Long-term survival of breast cancer patients with brain metastases: subanalysis of the BMBC registry

BACKGROUND

Up to 30% of metastatic breast cancer (BC) patients develop brain metastases (BM). Prognosis of patients with BM is poor and long-term survival is rare. Identification of factors associated with long-term survival is important for improving treatment modalities.

PATIENTS AND METHODS

A total of 2889 patients of the national registry for BM in BC (BMBC) were available for this analysis. Long-term survival was defined as overall survival (OS) in the upper third of the failure curve resulting in a cut-off of 15 months. A total of 887 patients were categorized as long-term survivors.

RESULTS

Long-term survivors compared to other patients were younger at BC and BM diagnosis (median 48 versus 54 years and 53 versus 59 years), more often had HER2-positive tumors (59.1% versus 36.3%), less frequently luminal-like (29.1% versus 35.7%) or triple-negative breast cancer (TNBC) (11.9% versus 28.1%), showed better Eastern Cooperative Oncology Group (ECOG) performance status (PS) at the time of BM diagnosis (ECOG 0-1, 76.9% versus 51.0%), higher pathological complete remission rates after neoadjuvant chemotherapy (21.6% versus 13.7%) and lower number of BM (n = 1, BM 40.9% versus 25.4%; n = 2-3, BM 26.5% versus 26.7%; n ≥4, BM 32.6% versus 47.9%) (P < 0.001). Long-term survivors had leptomeningeal metastases (10.4% versus 17.5%) and extracranial metastases (ECM, 73.6% versus 82.5%) less frequently, and asymptomatic BM more often at the time of BM diagnosis (26.5% versus 20.1%), (P < 0.001). Median OS in long-term survivors was about two times higher than the cut-off of 15 months: 30.9 months [interquartile range (IQR) 30.3] overall, 33.9 months (IQR 37.1) in HER2-positive, 26.9 months (IQR 22.0) in luminal-like and 26.5 months (IQR 18.2) in TNBC patients.

CONCLUSIONS

In our analysis, long-term survival of BC patients with BM was associated with better ECOG PS, younger age, HER2-positive subtype, lower number of BM and less extended visceral metastases. Patients with these clinical features might be more eligible for extended local brain and systemic treatment.

Characteristics of patients with brain metastases from human epidermal growth factor receptor 2-positive breast cancer: subanalysis of Brain Metastases in Breast Cancer Registry

Background

Up to 40% of patients with metastatic human epidermal growth factor receptor 2 (HER2)-positive breast cancer develop brain metastases (BMs). Understanding of clinical features of these patients with HER2-positive breast cancer and BMs is vital.

Patients and methods

A total of 2948 patients from the Brain Metastases in Breast Cancer registry were available for this analysis, of whom 1311 had primary tumors with the HER2-positive subtype.

Results

Patients with HER2-positive breast cancer and BMs were—when compared with HER2-negative patients—slightly younger at the time of breast cancer and BM diagnosis, had a higher pathologic complete response rate after neoadjuvant chemotherapy and a higher tumor grade. Furthermore, extracranial metastases at the time of BM diagnosis were less common in HER2-positive patients, when compared with HER2-negative patients. HER2-positive patients had more often BMs in the posterior fossa, but less commonly leptomeningeal metastases. The median overall survival (OS) in all HER2-positive patients was 13.2 months (95% confidence interval 11.4-14.4). The following factors were associated with shorter OS (multivariate analysis): older age at BM diagnosis [≥60 versus <60 years: hazard ratio (HR) 1.63, P < 0.001], lower Eastern Cooperative Oncology Group status (2-4 versus 0-1: HR 1.59, P < 0.001), higher number of BMs (2-3 versus 1: HR 1.30, P = 0.082; ≥4 versus 1: HR 1.51, P = 0.004; global P = 0.015), BMs in the fossa anterior (HR 1.71, P < 0.001), leptomeningeal metastases (HR 1.63, P = 0.012), symptomatic BMs at diagnosis (HR 1.35, P = 0.033) and extracranial metastases at diagnosis of BMs (HR 1.43, P = 0.020). The application of targeted therapy after the BM diagnosis (HR 0.62, P < 0.001) was associated with longer OS. HER2-positive/hormone receptor-positive patients showed longer OS than HER2-positive/hormone receptor-negative patients (median 14.3 versus 10.9 months; HR 0.86, P = 0.03), but no differences in progression-free survival were seen between both groups.

