Genome-wide studies in multiple myeloma identify XPO1/CRM1 as a critical target validated using the selective nuclear export inhibitor KPT-276.

RNA interference screening identified XPO1 (exportin 1) among the 55 most vulnerable targets in multiple myeloma (MM). XPO1 encodes CRM1, a nuclear export protein. XPO1 expression increases with MM disease progression. Patients with MM have a higher expression of XPO1 compared with normal plasma cells (P<0.04) and to patients with monoclonal gammopathy of undetermined significance/smoldering MM (P<0.0001). The highest XPO1 level was found in human MM cell lines (HMCLs). A selective inhibitor of nuclear export compound KPT-276 specifically and irreversibly inhibits the nuclear export function of XPO1. The viability of 12 HMCLs treated with KTP-276 was significantly reduced. KPT-276 also actively induced apoptosis in primary MM patient samples. In gene expression analyses, two genes of probable relevance were dysregulated by KPT-276: cell division cycle 25 homolog A (CDC25A) and bromodomain-containing protein 4 (BRD4), both of which are associated with c-MYC pathway. Western blotting and reverse transcription-PCR confirm that c-MYC, CDC25A and BRD4 are all downregulated after treatment with KPT-276. KPT-276 reduced monoclonal spikes in the Vk*MYC transgenic MM mouse model, and inhibited tumor growth in a xenograft MM mouse model. A phase I clinical trial of an analog of KPT-276 is ongoing in hematological malignancies including MM.

Antileukemic activity of nuclear export inhibitors that spare normal hematopoietic cells.

Drugs that target the chief mediator of nuclear export, chromosome region maintenance 1 protein (CRM1) have potential as therapeutics for leukemia, but existing CRM1 inhibitors show variable potencies and a broad range of cytotoxic effects. Here, we report the structural analysis and antileukemic activity of a new generation of small-molecule inhibitors of CRM1. Designated selective inhibitors of nuclear export (SINE), these compounds were developed using molecular modeling to screen a small virtual library of compounds against the nuclear export signal (NES) groove of CRM1. The 2.2-Å crystal structure of the CRM1-Ran-RanBP1 complex bound to KPT-251, a representative molecule of this class of inhibitors, shows that the drug occupies part of the groove in CRM1 that is usually occupied by the NES, but penetrates much deeper into the groove and blocks CRM1-directed protein export. SINE inhibitors exhibit potent antileukemic activity, inducing apoptosis at nanomolar concentrations in a panel of 14 human acute myeloid leukemia (AML) cell lines representing different molecular subtypes of the disease. When administered orally to immunodeficient mice engrafted with human AML cells, KPT-251 had potent antileukemic activity with negligible toxicity to normal hematopoietic cells. Thus, KPT-SINE CRM1 antagonists represent a novel class of drugs that warrant further testing in AML patients.

Guidelines for the use of spiral computed tomography in screening for lung cancer.

Screening should be considered in lung cancer, more than any other cancer. Not only is the disease highly fatal, essentially incurable, when diagnosed on the prompting of symptoms and/or clinical signs, but its occurrence is also highly concentrated in identifiably high-risk persons. The degree of usefulness of computed tomography (CT)-based screening for lung cancer must be thought of in reference to a particular, presumably optimal, regimen of pursuing early stage diagnosis. This is an algorithm that begins with the initial test ("screening CT") and ends in either discontinuation of the diagnostic pursuit or in diagnosis of lung cancer. A carefully developed, extensively pilot tested and critically reviewed, updated protocol for CT-based screening for lung cancer is presented here. Its implementation is addressed, together with quality assurance. Finally, the associated curability rate for lung cancer is addressed in the light of what is known or can be surmised from evidence already available. However, recommendation for or against screening requires further information. Principally, the patients risk for lung cancer (in the near future) and the patients life expectancy (when spared of death from lung cancer). These two factors influence when, if ever, to begin screening, and if it is initiated, when to discontinue it. Finally, cost-effectiveness of the screening program should also be considered.

Mesna, doxorubicin, ifosfamide, and dacarbazine (MAID) chemotherapy for gynecological sarcomas.

