Radiotherapy Plus Cisplatin With or Without Lapatinib for Non-Human Papillomavirus Head and Neck Carcinoma: A Phase 2 Randomized Clinical Trial

Importance

Patients with locally advanced non-human papillomavirus (HPV) head and neck cancer (HNC) carry an unfavorable prognosis. Chemoradiotherapy (CRT) with cisplatin or anti-epidermal growth factor receptor (EGFR) antibody improves overall survival (OS) of patients with stage III to IV HNC, and preclinical data suggest that a small-molecule tyrosine kinase inhibitor dual EGFR and ERBB2 (formerly HER2 or HER2/neu) inhibitor may be more effective than anti-EGFR antibody therapy in HNC.

Objective

To examine whether adding lapatinib, a dual EGFR and HER2 inhibitor, to radiation plus cisplatin for frontline therapy of stage III to IV non-HPV HNC improves progression-free survival (PFS).

Design, Setting, and Participants

This multicenter, phase 2, double-blind, placebo-controlled randomized clinical trial enrolled 142 patients with stage III to IV carcinoma of the oropharynx (p16 negative), larynx, and hypopharynx with a Zubrod performance status of 0 to 1 who met predefined blood chemistry criteria from October 18, 2012, to April 18, 2017 (median follow-up, 4.1 years). Data analysis was performed from December 1, 2020, to December 4, 2020.

Intervention

Patients were randomized (1:1) to 70 Gy (6 weeks) plus 2 cycles of cisplatin (every 3 weeks) plus either 1500 mg per day of lapatinib (CRT plus lapatinib) or placebo (CRT plus placebo).

Main Outcomes and Measures

The primary end point was PFS, with 69 events required. Progression-free survival rates between arms for all randomized patients were compared by 1-sided log-rank test. Secondary end points included OS.

Results

Of the 142 patients enrolled, 127 (median [IQR] age, 58 [53-63] years; 98 [77.2%] male) were randomized; 63 to CRT plus lapatinib and 64 to CRT plus placebo. Final analysis did not suggest improvement in PFS (hazard ratio, 0.91; 95% CI, 0.56-1.46; P = .34) or OS (hazard ratio, 1.06; 95% CI, 0.61-1.86; P = .58) with the addition of lapatinib. There were no significant differences in grade 3 to 4 acute adverse event rates (83.3% [95% CI, 73.9%-92.8%] with CRT plus lapatinib vs 79.7% [95% CI, 69.4%-89.9%] with CRT plus placebo; P = .64) or late adverse event rates (44.4% [95% CI, 30.2%-57.8%] with CRT plus lapatinib vs 40.8% [95% CI, 27.1%-54.6%] with CRT plus placebo; P = .84).

Conclusion and Relevance

In this randomized clinical trial, dual EGFR-ERBB2 inhibition with lapatinib did not appear to enhance the benefit of CRT. Although the results of this trial indicate that accrual to a non-HPV HNC-specific trial is feasible, new strategies must be investigated to improve the outcome for this population with a poor prognosis.

Trial Registration

ClinicalTrials.gov Identifier: NCT01711658.

TRYHARD, a randomized phase II trial (RTOG Foundation 3501) of concurrent accelerated radiation plus cisplatin (cis) with or without lapatinib (Lap) for stage III- IV Non-HPV head and neck carcinoma (HNC)

6014

Background: Chemoradiation (CRT) with cis or anti-EGFR Ab has been shown to improve survival of patients with stage III-IV HNC. Since Lap, a dual EGFR and HER2 inhibitor, has shown effectiveness with CRT in a pilot non-HPV HNC cohort, the RTOG Foundation launched a phase II trial to test the hypothesis that adding Lap to the RT-cis for frontline therapy of stage III-IV Non-HPV HNC improves progression-free survival (PFS). Methods: Patients with stage III-IV carcinoma of the oropharynx (p16-negative), larynx, and hypopharynx, having Zubrod performance of 0-1, and meeting predefined blood chemistry criteria were enrolled after providing consent. Patients were randomized (1:1) to 70 Gy (6 weeks) + 2 cycles of CDDP (q3 weeks) plus either Lap (1500 mg daily, Arm A) or placebo (Arm B) starting 1 week prior to RT and concurrent with RT and for 3 months post RT. PFS was the primary endpoint. The protocol specified 69 PFS events (142 patients) for the final analysis based on HR = 0.65, 80% power, 1-sided alpha 0.20, and one interim efficacy and futility analysis at 50% information. PFS rates between arms for all randomized patients were compared by 1-sided log-rank test (1-sided alpha 0.1803). Overall survival (OS) was a secondary endpoint. Results: From 10/’12 to 04/’17, 142 patients were enrolled, of whom 127 were randomized, 63 to Arm A and 64 to Arm B. Arms A vs B, respectively, were similar in baseline patient characteristics, radiation delivery, completing ≥ 70 Gy (85.7% vs. 82.8%) and cisplatin delivery, completing 200 (±5%) mg/m2 (65.1% vs 70.3%), but dissimilar in Lap/placebo delivery (median dose, 87000 mg vs. 125250 mg). Median follow-up was 4.1 years for surviving patients. The final analysis suggests no improvement in PFS of adding Lap to CRT (HR [A/B]: 0.91, 95% confidence interval CI 0.56-1.46; P= 0.34; 2-year rates: 50.6%, CI 37.5-63.7% vs. 56.2% CI 43.0-69.4%), or in OS (HR: 1.06, CI 0.61-1.86; P = 0.58; 2-year rates: 71.8% CI 60.1-83.5% vs. 76% CI 64.5-87.4%), death within 30 days of therapy (3.3% vs. 3.4%), and overall treatment-related grade 3-5 adverse event rate (86.7% vs. 84.7%). Grade 3-4 mucositis rates on Arm A and Arm B were 21.7% vs. 23.7%, all grade dysphagia and rash rates were 43.3% vs. 59.3%, and 13.3% vs. 6.8%, respectively. Conclusions: The addition of Lap to the radiation-cisplatin platform did not improve progression-free or overall survival in unselected non-HPV HN. Thus, dual EGFR, HER-2 inhibition does not appear to enhance the effects of chemoradiation. Although we showed that accrual to a non-HPV HN specific trial is feasible, new strategies must be investigated to improve the outcome for this poor prognosis HN population.