Conclusions

We identified factors associated with the prognosis of HER2-positive patients with BMs. Further research is needed to understand the factors determining the longer survival of HER2-positive/hormone receptor-positive patients.

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Patients with HER2-positive BMs from breast cancer have the best prognosis compared with other tumor subtypes.

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Among HER2-positive patients, hormone receptor-positive patients have the longest survival.

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HER2-targeted therapy is significantly associated with a better prognosis in patients with BMs.

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On average, two HER2-targeted therapy lines were administered prior to the development of BMs.

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New compounds are urgently needed to improve the outcome of this subgroup of patients.

Moral Distress and Involuntary COVID-19 Vaccination of a Mature Minor Receiving Inpatient Psychiatric Treatment

Mandatory vaccination against COVID-19 is a highly controversial issue, and many members of the public oppose it on the grounds that they should be free to determine what happens to their own body. Opinion has generally favored parental authority with respect to vaccination of children, but less attention has been paid to the ethical complexities of how to respond when mature minors refuse vaccination that is requested by their parents. We present a case in which an mature minor, who was psychiatrically hospitalized, refused vaccination that had been requested by her parents, which lead to significant moral distress for her caregivers.

Abstract P4-08-26: Validation of different prognostic scores in breast cancer patients with brain metastases of the BMBC registry (GBG-79)

Background

The incidence of brain metastases from breast cancer is increasing and treatment is a major challenge. Different scores were developed to estimate the prognosis of patients with brain metastases by objective criteria. Sperduto et al. established the disease-specific breast-graded prognostic assessment (GPA) score in 400 breast cancer patients which includes age, performance status and tumor subtype. It has been described that the Breast- GPA best identifies patients with bad prognosis (Laakmann et al. 2016). Aim of this analysis was to validate the Breast-GPA in a large cohort of breast cancer patients with brain metastases.

Materials and methods

Data of 613 breast cancer patients from the Brain Metastases in Breast Cancer (BMBC) registry treated in 80 different clinical German institutions between 2000 and 2016 was analyzed.

Results

135 patients (22%) had a triple-negative, 199 (32%) a luminal-like und 279 (46%) a HER2-positive primary breast cancer. At diagnosis of brain metastases most patients had a good Karnofsky performance status (100%: 14.4%, 80-90%: 44.7%, 60-70%: 28.9%, 40-50%: 9.0%, 10-30%: 3.1%). Median age of patients was 56 years (22-90 years).

Median survival in the overall cohort was 7.1 months (95% CI 6.2-7.8 months).

Distribution of GPA scores was: 0-1: 11.9% (n=73), 1,5-2: 22.3% (n=137), 2,5-3: 47.8% (n=293), 3,5-4: 18% (n=110).

Median overall survival within the GPA-subgroups varied between 2.4 (CI95% 2.0 - 3.4); 4.8 (3.6 - 6.9); 9.2 (7.2 - 11.3) and 12.3 (8.9 - 18.0) months and, thus, was significantly shorter compared with the times published by Sperduto et al. (3.4; 7.7; 15.1 und 25.3 months).

Conclusions

The breast-GPA is easy to calculate in clinical routine, allows to assess patients` prognosis objectively and can facilitate making therapeutic decisions. However, absolute survival may differ from the originally published cohort in other settings.

Citation Format: Witzel ID, Riecke K, Laakmann E, Weide R, Neunhoeffer T, Park-Simon T-W, Schmidt M, Fasching PA, Hesse T, Polasik A, Mohrmann S, Würschmidt F, Schem C, Bechtner C, Würstlein R, Fehm T, Möbus V, Burchardi N, Loibl S, Müller V. Validation of different prognostic scores in breast cancer patients with brain metastases of the BMBC registry (GBG-79) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-08-26.

Treatment and outcomes of patients in the Brain Metastases in Breast Cancer Network Registry

BACKGROUND

Brain metastases (BMs) have a major impact on life expectancy and quality of life for many breast cancer patients. Knowledge about treatment patterns and outcomes is limited.

METHODS

We analysed clinical data of 1712 patients diagnosed with BMs from breast cancer between January 2000 and December 2016 at 80 institutions.

