Inhibition of ANKRD1 sensitizes human ovarian cancer cells to endoplasmic reticulum stress-induced apoptosis.

High expression of Ankyrin Repeat Domain 1 (ANKRD1) in ovarian carcinoma is associated with poor survival, and in ovarian cancer cell lines is associated with platinum resistance. Importantly, decreasing ANKRD1 expression using siRNA increases cisplatin sensitivity. In this study, we investigated possible mechanisms underlying the association of ANKRD1 with cisplatin response. We first demonstrated that cisplatin-induced apoptosis in ovarian cancer cell lines was associated with endoplasmic reticulum (ER) stress, evidenced by induction of Glucose-Regulated Protein 78 (GRP78), growth arrest- and DNA damage-inducible gene 153 (GADD153) and increased intracellular Ca(2+) release. The level of sensitivity to cisplatin-induced apoptosis was associated with ANKRD1 protein levels and poly (ADP-ribose) polymerase (PARP) cleavage. COLO 316 ovarian cancer cells, which express high ANKRD1 levels, were relatively resistant to cisplatin, and ER stress-induced apoptosis, whereas OAW42 and PEO14 cells, which express lower ANKRD1 levels, are more sensitive to ER stress-induced apoptosis. Furthermore, we show that overexpression of ANKRD1 attenuated cisplatin-induced cytotoxicity, and conversely siRNA knockdown of ANKRD1 sensitized ovarian cancer cells to cisplatin and ER stress-induced apoptosis associated with induction of GADD153, and downregulation of BCL2 and BCL-XL. Taken together, these results suggest that ANKRD1 has a significant role in the regulation of apoptosis in human ovarian cancer cells, and is a potential molecular target to enhance sensitivity of ovarian cancer to chemotherapy.

Retrospective imaging audit and cost analysis of medical oncology inpatients admitted to Westmead Hospital.

BACKGROUND: Cancer patients often require complex and expensive admissions necessitating multiple investigations. We conducted an audit of cost of imaging performed on medical oncology inpatients in a teaching hospital in New South Wales. AIMS: Our overall aim was to assess cost and appropriateness of imaging studies in inpatients. METHODS: Data were collected on 219 consecutive evaluable inpatients admitted to Westmead Hospital (August-October 2012). A panel of oncology doctors assessed cost and appropriateness of imaging. RESULTS: The total expenditure for the cohort was $106,488.15 over 624 investigations (range: 0-26, median: two per admission). Of this sum, $8881.91 (8%) was deemed inappropriate. The most frequently ordered test was chest X-ray (251). Imaging cost per admission was $0-2478 (range), $324.95 (median), $486.99 (mean). Cost trended to increase with age of patient ($186.40 (18-40), $477.22 (41-65), $489.50 (66-75), $575.33 (>75) ). Mean cost was higher for patients treated with palliative ($493.98) vs curative ($307.59) intent. Mean cost was higher for patients consulted by palliative care and other subspecialties. There was variation of average cost by discharge destination - other hospital ($262.23), palliative care unit ($334.08), home ($480.84) and death ($769.93). Although imaging ordered was deemed overwhelmingly clinically appropriate, approximately $35,000/year is spent on inappropriate tests, mostly due to duplication or scans that could have been performed as an outpatient. CONCLUSION: Our audit supports that the current spending patterns on imaging within our department is predominantly appropriate and necessary. Duplication and expenditure may be reduced by improving electronic access from the ward to outpatient scan results.

Carboplatin and paclitaxel interact antagonistically in a megakaryoblast cell line--a potential mechanism for paclitaxel-mediated sparing of carboplatin-induced thrombocytopenia.

PURPOSE: Clinical observation has shown that paclitaxel ameliorates the antiplatelet toxicity of carboplatin when the two drugs are combined, although antitumour activity and white cell toxicity are at least additive. We hypothesized that this is due to an interaction between the two drugs at the level of the platelet precursor. METHODS: We measured inhibition of growth of the megakaryoblast cell line MEG-01 following exposure to paclitaxel and carboplatin singly or combined. Drug interaction was assessed by median effect analysis. RESULTS: An antagonistic interaction was observed, and this was most marked at drug concentrations giving a low level of growth inhibition (P < 0.002, sign test). The interaction was not sequence-dependent. There was no significant difference in whole-cell accumulation of platinum or the amount of platinum adducts on DNA following combined treatment in comparison with carboplatin alone. CONCLUSIONS: These results provide the first evidence of an antagonistic interaction between paclitaxel and carboplatin in a platelet precursor and provide an explanation for the platelet-sparing effect of the combination of these chemotherapeutic agents. While the mechanisms underlying the interaction described in this report are yet to be fully elucidated, this study provides evidence that the antagonism between paclitaxel and carboplatin in MEG-01 cells is not due to reduced platination of DNA.

Should doctors wear white coats?

The wearing of white coats by hospital doctors is becoming a rarity, making it difficult for patients to identify doctors from other hospital staff. I asked patients with cancer whether they thought that doctors, both junior and senior, should wear white coats. Only a minority disapproved.

Home or hospital? An evaluation of the costs, preferences, and outcomes of domiciliary chemotherapy.

This study compares the costs and outcomes of domiciliary and hospital-based chemotherapy, using a prospective randomized cross-over design. Eighty-seven eligible patients were recruited from oncology services at two metropolitan hospitals in Sydney, Australia. Forty patients completed study evaluation requirements, having two months of chemotherapy in each location (home and hospital). The domiciliary service was staffed by hospital-based oncology nurses. Marginal costs of domiciliary treatment over hospital treatment were estimated from the health service perspective. Home-based care was more expensive, largely due to extra nurse time. About half of the eligible patients (n = 87) and 73 percent of the evaluated patients (n = 40) preferred domiciliary care. Most evaluated patients and their informal carers were satisfied with the medical care provided, regardless of location. Patient needs were well met in either location, and no differences were found in quality of life. At current throughput rates, providing chemotherapy in the home was more expensive than providing it in hospital. However, if the demand for chemotherapy were to exceed ward capacity by up to 50 percent, moving chemotherapy into the home could provide a less costly strategy for the expansion of a chemotherapy service without compromising patient outcomes.

