Phase I/II trial of cilengitide with cetuximab, cisplatin and 5-fluorouracil in recurrent and/or metastatic squamous cell cancer of the head and neck: findings of the phase I part.

BACKGROUND: Novel therapies are needed to improve the poor prognosis of patients with recurrent and/or metastatic squamous cell cancer of the head and neck (SCCHN). METHODS: ADVANTAGE is a phase I/II, multicentre study evaluating the integrin inhibitor cilengitide combined with cetuximab and platinum-based chemotherapy in patients with recurrent and/or metastatic SCCHN. The phase I part tested cilengitide (500, 1000 and 2000 mg) twice weekly with standard doses of cetuximab, cisplatin and 5-fluorouracil. RESULTS: Ten patients (9 male, 1 female; median 56 years old) were included in the phase I part. No dose-limiting toxicities (DLTs: grade 3/4 toxicities in the first 3 weeks as defined per protocol) or deaths occurred. The most common adverse events (AEs) were constipation, rash, nausea, anorexia and fatigue. Cilengitide-related grade 3/4 AEs, all of which occurred after the DLT observation period, were anaemia, angioedema, asthenia, mucosal inflammation, nausea and vomiting (one event per category). Best overall tumour response was partial response (PR) for 4 out of 10 patients and stable disease (SD) for 6 out of 10 patients across all cohorts. Disease control rate (complete response, PR and SD) was 100%. CONCLUSION: Cilengitide combined with cetuximab and platinum-based chemotherapy was well tolerated. No DLTs or unexpected AEs were observed. Cilengitide 2000 mg was considered safe and was selected for the subsequent randomised phase II part assessing progression-free survival.

The new DR-70 immunoassay detects cancer of the gastrointestinal tract: a validation study.

BACKGROUND: Malignant cells characteristically possess high levels of plasminogen activator, which induce local fibrinolysis. The DR-70 immunoassay is a newly developed test, which quantifies fibrin degradation products in serum by a proprietary antibody. AIM: To evaluate the DR-70 immunoassay as a detection assay for the presence of gastrointestinal cancers. METHODS: We prospectively collected blood sera of 85 patients with histologically proven tumour and 100 healthy blood donors. Ten microlitres of the sera was used for the DR-70 immunoassay. Nineteen patients had a hepatocellular and 10 cholangiocellular carcinoma, 13 cancer of the pancreas, 30 colorectal cancer, 10 stomach cancer and three cancer of the oesophagus. RESULTS: Receiver-operator curve analysis revealed <0.7 microg/mL as the best cut-off value to distinguish between patients with cancer and healthy controls. Using this cut-off value, the DR-70 immunoassay showed a good clinical performance with a sensitivity of 91% and a specificity of 93%. Patients with advanced tumour spread showed significantly higher DR-70 values than those with early-stage tumours (P < 0.0003). CONCLUSION: The DR-70 immunoassay reliably differs between cancer patients and healthy controls. Therefore, it promises to become a useful test for the detection of cancer in clinical practice.

Immunohistochemical detection of 1,25-dihydroxyvitamin D3 receptors (VDR) in human skin. A comparison of five antibodies.

Increasing evidence suggests an important regulatory function for 1 alpha,25-dihydroxyvitamin D3 in the growth control of epidermal cells and in skin immunology. Using immunohistochemical techniques we investigated the in situ expression of 1,25-dihydroxyvitamin D3 receptors (VDR) in normal human skin with one monoclonal rat antibody and four monospecific polyclonal rat antibodies to the VDR. Polyclonal rabbit antibodies have been raised against synthetic peptides corresponding to different amino acid residues of the human VDR, including regions close to the DNA binding domain and the hormone-binding domain. All antibodies revealed positive immunoreactivity in normal human skin. The antibodies showed differences in subcellular immunoreactivity and staining-intensity. Differences in subcellular distribution of VDR immunoreactivity are caused by the different epitopes recognized by the antibodies and not by the affinity of the antibodies for VDR. It seems that the antibodies may recognize different functional modifications of the receptor molecule (i.e.: hormone bound vs. hormone free; DNA bound vs. non-DNA bound; VDR vs. VDR/retinoid-X receptor [RXR] heterodimers). Using these newly raised antibodies future studies will be carried out to analyse subcellular distribution of VDR immunoreactivity in skin pathology.