RESULTS

Median age at diagnosis of BMs was 56 years (22-90 years). About 47.8% (n = 732) of patients had HER2-positive, 21.4% (n = 328) had triple-negative and 30.8% (n = 471) had hormone receptor (HR)-positive, HER2-negative (luminal-like) primary tumours. The proportion of patients with HER2-positive BMs decreased comparing the years 2000-2009 with 2010-2015 (51%-44%), whereas the percentage of patients with luminal-like tumours increased (28%-34%; p = 0.0331). Patients with BMs in the posterior fossa were more often HER2 positive (n = 169/314, 53.8%) than those diagnosed with triple-negative (n = 65/314, 20.7%) or luminal-like primary breast cancer (n = 80/314, 25.5%), (p < 0.0001). Median overall survival (OS) time after development of BMs for the overall cohort was 7.4 months (95% confidence interval [CI]: 6.7-8.0 months). One-year survival rate was 37.7% (95% CI: 35.2-40.1). Patients with HER2-positive tumours had the longest median OS of 11.6 months (95% CI: 10.0-13.4) compared with 5.9 months (95% CI: 5.0-7.2) for patients with luminal-like and 4.6 months (95% CI: 3.9-5.4) for patients with triple-negative tumours. Patients with HER2-positive tumours who received anti-HER2 treatment had longer median OS than those without (17.1 months versus 7.2 months, p < 0.0001).

CONCLUSIONS

Prognosis of patients after developing BMs varies significantly according to the subtype. The outcome in this cohort is similarly poor in triple-negative and HR-positive/HER2-negative patients. Our results underline the high medical need for improvement of treatment and prevention strategies for BMs in breast cancer patients.

Abstract P6-17-08: Brain metastases in breast cancer network Germany (BMBC, GBG 79): First analysis of 548 patients from the multicenter registry

Background: The incidence of brain metastases (BM) in breast cancer patients is rising and has become a major clinical challenge. So far, limited therapeutic options and insights into the biology of BM exist since only a few studies analyzed exclusively data of breast cancer patients. In order to improve this situation, our multicenter registry was initiated in 2014: Brain Metastases in Breast Cancer Network Germany (BMBC, GBG79).

Materials and Methods: Patients with BM diagnosed since 2000, a history of breast cancer and no history of other malignant or neurologic disease can be included. Registration is allowed retrospectively as well as prospectively into a web–based database ("MedCodes"). Characteristics of the primary tumor, metastatic disease and BM as well as treatment details are documented. For this first analysis, 548 patients from 39 German centers were included.

Results: Median age at first diagnosis of BM was 55 years (25 – 90 years). 43% of patients (233/548) were HER2 positive, 19% (n=105) were triple–negative and 25% (n= 138) had luminal primary tumors indicating a selection of patients with specific tumor biology who develop BM. 54 % of the patients (n=267) had up to three BM whereas 45% (n=223) had more than three BM. 19% of patients (n=106) had BM without evidence of extracranial disease. 27% of the patients (n=146) underwent surgery of the BM. Of these patients, 61% (n= 89) were treated with whole brain radiotherapy and 16% (n=23) with stereotactic radiotherapy. In patients without surgery (n=397), 73% (n=289) received whole brain radiotherapy and 7% (n=28) stereotactic radiotherapy.

Median time from diagnosis of primary breast cancer to BM was 38.5 month for the entire cohort (CI95% 35.4 – 43.3). The time from first diagnosis to BM was shorter for triple–negative patients (20.9 month, CI95% 15.5 – 25.9) compared with patients with HER2–positive (37.0 month, CI95% 30.5 – 42.0) or luminal tumors (48.3 month, CI95% 38.2 – 54.0) (p&lt;0.001). Median time from first diagnosis of BM to death in the entire cohort was 6.1 months (CI95%: 5.2 – 7.3). One year survival rate from diagnosis of BM was 32.2 % (CI95%: 2.2 – 67.8). Regarding tumor subtypes, HER2–positive patients had the longest median survival with 9.4 months (CI95%: 7.1 – 13.4) compared with 6 months (CI95%: 4.0 – 7.3) for luminal primary tumors and 3.2 months (CI95%: 2.1 – 4.6) for triple–negative patients (p&lt;0.001). HER2 positive patients receiving HER2–directed therapy after the diagnosis of BM lived longer than those without (median 9.6 vs. 5.5 months, p=0.029). Regarding the number of BM, no difference in survival was observed between one, two or three BM (median survival of 7.8 months). However, survival was shorter in those patients with more than three BM (5.2 months; p=0.007).