This report summarizes our experience with the combination of mesna, doxorubicin, ifosfamide, and dacarbazine (MAID) for patients with gynecological sarcomas. We reviewed the records of all patients who had received the MAID regimen for a gynecological sarcoma between 1993 and 2000. The MAID regimen was administered intravenously every 4 weeks in the hospital as follows: (1) mesna 1500 mg/m2/day x 4 days; (2) doxorubicin 15 mg/m2/day x 3 days; (3) ifosfamide 1500 mg/m2/day x 3 days; (4) dacarbazine 250 mg/m2/day x 3 days. The results of treatment with MAID were disappointing. Overall, the response rate was 9% with one complete response and one partial response (both in patients with uterine leiomyosarcoma). We did not observe any responses among the patients with carcinosarcomas of either ovarian or uterine origin. The median progression-free interval and survival were 11 months and 29 months, respectively. This regimen was associated with substantial toxicity (including a death from neutropenic sepsis) as well as high cost and inconvenience due to the requirement for inpatient administration. Although our study contains a limited number of patients with a variety of gynecological sarcomas, our review has led us to discontinue using MAID. It remains to be established if any combination chemotherapy regimen is better than single agent treatment.

Individuals with cystic fibrosis do not display impaired endothelial function or evidence of oxidative damage in endothelial cells exposed to serum.

Heightened systemic oxidative stress is increasingly recognized as a feature of cystic fibrosis (CF). The consequences of long-term exposure to free radical attack include a predisposition to diseases such as cancer and atherosclerosis. An increased incidence of malignancy among adult patients with CF has been reported, but the absence of atherosclerotic disease is well described. The aim of the present study was to assess endothelial function in vivo and relate this to the potential of serum from patients with CF to induce oxidative-mediated damage in cultured human endothelial cells. A group of 11 CF patients was matched with a group of healthy volunteers with regard to age and sex. Endothelial function was assessed as endothelium-dependent and -independent vasodilation by measuring forearm blood flow in response to infused acetylcholine and sodium nitroprusside respectively. Confluent monolayers of cultured human endothelial cells were exposed to serum from CF patients and control subjects. Following exposure, cell death was assessed by lactate dehydrogenase release, and the degree of lipid peroxidation in the membrane was assessed by measuring the content of lipid hydroperoxides, malondialdehyde and 4-hydroxynonenal. Endothelial monolayers exposed to serum from CF patients released significantly less lactate dehydrogenase following exposure than those exposed to serum from healthy controls (1.8% and 3.0% respectively; mean difference -1.2%; 95% confidence intervals -1.9% to -0.1%; P<0.05) and contained significantly less 4-hydroxynonenal (0.75 and 3.41 micromol/g of protein respectively; mean difference -2.66 micromol/g; 95% confidence intervals -5.10 to -0.22 micromol/g; P<0.05). There was no significant difference between patients and controls in the extent of serum-induced membrane peroxidation, as assessed by malondialdehyde or lipid hydroperoxides, or in endothelial function, as assessed by forearm blood flow. In conclusion, despite evidence for heightened systemic oxidative stress in CF, patients displayed no impairment of endothelial function, and their serum caused significantly less damage to human endothelial cells than that from matched controls.

Early lung cancer action project: initial findings on repeat screenings.

BACKGROUND: The Early Lung Cancer Action Project (ELCAP) was designed to evaluate the usefulness of annual computed tomography (CT) screening for lung carcinoma. With the baseline results having been reported previously, the focus of the current study was on the early results of the repeat screenings. METHODS: A cohort of 1000 high-risk individuals was recruited for baseline and annual repeat CT screening. At last follow-up, a total of 1184 annual repeat screenings had been performed. A positive result from the screening test was defined as newly detected, one to six noncalcified pulmonary nodules with interim growth. The diagnostic workup of the individuals was guided by recommendations supplied by the ELCAP investigators to the collaborating clinicians. RESULTS: Of the 1184 repeat CT screenings, the test result was positive in 30 (2.5%). In 2 of these 30 cases, the individual died (of an unrelated cause) before diagnostic workup and the nodule(s) resolved in another 12 individuals. In the remaining 16 individuals, the absence of further growth was documented by repeat CT in 8 individuals and further growth was documented in the remaining 8 individuals. All eight individuals with further nodular growth underwent biopsy and malignancy was diagnosed in seven. Six of these seven malignancies were nonsmall cell carcinomas (five of which were Stage IA and one of which was Stage IIIA) and the one small cell carcinoma was found to be of limited stage. The median size dimension of these malignancies was 8 mm. In another two subjects, symptoms prompted the interim diagnosis of lung carcinoma. Neither of these malignancies was nodule-associated but rather were endobronchial; one was a Stage IIB nonsmall cell carcinoma and the other was a small cell carcinoma of limited stage. CONCLUSIONS: False-positive screening test results are uncommon and usually manageable without biopsy; compared with no screening, such screenings permit diagnosis at substantially earlier and thus more curable stages. Annual repetition of CT screening is sufficient to minimize symptom-prompted interim diagnoses of nodule-associated malignancies.

