SFRP1 decreases WNT-Mediated M2 macrophage marker expression in breast tissue.

The Wnt family of secreted proteins are involved in mammary gland development and tumorigenesis. It has recently been shown that Wnt ligands promote M2 macrophage polarization and so we sought to determine the effects of a Wnt signaling antagonist, Secreted Frizzled Related Protein 1 (SFRP1), on M2 marker expression. We measured a murine M2 marker (Arg1) in mice with a targeted deletion of Sfrp1 during different stages of mammary gland development including puberty, pregnancy, and lactation, as well as in response to obesity. Next, to determine whether Wnt signaling/antagonism affects human M2 markers (CD209 and CCL18), we treated a human patient derived explant (PDE) breast tissue sample with exogenous Wnt3a in the presence and absence of rSFRP1. Finally, we expanded our PDE study to 13 patients and performed bulk RNAseq analysis following the treatment described above. We found that in loss of Sfrp1 in the murine mammary gland increased Arg1 expression. Moreover, we showed that Wnt3a increases CD209 and CCL18 mRNA and protein expression in breast PDEs and that their expression is decreased in response to rSFRP1. Our RNAseq analysis unveiled novel genes that were affected by Wnt3a treatment and subsequently reversed when rSFRP1 was added. Validation of these data exhibited that chemokines involved in promoting macrophage polarization and cancer metastasis, including CCL11 and CCL26, were stimulated by Wnt3a signaling and their expression was abrogated by treatment with rSFRP1. Our data suggest that SFRP1 may be an important mediator that tempers Wnt signaling in the tumor microenvironment.

Benzophenone-3 exposure alters composition of tumor infiltrating immune cells and increases lung seeding of 4T1 breast cancer cells.

Environmental chemicals are a persistent and pervasive part of everyday life. A subset of environmental chemicals are xenoestrogens, compounds that bind to the estrogen receptor (ER) and drive estrogen-related processes. One such chemical, benzophenone-3 (BP3), is a common chemical in sunscreen. It is a potent UV protectant but also is quickly absorbed through the skin. While it has been approved by the FDA, there is a renewed interest in the safety of BP3, particularly in relation to breast cancer. The focus of this study was to examine the impact that BP3 has on triple negative breast cancer (TNBC) through alterations to cells in the immune microenvironment. In this study, we exposed female mice to one of two doses of BP3 before injecting them with a TNBC cell line. Several immune endpoints were examined both in the primary tissues and from in vitro studies of T cell behavior. Our studies revealed that in the lung tumor microenvironment, exposure to BP3 not only increased the number of metastases, but also the total area of tumor coverage. We also found that BP3 caused alterations in immune populations in a tissue-dependent manner, particularly in T cells. Taken together, our data suggest that while BP3 may not directly affect the proliferation of TNBC, growth and metastasis of TNBC-derived tumors can be altered by BP3 exposures via the alterations in the immune populations of the tumor microenvironment.

"No matter what, we just work with the trauma ": Mental Health Therapists' Care of Diverse Sexual and Gender Identity Citizens in Cambodia.

The convergence of trauma symptomatology, mental health symptoms, family and social difficulties, and intersectionality of diverse sexual and gender minority (SGM) individual issues is complex, multi-faceted, and challenging for the individuals in Cambodia who suffer them and for the therapists in Cambodia who meet individuals in treatment. We documented and analyzed the perspectives of mental health therapists in the context of a randomized control trial (RCT) intervention within the Mekong Project in Cambodia. The research questions explored perceptions of therapists' care of mental health clients, therapist wellbeing, and experiences of navigating within a research environment in which SGM citizens with mental health concerns receive treatment. The larger study enrolled 150 Cambodian adults, among which 69 identified as SGM. Three key patterns emerged across our interpretations. Clients seek help when symptoms interfere with daily life, therapists care for clients and themselves, and integrated research and practice is integral yet sometimes paradoxical. Therapists did not identify differences in terms of how they work with SGM clients compared with non-SGM clients. Future studies are warranted to examine a reciprocal academic-research partnership in which we examine therapists' work alongside rural community members, evaluate the process of embedding and fortifying peer supports within educational systems, and study the wisdom of traditional and Buddhist healers to address the discrimination and violence that citizens who identify as SGM disproportionately suffer. National Library of Medicine (U.S.). (2020). Trauma Informed Treatment Algorithms for Novel Outcomes (TITAN). Identifier NCT04304378.

