p27 and Skp2 immunoreactivity and its clinical significance with endocrine and chemo-endocrine treatments in node-negative early breast cancer.

BACKGROUND: Low p27 and high Skp2 immunoreactivity are associated with a poor prognosis and other poor prognostic features including resistant phenotypes and antiestrogen drug resistance. We investigated these proteins in two International Breast Cancer Study Group trials studying node-negative early breast cancer. PATIENTS AND METHODS: Trial VIII compared chemotherapy followed by goserelin with either modality alone in premenopausal patients. Trial IX compared chemotherapy followed by tamoxifen with tamoxifen alone in postmenopausal patients. Central Pathology Office assessed p27 and Skp2 expression in the primary tumor by immunohistochemistry among 1631 (60%) trial patients. RESULTS: p27 and Skp2 were inversely related; 13% of tumors expressed low p27 and high Skp2. Low p27 and high Skp2 were associated with unfavorable prognostic factors including larger size and higher grade tumors, absence of estrogen receptor and progesterone receptor, human epidermal growth factor receptor 2 overexpression and high Ki-67 (each P < 0.05). Low p27 and high Skp2 were not associated with disease-free survival (P = 0.42 and P = 0.48, respectively). The relative effects of chemo-endocrine versus endocrine therapy were similar regardless of p27 or Skp2. CONCLUSIONS: We confirm the association of low p27 and high Skp2 with other poor prognostic features, but found no predictive or prognostic value, and therefore do not recommend routine determination of p27 and Skp2 for node-negative breast cancer.

Treatment of ocular melanoma metastatic to the liver by hepatic arterial chemotherapy.

PURPOSE: Ocular melanoma is characterized by a high rate of liver metastases and is associated with a median survival time less than 5 months. There is no standard treatment available. Treatment strategies have, without success, relied on the experience with metastatic cutaneous melanoma. The only effective treatment is chemoembolization using cisplatin and polyvinyl sponge, which has never become accepted on a large scale. The objective of the study was to establish prospectively the efficacy and toxicity of hepatic intraarterial fotemustine, a third-generation nitrosourea, in patients with liver metastases from ocular melanoma. PATIENTS AND METHODS: Thirty-one patients were subjected to laparotomy to place a totally implantable catheter into the hepatic artery and received fotemustine 100 mg/m2 as a 4-hour infusion, first once a week for four times and then, after a 5-week rest period, every 3 weeks until progression or toxicity. Cox regression models were used to assess the prognostic role of patient survival characteristics. RESULTS: Objective responses were observed in 12 of 30 assessable patients (40%; 95% confidence interval, 22% to 59%). The median duration of response was 11 months and the median overall survival time, 14 months. Lactate dehydrogenase (LDH) appeared to be the strongest prognostic factor for survival. Toxicity was minimal and treatment could be administered on an outpatient basis. CONCLUSION: The results of hepatic arterial chemotherapy with fotemustine produced a high response rate and survival similar to chemoembolization therapy. It involves no major toxicity and preserves the quality of life. To assess further its effectiveness, a randomized study to compare hepatic intraarterial versus intravenous chemotherapy is being planned.

Acute myeloid leukemia in the elderly: results of an individualized approach in two centres.

We retrospectively assessed seventy-four consecutive patients with AML over 65 years of age (median 71; range 65-88) treated with an individualized approach in two specialized cancer centers. Patients were managed according to their performance status (PS) and associated diseases in both institutions. The proportion of patients with poor PS (3-4) was higher in center 1 (37%) than in center 2 (10%) and in center 1 palliative treatment was given more frequently (16/32 patients) than in center 2 (7/42 patients). Fifty-one patients received intensive combination chemotherapy including an anthracycline and ara-C or VP16 (2 patients) and 36 patients received a second intensive course as reinduction or as consolidation treatment after complete remission. Patients not eligible for myelosuppressive chemotherapy were treated with palliative measures (23 patients). With intensive chemotherapy, complete remission (CR) was achieved in 29 of 51 patients (57%), after first (20 patients) or second course (9 patients) and the rate of deaths during induction was 14% (7 patients). The CR rate was lower for patients with performance status >or= 2 (48%) as compared to patients with performance status or= 2) was associated with reduced survival (hazard ratio: 3.29, 95% confidence interval: 1.75-6.17). Overall 2-years and 5-years survival were 20% and 11% for the patients treated intensively. From this study it appears that an individualized approach of treatment with intensive chemotherapy for selected patients offers a substantial CR rate and an improvement in survival. This analysis also suggests that differences in outcome between single institutions can be explained mainly by referral and selection biases

Recent advances in the molecular genetics of cancer. Second joint conference of the American Association of Cancer Research and the European Association of Cancer Research, Oxford, 9-12 September 1997.