[Paraneoplastic hypoglycemia in localized fibrous tumors of the pleura]. / Paraneoplastische Hypoglykämie beim lokalisierten fibrösen Tumor der Pleura.

Localized fibrous tumor of the pleura is a rare, slowly growing, benign tumor which originates from the submesothelial stem cells of the pleura visceralis. Most of these tumors clinically behave asymptomatically, although tumor-associated hypoglycemia occurs in a few cases and can lead to hypoglycemic coma. Laboratory investigations show significant elevation of paraneoplastic IGF-II with a 2-3 times higher effect on the blood glucose level than insulin. Further, one finds reduced synthesis of IGFBP-3, which inhibits the action of IGF-II by inducing a complex with the paraneoplastic protein. As treatment, surgical resection of the tumor is recommended. We report on the case of a 72-year-old man with diabetes mellitus type II, who complained of recurrent hypoglycemic episodes. Diagnostic evaluation showed a fibrous tumor attached to the right diaphragm. After surgical treatment the hypoglycemic episodes disappeared.

[Reproducible determination of the glomerular filtration rate (GFR) and the effective renal plasma flow (ERPF) in conscious rats using inulin and p-aminohippuric acid]. / Wiederholbare Bestimmung der glomerulären Filtrationsrate (GFR) und des effektiven renalen Plasmaflusses (ERPF) an der wachen Ratte mit Inulin und p-Aminohippursäure.

Estimation of the glomerular filtration rate (GFR) and of the effective renal plasma flow (ERPF) by means of the test substances inulin and p-aminohippuric acid according to the steady state clearance measurement during the drop of the plasma level after the initially injection of an depot of the indicators was examined methodologically. The procedure should be repeatable in the same animal under conscious conditions. The results demonstrate that the described method is adequate with regard to accuracy, reproducibility and sensitivity for the estimation of the GFR, whereas limitations apply to calculation of the ERPF.

Incidence of antiretinal antibodies in melanoma: screening of 77 serum samples from 51 patients with American Joint Committee on Cancer stage I-IV.

BACKGROUND: Patients with melanoma-associated retinopathy (MAR) experience different visual symptoms caused by the production of antitumoral antibodies that cross-react with retinal epitopes. Immunofluorescence assays of serum from patients with MAR on sectioned monkey or human retina characteristically reveal antibody activity located within the inner nuclear layer, with a focus of activity upon the membranes of bipolar cells. OBJECTIVES: We inquired into the association with disease of this serological abnormality by evaluating sera from patients with melanoma with no MAR-like signs or symptoms. METHODS: Groups of patients were selected with different stages of melanoma (American Joint Committee on Cancer stages I-IV). Seventy-seven serum samples from 51 patients with melanoma were examined by indirect immunohistochemical assay on sections of human retina. RESULTS: Of the 77 serum samples, 53 were found to contain antibodies reactive with various components of retina. Eight were from 17 sera from patients in stage I or II, 14 were from 23 sera from patients in stage III, and 31 were from 37 sera from patients in stage IV. Statistical analysis revealed a correlation between antibody activity and the stage of disease, with a higher percentage of antibody activity in advanced stages (P = 0.002). CONCLUSIONS: The presence of antiretinal antibodies in patients with melanoma without ocular symptoms appears to be more common than previously suspected. Antibody activity similar to that ascribed to the MAR syndrome appears in some patients with melanoma who have no MAR-like retinopathy. Follow-up studies will determine if patients with antiretinal antibodies go on to develop MAR and if staining intensity and staining patterns change over the course of the disease.

Long-term effects of core decompression by drilling. Demonstration of bone healing and vessel ingrowth in an animal study.

Avascular necrosis of the femoral head is associated with bone marrow hyperpression. Although core decompression by drilling is an accepted treatment regimen, until today no experimental results exist concerning the physiological effects of this procedure. Published clinical data are controversial. In an animal study marrow decompression was carried out by drilling of both hips in 18 healthy male sheep. In the right hip of each animal a resorbable stent was implanted in order to prolong the duration of core decompression. Over a time period of 24 weeks the effects were studied by measurement of the intraosseous pressure, by the plastination method and by morphological examination with light and electron microscopy. Bone drilling is a procedure of high short-time efficacy in decompressing the bone marrow. But decompression lasts only for a short time period. Three weeks postoperatively the drill channel is sealed by hematoma and fibrous tissue in both hips (with/without stent) and no significant decompressive effect is measured. Ingrowth of vessels along the drill channel is found in all hips after a time period of 3 weeks. These vessels originate from the periosteum as well as from the bone marrow and form temporary anastomoses between the periostal-diaphyseal-metaphyseal and the epiphyseal-physeal circulatory system. In conclusion, for the first time an anastomosis induced by drilling between both circulatory systems of bone is demonstrated and the importance of the periosteum is confirmed. The time of decreased core pressure induced by drilling is too short for substitution of a necrotic area and could be the explanation of the inferior clinical results of the procedure.