Interindividual variation contributes to differential PCB 126 induced gene expression in primary breast epithelial cells and tissues.

PCB 126 is a pervasive, dioxin-like chemical pollutant which can activate the aryl hydrocarbon receptor (AhR). Despite being banned from the market, PCB 126 can be detected in breast milk to this day. The extent to which interindividual variation impacts the adverse responses to this chemical in the breast tissue remains unclear. This study aimed to investigate the impact of 3 nM PCB 126 on gene expression in a panel of genetically diverse benign human breast epithelial cell (HBEC) cultures and patient derived breast tissues. Six patient derived HBEC cultures were treated with 3 nM PCB 126. RNAseq was used to interrogate the impact of exposure on differential gene expression. Gene expression changes from the top critical pathways were confirmed via qRT-PCR in a larger panel of benign patient derived HBEC cultures, as well as in patient-derived breast tissue explant cultures. RNAseq analysis of HBEC cultures revealed a signature of 144 genes significantly altered by 3 nM PCB 126 treatment. Confirmation of 8 targets using a panel of 12 HBEC cultures and commercially available breast cell lines demonstrated that while the induction of canonical downstream target gene, CYP1A1, was consistent across our primary HBECs, other genes including AREG, S100A8, IL1A, IL1B, MMP7, and CCL28 exhibited significant variability across individuals. The dependence on the activity of the aryl hydrocarbon receptor was confirmed using inhibitors. PCB 126 can induce significant and consistent changes in gene expression associated with xenobiotic metabolism in benign breast epithelial cells. Although the induction of most genes was reliant on the AhR, significant variability was noted between genes and individuals. These data suggest that there is a bifurcation of the pathway following AhR activation that contributes to the variation in interindividual responses.

Building Families Through Healthcare: Experiences of Lesbians Using Reproductive Services.

The use of assisted human reproduction (AHR) represents a meaningful and important life event for lesbians wishing to create biologically related families. Despite increasing numbers of lesbians utilizing AHR services, barriers to access persist. This qualitative study investigated the experiences of lesbians and their interactions with reproductive services in Ontario, Canada, where limited public funding is available for all AHR patients and where the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community makes up to 30% of clientele. Eleven semi-structured interviews were conducted, and findings revealed a wide range of experiences. Lesbian patients expressed a desire for more support from their care providers in navigating a complex and costly medical journey through a system largely designed for the needs of heterosexual patients. Additionally, private fertility clinics, as the environment for accessing publicly funded services, were felt to contribute pressure to pay out-of-pocket for add-on medical procedures. To improve the quality of care, participants recommended providing more high-level information on the medical journey and taking an individual approach with lesbian patients, in particular, assuming a patient has sufficient fertility until proven otherwise.

The use of patient-derived breast tissue explants to study macrophage polarization and the effects of environmental chemical exposure.

Ex vivo mammary explant systems are an excellent model to study interactions between epithelium and stromal cell types because they contain physiologically relevant heterotypic interactions in the background of genetically diverse patients. The intact human mammary tissue, termed patient-derived explant (PDE), can be used to investigate cellular responses to a wide variety of external stimuli in situ. For this study, we examined the impact of cytokines or environmental chemicals on macrophage phenotypes. We demonstrate that we can polarize macrophages within human breast tissue PDEs toward M1 or M2 through the addition of interferon-γ (IFNγ) + lipopolysaccharide (LPS) or interleukin (IL)-4 + IL-13, respectively. Elevated expression levels of M(IFNγ + LPS) markers (HLADRA and CXCL10) or M(IL-4 + IL-13) markers (CD209 and CCL18) were observed in cytokine-treated tissues. We also examined the impact of the endocrine-disrupting chemical, benzophenone-3, on PDEs and measured significant, yet varying effects on macrophage polarization. Furthermore, a subset of the PDEs respond to IL-4 + IL-13 through downregulation of E-cadherin and upregulation of vimentin which is reminiscent of epithelial-to-mesenchymal transition (EMT) changes. Finally, we were able to show immortalized nonmalignant breast epithelial cells can exhibit EMT characteristics when exposed to growth factors secreted by M(IL-4 + IL-13) macrophages. Taken together, the PDE model system is an outstanding preclinical model to study early tissue-resident immune responses and effects on epithelial and stromal responses to stimuli found both endogenously in the breast and exogenously as a result of exposures.

Enrichment of CpG island shore region hypermethylation in epigenetic breast field cancerization.