Conclusion: This is so far the largest analysis of breast cancer patients with BM treated in Germany. In this cohort, triple–negative subtype or more than three BM were associated with shorter survival from the diagnosis of BM. HER2 positive patients with no HER2 directed therapy after the diagnosis of BM showed a shorter survival. The recruitment of the registry is ongoing and we aim to include more than 1000 patients by the end of 2015.

Citation Format: Witzel I, Loibl S, Laakmann E, Augustin D, Flock F, Dohmen H-H, Durmus G, Frank M, Hesse T, Ignatov A, Kühn T, Neunhöffer T, Park-Simon T-W, Schmidt M, Stefek A, Weide R, Würschmidt F, Fehm T, Moebus V, von Minckwitz G, Burchardi N, Mueller V. Brain metastases in breast cancer network Germany (BMBC, GBG 79): First analysis of 548 patients from the multicenter registry. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-17-08.

Abstract P4-14-08: Efficacy of trastuzumab re-therapy in the clinical routine of HER2-positive breast cancer patients who relapsed after completed anti-HER2 (neo)adjuvant therapy – 5th interim analysis of the national non-interventional study (NIS) ML21589

Background

HER2 overexpression occurs in approx. 20% of breast tumors and is associated with increased aggressiveness and mortality. Anti-HER2 re-therapy with trastuzumab (Herceptin®, T) is an established therapeutic option for the treatment of recurrent/metastatic HER2-positive breast cancer (MBC). Patients (pts) receiving T re-therapy appear to benefit from the retreatment after a relapse-free (neo)adjuvant anti-HER2 therapy.

Methods

This NIS is conducted in Germany to gain additional knowledge about efficacy of 1st-line T retreatment in the clinical routine. 122 sites enrolled a total of 239 pts with locally recurrent and/or MBC who relapsed after (neo)adjuvant treatment with T in their medical history. 230 pts met the eligibility criteria. The current analysis presents data collected between 10/2008-04/2015. Tumor progression was clinically assessed by the investigator.

Results

Median observation period for the total population (n=230) was 41.7 months (m) (range 0.4-94.5).

At start of T retreatment, 20.0% (n=46) of the pts presented with local recurrence only, 79.6% (n=183) presented with distant metastases ± local recurrence and one patient (0.4%) presented with elevated tumor markers. 27.4% (n=63) of the pts developed exclusively non-visceral metastases and 52.2% (n=120) were diagnosed with visceral (± non-visceral) metastases. Median duration of T re-therapy in the first line setting was 9.0 m (95% confidence interval (CI): 7.6-10.1). In 69.6% (n=160) of the cases, T was added to chemotherapy (CT). 15.2% of the pts (n=35) were treated with T+CT + endocrine therapy (ET).

A median progression free survival (PFS) of 10.1 m was observed among all eligible patients (n = 230) (95% CI: 8.5-12.0). The evaluation by risk groups revealed a PFS of 23.7 m (95% CI: 13.3-NE*) for patients with local recurrence only, 11.8 m (95% CI: 8.3-20.1) for patients with non-visceral metastases and 7.6 m (95% CI: 6.2-9.9) for patients with visceral metastases. *Not evaluable

Median PFS according to treatment regimen was 8.3 m for pts who were treated with T+CT (n=125, 54.3%), 17.7 m in pts who received T+CT+ET (n=35, 15.2%) and 11.2 m in pts treated with T+ET (n=38, 16.5%). Pts who received T monotherapy (n=32, 13.9%) had a median PFS of 13.4 m.

Of 230 pts, 121 deaths were documented (52.6%) within the observation period. The median overall survival (OS) was 29.6 m for all pts (95% CI: 27.3-36.8). Median OS was statistically reliable for pts with visceral metastases only: 19.4 m (95% CI: 16.9-27.3). The 2-year survival rate was 62.2% for all pts, 81.9% for pts with local recurrence only, 80.7% for pts with non-visceral metastases and 45.6% for pts with visceral metastases.

Conclusions

The survival observed for pts with HER2-positive MBC receiving T re-therapy in the clinical routine is in line with the results of recently published data. In terms of the 2-year survival rate, 81.9% of the pts with local recurrence were still alive and thus show the most favourable prognosis. T re-therapy provides an efficient treatment option regardless of given as combination-therapy together with CT and/or ET or as monotherapy.