[Interdisciplinary treatment concepts in chronic wounds]. / Interdisziplinäre Behandlungskonzepte bei chronischen Wunden.

Interdisciplinary concepts for the treatment of chronic wounds are mandatory because of the multifactorial reasons causing ulceration. This is a report on 6 years' experience at the wound care unit in Tübingen. Patients with chronic wounds (mainly diabetic, venous, and ischemic ulcers) were treated primarily as outpatients according to a standardised and interdisciplinary wound care protocol. Quality control was guaranteed by a standardised wound documentation system. The evaluation of this data demonstrates an overall healing rate of 69% within 52 weeks (mean). Before patients were referred to Tübingen, unsuccessful therapy was characterised by a mean wound duration of 35 weeks. The results presented justify this interdisciplinary wound care unit.

[44-year-old patient with fulminant liver failure]. / 44-jährige Patientin mit fulminantem Leberversagen.

The 44-year old female patient was admitted with acute hepatic failure and extensive haemolysis under the preliminary diagnosis of Wilson's disease. General characteristic criteria of Wilson's disease as Kayser-Fleischer ring, low serum copper and low ceruloplasmin levels were not observed. The preliminary diagnosis of acute Wilson's disease was established on the basis of the characteristic laboratory values with an AP/bilirubin ratio <2, an AST/ALT ratio >4, accompanying hemolysis and a highly elevated cupruresis. The definitive diagnosis of Wilson's disease was verified after orthotopic liver transplantation by quantitative copper evaluation in the explanted liver. The case represents the yet oldest patient reported with an acute manifestation of Wilson's disease.

Biologic effects of topical calcipotriol (MC 903) treatment in psoriatic skin.

BACKGROUND: The biologically active vitamin D analog calcipotriol is effective and safe in the topical treatment of psoriasis, but its exact mechanism of action is unknown. OBJECTIVE: We investigated expression of 1,25-dihydroxyvitamin D3 receptors, markers for inflammation (CD1a, CD4, CD8, CD11b, CD15; NAP-1/interleukin-8; 55 kd tumor necrosis factor-receptor; intercellular adhesion molecule-1; HLA-DR), proliferation (proliferating cell nuclear antigen, Ki-67), and differentiation (transglutaminase K; involucrin; cytokeratin 16) in psoriatic skin during topical calcipotriol treatment. METHODS: For immunohistochemical staining we used the labeled avidin-biotin technique on cryostat-cut sections. RESULTS: We found a significant increase of 1,25-dihydroxyvitamin D3 receptor expression in epidermal basal keratinocytes of lesional psoriatic skin during calcipotriol treatment. In all patients analyzed, effects on proliferation and differentiation of epidermal keratinocytes were stronger than effects on dermal inflammation. Effects on inflammation were more pronounced in the epidermal than in the dermal compartment. CONCLUSION: Our findings indicate that analogs of 1,25-dihydroxyvitamin D3 upregulate their corresponding receptor in human keratinocytes in vivo. This mechanism may be important in the therapeutic efficacy of vitamin D analogs in psoriasis. The differential therapeutic effects in the epidermal and dermal skin compartments may be due to a reduced bioavailability of calcipotriol in the dermal compartment.

Hair follicle expression of 1,25-dihydroxyvitamin D3 receptors during the murine hair cycle.

Because the hair follicle is a highly hormone-sensitive miniorgan, the role of hormones produced locally in the skin in the control of hair growth deserves systematic analysis. It has been shown previously that the potent steroid hormone 1,25-dihydroxyvitamin D3 (1,25-D3) modulates growth and differentiation of keratinocytes via binding to a high-affinity nuclear vitamin D receptor (VDR). In this study, we have examined the in situ expression of VDR during the murine hair cycle. VDR expression was detected immunohistochemically. To obtain defined stages of the murine hair cycle, hair growth was induced by depilation in C57 BL-6 mice. In addition to the recognized VDR expression of outer root sheath keratinocytes, we detected VDR immunoreactive cells in the dermal papilla, the mesenchymal key structure of the hair follicle. Furthermore, VDR immunoreactivity in the nuclei of outer root sheath keratinocytes and in dermal papilla cells was stronger during anagen IV-VI and catagen than during telogen and anagen I-III. This suggests hair cycle-associated changes in the expression of VDR, and points to a potential role for 1,25-D3 in hair follicle biology. Selected follicular cell populations may display hair cycle-dependent sensitivity to 1,25-D3 stimulation.

