Phase II study of conformal hypofractionated radiotherapy with concurrent gemcitabine in muscle-invasive bladder cancer

PURPOSE

The aim of this prospective, phase II trial was to determine the response of muscle-invasive bladder cancer (MIBC) to concurrent chemoradiotherapy of weekly gemcitabine with 4 weeks of radiotherapy (RT; GemX).

PATIENTS AND METHODS

Fifty patients with transitional cell carcinoma, stage T2-3, N0, M0 after transurethral resection and magnetic resonance imaging, were recruited. Gemcitabine was given intravenously at 100 mg/m(2) on days 1, 8, 15, and 22 of a 28-day RT schedule that delivered 52.5 Gy in 20 fractions. Chemotherapy was stopped for Radiation Therapy Oncology Group (RTOG) grade 3 bladder or bowel toxicity. The primary end points were tumor response, toxicity, and survival.

RESULTS

All patients completed RT; 46 tolerated all four cycles of gemcitabine. Two patients stopped after two cycles, and two stopped after three cycles, because of bowel toxicity. Forty-seven patients had a post-treatment cystoscopy; 44 (88%) achieved a complete endoscopic response. At a median follow-up of 36 months (range, 15 to 62 months), 36 patients were alive, and 32 of these had a functional and intact bladder. Fourteen patients died; seven died as a result of metastatic MIBC, five died as a result of intercurrent disease, and two died as a result of treatment-associated deaths. Four patients underwent cystectomy; three because of recurrent disease and one because of toxicity. One patient required a bowel resection for late toxicity. By using Kaplan-Meier analyses, 3-year cancer-specific survival was 82%, and overall survival was 75%.

CONCLUSION

Concurrent gemcitabine-based chemoradiotherapy (ie, GemX) produces a high response rate in MIBC and has durable local control and acceptable toxicity, which allows patients to preserve their own bladder. This treatment modality warrants additional investigation in a phase III setting.

Transurethral surgery and twice-daily radiation plus paclitaxel-cisplatin or fluorouracil-cisplatin with selective bladder preservation and adjuvant chemotherapy for patients with muscle invasive bladder cancer (RTOG 0233): a randomised multicentre phase 2 trial

BACKGROUND

We assessed effectiveness, safety, and tolerability of paclitaxel or fluorouracil when added to radiation plus cisplatin followed by adjuvant chemotherapy in a programme of selected bladder preservation for patients with muscle invasive bladder cancer.

METHODS

In our randomised phase 2 trial, we enrolled patients with T2-4a transitional cell carcinoma of the bladder at 24 medical centres in the USA. We randomly allocated patients to receive paclitaxel plus cisplatin (paclitaxel group) or fluorouracil plus cisplatin (fluorouracil group) with twice-daily radiation in random block sizes per site on the basis of clinical T-stage (T2 vs T3-4). Patients and physicians were aware of treatment assignment. All patients had transurethral resection of bladder tumour and twice-daily radiotherapy to 40·3 Gy, along with allocated chemotherapy, followed by cystoscopic and biopsy assessment of response. Patients who had a tumour response with downstaging to T0, Tcis, or Ta received consolidation chemoradiotherapy to 64·3 Gy, with the same chemotherapy regimen as in the induction phase. Patients received adjuvant cisplatin-gemcitabine-paclitaxel after the end of chemoradiotherapy. If, after induction, persistent disease was graded as T1 or worse, we recommended patients undergo cystectomy and adjuvant chemotherapy. We assessed the primary endpoints of rates of treatment completion and toxic effects in all randomly allocated patients. This study is registered with ClinicalTrials.gov, number NCT00055601.