The second joint conference of the AACR and the EACR held in Oxford from 9-12 September 1997 was successful from many vantage points. While providing an optimal setting in which European and American cancer researchers could meet and exchange information, the conference had an excellent scientific programme which encompassed both methodological updates on important models used in cancer research and presentations of recent key advances in the molecular genetics of cancer. Lower eukaryotes are established model organisms used to elucidate fundamental but complex eukaryotic processes, such as those involved in tumorigenesis and cancer progression, and the progressive availability of their genome sequence makes them even more attractive. Transgenic mouse models are increasingly used not only for the study of one gene of interest but for investigation of the interactions among genes involved in the same pathway. The family of tumour suppressor genes is growing fast and several presentations were devoted to recently identified members such as the Von Hippel-Lindau gene, the FHIT gene and the PTEN gene. The systematic analysis of loss of heterozygosity on multiple loci in tumour specimens can provide the basis for preliminary models of molecular multistep progression in some tumour types, even though this is limited by the high degree of complexity found. Mechanisms of cell cycle regulation and apoptosis continue to be dissected and to constitute a fruitful area of investigation, with important recent insights on the p53-MDM2 autoregulatory loop and on the involvement of E2F-1 in apoptosis.

Rhabdomyolysis associated with bacteremia due to Streptococcus pneumoniae: case report and review.

We report a case of bacteremic Streptococcus pneumoniae pneumonia associated with rhabdomyolysis and review seven other cases of pneumococcal infections associated with bacteremia and rhabdomyolysis. Most of these cases were complicated by transient myoglobinuric renal failure, and some patients required dialysis. Two patients died, but their deaths were not directly related to rhabdomyolysis. We discuss mechanisms that may be involved in rhabdomyolysis associated with pneumococcal infections. Rhabdomyolysis is a rare but potentially serious complication of a common disease.

Developing new anti-cancer drugs: novel targets and methodological problems.

The identification of molecular events relevant in the biology of cancer cells and the possibility of defining the molecular profile of cancer cell lines have radically changed the process of cancer-drug development. Cancer drug discovery relies now mainly on the National Cancer Institute cell line screening program; this screening system allows the selection of compounds with well-defined molecular mechanisms of action by screening them on cell lines characterised at the molecular level and by comparing their cytotoxicity through a computer-based analysis of the response profile. Biologically targeted drugs, which should hit specific molecular or biochemical targets, can be classified by a specific target, such as farnesyltransferase inhibitors, or by general mechanism of action. The clinical development of these new anti-cancer agents presents a significant challenge because clinical studies should comply with the molecular premises and be devised in order to provide the "proof of principle", that is the ability of the drug to interact with and activate or block the molecular target. After a summary of the main features and problems faced in the clinical development of biologically targeted anti-cancer therapies, the pre-clinical and clinical data available for some cell-cycle modulators, signal transduction inhibitors, drugs acting on the mitochondria and proteasome inhibitors will be reviewed.

Descriptive epidemiology of early and advanced gastric cancer in Ticino, Switzerland, with special emphasis on time trends.