Citation Format: Hanker L, Hitschold T, Grafe A, Förster F, Schröder J, Janssen J, Reichert D, Hielscher C, Keitel S, Hesse T. Efficacy of trastuzumab re-therapy in the clinical routine of HER2-positive breast cancer patients who relapsed after completed anti-HER2 (neo)adjuvant therapy – 5th interim analysis of the national non-interventional study (NIS) ML21589. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-14-08.

Abstract P1-13-02: Ibandronate Shows Marked Pain Relief and a Favorable Renal Safety Profile — Final Results of a Large-Scale Non Interventional Study in Breast Cancer Patients with Metastatic Bone Disease

Background: In patients (pts) with metastatic bone disease (MBD) due to breast cancer (BC) the incidence of skeletal related events (SRE) and the severity of bone pain are effectively reduced by bisphosphonates (BP), the current standard of care in this setting. As treatment with some BP may adversely affect kidney function, renal safety is a key determinant of BP risk/benefit assessment. Ibandronate (IBA), a BP available in IV and oral formulations, demonstrated sustained effects on skeletal related events (SRE) and bone pain with a low incidence of renal adverse events in randomized clinical trials (RCT). To verify those results under real life conditions, a large-scale non interventional study (NIS) was conducted in Germany.

Patients and methods: In accordance with the terms of the marketing authorization, BC pts with MBD received 6 mg IBA IV every 3-4 weeks or 50 mg of oral IBA once daily (at the physician's discretion) for up to 24 weeks. Pain severity (VAS), use of analgesics (classified according to the WHO analgesic ladder), SRE, and renal function (estimated creatinine clearance, eCrCl; Cockcroft-Gault formula) were recorded in 4-week intervals.

Results: 3515 pts, mean age 63.6 +11.7 years, were evaluated. 2320 (66%) were BP-naïve; 418 (12%) had received prior treatment with IBA, 777 (22%) with other BPs, including zoledronic acid (ZOL) (503; 14%) and pamidronate (256; 7%). At baseline, mean pain severity (VAS) was lower for pts pretreated with IBA (2.5 ± 2.1) compared to BP-naïve pts (3.2 ± 2.4; p &lt; 0.0001) or pts pretreated with other BPs (3.1 ± 2.4; p &lt; 0.0001) and analgesic use was less frequent (38% vs 47% and 44%, respectively). For the 2678 pts evaluable for renal function throughout the observation period, mean eCrCl at baseline was significantly lower in pts pretreated with ZOL (72.4 ± 31.7 ml/min) than in BP-naïve (79.5 ± 30.7 ml/min; P&lt;0.0001) or IBA-pretreated pts (77.8 ± 28.8 ml/min; p=0.0090). 64% of the total study population achieved a decrease in pain severity on IBA treatment. In pts reporting pain at baseline, mean pain severity decreased throughout the observation period (3.1 ± 2.4 to 2.3 ± 2; p &lt; 0.0001). In parallel, there was an overall reduction of analgesic use with 57% of pts not requiring analgesics at the last observation and more pts being switched to less potent or no analgesic treatment than patients requiring more analgesia. SRE were rare (7%), irrespective of prior treatment. Changes in renal function during IBA treatment were small and balanced across all subgroups; no severe renal adverse events were observed. Thirteen cases of osteonecrosis of the jaw were reported during the observation period, 8 of which had received ZOL as prior treatment. Overall tolerability of IBA treatment was rated as good or very good by 98% of physicians.

Conclusion: In this NIS in BC pts with MBD, the largest-to-date study with IBA, IV and oral IBA showed marked and sustained pain relief with an overall reduction of analgesic use and a renal safety profile comparable to results of RCT.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-13-02.

Wastewater recycling concept for an urban multi-storey building

An innovative system for blackwater recycling is described. An existing building comprising of 32 flats built in 1962 was renovated and equipped with vacuum toilets to collect blackwater separately. The energy and water consumption was determined. The flushing water consumption decreased from 40 l/p/d to 9 l/p/d.

First experimental test of a trace formula for billiard systems showing mixed dynamics

In general, trace formulas relate the density of states for a given quantum mechanical system to the properties of the periodic orbits of its classical counterpart. Here we report for the first time on a semiclassical description of microwave spectra taken from superconducting billiards of the Limaçon family showing mixed dynamics in terms of a generalized trace formula derived by Ullmo et al. [Phys. Rev. E 54, 136 (1996)]. This expression not only describes mixed-typed behavior but also the limiting cases of fully regular and fully chaotic systems and thus presents a continuous interpolation between the Berry-Tabor and Gutzwiller formulas.