FINDINGS

Between Dec 13, 2002, and Jan 11, 2008, we enrolled 97 patients, of whom 93 were eligible for analysis. Median follow-up was 5·0 years (IQR 5·0-6·2). Of 46 patients in the paclitaxel group, 45 (98%) completed induction (16 [35%] with grade 3-4 toxicity), 39 (85%) completed induction and consolidation (11 [24%] with grade 3-4 toxicity due to consolidation), and 31 (67%) completed the entire protocol with adjuvant chemotherapy. 34 (85%) of 40 assessable patients in the paclitaxel group had grade 3-4 toxicity during adjuvant chemotherapy. Of 47 patients in the fluorouracil group, 45 (96%) completed induction (nine [19%] with grade 3-4 toxicity), 39 (83%) completed induction and consolidation (12 [26%] had grade 3-4 toxicity due to consolidation), and 25 (53%) completed the entire protocol with adjuvant chemotherapy. 31 (76%) of 41 assessable patients in the fluorouracil group had grade 3-4 toxicity during adjuvant chemotherapy. Five (11%) patients treated with the paclitaxel regimen and three (6%) patients treated with the fluorouracil regimen developed late grade 3-4 radiotherapy toxicities. 11 (24%) patients treated with the paclitaxel regimen and 16 (34%) patients treated with the fluorouracil regimen developed late grade 3-4 toxicities unrelated to radiotherapy. One patient (in the fluorouracil group) died during follow-up. Six (13%) patients in the paclitaxel group and in three (6%) patients in the fluorouracil group discontinued due to treatment-related toxicity.

INTERPRETATION

In the absence of phase 3 data, our findings could inform selection of a bladder-sparing trimodality chemotherapy regimen for patients with muscle invasive bladder cancer.

FUNDING

US National Cancer Institute.

MRI evaluation of thermal ablation of tumors with focused ultrasound

MRI was used to target and evaluate the tissue effects of focused ultrasound ablation on tumors implanted in the skeletal muscle of rabbits in vivo. First, MRI was used to localize the tumors and plan the ultrasound therapy. Second, temperature-sensitive phase-difference images were acquired to monitor the location of the ultrasound focus and to estimate the effects of temperature rise. After the treatment, the spatial and temporal temperature profiles for defining boundaries of tissue coagulation were calculated. Finally, these boundaries were compared to T2-weighted and contrast-enhanced T1-weighted images obtained immediately after therapy. The results indicate that using MRI for planning and evaluating focused ultrasound surgery is feasible. We showed a linear relationship between applied power and shifts in the proton resonant frequency. Fluctuations in the location of the focus about the target location were on the order of the resolution of the MR images. The temperature rise and lesion size varied significantly. Regions of tissue coagulation calculated from MR data correlated well with post-therapy imaging.

Tumor response and endogenous immune reactivity after administration of HER2 CAR T cells in a child with metastatic rhabdomyosarcoma

Refractory metastatic rhabdomyosarcoma is largely incurable. Here we analyze the response of a child with refractory bone marrow metastatic rhabdomyosarcoma to autologous HER2 CAR T cells. Three cycles of HER2 CAR T cells given after lymphodepleting chemotherapy induces remission which is consolidated with four more CAR T-cell infusions without lymphodepletion. Longitudinal immune-monitoring reveals remodeling of the T-cell receptor repertoire with immunodominant clones and serum autoantibodies reactive to oncogenic signaling pathway proteins. The disease relapses in the bone marrow at six months off-therapy. A second remission is achieved after one cycle of lymphodepletion and HER2 CAR T cells. Response consolidation with additional CAR T-cell infusions includes pembrolizumab to improve their efficacy. The patient described here is a participant in an ongoing phase I trial (NCT00902044; active, not recruiting), and is 20 months off T-cell infusions with no detectable disease at the time of this report.

Successful treatment of solitary extracranial metastases from non-small cell lung cancer

BACKGROUND

Recurrence after resection of non-small cell lung carcinoma is generally associated with a poor outcome and is treated with either systemic agents or palliative irradiation. Recently, long-term survival has been reported after resection of isolated brain metastases from non-small cell lung carcinoma, but resection of other metastatic sites has not been explored fully.

METHODS

We have identified 14 patients who had solitary extracranial metastases treated aggressively after curative treatment of their non-small cell lung carcinoma. The histology was squamous carcinoma in 5, adenocarcinoma in 8, and large cell carcinoma in 1. Initially, 3 patients had stage I, 5 stage II, and 6 stage IIIa disease.

RESULTS

The sites of metastases included extrathoracic lymph nodes (six), skeletal muscle (four), bone (three), and small bowel (one). The median disease-free interval before metastases was 19.5 months (range, 5 to 71 months). Complete surgical resection of the metastatic site was the treatment in 12 of 14 patients. Two patients received only curative irradiation to the metastatic site, with complete response. The overall 10-year actuarial survival (Kaplan-Meier) was 86%. To date, 11 patients are alive and well after treatment of their metastases (17 months to 13 years), 1 has recurrent disease, 1 died of recurrent widespread metastases, and 2 died of unrelated causes.