A multi-institutional phase 2 trial of prostate stereotactic body radiation therapy (SBRT) using continuous real-time evaluation of prostate motion with patient-reported quality of life

PURPOSE

The use of stereotactic body radiation therapy (SBRT) for prostate cancer has been reported predominantly from single institutional studies, although concerns for broader adoption exist.

METHODS AND MATERIALS

From 2011 through 2013, 66 men were accrued to a phase 2 trial at 5 centers. SBRT consisted of 5 fractions of 7.4 Gy to a total dose of 37 Gy using conventional linear accelerators. Electromagnetic transponders were used for motion management. Health-related quality of life (HRQOL) was evaluated via the Expanded Prostate Cancer Index Composite 26 questionnaire. Acute and late toxicities were collected according to Common Terminology Criteria for Adverse Events, version 4.0. Linear mixed modeling was performed to assess changes in HRQOL over time.

RESULTS

Median follow-up was 36 months. All men had low- or intermediate-risk disease. There have been 0 biochemical recurrences. No grade 3 urinary or bowel toxicity was reported. Twenty-three percent of patients had acute grade 2 urinary toxicity, with 9% late grade 2 urinary toxicity. Four percent and 5% experienced acute or late grade 2+ bowel toxicity, respectively. Urinary bother and bowel HRQOL transiently decreased during the first 6 to 12 months post-SBRT, and then returned to baseline. In men with good erectile function at baseline, sexual HRQOL declined during the first 6 months and stabilized thereafter. On linear mixed modeling, the strongest predictor of sustained bowel and sexual HRQOL was baseline HRQOL.

CONCLUSIONS

In this multi-institutional phase 2 clinical trial using continuous real-time evaluation of prostate motion, prostate SBRT has excellent intermediate-term tumor control with mild and expected treatment-related side effects.

Dedicated linear accelerator radiosurgery for the treatment of trigeminal neuralgia

OBJECT

In this study the authors evaluate the efficacy of and complications associated with dedicated linear accelerator (LINAC) radiosurgery for trigeminal neuralgia (TN).

METHODS

Between August 1995 and February 2001, 60 patients whose median age was 66.1 years (range 45-88 years) were treated with dedicated LINAC radiosurgery for TN. Forty-one patients (68.3%) had essential TN, 12 (20%) had secondary facial pain, and seven (11.7%) had atypical features. Twenty-nine patients (48.3%) had undergone previous surgical procedures. Radiation doses varied between 70 and 90 Gy (mean 83.3 Gy) at the isocenter, with the last 35 patients (58.3%) treated with a 90-Gy dose. A 5-mm collimator was used in 45 patients (75%) and a 7.5-mm collimator in 15 patients (25%). Treatment was focused at the nerve root entry zone. At last follow up (mean follow-up period 23 months, range 2-70 months), 36 (87.8%) of the 41 patients with essential TN had sustained significant pain relief (good plus excellent results). Twenty-three patients (56.1%) were pain free without medication (excellent outcome), 13 (31.7%) had a 50 to 90% reduction in pain with or without medication (good outcome), and five (12.2%) had minor improvement or no relief. Of 12 patients with secondary facial pain, significant relief was sustained in seven patients (58.3%); worse results were found with atypical pain. Fifteen (25%) of the 60 patients experienced new numbness postprocedure; no other significant complications were found. Pain relief was experienced at a mean of 2.7 months (range 0-12 months).

CONCLUSIONS

Dedicated LINAC radiosurgery is a precise and effective treatment for TN.

Stereotactic radiotherapy for the treatment of lymphocytic hypophysitis. Report of two cases

Lymphocytic hypophysitis is a rare inflammatory disorder of the pituitary gland. Standard therapy consists of transsphenoidal resection or oral administration of corticosteroid medications. Two patients with symptomatic lymphocytic hypophysitis, which recurred after standard therapy, were treated with low-dose stereotactic radiotherapy. On imaging studies both lesions demonstrated a response to radiation and each patient experienced relief of symptoms. There has been no adverse sequela of the radiation treatment. The authors conclude that stereotactic radiotherapy represents an effective, noninvasive treatment option for patients with lymphocytic hypophysitis, particularly if the disease is recurrent after surgery or resistant to corticosteroid medications.

An analysis of MCNP cross-sections and tally methods for low-energy photon emitters

Monte Carlo calculations are frequently used to analyse a variety of radiological science applications using low-energy (10-1000 keV) photon sources. This study seeks to create a low-energy benchmark for the MCNP Monte Carlo code by simulating the absolute dose rate in water and the air-kerma rate for monoenergetic point sources with energies between 10 keV and 1 MeV. The analysis compares four cross-section datasets as well as the tally method for collision kerma versus absorbed dose. The total photon attenuation coefficient cross-section for low atomic number elements has changed significantly as cross-section data have changed between 1967 and 1989. Differences of up to 10% are observed in the photoelectric cross-section for water at 30 keV between the standard MCNP cross-section dataset (DLC-200) and the most recent XCOM/NIST tabulation. At 30 keV, the absolute dose rate in water at 1.0 cm from the source increases by 7.8% after replacing the DLC-200 photoelectric cross-sections for water with those from the XCOM/NIST tabulation. The differences in the absolute dose rate are analysed when calculated with either the MCNP absorbed dose tally or the collision kerma tally. Significant differences between the collision kerma tally and the absorbed dose tally can occur when using the DLC-200 attenuation coefficients in conjunction with a modern tabulation of mass energy-absorption coefficients.