While changes in DNA methylation are known to occur early in breast carcinogenesis and the landscape of breast tumour DNA methylation is profoundly altered compared with normal tissue, there have been limited efforts to identify DNA methylation field cancerization effects in histologically normal breast tissue adjacent to tumour. Matched tumour, histologically normal tissue of the ipsilateral breast (ipsilateral-normal), and histologically normal tissue of the contralateral breast (contralateral-normal) were obtained from nine women undergoing bilateral mastectomy. Laser capture microdissection was used to select epithelial cells from normal tissue, and neoplastic cells from tumour for genome-scale measures of DNA methylation with the Illumina HumanMethylationEPIC array. We identified substantially more CpG loci that were differentially methylated between contralateral-normal and tumour (63,271 CpG loci q < 0.01), than between ipsilateral-normal and tumour (38,346 CpG loci q < 0.01). We identified differential methylation in ipsilateral-normal relative to contralateral-normal tissue (9,562 CpG loci p < 0.01). In this comparison, hypomethylated loci were significantly enriched for breast cancer-relevant transcription factor binding sites including those for ESR1, FoxA1, and GATA3 and hypermethylated loci were significantly enriched for CpG island shore regions. In addition, progression of shore hypermethylation was observed in tumours compared to matched ipsilateral normal tissue, and these alterations tracked to several well-established tumour suppressor genes. Our results indicate an epigenetic field effect in surrounding histologically normal tissue. This work offers an opportunity to focus investigations of early DNA methylation alterations in breast carcinogenesis and potentially develop epigenetic biomarkers of disease risk. ABBREVIATIONS: DCIS: ductal carcinoma in situ; GO: gene ontology; OR: odds ratio; CI: confidence interval; TFBS: transcription factor binding site; LOLA: Locus Overlap Analysis.

Gene expression signature of atypical breast hyperplasia and regulation by SFRP1.

BACKGROUND: Atypical breast hyperplasias (AH) have a 10-year risk of progression to invasive cancer estimated at 4-7%, with the overall risk of developing breast cancer increased by ~ 4-fold. AH lesions are estrogen receptor alpha positive (ERα+) and represent risk indicators and/or precursor lesions to low grade ERα+ tumors. Therefore, molecular profiles of AH lesions offer insights into the earliest changes in the breast epithelium, rendering it susceptible to oncogenic transformation. METHODS: In this study, women were selected who were diagnosed with ductal or lobular AH, but no breast cancer prior to or within the 2-year follow-up. Paired AH and histologically normal benign (HNB) tissues from patients were microdissected. RNA was isolated, amplified linearly, labeled, and hybridized to whole transcriptome microarrays to determine gene expression profiles. Genes that were differentially expressed between AH and HNB were identified using a paired analysis. Gene expression signatures distinguishing AH and HNB were defined using AGNES and PAM methods. Regulation of gene networks was investigated using breast epithelial cell lines, explant cultures of normal breast tissue and mouse tissues. RESULTS: A 99-gene signature discriminated the histologically normal and AH tissues in 81% of the cases. Network analysis identified coordinated alterations in signaling through ERα, epidermal growth factor receptors, and androgen receptor which were associated with the development of both lobular and ductal AH. Decreased expression of SFRP1 was also consistently lower in AH. Knockdown of SFRP1 in 76N-Tert cells resulted altered expression of 13 genes similarly to that observed in AH. An SFRP1-regulated network was also observed in tissues from mice lacking Sfrp1. Re-expression of SFRP1 in MCF7 cells provided further support for the SFRP1-regulated network. Treatment of breast explant cultures with rSFRP1 dampened estrogen-induced progesterone receptor levels. CONCLUSIONS: The alterations in gene expression were observed in both ductal and lobular AH suggesting shared underlying mechanisms predisposing to AH. Loss of SFRP1 expression is a significant regulator of AH transcriptional profiles driving previously unidentified changes affecting responses to estrogen and possibly other pathways. The gene signature and pathways provide insights into alterations contributing to AH breast lesions.

Regulation of early growth response 2 expression by secreted frizzled related protein 1.