CONCLUSION

Long-term survival is possible after treatment of isolated metastases to various sites from non-small cell lung carcinoma, but patient selection is critical.

Congenital muscular torticollis and sternomastoid tumor: results of nonoperative treatment

BACKGROUND

Congenital muscular torticollis (CMT) and sternocleidomastoid tumor of infancy remains to be one of the mysteries of pediatric surgery. Its cause is still debated and its management is controversial.

METHODS

Fifty-seven infants and children treated consecutively for sternomastoid tumors and CMT over a 5-year period (1992 to 1997) at the Pediatric Surgery Clinic of Social Security Council Ankara Children's Hospital are reviewed. The obstetric history was recorded in 48 patients. A lump in the neck, head tilt, plagiocephaly, and facial asymmetry were reasons for refferal correlating with the age of admission. Under 18 months of age passive and active stretching exercises (PSE and ASE) were initiated in all of the cases.

RESULTS

In 28 children under the age of 3 months the outcome was excellent with none needing surgery. Successively 25% of the 3- to 6-month-old infants, 70% of the 6- to 18-month-old children, and 100% of all the older children required surgery. Spontaneous normal vaginal delivery was recorded in 23 of 48 (48%) cases, whereas vaginal vacuum extraction in four cases, vaginal forceps in six, vaginal as breech in two, and caesarean section in 11 was noted.

CONCLUSIONS

It was concluded that PSE and ASE are highly effective for the treatment of congenital muscular torticollis. The success rate of conservative treatment is primarily dependent on the patients' age at the initiation of exercises. The hypothesis of injury through the birth canal and intrauterine malposition are valid only in 12 (25%) and 13 (27%) of cases, respectively. Therefore, it is difficult to attribute as an etiologic factor.

Publication rates of abstracts presented at annual musculoskeletal tumor society meetings

Beware of the unpublished abstract! What is the publication rate of abstracts presented at Musculoskeletal Tumor Society meetings, and how does this compare with other orthopaedic and medical meetings? Three hundred thirty-six podium presentations from six annual meetings were identified and their publication was searched at a minimum of 3 years after the event. An effort was made to determine what percent of these abstracts eventually were published in a peer-reviewed journal. It was determined that 137 abstracts were published for a publication rate of 41%. The average time between presentation at the meeting and publication was 21.8 plus or minus 13.5 months. The published articles appeared in 48 peer-reviewed journals. The rate of publication and time until publication was similar to other orthopaedic meetings and to other medical disciplines. Changes to the cohort, title, or authors occurred in approximately (1/3) of the published articles compared with the abstracts. These results suggest that for various reasons the majority of presented material at Musculoskeletal Tumor Society meetings may not survive peer review and may not be scientifically valid.

Kaposi sarcoma of the musculoskeletal system

Kaposi sarcoma (KS) of bone and skeletal muscle is unusual. In this report, the authors review 66 published patients with KS who had involvement of the musculoskeletal system reported from 1925 to 2006. In only 3 patients was acquired immunodeficiency syndrome (AIDS)-related KS identified within skeletal muscle. Osseous KS lesions were more frequent and occurred with African, classic, and AIDS-related KS and occurred rarely in transplantation-associated KS. Patients seldom were asymptomatic. They usually had bone pain with limited mobility or infrequently developed serious sequelae like spinal cord compression. Locally aggressive African and classic KS lesions typically involved the peripheral skeleton; whereas, in patients with AIDS, the axial (vertebrae, ribs, sternum, and pelvis) and/or maxillofacial bones more commonly were involved. Almost all patients had concomitant nonosseous KS lesions. Joint involvement was exceptional, and pathologic fractures were not observed. Computed tomography scans and magnetic resonance images were better at detecting osseous KS lesions, which frequently went undetected on plain x-ray films or bone scans. Pathologic diagnosis was important to exclude similar lesions like bacillary angiomatosis. Treatment options, including surgery and, in more recent patients, radiation and/or chemotherapy, had limited success.