Early and periodic screening, diagnosis, and treatment examination completion rates for Oklahoma Medicaid managed care: 1995-1998.

Although quality medical care is a goal of all health care providers, finding a means by which to take that idea from the abstract to the measurable is often an arduous task. The Oklahoma Health Care Authority and the Oklahoma Foundation for Medical Quality confronted that challenge when examining the state of Oklahoma's Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) examination completion rates. Focused on measuring processes of care, the Oklahoma Health Care Authority (OHCA) and the Oklahoma Foundation for Medical Quality (OFMQ) used chart abstraction to track EPSDT examination rates for SoonerCare Plus Medicaid managed care recipients from 1995 through 1998. During the abstractions, an examination was interpreted as an EPSDT screen if a comprehensive health and development history plus a comprehensive unclothed physical examination were recorded. Examination rates have improved from 1995 when there was a documented 17.6% completion rate. The 1998 documented rate of completion was 60.0%. Trend analysis shows significant improvement over the four-year period. The results also suggest the necessity for continued improvement in the provision of documented EPSDT examinations to individuals in Medicaid managed care plans in Oklahoma.

Early lung cancer action project: a summary of the findings on baseline screening.

PURPOSE: The Early Lung Cancer Action Project (ELCAP) is designed to evaluate baseline and annual repeat screening by low radiation dose computed tomography (low-dose CT) in persons at high-risk for lung cancer. METHODS: Since starting in 1993, the ELCAP has enrolled 1,000 asymptomatic persons, 60 years of age or older, with at least 10 pack-years (1 pack per day for 10 years, or 2 packs per day for 5 years) of cigarette smoking, no prior cancer, and medically fit to undergo thoracic surgery. After a structured interview and informed consent, baseline chest radiographs and low-dose CT were obtained on each subject. The diagnostic work-up of screen-detected noncalcified pulmonary nodules (NCN) was guided by ELCAP recommendations which included short-term high-resolution CT follow-up for the smallest nodules. Baseline RESULTS: On low-dose CT at baseline compared to chest radiography, NCN were detected three times as commonly (23% versus 7%), malignancies four times as commonly (2.7% versus 0.7%), and stage I malignancies six times as commonly (2.3% versus 0.4%). Of the 27 CT-detected cancers, 96% (26/27) were resectable; 85% (23/27) were stage I, and 83% (19 of the 23 stage I) were not seen on chest radiography. Following the ELCAP recommendations, biopsies were performed on 28 of the 233 subjects with NCN; 27 had a malignant and one a benign NCN. Another three individuals underwent biopsy outside of the ELCAP recommendations; all had benign NCNS: No one had thoracotomy for a benign nodule. CONCLUSION: Baseline CT screening for lung cancer provides for detecting the disease at earlier and presumably more commonly curable stages in a cost-effective manner.

Early lung cancer action project: annual screening using single-slice helical CT.

The advent of helical CT imaging held promise for the early diagnosis, and thereby, for enhanced curability of lung cancer--a highly fatal disease. In 1993, the Early Lung Cancer Action Project (ELCAP) was initiated and experimentally screened a cohort of 1,000 high-risk persons. Here we summarize the results of the baseline and annual repeat CT screening of these 1,000 subjects. CT-based screening (compared to traditional radiology) was clearly shown to enhance the detection of lung cancer at earlier and more curable stages. A discussion follows of the meaning of the results and possible future screening protocols.