BACKGROUND: The main purpose of the study was to describe early gastric cancer (EGC) epidemiology in the population of Ticino, Switzerland (about 280,000 inhabitants) over the period 1981-1990, as compared with the epidemiology of overall gastric cancer (GC). PATIENTS AND METHODS: Incidence data were derived from the diagnosis data-file of the Cantonal Institute of Pathology. Numbers of certified deaths were abstracted from the registries of the Swiss Federal Office of Statistics. RESULTS: The age-standardized (world population) incidence was 1.6/100,000 males and 0.7/100,000 females for EGC (sex ratio: 2.3) and 19.8/100,000 males and 9.1/100,000 females for GC (sex ratio: 2.2). Age- and sex-specific incidence rates for GC and for EGC showed similar distribution patterns. Mortality rates from GC declined over the period considered by about 20% in both sexes, while incidence rates decreased by only about 7%, suggesting diminished lethality. There was a slight increase in EGC incidence, which was restricted to men younger than 65 years and women older than 64 years. CONCLUSIONS: EGC incidence rates were less than 10% of advanced gastric cancer incidence rates for both sexes and most age groups. Early and advanced gastric cancer had similar age and sex distributions. The downward trend in GC lethality over 1981-1990 was not entirely explained by the increase in the incidence of EGC.

[Stomach cancer: 10 years experiences with surgical treatment and possibilities for improving the prognosis]. / Carcinome gastrique: expérience de 10 ans de traitement chirurgical et possibilités d'amélioration pronostique.

We retrospectively evaluated data on 111 consecutive patients operated between 1976 and 1985 for gastric carcinoma. Patients were staged according to the TNM classification (stage I - 17%, II - 15%, III - 30%, IV - 37%). 66 patients (59.5%) underwent radical resection. Most of curative resections were subtotal distal gastrectomies. Extended lymphadenectomy was not performed. The operative mortality rate was 7.4% in case of curative resections, and 9.6% overall. 20 out of 66 radically operated patients (30%) were treated with adjuvant cytotoxic chemotherapy, while 9 out of 45 non radically operated patients were treated with palliative cytotoxic chemotherapy. The median follow-up time was 36 months (range: 1-166 months) for patients operated for cure and 25 months for the whole population. The estimated adjusted 5-year survival rate was 41.3% after operation in a curative intent, 82.9% for stage I, 62.8% for stage II, 17.8% for stage III, 3.3% for stage IV. The duration of symptoms before diagnosis was longer than 6 months in 18 patients (16.2%) and longer than 10 months in 9 patients (8.1%). Patients who were symptomatic since more than 10 months were on the average about 10 years younger than the rest of the population. The median duration of symptoms was 3.2 months overall, but reached 7.1 months in patients less than 40 years old. Patients with an early gastric cancer (11/111: 9.9%) or stage I disease (19/111: 17.1%) had always symptoms since less than 5 months. The proportion of early gastric cancer increased from 6.3% (3/48) to 12.7% (8/63) from 1976-1980 to 1981-1985, simultaneously to the diffusion of the upper gastrointestinal endoscopy.(ABSTRACT TRUNCATED AT 250 WORDS)

The ubiquitin-proteasome pathway in cancer.

Degradation by the 26S proteasome of specific proteins that have been targeted by the ubiquitin pathway is the major intracellular non-lysosomal proteolytic mechanism and is involved in a broad range of processes, such as cell cycle progression, antigen presentation and control of gene expression. Recent work, reviewed here, has shown that this pathway is often the target of cancer-related deregulation and can underlie processes, such as oncogenic transformation, tumour progression, escape from immune surveillance and drug resistance.

Sequence of Crm1/exportin 1 mutant alleles reveals critical sites associated with multidrug resistance.

We have previously shown that genes involved in a novel pathway of multidrug resistance (MDR) in the fission yeast Schizosaccharomyces pombe are functionally conserved in human cells (V. Spataro et al. (1997) J Biol Chem 272: 30470-30475). The human homologue of one of these genes, hCRM1, has recently been identified and found to function in nucleocytoplasmic export, a process which controls the subcellular localization and hence activity of a number of key cell cycle regulators and transcription factors. Several mutant alleles of crm1 confer a phenotype of MDR in S. pombe, through the nuclear accumulation of the AP-1 transcription factor Pap1. We therefore sequenced mutations of crm1 in fission yeast in order to guide the search for analogous hCRM1 mutations which could play a role in tumour-drug resistance. Fifteen yeast crm1 mutants were assessed by PCR and DNA sequencing. Four mis-sense mutations were identified in the open reading frame, three of which (G to A transitions at nucleotide positions 385, 895 and 1,288) were capable of conferring the MDR phenotype alone. For three of the four mutations found, the corresponding amino acid changes affect residues which are conserved in the human homologue hCRM1 and lie in highly conserved regions of the CRM1 protein. We analysed the corresponding hCRM1 coding regions by RT-PCR and sequencing in a panel of ten tumour cell lines, including three ovarian lines resistant either to cisplatin or paclitaxel, or to both and one MDR breast cancer cell line with nuclear accumulation of the transcription factor YB-1. No hCRM1 mutations were found in the three cDNA fragments examined in this panel of tumour cell lines. However, the identification of amino acid residues within the CRM1 protein that are critical for the export of the MDR-associated transcription factor Pap1 in fission yeast can guide further analysis of hCRM1 mutations in tumours with a MDR phenotype.