Rhabdomyosarcoma: current challenges and their implications for developing therapies

Rhabdomyosarcoma (RMS) represents a rare, heterogeneous group of mesodermal malignancies with skeletal muscle differentiation. One major subgroup of RMS tumors (so-called "fusion-positive" tumors) carries exclusive chromosomal translocations that join the DNA-binding domain of the PAX3 or PAX7 gene to the transactivation domain of the FOXO1 (previously known as FKHR) gene. Fusion-negative RMS represents a heterogeneous spectrum of tumors with frequent RAS pathway activation. Overtly metastatic disease at diagnosis is more frequently found in individuals with fusion-positive than in those with fusion-negative tumors. RMS is the most common pediatric soft-tissue sarcoma, and approximately 60% of all children and adolescents diagnosed with RMS are cured by currently available multimodal therapies. However, a curative outcome is achieved in <30% of high-risk individuals with RMS, including all those diagnosed as adults, those diagnosed with fusion-positive tumors during childhood (including metastatic and nonmetastatic tumors), and those diagnosed with metastatic disease during childhood (including fusion-positive and fusion-negative tumors). This white paper outlines current challenges in RMS research and their implications for developing more effective therapies. Urgent clinical problems include local control, systemic disease, need for improved risk stratification, and characterization of differences in disease course in children and adults. Biological challenges include definition of the cellular functions of PAX-FOXO1 fusion proteins, clarification of disease heterogeneity, elucidation of the cellular origins of RMS, delineation of the tumor microenvironment, and identification of means for rational selection and testing of new combination therapies. To streamline future therapeutic developments, it will be critical to improve access to fresh tumor tissue for research purposes, consider alternative trial designs to optimize early clinical testing of candidate drugs, coalesce advocacy efforts to garner public and industry support, and facilitate collaborative efforts between academia and industry.

Pseudotumor of infancy and congenital muscular torticollis: 170 cases

OBJECTIVES

To review pseudotumor of infancy (POI) and congenital muscular torticollis (CMT) and to suggest an algorithm for treatment.

STUDY DESIGN

Retrospective review of cases from 1962 to 1998 at a tertiary care center.

METHODS

Patients included in this study were 81 boys and 89 girls who had a diagnosis of POI (n = 38) or CMT (n = 132) before 24 months of age.

RESULTS

For all patients, the mean age at diagnosis was 4 months; 54.1% had the left side of the neck affected, over 90% had a head tilt, and 2.4% had feeding difficulty as a result of the disorder. Plagiocephaly was present in 39.5% of patients with POI and 63.6% of patients with CMT; a neck mass, in 63.2% and 18.2%, respectively; and facial asymmetry, in 7.9% and 15.9%, respectively. All patients had a complete physical examination; 54.1% had plain cervical radiography, 4.1%, computed tomography, and 2.9%, ultrasonography. Passive range of motion was the initial treatment recommended for 65.3% of patients. Conservative treatment failed for 16 patients; subsequently, they had surgical treatment. Follow-up data were available for 159 patients; 85.5% experienced total resolution and 14.5% experienced subtotal resolution or long-term abnormality.

CONCLUSIONS

Children diagnosed with POI or CMT should be treated and observed for at least 12 months or until symptoms resolve. If symptoms persist 1 year after diagnosis despite conservative therapy, surgical treatment should be considered. The majority of children with POI or CMT experience total resolution of symptoms.

Imaging findings in noncraniofacial childhood rhabdomyosarcoma

Rhabdomyosarcoma (RMS) is the most common soft-tissue sarcoma of childhood. This paper is focuses on imaging for diagnosis, staging, and follow-up of noncraniofacial RMS.

In vitro and in vivo evaluations of increased effective beam width for heat deposition using a split focus high intensity ultrasound (HIFU) transducer

PURPOSE

To develop a novel and efficient, in vitro method for characterizing temporal and spatial heat generation of focused ultrasound exposures, and evaluate this method to compare a split focus and conventional single focus high intensity focused ultrasound transducer.

MATERIALS AND METHODS

A HIFU tissue-mimicking phantom was validated by comparing respective temperature elevations generated in the phantoms and in murine tumors in vivo. The phantom was then used in combination with IR thermography to spatially and temporally characterize differences in low-level temperature elevation (e.g. 3-5 degrees C) produced by a single focus and split focus HIFU transducer, where the latter produces four simultaneous foci. In vivo experiments with heat sensitive liposomes containing doxorubicin were then carried out to determine if the larger beam width of the split focus transducer, compared to the single focus, could increase overall deployment of the drug from the liposome.