Transcutaneous electrical nerve stimulation as an adjunct for controlling chemotherapy-induced nausea and vomiting in gynecologic oncology patients.

BACKGROUND: To evaluate the efficacy of a miniaturized portable transcutaneous electrical nerve stimulation (TENS) unit (ReliefBand) as an adjunct to standard antiemetic therapy for controlling nausea and vomiting induced by cisplatin-based chemotherapy in gynecologic oncology patients. METHODS: Forty-two patients were enrolled in a randomized, double-blind, placebo-controlled parallel-subjects trial with a follow-up crossover trial. All patients received a standardized antiemetic protocol, then wore the ReliefBand continuously for 7 days. RESULTS: Thirty-two patients were evaluable for the parallel-subjects component, 16 in each group. The percentage of patients with absent or minimal nausea was 59% overall, which was similar to that for both the active (56%) and placebo (62%) groups. The incidence and severity of nausea and vomiting was similar for each group. Eighteen patients completed two consecutive cycles and were evaluable for the crossover component. The average age of the crossover patients and their dose intensity were comparable with those of the overall study population (56.3 versus 58.6 years and 22.7 versus 22.7 mg/m2/week, respectively). The percentage of cycles with absent or minimal nausea was 47% overall, which was similar to that of the active (50%) and placebo (44%) cycles. However, the severity of nausea was significantly lower in the active cycles during days 2 to 4. Patients averaged less than one episode of vomiting daily in each cycle. CONCLUSIONS: The ReliefBand is an effective adjunct to standard antiemetic agents for controlling nausea induced by cisplatin-based chemotherapy in gynecologic oncology patients.

Early Lung Cancer Action Project: overall design and findings from baseline screening.

BACKGROUND: The Early Lung Cancer Action Project (ELCAP) is designed to evaluate baseline and annual repeat screening by low-radiation-dose computed tomography (low-dose CT) in people at high risk of lung cancer. We report the baseline experience. METHODS: ELCAP has enrolled 1000 symptom-free volunteers, aged 60 years or older, with at least 10 pack-years of cigarette smoking and no previous cancer, who were medically fit to undergo thoracic surgery. After a structured interview and informed consent, chest radiographs and low-dose CT were done for each participant. The diagnostic investigation of screen-detected non-calcified pulmonary nodules was guided by ELCAP recommendations, which included short-term high-resolution CT follow-up for the smallest non-calcified nodules. FINDINGS: Non-calcified nodules were detected in 233 (23% [95% CI 21-26]) participants by low-dose CT at baseline, compared with 68 (7% [5-9]) by chest radiography. Malignant disease was detected in 27 (2.7% [1.8-3.8]) by CT and seven (0.7% [0.3-1.3]) by chest radiography, and stage I malignant disease in 23 (2.3% [1.5-3.3]) and four (0.4% [0.1-0.9]), respectively. Of the 27 CT-detected cancers, 26 were resectable. Biopsies were done on 28 of the 233 participants with non-calcified nodules; 27 had malignant non-calcified nodules and one had a benign nodule. Another three individuals underwent biopsy against the ELCAP recommendations; all had benign non-calcified nodules. No participant had thoracotomy for a benign nodule. INTERPRETATION: Low-dose CT can greatly improve the likelihood of detection of small non-calcified nodules, and thus of lung cancer at an earlier and potentially more curable stage. Although false-positive CT results are common, they can be managed with little use of invasive diagnostic procedures.

Serotonin plays an early role in the metamorphosis of the hydrozoan Phialidium gregarium.

Hydrozoan larvae normally metamorphose in response to an obligate external environmental cue. Application of certain artificial chemical stimuli will also induce metamorphosis. These chemicals and their inhibitors have been used to define and order some of the signal transduction events involved in this process. Results from this study show that exogenous application of serotonin (5-HT) will induce metamorphosis and that 5-HT immunoreactive cells are present in larvae when they are competent to metamorphose. The 5-HT inhibitors ketanserin, clozapine, and 5,7-DHT prevent metamorphosis from occurring as a response to a natural inducing stimulus. Additionally, 5-HT signaling occurs prior to both an influx of external Ca2+ from seawater and activation of protein kinase C, two other steps in the metamorphic signal transduction pathway. The neuropeptide LWamide, previously shown to induce metamorphosis in a related hydrozoan, Hydractinia echinata, also induced metamorphosis in Phialidium. When larvae were cotreated with LWamide and the 5-HT antagonist ketanserin, settlement occurred but was not followed by polyp morphogenesis. These results are used to present a model for the action of 5-HT during metamorphosis in Phialidium gregarium.