[Should patients over 65 years old with acute myeloid leukemia be treated with myelosuppressive chemotherapy?]. / Faut-il traiter avec une chimiothérapie aplasiante des patients de plus de 65 ans souffrant d'une leucémie myéloïde aiguë?

Acute myeloid leukemia (AML) is frequently encountered in elderly patients (> 65) whereas most myelosuppressive chemotherapy protocols are restricted to younger patients. We retrospectively reviewed the 21 patients older than 65 (median age: 70, range: 66-86) hospitalized in our leukemia unit for recently diagnosed AML between 1. 1. 1988 and 31. 3. 1993. 16 had de novo AML (n-AML) and 5 had AML secondary to myelodysplastic syndromes (s-AML). Induction therapy consisted of cytarabine and either daunorubicine or mitoxantrone at conventional dosage in 18/21 patients. Early consolidation therapy was given to 14/21 patients and consisted of m-AMSA and VP-16 in 11 of them. The response to, and toxicity from, myelosuppressive chemotherapy was different according to the type of AML. In patients with n-AML a complete remission (CR) was obtained in 63% (10/16) and only 19% (3/16) died of MCT-related toxicity. In contrast, only 1/5 patients with s-AML achieved CR while 4/5 died of toxicity. The median duration of CR was 40 weeks (range: 5-147+) and median overall survival 23 weeks (range: 1-211+), with an estimated 3-year overall survival rate of 9.5% (2/21). Overall survival of patients with n-AML was significantly longer than that of patients with s-AML (p < 0.05). Hospital stay in relation to survival time was 100% for patients with s-AML, 49% for patients with n-AML not achieving CR and 25% for patients with n-AML with CR. In conclusion, elderly patients with AML can benefit from myelosuppressive chemotherapy providing they present with de novo AML.

Resistance to diverse drugs and ultraviolet light conferred by overexpression of a novel human 26 S proteasome subunit.

We have investigated the usefulness of the fission yeast Schizosaccharomyces pombe as a model organism for the discovery of novel modes of drug resistance in human cells. In fission yeast, overexpression of the essential pad1(+) gene confers pleiotropic drug resistance through a pathway involving an AP-1 transcription factor encoded by pap1(+). We have identified POH1, a human pad1 homologue that can substitute fully for pad1(+) and induce AP-1-dependent drug resistance in fission yeast. POH1 also confers P-glycoprotein-independent resistance to taxol (paclitaxel), doxorubicin, 7-hydroxystaurosporine, and ultraviolet light when transiently overexpressed in mammalian cells. Poh1 is a previously unidentified component of the human 26 S proteasome, a multiprotein complex that degrades proteins targeted for destruction by the ubiquitin pathway. Hence, Poh1 is part of a conserved mechanism that determines cellular susceptibility to cytotoxic agents, perhaps by influencing the ubiquitin-dependent proteolysis of transcription factors.

A comparison of the early outcome of acute myocardial infarction in women and men. The Third International Study of Infarct Survival Collaborative Group.