Immunoreactivity of six monoclonal antibodies directed against 1,25-dihydroxyvitamin-D3 receptors in human skin.

Using confocal laser scanning microscopy, we tested the suitability of five monoclonal mouse antibodies (IVA7E7, IVB12G12, IVG9C11, VD2F12, and VIIID8C12) that had been raised against different domains of the porcine intestinal 1,25-dihydroxyvitamin-D3 receptor (VDR), for the immunohistological detection of VDR in human skin. The VDR immunoreactivity of these antibodies was compared with the well-characterized VDR-staining pattern of the mouse monoclonal antibody 9A7gamma raised against chick intestinal VDR. All six antibodies revealed strong nuclear and qualitatively similar immunoreactivity in all cell layers of the viable epidermis. Our data demonstrate that the five mouse monoclonal antibodies are suitable for immunohistochemical detection of VDR in frozen sections. These antibodies show comparable staining patterns in human skin even though they had been raised against different functional domains of the 1,25-dihydroxyvitamin-D3 receptor.

In situ detection of retinoid-X receptor expression in normal and psoriatic human skin.

Increasing evidence suggests that the retinoid-X receptors RXR(-alpha,-beta,-gamma) play a crucial part in regulating the transcriptional activity of several steroid hormone receptors, including 1,25-dihydroxyvitamin D3 receptors (VDR) and retinoic acid receptors (RAR-alpha,-beta,-gamma). We developed a new technique for immunohistochemical in situ detection of RXR receptors, and investigated the localization of RXR-alpha in normal and psoriatic human skin using a recently raised corresponding specific antibody. RXR-alpha positive cells related to the skin were phenotyped by sequential sections and a double-labelling procedure for the simultaneous demonstration of this nuclear receptor and cell membrane antigens, as well as cytokeratin 10, HLA-DR and vimentin. Our findings indicate that: (i) RXR-alpha is strongly expressed in normal and psoriatic human skin; (ii) most of the cell types in normal human skin, including keratinocytes, melanocytes, fibroblasts and skin immune cells such as Langerhans cells, reveal strong nuclear immunoreactivity for RXR-alpha, with less cytoplasmic staining; (iii) altered levels or distribution of RXR-alpha in the skin do not appear to be involved in the genesis of psoriasis vulgaris, but subepidermal and subcellular distribution suggest a function of RXR-alpha in the transition from proliferation to differentiation in epidermal keratinocytes; (iv) expression in the hair follicle points to a contribution from RXR-alpha to hair growth.

Topical calcitriol (1,25-dihydroxyvitamin D3) treatment of psoriasis: an immunohistological evaluation.

The potent calciotropic hormone calcitriol (1,25-dihydroxyvitamin D3, 1,25(OH)2D3) has been shown to be very effective and safe in the topical treatment of psoriasis. In vitro, 1,25(OH)2D3 inhibits proliferation and stimulates differentiation of human keratinocytes. Increasing evidence suggests an immunoregulatory function of this potent steroid hormone. To further characterize the biological effects of topical calcitriol treatment in psoriasis, we have analyzed immunohistochemically the expression of markers for epidermal proliferation (proliferating cell nuclear antigen=PCNA) and differentiation (transglutaminase K, involucrin, cytokeratin 16), as well as inflammation (CD1a, 55 kDa TNF-receptor, NAP-1/IL-8) in calcitriol-treated psoriatic skin in situ. Our findings strongly support the hypothesis that calcitriol modulates keratinocyte proliferation/differentiation as well as inflammation in human skin in vivo. The immunoreactivity of markers for epidermal proliferation and differentiation, as well as of CD1a and NAP-1/IL-8, changed after 8 weeks of calcitriol treatment almost completely to the pattern characteristic for non-lesional psoriatic skin, while a large number of 55 kDa TNF-receptor positive cells could be found in the dermal compartment.