Weekly intravenous recombinant humanized anti-P185HER2 monoclonal antibody (herceptin) plus docetaxel in patients with metastatic breast cancer: a pilot study

BACKGROUND

In patients with HER2-positive metastatic breast cancer (MBC), combined treatment of herceptin (H) and chemotherapy (CT) improves time to progression, response rates and survival compared with CT alone.

MATERIALS AND METHODS

We evaluated the safety and efficacy of weekly Docetaxel combined with weekly H as treatment in HER2 overexpressing MBC.

RESULTS

Preliminary toxicity data from 12 patients and 76 cycles of D and 80 cycles of H were analysed. No G3/4 toxicity was observed. The most frequent non-hematologic toxicities were fatigue (2 patients G2, 2 patients G1), dyspepsia (1 patients G2, 3 patients G1), diarrhea (1 patient G2, 3 patients G1), and nausea (1 patient G2, 3 patients G1). Six partial responses have been observed in 12 patients (ORR 50%).

CONCLUSIONS

The combination of weekly Docetaxel and Herceptin is well tolerated with significant anti-tumor activity.

Enhancement characteristics of liver metastases, hepatocellular carcinomas, and hemangiomas with Gd-EOB-DTPA: preliminary results with dynamic MR imaging

Our objective was to study Gd-EOB-DTPA for the characterization of focal liver lesions by means of dynamic MR imaging. A double-blind and randomized dose-ranging phase-2 clinical trial was performed in 31 patients (liver metastases n = 23, hepatocellular carcinoma n = 4, and hemangioma n = 4) at a field strength of 1.0 Tesla. Gd-EOB-DTPA (Schering AG, Berlin, Germany) was administered as an IV bolus (12.5, 25, or 50 micromol/kg body weight) with dynamic T1-weighted MRI during the distribution and cellular uptake of the contrast agent at multiple time points up to 45 min post contrast. Dynamic changes in tumor signal intensity, tumor-liver contrast, enhancement patterns, side effects, and adverse events were evaluated. Monitoring of vital signs revealed no significant changes during bolus injection of Gd-EOB-DTPA. Liver metastases demonstrated an inhomogeneous uptake of Gd-EOB-DTPA during the distribution phase with a washout effect on delayed images > 3 min and highest tumor-liver contrast 20 and 45 min post contrast. Hepatocellular carcinomas showed prolonged enhancement as compared with metastases and hemangiomas. Hemangiomas exhibited an early peripheral-nodular enhancement with subsequent partial or complete filling, persisting enhancement < 10 min following injection of Gd-EOB-DTPA, and delayed washout as compared with liver metastases. Initial clinical experience suggests that Gd-EOB-DTPA as a bolus injectable hepatobiliary MR contrast agent may offer useful features for the characterization of focal liver lesions.

Phase II clinical evaluation of Gd-EOB-DTPA: dose, safety aspects, and pulse sequence

PURPOSE

To investigate the efficacy of gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid (Gd-EOB-DTPA) in the detection of focal liver lesions with respect to dose, side effects, and pulse sequence.

MATERIALS AND METHODS

A randomized double-blinded trial was performed in 33 patients with focal solid liver lesions. A bolus of Gd-EOB-DTPA, a liver-specific contrast agent, was intravenously administered at three different doses (12.5, 25, and 50 mumol per kilogram of body weight). Magnetic resonance imaging with different T1-weighted techniques was performed 20 and 45 minutes after administration of Gd-EOB-DTPA. Changes in liver signal intensity, lesion-liver contrast-to-noise ration (C/N), detectable liver lesions, side effects, and adverse events were evaluated.

RESULTS

Gd-EOB-DTPA significantly (P < .05) increased liver signal intensity and lesion-liver C/N within the dose range tested. Lesion detection was improved 20 and 45 minutes after administration of Gd-EOB-DTPA. A dose of 12.5 mumol was sufficient for the detection of focal liver lesions, and the breath-hold, T1-weighted, fast low-angle shot pulse sequence was the most useful. No significant changes in vital signs, clinical laboratory test results, and urinalysis were observed.

CONCLUSION

Gd-EOB-DTPA is an efficient, diagnostically useful, and safe contrast agent.