BACKGROUND: In previous studies, unadjusted comparisons of mortality and major morbidity after acute myocardial infarction have generally indicated that women have a poorer outcome than men. Much larger studies are needed, with more complete adjustment for coexisting conditions, to determine whether this difference is explained by the older age of the women studied or by the presence of other unfavorable prognostic factors, or both. METHODS: As part of the Third International Study of Infarct Survival (ISIS-3), information was collected on deaths during days 0 to 35 and on major clinical events during hospitalization up to day 35 for 9600 women and 26,480 men with suspected acute myocardial infarction who were considered to have a clear indication for fibrinolytic therapy. We compared the outcome among women and men, first without adjustment, then with adjustment for age, and finally with adjustment for other recorded baseline characteristics by means of multiple logistic regression. RESULTS: The unadjusted odds ratio for death among women as compared with men was 1.73 (95 percent confidence interval, 1.61 to 1.86). The women were significantly older than the men, and after adjustment for age the odds ratio was reduced markedly to 1.20 (95 percent confidence interval, 1.11 to 1.29). Adjustment for other differences in base-line clinical features further reduced the odds ratio to 1.14 (95 percent confidence interval, 1.05 to 1.23). Excesses in other major clinical events among women were generally reduced to a similar extent by adjustment. CONCLUSIONS: It seems likely that there is at most only a small independent association between female sex and early mortality and morbidity after suspected acute myocardial infarction.

Sequential estrogen receptor determinations from primary breast cancer and at relapse: prognostic and therapeutic relevance. The International Breast Cancer Study Group (formerly Ludwig Group).

We retrospectively evaluated 401 selected patients who had estrogen receptor (ER) assays both at primary surgery and at relapse in an accessible site to determine the clinical relevance of the subsequent ER determination. The median time between ER assessments was 27 months (range: 2-122 months). The median follow-up time from diagnosis was 6 years (range: 2-12 years). For patients with ER+ tumors at primary diagnosis, 29% (76/261) had ER- tumors at relapse, while for ER- primaries, the conversion rate was 33% (46/140). Conversions from ER+ to ER- occurred more often when the time interval between assays was less than one year (p = 0.004), while conversions from ER- to ER+ tended to occur late (beyond three years; p = 0.0003). Treatments received between assays (usually adjuvant therapy) had only a slight influence on ER status conversion. Post-relapse survival was poor for patients who had the biopsy accessible recurrence within one year; an expression of the aggressive nature of the disease. Among patients whose accessible relapse was beyond one year, those with ER- primaries who converted to ER+ had a longer survival than those whose recurrence was classified again as ER- (p = 0.006). This group of patients with ER- primaries who recurred beyond one year with an ER+ tumor in an accessible site represented 29% (40/140) of all patients with ER- primaries and had an estimated overall survival rate of more than 60% at 6 years from the accessible relapse. ER determination upon relapse within one year has very little clinical relevance.(ABSTRACT TRUNCATED AT 250 WORDS)

Sphincter-sparing surgery after preoperative radiotherapy for low rectal cancers: feasibility, oncologic results and quality of life outcomes.

The present study assesses the choice of surgical procedure, oncologic results and quality of life (QOL) outcomes in a retrospective cohort of 53 patients with low-lying rectal cancers (within 6 cm of the anal verge) treated surgically following preoperative radiotherapy (RT, median dose 45Gy) with or without concomitant 5-fluorouracil. QOL was assessed in 23 patients by using two questionnaires developed by the QOL Study Group of the European Organization for Research and Treatment of Cancer: EORTC QLQ-C30 and EORTC QLQ-CR38. After a median interval of 29 days from completion of RT, abdominoperineal resection (APR) was performed in 29 patients (55%), low anterior resection in 23 patients (20 with coloanal anastomosis) and transrectal excision in one patient. The 3-year actuarial overall survival and locoregional control rates were 71.4% and 77.5% respectively, with no differences observed between patients operated by APR or restorative procedures. For all scales of EORTC QLQ-C30 and EORTC QLQ-CR38, no significant differences in median scores were observed between the two surgical groups. Although patients having had APR tended to report a lower body image score (P = 0.12) and more sexual dysfunction in male patients, all APR patients tended to report better physical function, future perspective and global QOL. In conclusion, sphincter-sparing surgery after preoperative RT seems to be feasible, in routine practice, in a significant proportion of low rectal cancers without compromising the oncologic results. However, prospective studies are mandatory to confirm this finding and to clarify the putative QOL advantages of sphincter-conserving approaches.