day 1, cisplatin 60 mg/m(2) on day 1, and fluorouracil [FU] 200 mg/m(2)/d on days 1 to 21), TC (docetaxel initially 85 mg/m(2) on day 1 [later reduced to 75 mg/m(2) as a result of toxicity] and cisplatin 75 mg/m(2) on day 1), or TCF (TC plus FU 300 mg/m(2)/d on days 1 to 14). Study objectives included response (primary), survival, toxicity, and quality of life (QOL).

RESULTS

ORR was 25.0% (95% CI, 13% to 41%) for ECF, 18.5% (95% CI, 9% to 34%) for TC, and 36.6% (95% CI, 23% to 53%) for TCF (n = 119). Median overall survival times were 8.3, 11.0, and 10.4 months for ECF, TC, and TCF, respectively. Toxicity was acceptable, with one toxic death (TC arm). Grade 3 or 4 neutropenia occurred in more treatment cycles with docetaxel (TC, 49%; TCF, 57%; ECF, 34%). Global health status/QOL substantially improved with ECF and remained similar to baseline with both docetaxel regimens.

CONCLUSION

Time to response and ORR favor TCF over TC for further evaluation, particularly in the neoadjuvant setting. A trend towards increased myelosuppression and infectious complications with TCF versus TC or ECF was observed.

Safety study of induction chemotherapy and synchronous radiotherapy (RT) and cetuximab in stage III non-small cell lung cancer (NSCLC): SCRATCH (Cohort I)

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Background: The addition of cetuximab can increase the efficacy of chemotherapy for advanced NSCLC. Concomitant cetuximab and RT is superior to RT alone for locally advanced squamous cell head & neck carcinoma. The SCRATCH study (cohort I) is a phase I study to assess the safety of synchronous cetuximab and radical RT in patients with Stage III NSCLC. Methods: Cohort I will contain 12 patients with inoperable stage III NSCLC. Inclusion criteria are performance status 0–1, adequate organ function, and disease encompassable within a radical RT volume. Exclusion criteria are previous malignancy, thoracic RT or treatment with EGFR targeted therapy. Patients receive platinum-based induction chemotherapy, followed by weekly intravenous cetuximab (initial dose 400mg/m2; maintenance dose 250mg/m2) and concomitant RT (64Gy/32fractions/45days). The primary end-point is toxicity. NCI Common Toxicity Criteria (CTC) V3.0 assessments are performed weekly during radiotherapy, and at regular follow-up visits. Results: Data from the first 9 patients is available. 2 patients stopped receiving cetuximab early due to toxicity. 1 experienced grade 3 fatigue following the initial dose, and the other declined further treatment after developing grade 2 skin toxicity. 2 patients have died, 1 from disease progression and 1 from thromboembolic disease. Both deaths occurred between months 2 and 4 post RT and were not attributed to the cetuximab therapy. Of the 7 living patients, 2 have survived 1 year (measured from the first day of induction chemotherapy). The maximum NCI CTC V3.0 scores are summarised in the table below. Conclusions: The results suggest that the early and late toxicities of synchronous cetuximab and radical RT are acceptable. Data on all 12 patients will be available by June 2007. SCRATCH Study cohorts II-IV follow on and will recruit sequentially. They will assess the safety of adding concomitant cisplatin (±vinorelbine) to cetuximab and radical RT.

[Table: see text]

No significant financial relationships to disclose.

EXIBIT: An international multicenter phase II trial of gemcitabine and oxaliplatin (GEMOX) in patients with advanced biliary tract cancer

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Background: Biliary tract carcinomas (BTC) are often diagnosed at an advanced/metastatic stage and have a poor prognosis. The combination of gemcitabine and oxaliplatin (GEMOX) showed promising activity in a French Phase II study (4 centers) in advanced BTC (André. Ann Oncol 2004;15:1339–1343). The objective of this study is to further evaluate the efficacy and safety of GEMOX as first-line therapy in patients (pts) with advanced BTC. Methods: Eligible pts were >18 years of age with histologically proven and measurable, locally advanced or metastatic BTC, had an ECOG PS ≤ 2, adequate renal and hematologic functions, bilirubin < 2.5 × upper limit of normal, and no prior malignancy or brain metastases. Gemcitabine 1000 mg/m2 (Day 1) and oxaliplatin 100 mg/m2 (Day 2) were administered every 2 weeks. The primary objective was response rate (RR) by RECIST (one dimension); secondary objectives were progression-free survival (PFS), overall survival (OS), and safety. Here we report an interim analysis of OS and safety. Results: A total of 70 pts were enrolled between April 2003 and April 2005. The median age was 62 years (range 30–83), 40.0% of pts were male, 94.3% had ECOG PS 0–1. Tumor sites were intrahepatic bile ducts (37.1%), gallbladder (31.4%), extrahepatic bile ducts (12.9%), ampulla of Vater (1.4%), intra/extrahepatic bile ducts (1.4%), missing data (15.7%); 98.6% of pts had no prior radiotherapy and 50% had no prior surgery for BTC. Median OS is 8.25 months (68% of pts are dead and 32% have censored data). Sixty-seven pts were evaluable for safety. Grade 3/4 (NCI-CTC v. 2) hematologic toxicities (% of pts) included thrombocytopenia 10.4%, anemia 9.0%, and neutropenia 9.0%. One pt had febrile neutropenia. Grade 3/4 nonhematologic toxicities included pain 10.4%, ALT elevation 9.0%, fatigue 9.0%, infection 10.4%, vomiting 9.0%, sensory neuropathy 4.5%, nausea 4.5%, and diarrhea 3.0%. One patient died during treatment (cause unknown). Conclusions: GEMOX has acceptable toxicity in pts with BTC. Updated efficacy data (RR, PFS, and OS for the entire population and also by tumor sites) will be presented at the meeting.