BACKGROUND: Secreted frizzled-related protein 1 (SFRP1) expression is down-regulated in a multitude of cancers, including breast cancer. Loss of Sfrp1 also exacerbates weight gain as well as inflammation. Additionally, loss of SFRP1 enhances TGF-ß signaling and the downstream MAPK pathway. TGF-ß has been shown to increase the expression of Early Growth Response 2 (EGR2), a transcription factor implicated in immune function in a wide variety of cell types. The work described here was initiated to determine whether SFRP1 modulation affects TGF-ß mediated EGR2 expression in mammary tissues as well as macrophage polarization. METHODS: Real-time PCR analysis was performed to examine EGR2 expression in human and murine mammary epithelial cells and tissues in response to SFRP1 modulation. Chemical inhibition was employed to investigate the roles TGF-ß and MAPK signaling play in the control of EGR2 expression in response to SFRP1 loss. Primary murine macrophages were isolated from Sfrp1-/- mice and stimulated to become either M1 or M2 macrophages, treated with recombinant SFRP1, and real-time PCR was used to measure the expression of murine specific M1/M2 markers [Egr2 (M2) and Gpr18 (M1)]. Immunohistochemical analysis was used to measure the expression of human specific M1/M2 markers [CD163 (M2) and HLA-DRA (M2)] in response to rSFRP1 treatment in human mammary explant tissue. RESULTS: Knockdown of SFRP1 expression increases the expression of EGR2 mRNA in human mammary epithelial cells and addition of rSFRP1 decreases the expression of EGR2 when added to explant mammary gland tissues. Chemical inhibition of both TGF-ß and MAPK signaling in Sfrp1-/- or knockdown mammary epithelial cells results in decreased expression of EGR2. Stimulated murine macrophages obtained from Sfrp1-/- mice and treated with rSFRP1 exhibit a reduction in Egr2 expression and an increase in Gpr18 mRNA expression. Human mammary explant tissue treated with rSFRP1 decreases CD163 protein expression whereas there was no effect on the expression of HLA-DRA. CONCLUSIONS: Loss of SFRP1 likely contributes to tumor progression by altering the expression of a critical transcription factor in both the epithelium and the immune system.

The influence of tumor necrosis factor-α on the tumorigenic Wnt-signaling pathway in human mammary tissue from obese women.

Epidemiological studies have convincingly suggested that obesity is an important risk factor for postmenopausal breast cancer, but the mechanisms responsible for this relationship are still not fully understood. We hypothesize that obesity creates a low-grade inflammatory microenvironment, which stimulates Wnt-signaling and thereby promotes the development of breast cancer. To test this hypothesis, we evaluated the correlations between expression of multiple inflammatory cytokines and Wnt pathway downstream genes in mammary tissues from women (age ≥ 50) undergoing reduction mammoplasty. Moreover, we specifically examined the role of tumor necrosis factor-α (TNF-α), an important proinflammatory cytokine associated with obesity and a possible modulator of the Wnt pathway. The regulatory effects of TNF-α on Wnt pathway targets were measured in an ex vivo culture of breast tissue treated with anti-TNF-α antibody or TNF-α recombinant protein. We found that BMI was positively associated with the secretion of inflammatory cytokines IL-1ß, IL-6 and TNF-α, all of which were negatively correlated with the expression of SFRP1. The transcriptional expression of Wnt-signaling targets, AXIN2 and CYCLIN D1, were higher in mammary tissue from women with BMI ≥ 30 compared to those with BMI < 30. Our ex vivo work confirmed that TNF-α is causally linked to the up-regulation of active ß-CATENIN, a key component in the Wnt pathway, and several Wnt-signaling target genes (i.e. CYCLIN D1, AXIN2, P53 and COX-2). Collectively, these findings indicate that obesity-driven inflammation elevates Wnt-signaling in mammary tissue and thereby creates a microenvironment conducive to the development of breast cancer.

Rhodiola crenulata induces an early estrogenic response and reduces proliferation and tumorsphere formation over time in MCF7 breast cancer cells.