Model 3500 125I brachytherapy source dosimetric characterization

Low-energy gamma-emitting isotopes encapsulated for permanent implant are routinely applied in brachytherapy, most notably for prostate cancer. Before clinical use of a new source design, a full dosimetric analysis and standardized calibration are essential. Results of experimental measurement and analysis are reported here for the I-Plant (Implant Sciences Corporation) 125I source, model 3500. Dose measurements were made using standard methods employing thermoluminscent dosimeters in a water equivalent plastic phantom. Precision machined bores in the phantom located dosimeters and source(s) in a reproducible fixed geometry providing for transverse-axis and angular dose profiles over a range of distances from 0.17 to 10 cm. The data were analyzed in terms of parameters recommended by AAPM TG-43. The dose-rate constant, delta = 1.01 cGy/h U (+/-6%) (1 U = 1 cGy cm2 h(-1)), was evaluated with reference to a TG-51 calibrated 60Co standard, accounting for dosimeter response differences between 60Co and 125I photons. The radial dose function, g(r), the anisotropy function, F(r, theta), the anisotropy factor, phi(an)(r), and the point-source approximation anisotropy constant, phi(an), were derived from one- and two-dimensional dose distribution data measured in the phantom, accounting for finite dosimeter volume and with attention to inter-chip effects. The results confirm prior dosimetric characterization of the model 3500, and indicate that the new source is comparable to the MED3631-A/M and 6702 source designs and may substitute for model 6711 in permanent implants for the treatment of prostate cancer.

Initial clinical results of stereotactic radiotherapy for the treatment of craniopharyngiomas

The efficacy and toxicity of stereotactic radiotherapy (SRT) for the treatment of craniopharyngioma has been retrospectively evaluated in 16 patients. The median tumor diameter was 2.8 cm (range 1.5-6.1) and the median tumor volume was 7.7 cc (range 0.7-62.8). SRT was delivered to a single isocenter using a dedicated 6 MV linear accelerator to patients immobilized with a relocatable stereotactic head frame. The three-year actuarial overall survival was 93% and the rate of survival free of any imaging evidence of progressive disease was 75%. The three-year actuarial survival rates free of solid tumor growth or cyst enlargement were 94% and 81% respectively. Our results suggest that SRT is a safe and effective treatment approach for patients with craniopharyngioma. Long-term follow-up is required to determine whether the normal tissue-sparing inherent with SRT results in reduction of the neurocognitive effects of conventional radiotherapy for craniopharyngioma. SRT can be delivered to craniopharyngioma that may be difficult to treat with stereotactic radiosurgery due to proximity of the optic chiasm. Further clinical experience is necessary to determine the clinical utility of beam shaping in the setting of SRT.

Dosimetric parameters of three new solid core I-125 brachytherapy sources

Monte Carlo calculations and TLD measurements have been performed for the purpose of characterizing dosimetric properties of new commercially available brachytherapy sources. All sources tested consisted of a solid core, upon which a thin layer of 125I has been adsorbed, encased within a titanium housing. The PharmaSeed BT-125 source manufactured by Syncor is available in silver or palladium core configurations while the ADVANTAGE source from IsoAid has silver only. Dosimetric properties, including the dose rate constant, radial dose function, and anisotropy characteristics were determined according to the TG-43 protocol. Additionally, the geometry function was calculated exactly using Monte Carlo and compared with both the point and line source approximations. The 1999 NIST standard was followed in determining air kerma strength. Dose rate constants were calculated to be 0.955+/-0.005, 0.967+/-0.005, and 0.962+/-0.005 cGy h(-1) x U(-1) for the PharmaSeed BT-125-1, BT-125-2, and ADVANTAGE sources, respectively. TLD measurements were in excellent agreement with Monte Carlo calculations. Radial dose function, g(r), calculated to a distance of 10 cm, and anisotropy function, F(r,theta), calculated for radii from 0.5 to 7.0 cm, were similar among all source configurations. Anisotropy constants, phi(an), were calculated to be 0.941, 0.944, and 0.960 for the three sources, respectively. All dosimetric parameters were found to be in close agreement with previously published data for similar source configurations. The MCNP Monte Carlo code appears to be ideally suited to low energy dosimetry applications.

Comparison of I-125 sources used for permanent interstitial implants

The increase in the number of manufacturers of 125I sources used in prostate brachytherapy has generated many questions in the radiation oncology community. In this investigation, the physical and dosimetric characteristics were evaluated for the following sources listed by marketing company and source model: Nycomed-Amersham 6711 (OncoSeed), Nycomed-Amersham 6702, Mentor IoGold, UroMed Symmetra, Imagyn IsoSTAR, UroCor, (PSA, Mallincrkrodt) ProstaSeed, Syncor PharmaSeed, SourceTech Medical, (BARD) 125Implant (BrachySource), Med-Tec I-Plant, Best Medical Model 2301, DraxImage BrachySeed, and International Brachytherapy, Inc. (IBT) InterSource125. The investigation examined the differences in design, construction, and the dosimetric characteristics created from each source. The dosimetric characteristics of the new sources were compared to that of the Amersham 6711 source. Parameter studies have led to the development of a simple equation that can be used to clinically convert the standard 6711 source strength to an equivalent strength of a new source.