[New MR contrast media in liver diagnosis. Initial clinical results with hepatobiliary Eovist (gadolinium-EOB-DTPA) and RES-specific Resovist (SH U 555 A)]

The purpose of this work is to describe our initial clinical experience (in 66 patients) with Resovist and Eovist, two new liver-specific MR contrast agents. We focus our report on safety aspects, dose finding, and optimization and technical parameters. Both contrast agents were well tolerated and improved the detectability of focal liver lesions. With Resovist, postcontrast MRI may be started as early as 10 min following injection. The dose of 8 mumol Fe/kg bodyweight was sufficient to achieve diagnostic tumor-liver contrast levels. Since Eovist can also be administered as a bolus, dynamic enhancement patterns may be studied for tumor characterization as well. Breath-hold T1-weighted FLASH images were superior to other T1-weighted techniques with and without fat saturation.

[Spinal para-medullary conduction anesthesia in therapy with anticoagulant drugs]

Epidural and spinal blocks can lead to iatrogenic bleeding in the spinal canal. Incidence of this severe complication is considered low, but the risk of irreversible neurological defects for the patient requires increased attention by the anaesthetist. The perioperative risk is higher in patients under anticoagulant therapy. The different pharmacodynamics and pharmacokinetics of practically relevant anticoagulants are discussed and recommendations for the performance of centroneuraxis blocks in patients under anticoagulant therapy are given.

Two members of the ERabp gene family are expressed differentially in reproductive organs but to similar levels in the coleoptile of maize

A Zea mays cDNA clone, ZmERabp4, coding for a new member of the auxin-binding protein family was isolated. The primary amino acid sequence contains an N-terminal hydrophobic leader sequence, a potential glycosylation site (Asn136-Thr-Thr) and a C-terminal KDEL motif known to be responsible for retention of proteins within the lumen of the ER. The expression pattern of the ZmERabp4 gene in various organs of maize differs from the expression pattern previously observed for the ZmERabp1 gene. The ZmERabp4 gene is expressed highly in male flower organs, whereas the ZmERabp1 gene shows highest expression in female flower parts. In situ hybridization and analysis by laser scanning microscopy revealed enhanced levels of expression for both genes in the coleoptile when compared with the primary leaf of etiolated maize seedlings.

Molecular analysis of three maize 22 kDa auxin-binding protein genes--transient promoter expression and regulatory regions

The site I 22 kDa auxin-binding proteins from maize are encoded by a small gene family comprising at least five members. Here the cloning and molecular analysis of the Zm-ERabp1, Zm-ERabp4, and Zm-ERabp5 genes is presented. All three encode 22-23 kDa proteins displaying a transit peptide, a C-terminal KDEL sequence, as well as glycosylation and auxin-binding sites. The Zm-ERabp4 and Zm-ERabp5 genes are very similar. The Zm-ERabp1 gene encodes a related protein, but its promoter, leader and signal peptide are very different. Northern analysis using gene-specific oligonucleotide probes indicates that Zm-ERabp4 is expressed in leaves and coleoptiles but weakly in roots, whereas Zm-ERabp5 expression is barely detectable in these tissues. RNA-PCR indicated that all three genes are none the less expressed in many tissues. Primer-extension analysis revealed an unusually long (320 bases) Zm-ERabp1 leader containing an 80 codon ORF which, if expressed, would encode a positively charged protein with some similarity to transcription factors. In a transient promoter-reporter gene expression system using maize leaf protoplasts the Zm-ERabp1 promoter is more active than the Zm-ERabp4 and Zm-ERabp5 promoters. Promoter deletion analysis of Zm-ERabp1 has identified a negative regulatory sequence in a region from -364 bp and -130 bp, deletion of which results in about twofold higher expression. This region contains both enhancer- and G-box-related sequences. Deletion of -126 bp to +64 bp, which contains the TATA box and transcription start, results in a large decrease in expression.

Molecular analysis of an auxin binding protein gene located on chromosome 4 of Arabidopsis