BACKGROUND: Rhodiola crenulata is a Tibetan mountainous plant, commonly used in Eastern alternative medicine. Many phytochemicals possess estrogenic activity, a critical regulator of proliferation in mammary epithelial cells. We have previously characterized anti-cancer properties of R. crenulata in aggressive triple negative breast cancer cells, lacking the expression of estrogen receptor. Currently, it is unknown whether R. crenulata exerts estrogenic effects and as such consumption may be a concern for women with estrogen receptor positive breast cancer that use Rhodiola sp. to relieve mild to moderate depression. PURPOSE: In this study, we wished to determine whether a hydroalcoholic fraction of the R. crenulata root extract exhibits estrogenic activity in estrogen receptor positive (ER+) breast cancer cells in vitro and whether it affects normal mammary epithelial ER target gene expression in vivo. METHODS: ER transcriptional activity was analyzed in MCF7 cells expressing an ERE reporter construct and confirmed via qPCR of endogenous ER target genes. We also monitored cellular proliferation over time. Additionally, to assess stem-like properties in MCF7 cells, we performed a tumorsphere formation assay under anchorage independent conditions. We examined whether R. crenulata treatment reduced ß-catenin levels via Western blotting and measured ß-catenin transcriptional activity by a reporter assay. To examine the effects of R. crenulata on normal mammary epithelial cells, we performed immunohistochemical staining of ER and PR in the mammary glands of mice fed R. crenulata for 12 weeks. RESULTS: We show an initial activation of ER transcriptional activity by dual reporter assay, qPCR and proliferation of MCF7 ER+ cells in response to 24 h of R. crenulata treatment. However, upon longer treatment basal and R. crenulata induced transcriptional activity was suppressed. There was a decrease in cell doubling times and a decrease in tumorsphere formation. In association with these changes, ERα transcript levels were decreased and active ß-catenin levels were reduced in the cells treated for 2 weeks. Finally, we show no change in estrogen targets in normal mammary cells in vivo. CONCLUSION: These data suggest that the R. crenulata extract contains components with estrogenic activity. However, R. crenulata treatment could still be protective in ER+ breast cancer cells, as longer treatment reduced the transcriptional activity of ß-catenin and ER responses leading to reduced proliferation and tumorsphere formation. Furthermore, administration of 20 mg/kg/day R. crenulata to mice did not have an observable effect on mammary epithelial ERα target gene expression in vivo.

Estrogen-mediated signaling is differentially affected by the expression levels of Sfrp1 in mammary epithelial cells.

Estrogen has been implicated in breast cancer risk for a variety of reasons including its role in stimulating mammary cell division. Secreted frizzled-related proteins (SFRPs) are a family of Wnt signaling antagonists. Loss of Sfrp1 in mice results in focal ductal epithelial hyperplasias and in humans, loss of SFRP1 is associated with early changes in premalignant breast lesions as well as poor overall survival in patients with early stage breast cancer. Considering that SFRP1 expression is further reduced in ER positive breast cancers when compared with ER negative breast cancers, we chose to determine whether loss of Sfrp1 alters ER signaling. Immunohistochemical analysis revealed that loss of Sfrp1 significantly increased the number of PR and BrdU positve cells in the mammary gland. We further demonstrate that down stream actions of ER-mediated signaling, including cellular proliferation and PR transcription, are elevated in estradiol treated explant cultures derived from Sfrp1(-/-) mice. Additionally, we show that Control explant cultures treated with estradiol exhibit an increase in the mRNA levels of Sfrp1. Finally, we establish that in human mammary epithelial cells with either SFRP1 knocked down (TERT-siSFRP1) and rescued SFRP1 expression (MCF7-SFRP1), estrogen signaling is augmented. Modulation of ER activity appears to be through a mechanism dependent upon Wnt/ß-catenin activity. Taken together, our data suggest an important control mechanism by which estrogen signaling is tempered in normal cells and indicates why loss of SFRP1 in early lesions might be a causal change leading to enhanced estrogen-mediated proliferation.

The oncology pharmacy in cancer care delivery in a resource-constrained setting in western Kenya.

The movement to deliver cancer care in resource-limited settings is gaining momentum, with particular emphasis on the creation of cost-effective, rational algorithms utilizing affordable chemotherapeutics to treat curable disease. The delivery of cancer care in resource-replete settings is a concerted effort by a team of multidisciplinary care providers. The oncology pharmacy, which is now considered integral to cancer care in resourced medical practice, developed over the last several decades in an effort to limit healthcare provider exposure to workplace hazards and to limit risk to patients. In developing cancer care services in resource-constrained settings, creation of oncology pharmacies can help to both mitigate the risks to practitioners and patients, and also limit the costs of cancer care and the environmental impact of chemotherapeutics. This article describes the experience and lessons learned in establishing a chemotherapy pharmacy in western Kenya.

Integration of a clinical pharmacist into the hematology-oncology clinics at an academic medical center.