RESULTS

Temperature elevations generated in the HIFU phantom were not found to be different from those measured in vivo when compensating for disparities in attenuation coefficient and specific heat, and between the two transducers by increasing the energy deposition. Exposures with the split focus transducer provided significant increases in the area treated compared to the single focus, which then translated to significant increases in drug deposition in vivo.

CONCLUSIONS

Preliminary evidence was provided indicating the potential for using this novel technique for characterizing hyperthermia produced by focused ultrasound devices. Further development will be required for its suitability for correlating in vitro and in vivo outcomes.

Long non-coding RNAs identify a subset of luminal muscle-invasive bladder cancer patients with favorable prognosis

BACKGROUND

Muscle-invasive bladder cancer (MIBC) is a heterogeneous disease, and gene expression profiling has identified several molecular subtypes with distinct biological and clinicopathological characteristics. While MIBC subtyping has primarily been based on messenger RNA (mRNA), long non-coding RNAs (lncRNAs) may provide additional resolution.

METHODS

LncRNA expression was quantified from microarray data of a MIBC cohort treated with neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) (n = 223). Unsupervised consensus clustering of highly variant lncRNAs identified a four-cluster solution, which was characterized using a panel of MIBC biomarkers, regulon activity profiles, gene signatures, and survival analysis. The four-cluster solution was confirmed in The Cancer Genome Atlas (TCGA) cohort (n = 405). A single-sample genomic classifier (GC) was trained using ridge-penalized logistic regression and validated in two independent cohorts (n = 255 and n = 94).

RESULTS

NAC and TCGA cohorts both contained an lncRNA cluster (LC3) with favorable prognosis that was enriched with tumors of the luminal-papillary (LP) subtype. In both cohorts, patients with LP tumors in LC3 (LPL-C3) were younger and had organ-confined, node-negative disease. The LPL-C3 tumors had enhanced FGFR3, SHH, and wild-type p53 pathway activity. In the TCGA cohort, LPL-C3 tumors were enriched for FGFR3 mutations and depleted for TP53 and RB1 mutations. A GC trained to identify these LPL-C3 patients showed robust performance in two validation cohorts.

CONCLUSIONS

Using lncRNA expression profiles, we identified a biologically distinct subgroup of luminal-papillary MIBC with a favorable prognosis. These data suggest that lncRNAs provide additional information for higher-resolution subtyping, potentially improving precision patient management.

Preclinical evaluation of oncolytic vaccinia virus for therapy of canine soft tissue sarcoma

Virotherapy using oncolytic vaccinia virus (VACV) strains is one promising new strategy for canine cancer therapy. In this study we describe the establishment of an in vivo model of canine soft tissue sarcoma (CSTS) using the new isolated cell line STSA-1 and the analysis of the virus-mediated oncolytic and immunological effects of two different Lister VACV LIVP1.1.1 and GLV-1h68 strains against CSTS. Cell culture data demonstrated that both tested VACV strains efficiently infected and destroyed cells of the canine soft tissue sarcoma line STSA-1. In addition, in our new canine sarcoma tumor xenograft mouse model, systemic administration of LIVP1.1.1 or GLV-1h68 viruses led to significant inhibition of tumor growth compared to control mice. Furthermore, LIVP1.1.1 mediated therapy resulted in almost complete tumor regression and resulted in long-term survival of sarcoma-bearing mice. The replication of the tested VACV strains in tumor tissues led to strong oncolytic effects accompanied by an intense intratumoral infiltration of host immune cells, mainly neutrophils. These findings suggest that the direct viral oncolysis of tumor cells and the virus-dependent activation of tumor-associated host immune cells could be crucial parts of anti-tumor mechanism in STSA-1 xenografts. In summary, the data showed that both tested vaccinia virus strains and especially LIVP1.1.1 have great potential for effective treatment of CSTS.