Empirical dosimetric characterization of model I125-SL 125iodine brachytherapy source in phantom

Low-energy photon emitting radionuclides encapsulated for a permanent implant are routinely applied in prostate cancer brachytherapy. Before clinical use, a new source design requires full dosimetric analysis and calibration standardization. The results of one such experimental measurement and analysis are reported here for a new design of 125I source, model I125-SL. Dose measurements were made using standard methods employing thermoluminscent dosimeters in a water equivalent plastic phantom, in accord with the AAPM Task Group #43 recommendation of liquid water reference material. Precision machined bores in the phantom located dosimeters and source(s) in a reproducible fixed geometry providing for transverse-axis and angular dose profiles over a range of distances from 0.17 to 10 cm. The data were analyzed in terms of parameters recommended by AAPM TG43. The dose-rate constant, lambda, was evaluated by two methods, the first with reference to a 60Cobalt standard, accounting for response variation with photon energy spectrum. Second, the dose-rate constant was determined with reference to phantom measurements using NIST traceable calibrated model 6702 and 6711 sources. The radial dose function, g(r), the anisotropy function, F(r,theta), the anisotropy factor, phi(an)(r), and the point-source approximation anisotropy constant, phi(an), were derived from one- and two-dimensional dose distribution data measured in the phantom, accounting for finite dosimeter volume and with attention to interchip effects. The results are compared to TG43 and other existing data for 125I sources. The new source is comparable to the model 6711 source design.

Fitting and benchmarking of dosimetry data for new brachytherapy sources

New source designs of encapsulated low-energy gamma emitting nuclides for permanent implants require dosimetric analysis and calibration standardization. The dosimetry measurements can be incorporated into a treatment planning system by fitting the data. The use of a fitting function whose behavior at range limits mimics the physical phenomena, using as few parameters as possible, eliminates noisy outliers and lends credence to calculations beyond the measured range. Clinical implementation of the new sources also requires benchmarking against existing sources, where the current clinical experience lies. We present an analysis of measured dosimetry data for three brachytherapy sources recently available from North American Scientific, Inc. (North Hollywood, CA): 103Pd source model MED3633 ("PdGold"), 125I source models MED3631-A/M ("IoGold-AM") and MED3631-A/S ("IoGold-AS"). Using the formalism of the Interstitial Collaborative Working Group (ICWG) the radial dose function, g(r), the anisotropy function, F(r, theta), and the anisotropy factor, phi an(r), were previously evaluated from measurements of each source design. In this report we use fitting functions whose forms are chosen to approach reasonable values at data limits. These forms are quite similar to those used in a previous analysis of TG43 Iodine and palladium compendium data. Fitting parameter results for each function are provided for each brachytherapy source model. Fit-data discrepancies are smaller than measurement uncertainties, meaning that incorporation into treatment planning systems will not introduce significant errors in clinical use. Current clinical experience is based on the Theragenics (Norcross, GA) 103Pd seed ("PdThera"), and the Nycomed-Amersham (Arlington Heights, IL) 125I seed models 6711 ("6711") and 6702 ("6702"). The new sources are benchmarked against these seeds.

Dosimetric characterization of a new design 103 palladium brachytherapy source

Low-energy gamma emitting isotopes encapsulated for permanent implant are in routine use in the treatment of prostate cancer. New source designs require full dosimetric analysis and calibration standardization before responsible clinical application. The results of one such experimental measurement and analysis are here reported for a new design of 103palladium source, model MED3633 (North American Scientific, Inc.). By AAMP Task Group #43 recommendations, the reference material for brachytherapy dosimetry is liquid water. The dose measurements were made using standard methods employing thermoluminescent dosimeters in a water equivalent plastic phantom. Precision machined bores in the phantom located dosimeters and source(s) in a reproducible fixed geometry providing for transverse-axis and angular dose profiles over a range of distances from 0.17 to 7 cm. The data were analyzed in terms of parameters recommended by AAPM TG43. The dose-rate constant, lambda, was evaluated with reference to a 60 cobalt standard, accounting for response variation with isotope energy spectrum. The radial dose function, g(r), the anisotropy function, F(r, theta), the anisotropy factor, phi,un(r), and the point-source approximation anisotropy constant, phi(un), were derived from one- and two-dimensional dose distribution data measured in the phantom, accounting for finite dosimeter volume and with attention to interchip effects. The results are compared to TG43 and other existing data for 103Pd sources. The new source is comparable to the model 200 103Pd source design, demonstrating equivalent radial dose function, g(r). The dose surrounding a MED3633 source may be slightly more isotropic than for the model 200 source. The air-kerma strength of the MED3633 source used in this study was provided by the manufacturer and is traceable to the NIST 1999 standard. The evaluated dose-rate constant, lambda, with NIST traceable strength calibration is lower than that of the model 200 source, with that manufacturer's strength calibration.

Report on the dosimetry of a new design 125Iodine brachytherapy source

Dosimetric measurements were performed to characterize a new 125I source that is a variant design of an existing source, designated as MED3631-A/S, and that has application in interstitial brachytherapy. The new source, designated as MED3631-A/M, has centralized radio-opaque markers. In the original MED3631-A/S source, the radio-opaque markers are separated. Thermoluminescent dosimeters were placed in phantom to measure transverse axis and angular dose profiles over a range of distances from 0.5 to 7 cm. The data were analyzed in terms of parameters recommended by AAPM Task Group No. 43. Tabular data evaluated in liquid water are provided for the dose-rate constant, lambda, radial dose function, g(r), the anisotropy function, F(r,theta), the anisotropy factor, phi(an)(r), the point-source approximation anisotropy constant, phi(an). The dose-rate constant was determined by an absolute method using a Cobalt-60 reference and by relative measurements using calibrated 125I source(s). Values of the dose-rate constant are provided for both the 1985 and 1999 NIST air-kerma strength standards. The new source is comparable to both the MED3631-A/S and the model 6702 125I source designs, demonstrating equivalent radial dose function, g(r). Differences in the value of the dose-rate constant, lambda, and the anisotropy of the dose distributions in phantom are discussed in light of the improved isotropy of the new design, the MED3631-A/M source, and the uncertainty involved in the dose measurement using a Cobalt-60 reference.