PURPOSE: The development, implementation, and early experience with a program providing clinical pharmacist services at the hematology-oncology clinics of a university teaching hospital are described. SUMMARY: With funding from a university research grant and other sources, a pharmacist was hired to launch a new program addressing four goals identified in a needs assessment: (1) improved management of supportive care, (2) enhanced education of patients receiving complicated chemotherapy regimens, (3) improved efficiency in the chemotherapy infusion unit, and (4) development of an experiential learning opportunity for pharmacy students and residents. The pharmacist hired to lead the ongoing program was a state-approved clinical pharmacist practitioner (CPP) who had authority to prescribe with physician oversight under established protocols. EXPERIENCE: An oncology supportive care consultation service implemented by the CPP in collaboration with a nurse and a physician served 89 new patients in its first 18 months of operation; during that period the CPP made 186 interventions and wrote 136 prescriptions. The CPP also established a chemotherapy counseling service that provided more than 900 bill-able patient education sessions over 18 months. In addition, the CPP launched an effort to increase use of a rituximab rapid-infusion protocol among eligible patients. The creation of the new oncology pharmacist position has given dozens of pharmacy students and residents a new opportunity for interaction with oncology clinic patients and other health care team members. CONCLUSION: Integration of the services of a CPP into the hematology-oncology clinics has helped achieve goals set by physician, nursing, and pharmacy leaders.

Plerixafor dosing and administration in a patient with dialysis-dependent renal failure.

OBJECTIVE: To report on the use of plerixafor in a patient with multiple myeloma and dialysis-dependent renal failure. CASE SUMMARY: A 38-year-old man with multiple myeloma and dialysis-dependent renal failure was evaluated for stem cell transplantation. Stem cell mobilization with 6 doses of granulocyte colony-stimulating factor (G-CSF) 10 µg/kg/day yielded an inadequate maximum pre-apheresis CD34+ count of 5.6 cells/µL. The patient was treated with a postdialysis subcutaneous dose of plerixafor 160 µg/kg after 4 days of G-CSF therapy. After a single dose of plerixafor, the patient's pre-apheresis CD34+ count was 125.6 cells/µL. After 1 apheresis session, the stem cell collection yield was 5.33 x 106 CD34+ cells/kg. There were no observed plerixafor toxicities. The patient underwent successful autologous stem cell transplantation. Times to neutrophil and platelet engraftment were 12 and 15 days, respectively. At 100-day follow-up, the patient's myeloma was in remission and he met all criteria for durable engraftment. DISCUSSION: Renal impairment is a common comorbidity in patients with multiple myeloma. Plerixafor is a chemokine receptor 4 antagonist approved for use to mobilize stem cells for collection and subsequent autologous transplantation in patients with non-Hodgkin's lymphoma and multiple myeloma. To date, there is limited information on safe and effective dosing and administration of plerixafor in patients who are dialysis-dependent. This report describes the use of plerixafor in a patient with multiple myeloma and dialysis-dependent renal failure. CONCLUSIONS: Based on our experience, we are instituting a policy to administer plerixafor at Food and Drug Administration-approved renal adjustment doses in patients on hemodialysis, with dialysis sessions scheduled prior to plerixafor administration and repeated as necessary after apheresis and prior to subsequent plerixafor doses. If clinically feasible, dialysis should be held during the days required to collect stem cells.

Retrospective analysis of the efficacy of gemcitabine for previously treated AIDS-associated Kaposi's sarcoma in western Kenya.

OBJECTIVES: Evaluation of outcomes in the use of single-agent gemcitabine for the treatment of AIDS-associated Kaposi's sarcoma (KS) in a western Kenyan cancer treatment program. METHODS: Retrospective chart review of all patients with KS treated with single agent gemcitabine following failure of first-line Adriamycin, bleomycin, and vincristine (ABV). Baseline demographics were collected, and clinicians' assessments of response were utilized to fill out objective criteria for both response as well as symptom benefit assessment. RESULTS: Twenty-three patients with KS who had previously failed first-line therapy with ABV were evaluated. Following treatment, 22 of the 23 patients responded positively to treatment with stable disease or better. Of the 18 patients who had completed therapy, with a median follow-up of 5 months, 12 patients had no documented progression. CONCLUSIONS: Treatment options in the resource-constrained setting are limited, both by financial constraints as well as the need to avoid myelotoxicity, which is associated with high morbidity in this treatment setting. This work shows that gemcitabine has promising activity in KS, with both objective responses and clinical benefit observed in this care setting. Gemcitabine as a single agent merits further investigation for AIDS-associated KS.