Follow-up of musculoskeletal tumors. I. Local recurrence

The prognosis for a patient with a musculoskeletal sarcoma has improved considerably over the past two decades largely due to the use of adjuvant chemotherapy. Surgical techniques have become more sophisticated with limb salvage, the preferred management in the majority of cases. Imaging plays an important role in the assessment of suspected local recurrence of tumor. This pictorial essay reviews the different imaging options and highlights various pitfalls in the detection and diagnosis of recurrence. The role of magnetic resonance imaging in this respect is stressed.

Ultrasound in musculoskeletal tumors with emphasis on its role in tumor follow-up

Ultrasonography allows visualization of musculoskeletal masses that are not confined to the intraosseous compartment and assists in the determination of the consistency of such masses. Making a specific diagnosis using ultrasonography is hampered by the lack of specificity; however, it may be an indicator in guiding diagnostic needle biopsy, especially in large heterogeneous tumors. Color Doppler flow imaging allows visualization of blood flow within solid soft tissue masses. Probably, CDFI features do not assist in differentiation between malignant and benign tumors; however, it has proved to be a useful tool to monitor regression of tumor neovascularity induced by therapy in patients with musculoskeletal sarcoma. When recurrence of a soft tissue sarcoma is clinically suspected, ultrasonography can be used as the initial imaging technique for evaluation. Ultrasonography can also be used in addition to MR imaging when susceptibility artifacts secondary to orthopedic hardware (including prostheses) prevent evaluation of specific areas.

Uterine smooth muscle tumors of uncertain malignant potential: diagnostic challenges and therapeutic dilemmas. Report of 2 cases and review of the literature

Morphologically, there exist variants of uterine smooth muscle tumors that cannot be clearly interpreted and classified as benign or malignant. Because their behavior and clinical prognosis is also uncertain, the World Health Organization has termed these "smooth muscle tumors of uncertain malignant potential" (STUMP). Herein we describe 2 cases, present a review of the literature, and highlight the diagnostic challenges and therapeutic dilemmas associated with uterine STUMP in myomectomy specimens from women who wish to maintain or enhance their fertility. The clinical course of residual STUMP remains speculative.

Skeletal muscle metastasis from transitional cell carcinoma of the urinary bladder: clinicoradiological features

AIM

To define the clinicoradiological characteristics of skeletal muscle metastasis from transitional cell carcinoma of the urinary bladder.

MATERIALS AND METHODS

A retrospective review of all patients with skeletal muscle metastasis was undertaken between January 1999 to December 2001. Patients suspected of having a metastasis on radiological examinations, and subsequently proven to have metastatic disease on histological examination were included in study. The clinical presentation and radiological features of five patients with skeletal muscle metastasis from bladder tumours were reviewed from hospital records.

RESULTS

Twenty-four patients had skeletal muscle metastasis from various primaries. Of these five patients had previous or concurrent primary tumours in the bladder. Patients were aged between 27-70 years (mean 52 years), and all had persistent, localized pain with or without accompanying swelling. The muscles involved were psoas in three patients, adductor muscles of thigh in one and rectus abdominis in one. Four patients had radical cystectomy with urinary diversion (two ileal conduit and two orthotopic sigmoid neobladder). One patient presented with bladder tumour and concomitant muscular metastasis. All patients underwent helical computed tomography (CT) before confirmation of diagnosis by fine-needle aspiration (FNA) or biopsy. The typical appearance of low-density enhancing lesions on CT was mistaken for abscess in two patients and failure to respond to conservative treatment led to suspicion of metastasis. Diagnosis was proven histologically in all patients (FNA in three and biopsy in two). All patients had palliative chemotherapy (Mitomycin, Vincristine, Adriamycin and Cyclophosphamide). Two patients had local palliative 3500 rad radiotherapy for persistent pain. Mean survival was 8 months (range 6-12 months).

CONCLUSION

Muscular metastasis from urothelial tumours typically presents with persistent localized pain with or without swelling. The characteristic low-density, ring-enhancing lesions on CT in a patient with previous or concomitant urothelial tumours should raise the suspicion of metastasis until proven otherwise. Prognosis is dismal.