Evaluation of a new brachytherapy iodine-125 source by AAPM TG43 formalism

Dosimetric measurements were performed to characterize a new 125I source that is similar in design to existing sources and that has application in interstitial brachytherapy. Thermoluminescent dosimeters were placed in phantom to measure transverse-axis and angular dose profiles over a range of distances from 0.5 to 7 cm. The data were analyzed in terms of parameters recommended by AAPM Task Group #43. Tabular data evaluated in liquid water are provided for the dose-rate constant, lambda, radial dose function, g(r), the anisotropy function, F(r, theta), the anisotropy factor, phi an(r), the point-source approximation anisotropy constant, phi an, and the point-source average dose rate times the square of distance for unit air kerma strength, r2D(r). The new source is compared to the model 6702 125I source design, demonstrating similar dose-rate constant, lambda, and radial dose function, g(r). Differences in the anisotropy of the dose distributions are discussed. Finally, a comparison of the radial dose distribution is made between liquid water and tissue equivalent materials.

Expression of human group II PLA2 in transgenic mice results in epidermal hyperplasia in the absence of inflammatory infiltrate

Group II PLA2 has been implicated in inflammatory processes in both man and other animals and has been shown to be involved in inflammatory conditions, such as arthritis and sepsis. Transgenic mice expressing the human group II PLA2 gene have been generated using a 6.2-kb genomic fragment. These mice express the group II PLA2 gene abundantly in liver, lung, kidney, and skin, and have serum PLA2 activity levels approximately eightfold higher than nontransgenic littermates. The group II PLA2 transgenic mice reported here exhibit epidermal and adnexal hyperplasia, hyperkeratosis, and almost total alopecia. The chronic epidermal hyperplasia and hyperkeratosis seen in these mice is similar to that seen in a variety of dermatopathies, including psoriasis. However, unlike what is seen with these dermatopathies, no significant inflammatory-cell influx was observed in the skin of these animals, or in any other tissue examined. These mice provide an important tool for examining group II PLA2 expression, and for determining the role of group II PLA2 in normal and disease physiology. They serve as an in vivo model for identifying inhibitors of group II PLA2 activity and gene expression.

Mutant and native human beta-amyloid precursor proteins in transgenic mouse brain

Human beta-amyloid precursor protein (beta APP) has been targeted to transgenic neurons using synapsin I promoter-based chimeric transgenes. Native human beta APP was introduced as well as beta APP containing mutations genetically linked to familial Alzheimer's disease (AD) and to hereditary cerebral hemorrhage with amyloidosis-Dutch type. In mouse brain, human beta APP RNA was up to 60% as abundant as total endogenous beta APP RNA. Human beta APP gene expression was most abundant in the CA subfields of the hippocampus and in the piriform cortex. Correct processing of human beta APP at the beta-secretase cleavage site was demonstrated in transgenic mouse brains. Despite a 40% increase in total beta APP immunoreactivity in lines expressing mutant human beta APP, no evidence of amyloid deposition was found in brains of mice up to 14 months in age. Higher levels of mutant human beta APP, increased age, or other factors may be necessary to elicit beta-amyloid-related neuropathologies in the rodent brain.

Transgenic mice expressing both human apolipoprotein B and human CETP have a lipoprotein cholesterol distribution similar to that of normolipidemic humans

Transgenic mice expressing both human apolipoprotein (apo) B and human cholesteryl ester transfer protein (CETP) have been developed. When fed a normal mouse chow diet, the apoB/CETP double transgenic animals had threefold higher serum CETP activity than humans and had human apoB levels that were similar to those of normolipidemic humans. When compared with nontransgenic mice, the total serum cholesterol levels in the female apoB/CETP transgenic animals were increased significantly. Serum HDL cholesterol levels were decreased significantly in both male and female apoB/CETP transgenic animals. The percentages of the total cholesterol within the HDL, LDL, and VLDL fractions of the apoB/CETP animals were approximately 30%, 65%, and 5%, respectively, similar to the distribution of cholesterol in the plasma of normolipidemic humans. Thus, by expressing both human apoB and human CETP, the lipoprotein cholesterol distribution in the serum of a chow-fed mouse was transformed into one that resembles a human profile.

Implications of tissue heterogeneity for radiosurgery in head and neck tumors

PURPOSE

This study was undertaken to investigate the perturbation of small radiation beams by low density heterogeneities and to evaluate the ability of a Monte Carlo code to account for such perturbation. Performance of an inexpensive film scanning system was also evaluated.

METHODS AND MATERIALS

Film and diode measurements were made in an acrylic phantom in which the size and position of an air gap were varied. Monte Carlo analysis was used to obtain additional verification of the measurements, to provide insight into photon and electron transport phenomena not directly measurable, and as a benchmark for the code.

RESULTS

With 10 MV photons and a 1 cm circular field, a small 3-mm air cavity placed 2.6 cm deep in acrylic (full buildup) results in a reduction in central axis dose of 21% immediately following the cavity. Equilibrium is then reestablished over the next centimeter, after which the dose exceeds that of the homogeneous case by 3-4%. The loss in central axis equilibrium is highly field-size dependent, with some loss occurring even for the largest (32 mm) collimator. In addition, the presence of the air cavity produces a significant increase in dose up to 2 cm lateral and outside the primary field.