High-dose chemotherapy with stem-cell rescue for the treatment of breast cancer.

The use of high-dose chemotherapy with stem-cell rescue (HDC-SCR) in the treatment of breast cancer is reviewed. The rationale for HDC-SCR in breast cancer is based on the principles of dose response and dose intensity. After conventional-dose chemotherapy, hematopoietic progenitor cells are harvested from the bone marrow or peripheral blood. The patient then undergoes HDC-SCR. Peripheral-blood progenitor cells are becoming the preferred cells for hematopoietic rescue. Most clinical trails of HDC-SCR in metastatic breast cancer have resulted in high overall objective response rates (57-100%), with the highest rates occurring in patients with minimal residual disease or chemotherapy-sensitive disease at the time of high-dose treatment. Most protocols now include induction therapy before HDC-SCR; only patients who show sensitive disease proceed to high-dose therapy. In most studies published to date, the median duration of remission was less than one year from the time of high-dose therapy; however, 10-15% of patients achieved complete remissions lasting two or more years. Most patients relapse, however. Some studies have suggested value of HDC-SCR as consolidation therapy in the adjuvant setting for women at high risk of relapse. Short-term toxicities of HDC-SCR are manageable in experienced hands. Notable long-term adverse effects include leukemia, sterility, pulmonary toxicity, and hemolytic uremic syndrome. Unresolved issues include the utility of purging occult cancer cells from stem-cell-bearing specimens, the best preparative regimen, the implications of autologous graft-versus-host disease, the use of sequential cycles of high-dose chemotherapy, cost-effectiveness, and effectiveness compared with standard therapy. HDC-SCR appears to be a valid option for selected patients with metastatic breast cancer, and in the adjuvant setting for patients at high risk of recurrence. The cost-benefit profile remains to be defined in randomized trials.

Effect of different mathematical methods on etoposide area under the curve estimations and pharmacodynamic response predictions.

Different methods to calculate interval area under the curve (AUC) data may produce substantial error. The purpose of this study was to compare methods of calculating etoposide AUC and determine the effect of these values on white blood cell (WBC) count nadir predictions calculated from a previously reported equation. Three AUC calculation methods were used: (1) the linear trapezoidal method, (2) a combination of the linear and logarithmic trapezoidal methods, and (3) the Lagrange method. Since none of the methods for determining the AUC could be considered the standard, the methods were evaluated by comparing differences between pairs of calculated AUC values by each method. The 95% CI for differences between all pairs of AUC values were greater than zero (no difference) indicating significance. Consistent with the smoother fitting function between data points, the Lagrange method tended to produce a larger AUC, lower clearance values, and lower WBC nadir count predictions than the other methods. The largest difference encountered was between the Lagrange and the linear-log AUC methods with a mean value of 16.9 micrograms h/ml (95% CI 9.4-24.3) This difference would account for approximately 11% of the total AUC. Using a previously published equation, where WBC nadir = -0.057 +0.048 x etoposide clearance, with clearance determined as dose/AUC, mean differences in calculated WBC nadir count values between the three AUC methods ranged from 80 to 220 cells/microliters, which would be expected to be of little clinical consequence. The precision of this equation, using data derived from linear trapezoidal AUC calculations, had a mean absolute error of 0.93 x 10(3)/microliters (95% CI 0.53-1.32). Our findings suggest that any of the three mathematical methods studied would produce similar etoposide AUC values and pharmacodynamic predictions. Further, these findings also suggest that the major limitation in predicting etoposide leukopenia lies with the imprecision of the pharmacodynamic model more so than the ability to accurately determine the AUC. However, our findings may not be applicable if other factors intervene which dramatically alter the shape of the etoposide concentration-time curve.

Fusion of immunoscintigraphy single photon emission computed tomography (SPECT) with CT of the chest in patients with non-small cell lung cancer.