The role of 99mTc-MIBI scintigraphy in the assessment of MDR1 overexpression in patients with musculoskeletal sarcomas: comparison with therapy response

The occurrence of multidrug resistance (MDR), which is in part due to the overexpression of P-glycoprotein (Pgp), is a major problem in neoadjuvant therapy of malignant musculoskeletal tumours. The aim of this study was to investigate the role of technetium-99m hexakis-2-methoxyisobutylisonitrile (99mTc-MIBI) scintigraphy for functional imaging of the MDR1 phenotype in patients with musculoskeletal sarcomas. We aimed to compare 99mTc-MIBI uptake and washout kinetics with the expression of Pgp and with chemotherapy response. Twenty-five patients (16 males and 9 females, aged between 8 and 65 years) with malignant musculoskeletal tumours were studied. After injection of 555-740 MBq 99mTc-MIBI, dynamic flow images of the involved area were obtained for 3 min, and planar images were acquired at 10 min and 1 h. From the dynamic images, a tumour perfusion index (TPI) was obtained using Patlak-Rutland analysis. Tumour to background (T/B) ratios of both early and delayed images and percent wash-out rate (WR%) of 99mTc-MIBI were calculated. Immunohistochemical analysis of Pgp was performed on biopsy specimens and the degree of expression was graded according to a semiquantitative scoring system, from 0 to 6. After neoadjuvant therapy, tumour response was assessed by examining the ratio of viable cells and by detecting percent necrosis. Scintigraphic results were compared with Pgp status and therapy response. Irrespective of the Pgp status, all patients showed significant perfusion and 99mTc-MIBI uptake in early images. There was not a significant correlation between T/B ratios of early and delayed images and Pgp expression. We observed a positive correlation between WR% and Pgp status (r=0.61, P<0.01), and the wash-out rate of 99mTc-MIBI was significantly higher in patients with high Pgp expression than in those with a low Pgp score (33% +/- 9% vs 17% +/- 9%). Therapy response was determined in 21 of 25 patients, and in only 5 of 21 cases was the percent necrosis more than 90%. Neither Pgp expression rate nor WR% was found to show a significant correlation with percent necrosis in the bulk tumour specimens. In conclusion, the initial uptake of 99mTc-MIBI in bone and soft tissue sarcomas did not correlate with Pgp expression. A relationship was found between the wash-out rate of 99mTc-MIBI and the Pgp score, with a significant difference in WR% being observed between patients with high and patients with low Pgp expression.

Snapping during manual stretching in congenital muscular torticollis

Manual stretching frequently is used in the treatment of congenital muscular torticollis in infants. During manipulation, it is not uncommon for the sternocleidomastoid muscle to snap or suddenly give way. The main objective of this study was to evaluate the predisposing causes and clinical significance of such snapping. Four hundred fifty-five patients younger than 1 year of age with congenital muscular torticollis treated with a standardized gentle manual stretching program during a 13-year period were studied. Using prospective standardized assessment parameters, the pretreatment, treatment, and followup results of a group of 41 patients with snapping detected during treatment were compared with the results of a group of 404 patients without snapping during treatment. The group with snapping was associated with a more severe sternomastoid tumor, higher incidence of hip dysplasia, earlier clinical presentation, and shorter duration of treatment. With a mean followup of 3.5 years, the group with snapping was not different from the group that had no snapping in the final assessment score and percentage requiring surgery. From this study, unintentional snapping during the gentle manipulation treatment of congenital muscular torticollis has clinical and ultrasonographic evidence of partial or complete rupture of the sternocleidomastoid muscle. No long-term deleterious effect on the outcome was observed after the snapping.

ErbB2 and NFκB overexpression as predictors of chemoradiation resistance and putative targets to overcome resistance in muscle-invasive bladder cancer