CONCLUSIONS

Tissue heterogeneities are not presently accounted for in radiosurgery calculations, yet have the ability to perturb dose significantly. Targets may potentially be underdosed, and adjacent critical structures overdosed. Inability to account for tissue heterogeneities may limit the use of the radiosurgery approach in some areas. A Monte Carlo approach may be the method of choice for small field dose calculation when tissue heterogeneities are encountered.

Mineralization of mono- and dichlorobenzenes and simultaneous degradation of chloro- and methyl-substituted benzenes by the white rot fungus Phanerochaete chrysosporium

Phanerochaete chrysosporium extensively degraded and mineralized chlorobenzene and o-, m-, and p-dichlorobenzenes. The rate of degradation was in the following order: monochlorobenzene > m-dichlorobenzene > o-dichlorobenzene > p-dichlorobenzene. Net level of degradation was generally higher than mineralization. Maximal degradation and mineralization of chlorobenzenes were observed in malt extract cultures in which the lignin peroxidases and manganese peroxidases are not known to be produced. The fungus degraded both chlorobenzene and toluene when presented as a mixture, indicating its ability to simultaneously degrade chloro-substituted and methyl-substituted benzenes.

A verification of the Monte Carlo code MCNP for thick target bremsstrahlung calculations

The bremsstrahlung spectra from thick targets of Be, Al, and Pb are calculated using the Monte Carlo code MCNP (Monte Carlo N-particle). The current version of MCNP (v.4A) incorporates a coupled electron-photon transport scheme that allows the user to estimate the photon fluence produced from primary electron interactions. The simulation parameters are based on bremsstrahlung measurements of 15 MeV electrons incident on thick targets of Be, Al, and Pb at various angles between 0 degree and 90 degrees. The integrated yield and mean energy of each bremsstrahlung spectrum is calculated for the three targets at these angles. For angles less than 60 degrees the integrated yield calculated by MCNP4A is within 6% of measured values for the three targets. Furthermore, predicted mean energy is within 7% of the values derived from measurement for all angles tested. Also compared are the performances of two MCNP4A fluence tallies; a next-event estimator (detector tally) and a track length estimator (cell tally). Timing studies indicate the detector tally will perform the integrated yield calculations to a precision of 1% approximately 10 to 50 times faster than the conventional cell tally for an emission angle of 0 degree.

Mutational spectrum of revertants in the hisD3052 allele of Salmonella typhimurium induced by hydrogen peroxide-activated benzidine

Benzidine is mutagenic in a modified Ames (Salmonella typhimurium) assay, which uses hydrogen peroxide-dependent peroxidative activation. The mutational specificity of benzidine was investigated in tester strain TA98, which reverts by frameshifts of the hisD3052 allele. The most frequently observed mutation is a deletion of two bases from a (CG)4 run. This deletion was elevated in frequency among benzidine-induced revertants, relative to spontaneous revertants. Many other mutations were also observed, including additions, deletions, and complex events. Only small frameshifts were observed among the benzidine-induced revertants, whereas some larger deletions were observed among the spontaneous revertants.

A new family of water-soluble, third generation antitumor platinum complexes

[1,1-Cyclobutanedicarboxylato(2)-O,O'](1,3-dioxane-5,5-dimethan amine- N,N')platinum(II), 3a, a third generation, very water-soluble platinum complex, has been synthesized along with several of its analogues. All members of the new family contain a 1,3-dioxane or 1,3-dioxolane-1,3-diamine as their basic ligand, a moiety which contributes to their increased water solubility, and a bidentate acid ligand, which is responsible for their good stability. They were all easily crystallized and characterized by 1H NMR and elemental analysis, and the parent complex 3a was further characterized by 13C NMR. Their very desirable physical properties combined with their broad spectrum of antitumor activity and reduced toxicity make them good candidates of further development.

Arabinofuranosyl-5-azacytosine: activity against human tumors in athymic mice

Arabinofuranosyl-5-azacytosine (Ara-AC), a new compound structurally related to arabinofuranosylcytosine (Ara-C) and 5-azacytidine (5-AC), has demonstrated significant therapeutic activity against a wide spectrum of murine tumors and three human tumor xenografts in the NCI tumor panel. Studies on the activity of Ara-AC in these and other human tumor xenograft models were undertaken to define its potential anti-human-tumor profile more completely. Ara-AC demonstrated marked antitumor activity against human tumor xenografts, including leukemias and solid tumors that do not respond to Ara-C or 5-AC. An important finding was the demonstration that Ara-AC was as effective by the oral route as when given intraperitoneally. Furthermore, the compound demonstrated synergism when combined with cisplatin in the treatment of refractory solid tumors and also induced monocyte-type differentiation of promyelocytic leukemia (HL-60) cells in vitro. Ara-AC is a promising new compound that may have utility in the treatment of human cancer beyond that anticipated for a cytotoxic nucleoside.

Characterization of Vero cells

A cell line used in the production of biologicals should be free of infectious agents, and 'described with respect to cytogenetic characteristics and tumorigenicity'. Vero, a continuous cell line derived from a normal African green monkey kidney, was examined for the presence of retroviruses and for tumorigenic potential. We were unable to detect the presence of retroviruses by reverse transcriptase assay, electron microscopy or hybridization of cellular genomic DNA with Mason-Pfizer monkey virus DNA probes. In addition, passage 156 Vero cells did not form progressively growing tumors in nude mice or grow with high efficiency in soft agarose.