[Table: see text]

Expression levels of asparagine synthetase in blasts from children and adults with acute lymphoblastic leukaemia

L-asparaginase is active in the treatment of acute lymphoblastic leukaemia (ALL) through the depletion of serum asparagine. Here we report that median asparagine synthetase (AS) mRNA levels were higher in acute myeloid leukaemia (AML) than ALL blasts in both children and adults, with intermediate levels in normal peripheral blood mononuclear cells (NPBMC). NPBMC versus child ALL (Tukeys multiple comparison test, P < 0.05); child ALL versus child AML (P < 0.001) and adult ALL versus adult AML (P < 0.01) were all significant and support the hypothesis that selectivity to treatment with l-asparaginase is due, at least in part, to lower AS expression.

Cognitive and behavioral performance among FMR1 high-repeat allele carriers surveyed from special education classes

The fragile X syndrome is caused by an unstable CGG repeat sequence in the 5' untranslated region of the X-linked, FMR1 gene. When the number of repeats exceeds 200, the region is hypermethylated and the gene is silenced. The lack of the protein produced by the FMR1 gene, FMRP, causes the fragile X syndrome. Recent evidence suggests that FMR1 alleles with unmethylated long repeat tracks (40-200 repeats) may cause a specific somatic phenotype in women, premature ovarian failure, and may cause variation in the levels of FMR1 mRNA and FMRP. Because FMR1 is known to be involved in the regulation of subset of genes expressed in the brain, we investigated the variation in cognitive and/or behavioral performance among carriers of high repeat alleles. Specifically, we administered cognitive, behavioral, and adaptive performance tests to children identified with high repeat alleles who attended special education classes in Atlanta, Georgia public schools and to those with < 40 repeats drawn from the same population. Overall, we found no significant effect of repeat size and the psychometric measures in our test battery after adjustment for multiple comparisons. All scales were found to be within 1 SD standard deviation of the mean. We did find an intriguing, albeit marginally statistically significant, association in the cognitive profile among males and not females, consistent with an X-linked effect. After adjusting for the overall cognitive abilities score, Verbal Ability scores decreased and Nonverbal Reasoning scores increased with repeat number to a greater extent in males than females. Spatial Ability scores were not associated with repeat number.

Aging research grows up

Long viewed as an insoluble enigma, aging is shedding its cloak of mystery as scientists start to understand why and how we age. Many studies support the theoretical argument that aging occurs because natural selection weakens with age, leaving us vulnerable to harmful, late-acting genes. As for what causes aging, scientists have narrowed the pack of candidates to a handful, including free radicals and reactions between glucose and proteins. In recent decades, many mechanisms for lengthening life in animals have come to light. By extending this research, scientists may be closing in on ways to lengthen the human life-span.

Structure-activity relationship for the endogenous cannabinoid, anandamide, and certain of its analogues at vanilloid receptors in transfected cells and vas deferens

1. This study was directed at exploring the structure-activity relationship for anandamide and certain of its analogues at the rat VR1 receptor in transfected cells and at investigating the relative extent to which anandamide interacts with CB(1) and vanilloid receptors in the mouse vas deferens. 2. pK(i) values for displacement of [(3)H]-resiniferatoxin from membranes of rVR1 transfected CHO cells were significantly less for anandamide (5.78) than for its structural analogues N-(4-hydroxyphenyl)-arachidonylamide (AM404; 6.18) and N-(3-methoxy-4-hydroxy)benzyl-arachidonylamide (arvanil; 6.77). 3. pEC(50) values for stimulating (45)Ca(2+) uptake into rVR1 transfected CHO cells were significantly less for anandamide (5.80) than for AM404 (6.32) or arvanil (9.29). Arvanil was also significantly more potent than capsaicin (pEC(50)=7.37), a compound with the same substituted benzyl polar head group as arvanil. 4. In the mouse vas deferens, resiniferatoxin was 218 times more potent than capsaicin as an inhibitor of electrically-evoked contractions. Both drugs were antagonized to a similar extent by capsazepine (pK(B)=6.93 and 7.18 respectively) but were not antagonized by SR141716A (1 microM). Anandamide was less susceptible than capsaicin to antagonism by capsazepine (pK(B)=6.02) and less susceptible to antagonism by SR141716A (pK(B)=8.66) than methanandamide (pK(B)=9.56). WIN55212 was antagonized by SR141716A (pK(B)=9.02) but not by capsazepine (10 microM). 5. In conclusion, anandamide and certain of its analogues have affinity and efficacy at the rat VR1 receptor. In the mouse vas deferens, which seems to express vanilloid and CB(1) receptors, both receptor types appear to contribute to anandamide-induced inhibition of evoked contractions.

Infusional 5-fluorouracil can be a pain in the neck: A case for repositioning displaced Hickman lines

Increasing numbers of patients receive infusional chemotherapy or total parenteral nutrition via Hickman or Grochong lines. Although the insertion of these indwelling catheters is generally performed under radiological guidance and their positions verified by chest radiography, it is still feasible for them to become displaced at a later date. This possibility should be excluded in patients who develop unusual symptoms during the course of their infusional therapy. We review the reported complications associated with Hickman lines, and present a case history demonstrating that interventional radiology has a valuable role in displaced line repositioning, after the exclusion of thrombosis and infection.