Radical cystectomy for muscle-invasive bladder cancer (MIBC) patients frequently impairs their quality of life (QOL) due to urinary diversion. To improve their QOL, a bladder-sparing alternative strategy using chemoradiation has been developed. In bladder-sparing protocols, complete response (CR) to induction chemoradiation is a prerequisite for bladder preservation and favorable survival. Thus predicting chemoradiation resistance and overcoming it would increase individual MIBC patients' chances of bladder preservation. The aim of this study is to investigate putative molecular targets for treatment aimed at improving chemoradiation response. Expression levels of erbB2, NFκB, p53, and survivin were evaluated immunohistochemically in pretreatment biopsy samples from 35 MIBC patients in whom chemoradiation sensitivity had been pathologically evaluated in cystectomy specimens, and associations of these expression levels with chemoradiation sensitivity and cancer-specific survival (CSS) were investigated. Of the 35 patients, 11 (31%) achieved pathological CR, while tumors in the remaining 24 patients (69%) were chemoradiation-resistant. Multivariate analysis identified erbB2 and NFκB overexpression and hydronephrosis as significant and independent risk factors for chemoradiation resistance with respective relative risks of 11.8 (P = 0.014), 15.4 (P = 0.024) and 14.3 (P = 0.038). The chemoradiation resistance rate was 88.5% for tumors overexpressing erbB2 and/or NFκB, but only 11.1% for those negative for both (P <0.0001). The 5-year CSS rate was 74% overall. Through multivariate analysis, overexpression of erbB2 and/or NFκB was identified as an independent risk factor for bladder cancer death with marginal significance (hazard ratio 21.5, P = 0.056) along with chemoradiation resistance (P = 0.003) and hydronephrosis (P = 0.018). The 5-year CSS rate for the 11 patients achieving pathological CR was 100%, while that for the 24 with chemoradiation-resistant disease was 61% (P = 0.018). Thus, erbB2 and NFκB overexpression are relevant to chemoradiation resistance and are putative targets aimed at overcoming chemoradiation resistance in MIBC.

Fibromatoses of the extremities: clinicopathologic study of 36 cases

BACKGROUND AND OBJECTIVES

Fibromatoses of the extremities are rare and often recalcitrant to treatment. We evaluated the clinical and pathologic features of a group of extremity fibromatoses treated by surgical excision with or without adjuvant therapy to determine if any clinical or pathologic parameters were predictive of clinical outcome.

METHODS

Thirty-six extremity fibromatoses were evaluated. A number of clinical and histologic features were correlated with risk of local recurrence.

RESULTS

The cohort included 19 females and 17 males with ages ranging from 11-72 years (mean: 35 years), with 12 tumors of the upper and 24 tumors of the lower extremity. Tumors ranged in size from 1.5-15.5 cm (mean: 7.5 cm).Histologically, 26 were infiltrative, 3 had pushing borders and 7 had both. Mitotic counts ranged from 0-5/50 high-power fields (mean: 0.74). Surgical margins were positive in 22 cases. Seventeen patients were treated with postoperative adjuvant therapy including radiation therapy and tamoxifen. Follow-up information was available in 34 cases (from 1-202 months; mean: 83 months). Nineteen patients (56%) had recurrences, including 11 with multiple recurrences (range to first recurrence: 5-61 months; mean 23 months). Seventy-one percent of patients with a positive surgical margin and clinical follow-up had a local recurrence, compared to 31%with a negative surgical margin (P < 0.05). None of the other clinical or histologic parameters correlated with the risk for local recurrence.

CONCLUSIONS

Local control in fibromatoses of the extremities remains problematic. Aside from positive surgical margins, none of the other clinical or histologic parameters evaluated in this study were useful in predicting the risk of local recurrence.

Malignant lymphoma in skeletal muscle with rhabdomyolysis: a report of two cases

Malignant lymphoma is rarely found in skeletal muscle. In this article, we present two cases of malignant lymphomas that were located in skeletal muscle and caused rhabdomyolysis. One case was a primary skeletal muscle lymphoma (which is quite rare), and the other was a skeletal muscle metastasis of lymphoma. The patient with primary skeletal muscle lymphoma was diagnosed with a diffuse type of non-Hodgkin's lymphoma of T-cell origin, which may be linked to a history of injury. Both patients exhibited diffuse, homogeneous lesions of the affected muscles on computed tomography (CT) and magnetic resonance imaging (MRI). The blood levels of some enzymes and potassium, indicative of rhabdomyolysis, were elevated. Bone scintigraphy depicted widespread, diffuse accumulation of the radioisotope in the affected muscles of both patients, typical of rhabdomyolysis. Rhabdomyolysis may be a sequela of lymphoma, as a result of the tendency of malignant lymphoma to infiltrate diffusely into muscles, to affect multiple neighboring muscle compartments, and to metastasize into other soft tissues, as well as being a sequela of possible cytotoxic or humoral actions, all of which may increase the amount of muscle damage. When a patient presents with diffuse muscle swelling, one should consider a diagnosis of a hematogenous disease, which may cause rhabdomyolysis complicated by renal dysfunction.