Development of resistance and characteristics of a human colon carcinoma subline resistant to mitoxantrone in vitro

A subline of human colon carcinoma cells (WiDr/R) resistant to the cytotoxic effects of mitoxantrone in vitro, was developed by continuous exposure to increasing concentrations of drug. After 16 culture passages in the presence of mitoxantrone, a cell population emerged which was 30-40 times more resistant to the cytolytic effect of mitoxantrone than the mitoxantrone-sensitive parent (WiDr/S) line. Resistance to mitoxantrone was retained by WiDr/R cells propagated for more than 40 cell generations in mitoxantrone-free medium. Decreased drug sensitivity was strongly associated with reduced intracellular accumulation of mitoxantrone. Moderate differences in drug retention by sensitive and resistant cells were demonstrated. However, decreased uptake due to alterations at the cell membrane which impair transport of drug into the cell, reducing interaction with DNA, appears to be the principal basis of resistance in these cells.

Modulation of the immune response to tumors by a novel synthetic compound, N-[4-[(4-fluorophenyl)sulfonyl]phenyl] acetamide (CL 259,763)

CL 259,763, N-[4-[(4-fluorophenyl)sulfonyl]phenyl] acetamide, is an orally active compound capable of modifying the reactivity of certain lymphoid cell populations affected by the growth of a tumor. The compound augmented the response of lymphocytes from tumor-primed animals to syngeneic tumor cells, resulting in a marked increase in tumor cell destruction. Likewise, it enhanced macrophage inhibitory effects on the growth of tumor cells in vitro. These "activated" macrophages were detectable in peritoneal exudates of treated mice 4 to 12 days after receiving a single oral dose of CL 259,763, with peak activity being demonstrable by day 7. The compound also restored the alloreactivity of lymphocytes from immunodepressed mice bearing the Lieberman plasma cell tumor, possibly by interfering with suppressor cells. Macrophages and lymphocytes from treated mice released significantly more IL-1 and IL-2-like factors in culture than did the control counterparts. Sera from treated mice also possessed more colony stimulating factor than those from normal mice. Immunoadjuvant effects were evident when the compound was administered with an inactivated L1210 leukemia vaccine and it enhanced the effectiveness of cytotoxic chemotherapy when given to mice challenged with P388 murine leukemia. These immunomodulating effects of CL 259,763 may hopefully be exploited in efforts to augment the immune response of the host to a progressively growing tumor.

Induction of alloreactive immunosuppression by 1,4-bis [( 2-aminoethyl)amino]-5,8-dihydroxy-9,10-anthracenedione dihydrochloride (CL 232,468)

1,4-bis[2-aminoethyl)amino]-5,8-dihydroxy-9,10-anthracenedione (AEAD) has been investigated for its potential immunosuppressive effect on cell-mediated immune responses. Addition of the compound to mixed lymphocyte cultures (MLC) not only significantly inhibited these cells from responding to alloantigens but also prevented the induction of cytolytic T lymphocytes (CTL). A structurally related compound, mitoxantrone, was also found to be active in inhibiting CTL induction. AEAD had to be present during the first 3 days of a 5-day MLC in order to produce a significant effect and it had no effect on those CTL already generated, suggesting that it acted upon induction of CTL rather than the effector phase. Lymphocytes from mice treated with the compound were incapable of responding to alloantigens in vitro and the effect was dose- and time-dependent. Furthermore, lymphocytes from treated mice were found to inhibit CTL generation from normal mouse lymphocytes, indicating that a suppressor cell population might be induced in the spleens of animals treated with the compound. The present findings clearly demonstrate that AEAD is a compound with potent immunosuppressive activity on alloreactive immune responses.

Molecular and biochemical pharmacology of mitoxantrone

Evidence has been presented which indicates that Nv: intercalates DNA and additionally causes inter- and intra-strand crosslinking possibly associated with its charged side arms; there is an apparent preference for G-C base pairs; induces single strand and double strand breaks in DNA; strongly inhibits DNA and RNA synthesis; causes nuclear aberrations and chromosomal scattering; induces a block in the G2 phase of the cell cycle with an increase in cellular RNA and polyploidy; is not cell cycle phase-specific with respect to cell kill; does not induce free-radical formation; does not induce lipid peroxidation or superoxide formation; rather it may inhibit ADR-stimulated lipid peroxidation and microsomal superoxide production; does not appear to have a strong potential for cardiotoxicity on the basis of currently postulated mechanisms of action; is capable of inducing cellular resistance in vitro; resistance is associated with an apparent alteration in the cell membrane impairing drug transport into the cell. Although the precise mechanism(s) of tumor cell killing has not been fully defined it is most likely associated with an interaction by Nv with chromosomes resulting in DNA damage, which if not efficiently repaired, will lead to inhibition of nucleic acid synthesis and eventual cell death.

Antitumor agents. 2. Bisguanylhydrazones of anthracene-9,10-dicarboxaldehydes

9,10-Anthracenedicarboxaldehyde bis[(4,5-dihydro-1H-imidazol-2-yl)hydrazone] (bisantrene, VI-1) showed anticancer activity in mice vs. both leukemias and solid tumors. Increases in life span vs. the following neoplasms were: P-388 leukemia, 137%; B-16 melanoma, 122%; Lieberman plasma cell tumor, greater than 85%; colon tumor 26, 150%; Ridgway osteogenic sarcoma, 85%. There were significant numbers of long-term survivors. Both DNA and RNA synthesis were strongly inhibited. The drug was resistant to biodegradation and was bound strongly to tissues; in monkeys the half-life for disappearance from serum was 6 days. Related hydrazones were synthesized, and structure-activity relationships are discussed. Two routes to ring-substituted anthracene-9,10-dicarboxaldehyde intermediates were developed.