We have isolated a cDNA clone from Arabidopsis, At-ERabp1, for the Arabidopsis auxin binding protein located in the lumen of the endoplasmic reticulum (ER). This cDNA clone codes for a protein related to the major auxin binding protein from maize, Zm-ERabp1. A single open reading frame, 594 bases in length, predicts a protein of 198 amino acid residues and a molecular mass of 22,044 D. The primary amino acid sequence contains an N-terminal hydrophobic signal sequence of 33 amino acids. We demonstrated by in vitro studies that the At-ERabp1 protein is translocated into ER-derived microsomes. The protein was processed, and the cleavage site for the N-terminal signal peptide was determined by radiosequencing. The mature protein is composed of 165 amino acid residues, with a molecular mass of 18,641 D. The At-ERabp1 protein contains potential N-glycosylation sites (Asn46-Ile-Ser and Asn130-Ser-Thr). In vitro transport studies demonstrated cotranslational glycosylation. Retention within the lumen of the ER correlates with an additional signal located at the C terminus and represented by the amino acids Lys196-Asp-Glu-Leu, well known to be essential for active retrieval of proteins into the lumen of the ER. DNA gel blot analysis of genomic DNA revealed single hybridizing bands, suggesting that only a single At-ERabp1 gene is present in the Arabidopsis genome. Restriction fragment length polymorphism mapping indeed revealed a single locus mapping to chromosome 4.

Hormonal modulation of plant growth: the role of auxin perception

The organisation of growth and development in vascular plants appears to be highly adapted to meet the specific demands of a sessile, autotrophic habit. Many of the characteristic features of plant development are associated with the activities of five groups of phytohormones. Each of the phytohormones has the ability to influence fundamentally a remarkable variety of developmental and physiological processes. This ability has been widely documented but remains to be explained. Here we describe how recent breakthroughs in the analysis and understanding of eucaryotic signal transduction are being applied, in conjunction with technical advances in molecular genetics, to elucidate the molecular basis of the phytohormonal properties of auxin. Both auxin concentration, and the sensitivity of plant cells to this phytohormone have been implicated as important parameters in auxin action. We describe recent molecular biological approaches to assess the contribution made by each of these parameters. Emphasis is given to a description of recent genetic and biochemical progress towards identification of the molecular targets of the auxin signal and the molecular components involved in its subsequent transduction.

cDNA clones of the auxin-binding protein from corn coleoptiles (Zea mays L.): isolation and characterization by immunological methods

An auxin-binding protein (ABP) cDNA clone was selected from a lambda gt11 cDNA library from corn coleoptiles with highly purified IgGanti ABP. The sequence of 794 bp contains an open reading frame (ORF) of 603 bp, coding for a 22 kd protein. There are indications of a signal peptide of 38 amino acids (von Heijne, G. 1983, Eur. J. Biochem., 133, 17-21). A N-glycosylation site can be deduced and a C-terminal KDEL amino acid sequence is detected. An EcoRI fragment containing the beginning portion of the cDNA with about three quarters of the ORF was used to select cDNA clones from an independently produced lambda gt11 cDNA library of corn coleoptiles. Northern blot analysis with in vitro transcribed biotinylated RNA showed a single band of not more than 850 bases. The full-length in vitro transcript directed the in vitro synthesis of a protein which is precipitated by IgGanti ABP. Rabbit antibodies raised against a fusion protein detect the ABP as a double band on Western blots. Only the smaller of the two ABP bands is labeled by two different KDEL-specific IgG preparations.

Molecular cloning and structural analysis of a gene from Zea mays (L.) coding for a putative receptor for the plant hormone auxin

The major auxin-binding protein from maize coleoptiles was purified to homogeneity. The protein has an apparent mol. wt of 22 kd and binds 1-naphthylacetic acid with a KD of 2.40 x 10(-7) M. Additional antigenically related proteins, present in very low amounts, could be demonstrated in maize coleoptiles using immunodetection. Extensive protein sequence analysis of the major auxin-binding protein allowed the construction of several synthetic oligonucleotide probes which were used to isolate a cDNA coding for this protein. The cDNA corresponds to a mRNA with a 3'-poly(A)+ sequence and a single, long open reading frame of 603 bases. The open reading frame, starting 34 residues from the 5' end of the cDNA, predicts a 21,990 Dalton protein of 201 amino acids. Comparison of this deduced amino acid sequence with the partial amino acid sequences of purified auxin-binding protein, revealed a perfect match, involving a total of 53 amino acid residues. The primary amino acid sequence includes a 38-amino-acid-long N-terminal hydrophobic leader sequence which could represent a signal for translocation of this protein to the endoplasmic reticulum. An additional signal is located at the C-terminal end, consisting of the amino acids KDEL known to be responsible for preventing secretion of proteins from the lumen of the endoplasmic reticulum in eucaryotic cells. The primary sequence contains a N-glycosylation site (-asp133-thr-thr-). This site was found to be glycosylated by a high-mannose-type oligosaccharide.(ABSTRACT TRUNCATED AT 250 WORDS)