In non-small cell lung cancer (NSCLC), accurate staging is critical in deciding between potentially curative surgery and palliative treatment. Image registration, or fusion, combines the unique functional information provided by SPECT imaging with the excellent anatomic detail offered by computed tomography (CT) or magnetic resonance imaging to better characterize the information provided by each separate modality. In this study, we explored the role of fusion of immunoscintigraphy SPECT with CT in the staging of NSCLC. We fused chest CT with 99mTc-labeled IMMU-4 anti-carcinoembryonic antigen Fab' antibody fragment SPECT in 14 patients with NSCLC using a landmark-based algorithm. The algorithm's accuracy was a measure from the center-to-center distance and the percentage overlap of two regions of interest: one drawn on CT and warped onto SPECT, the other drawn directly on the SPECT. We found that the average center-to-center distance was 1.3 +/- 0.8 pixels. Average overlap was 46 +/- 20%. CT-SPECT fusion helped differentiate tumor from normal blood pool, necrotic areas within viable tumor, tumor recurrence from scar, and malignant lymphadenopathy from hyperplasia. We conclude that fusion of CT and SPECT augments the information provided by each separate modality. Future clinical applications of fusion in NSCLC staging using immunoscintigraphy appear promising.

Unusual lymphoproliferative disorders in nine adults with HIV or AIDS: CT and pathologic findings.

PURPOSE: To identify characteristic computed tomographic (CT) findings in unusual pulmonary lymphoproliferative disorders seen in adults with the human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS). MATERIALS AND METHODS: The authors retrospectively reviewed the CT scans and pathologic specimens from nine patients with pulmonary lymphoproliferative disorders. CT scans were evaluated for nodules, reticulation, areas of ground-glass attenuation, consolidation, and bronchial disease. Changes seen in pathologic specimens were classified as consistent with classic lymphocytic interstitial pneumonitis (LIP), mucosa-associated lymphoid tissue lymphoma (MALTOMA), or atypical lymphoproliferative disorder (ALD). Immunopathologic results were reviewed when available. RESULTS: Eight patients had AIDS. Five patients had classic LIP. One patient had MALTOMA, and three patients had ALD. Altogether, 2-4-mm-diameter nodules were the predominant CT finding in eight patients; these were peribronchovascular in four patients. The presence of interstitial nodules correlated with the pathologic finding of nodular disease in seven patients. CONCLUSION: Familiarity with these AIDS-related disorders and their CT appearance should assist in the differential diagnosis.

Absent right and persistent left superior vena cava without other congenital anomaly: a rare combination diagnosed by transesophageal echocardiography.

A 70-year old man with a history of anorexia, weight loss, and progressive shortness of breath was studied by transesophageal echocardiography. In addition to a mass occupying the right ventricular outflow tract, a rare congenital heart anomaly was discovered serendipitously: persistent left superior vena cava, absent right superior vena cava, and no other congenital abnormality. The echocardiographic findings were confirmed by computed tomographic scanning and later during heart surgery performed to resect the malignant tumor.

Cytomegalovirus pneumonitis: spectrum of parenchymal CT findings with pathologic correlation in 21 AIDS patients.

PURPOSE: To identify characteristic features of cytomegalovirus (CMV) pneumonitis at computed tomography (CT), particularly markers that may help differentiate CMV from Pneumocystis carinii pneumonia. MATERIALS AND METHODS: Bronchoalveolar lavage (BAL) and biopsy results in 21 patients with acquired immunodeficiency syndrome, cytopathologic evidence of CMV infection without other infections, and available CT scans were retrospectively evaluated. CT findings were correlated with radiographic and pathologic findings when available. RESULTS: BAL findings were positive for CMV in only six cases, 13 patients had extrathoracic CMV infection, and 10 had Kaposi sarcoma. CT findings included ground-glass attenuation, dense consolidation, bronchial wall thickening or bronchiectasis, and interstitial reticulation without air-space disease (12 patients had discrete pulmonary nodules or masses). Biopsy revealed air-space disease as the dominant process in eight cases. Histopathologic findings correlated well with CT appearances. CONCLUSION: CMV pneumonitis should be suspected in patients with either extrathoracic CMV or documented Kaposi sarcoma, especially when radiographic or CT evidence of pulmonary nodules or masses exists.