Activity of a novel anthracenyl bishydrazone, 9,10-anthracenedicarboxyaldehyde Bis[(4,5-dihydro-1H-imidazol-2-yl)hydrazone] dihydrochloride, against experimental tumors in mice

9,10-Anthracenedicarboxaldehyde bis[(4,5-dihydro-1H-imidazol-2-yl)hydrazone] dihydrochloride (CL 216942; bisantrene hydrochloride; NSC 337766), a member of a new chemical class of compounds with antineoplastic properties, has been evaluated for antitumor activity in experimental murine tumor systems. The compound produced significant increases in life span (LS) and long-term survivors among mice bearing transplantable leukemias and solid tumors. Optimal treatment regimens resulted in an ILS of greater than 173 and 151% in mice with P388 and L1210 leukemia, respectively, an ILS of greater than 85% in mice with Lieberman plasma cell tumor, and an ILS of greater than 200, 150, and 63%, respectively, in mice with B16 melanoma, colon tumor 26, and Ridgway osteogenic sarcoma. An adriamycin-resistant subline of P388 leukemia showed complete cross-resistance to CL of 216942. The compound was active when administered by the i.p., i.v., and s.c. routes, but p.o. activity was not observed. Significant schedule dependency was not observed when the drug was administered once daily for 9 days, once every 4 days, or as a single dose, but single doses typically produced the best effects. CL 216942 was a potent inhibitor of DNA and RNA synthesis in L5178Y lymphoma cells cultured in vitro, and preliminary studies indicated the drug was a DNA-intercalating agent. The drug was cytotoxic for rapidly proliferating and nonproliferating (G0) human colon carcinoma WiDR cells in vitro.U

Computer calculation of the dose distribution in the electron build-up region

A procedure has been developed for producing accurate computer-calculated dose distributions at the air-tissue boundaries for oblique incidence of a photon beam. Measurements of the dose distribution under conditions of tangential incidence are presented for a Siemens 6 MV linear accelerator. These measurements have been compared with calculated distributions using the standard Cunningham-Clarkson calculation technique. Based on this comparison, two changes are suggested for improving the accuracy of the calculation. The grid spacing for the calculation is decreased in order that the rapid dose variations that occur at the boundary may be better followed. Furthermore, the dose calculation scheme is modified to take into account the differences in the amount of electron build-up which occurs. An algorithm is presented for making this modification. Also, the calculated dose at the exit surface had to be modified to handle the deficit of scatter material behind the calculation points. The results of these changes are shown as a comparison of a typical chest wall irradiation treatment plan using two opposing tangential fields.

Antitumor agents. 1. 1,4-Bis[(aminoalkyl)amino]-9,10-anthracenediones

The condensation of alkylenediamines with quinizarin or with 2,3-dihydro-1,4,5,8-tetrahydroxy-9,10-anthracenedione, followed by oxidation, gave 1,4-bis[aminoalkyl)amino]-9,10-anthracenediones. Some of these compounds and their 2,3-dihydro derivatives were markedly active against both leukemias and solid tumors in mice. Activity was maximal with 5,8-dihydroxylation and 1,4-bis[(2-aminoethyl)amino] substitution, in which the terminal nitrogen atoms were either unsubstituted (compound 50) or carried 2-hydroxyethyl groups (compound 40), indicating the importance of hydrophilicity. Against B-16 melanoma, 50 gave greater than 433% increase in median life span (ILS) with 7/10 80-day survivors. Against P-388 leukemia, 40 gave greater than 500% ILS with 4/5.60-day survivors; its efficacy and therapeutic index equaled or surpassed those of adriamycin, cyclophosphamide, daunorubicin, methotrexate, or 5-fluorouracil. Against L-1210 leukemia, B-16 melanoma, and colon tumor 26, 40 was generally as effective or more effective than adriamycin and is now undergoing preclinical toxicological evaluation.

Activity of a novel anthracenedione, 1,4-dihydroxy-5,8-bis(((2-[(2-hydroxyethyl)amino]ethyl)amino])-9,10-anthracenedione dihydrochloride, against experimental tumors in mice

1,4-Dihydroxy-5,8-bis(((2[(2-hydroxyethyl)amino]ethyl)amino))-9,-10-anthracenedione dihydrochloride (CL 232315; NSC 301739D), a representative of a new chemical class of compounds with antineoplastic properties, has been evaluated for antitumor activity in experimental mouse tumor systems. The compound produced significant increases in life span (ILS) and long-term survivors when tested against the P388 and L1210 leukemias as well as the solid neoplasms, B16 melanoma and Colon Tumor 26. The optimal treatment regimens resulted in a 173 to greater than 200% ILS with 20 to 80% 60-day survivors in mice with P388 leukemia, A 205% ILS with 55% 60-day survivors in mice with L1210 leukemia, and an ILS of greater than 300% with 80% 90-day survivors in mice with B16 melanoma. In contrast to Adriamycin, CL 232315 was active against the i.v. implanted L1210 leukemia and demonstrated moderate activity against P388/Adria, a subline of P388 resistant to Adriamycin. The compound was ineffective when tested against the Lewis lung carcinoma and the Ridgway osteogenic sarcoma. CL 232315 was active i.p., s.c., and i.v., but p.o. activity was not demonstrated. Schedule dependency was not observed when the compound was administered once daily for nine days, once every four days, or as a single dose.

Safety of viral vaccine cell substrates: a reevaluation

Primary cultures of African green monkey kidney and rabbit kidney as well as diploid cell lines WI-38 and DBS-FRhL-2 were examined for evidence of tumorigenicity and latent RNA tumor viruses. Cells inoculated into immunosuppressed newborn hamsters and rhesus monkeys were not tumorigenic. Cells treated with 2'-deoxy-5-iodouridine to induce the production of latent viruses were examined by electron microscopy, density gradient centrifugation, and the reverse transcriptase enzyme assay. No evidence was found for RNA tumor viruses by the biochemical or biophysical methods used. The results indicated that each type of mammalian cell currently used in the production of virus vaccines would be acceptable for these parameters of safety if similar control procedures were applied at the time the vaccines were manufactured.