Integrated multimodality therapy for embryonal rhabdomyosarcoma of the lower genital tract in postpubertal females.

Embryonal rhabdomyosarcoma of the female lower genital tract is generally regarded as a neoplasm occurring in childhood, but has also been reported in adults. The philosophy of therapy, largely based on data obtained from pediatric patients, has evolved slowly from ultraradical surgery, without adjuvant therapy, to neoadjuvant chemotherapy followed by less radical surgery and postoperative radiation. We report here three cases of lower genital tract rhabdomyosarcoma in postpubertal females. A failure to observe complete responses from any single treatment modality suggests that for embryonal rhabdomyosarcoma in adult and adolescent women a multimodality approach to therapy is essential.

Mechanisms determining sensitivity to cisplatin in three mutant Chinese hamster ovary cell lines.

To gain insight into factors determining the response of tumours to cisplatin, we studied pathways involved in resistance to cisplatin: drug uptake, cytoplasmic detoxification and DNA repair, in three cisplatin-sensitive Chinese hamster ovary (CHO)2 mutant cell lines. The mutant lines, CHO-MMC6, CHO-MMC1, CHO-MMS2, displayed inherent sensitivity to cisplatin (2.2, 4.1 and 10.6-fold, respectively) compared to the CHO-K1 line from which they were derived. CHO-MMS2 was the only mutant to show sensitivity to UV and this was slight (< 2-fold). None of the mutants displayed increased sensitivity to X-irradiation. The CHO-MMS2 cell line appeared to have multiple mechanisms involved in its sensitivity to cisplatin, including increased drug accumulation, decreased levels of glutathione and a decreased capacity for DNA repair. The CHO-MMC1 mutant demonstrated reduced ability for DNA repair in a host cell reactivation assay, but no difference in drug accumulation or glutathione levels compared to the parent. The CHO-MMC6 cell line was not defective in any of the mechanisms studied. These three mutant cell lines demonstrate that similar mechanisms may account for inherent sensitivity or resistance to cisplatin, and suggest that multiple mechanisms may determine the sensitivity of human tumours to cisplatin.

Elevated germ cell markers in carcinoma of uncertain primary site do not predict response to platinum based chemotherapy.

We carried out a retrospective review of the medical records of patients with metastatic carcinoma of unknown primary and either raised alpha fetoprotein (AFP) or beta human chorionic gonadotrophin (beta HCG) over a period of 6 years at three teaching hospital oncology units to assess response to platinum based chemotherapy. 15 patients were identified who fitted these criteria. Of these, 3 received no treatment because of poor functional status, 2 patients received only radiotherapy for symptomatic disease and died within 3 months of diagnosis and 1 patient died 2 weeks after diagnosis having received his first cycle of cisplatin-based chemotherapy. 9 patients received at least 2 cycles of chemotherapy. A complete tumour response was seen in only one patient who presented with midline lymphadenopathy and remains disease-free 46 months after treatment. This presentation was consistent with disease already known to herald platinum sensitivity. In the other 8 patients, there was only one partial response that lasted 2 months. The median survival for this group of 9 patients was 4.5 months (range 3 to > 46 months). Our data do not support the postulate that elevated germ cell markers in patients with carcinoma of unknown primary predict a response to cisplatin based chemotherapy.

Adenocarcinoma of the duodenum with liver metastases. Complete remission and long-term survival with 5-fluorouracil chemotherapy--a case report.

Primary duodenal carcinoma is an uncommon malignancy, and experience with chemotherapeutic regimes in this condition is limited. We report a case of duodenal carcinoma with liver metastases in which complete remission was achieved with 5-fluorouracil chemotherapy. The patient remains well 30 months after completing treatment.

Primary peritoneal carcinoma: a treatable subset of patients with adenocarcinoma of unknown primary.

The syndrome of adenocarcinoma of unknown primary (ACUP) is a frequent problem in both medical and surgical practice. The prognosis is poor, the median lifespan being 4 months. In general, multiple invasive procedures aimed at determining the primary tumour are not warranted due to the low frequency of detecting a tumour for which adequate treatment exists. In this paper we wish to highlight a subset of female patients presenting with malignant ascites and no evidence of a pelvic mass, who on laparotomy were found to have primary peritoneal papillary serous adenocarcinoma. These tumours must be regarded as a potentially treatable subset of patients with ACUP in view of their frequent response to chemotherapy and relatively good prognosis.

A comparison of two quality-of-life questionnaires for cancer clinical trials: the functional living index--cancer (FLIC) and the quality of life questionnaire core module (QLQ-C30).

Choosing a measure instrument for a study raises the question of whether instruments designed for the same purpose produce the same results. We investigated this question for two instruments designed to measure subjective quality of life (QOL) in cancer clinical trials: the Functional Living Index-Cancer (FLIC) and the Quality of Life Questionnaire Core module (QLQ-C30). These were administered concurrently to 98 cancer patients. Four patient groups were defined: (1) well, no chemotherapy (n = 23); (2) adjuvant chemotherapy (n = 24); (3) stable disease, active chemotherapy (n = 24); (4) progressive disease (n = 27). Both instruments have global, role, social, emotional, pain, and nausea scales; QLQ-C30 also assesses physical function, cognitive function, and fatigue, while FLIC assesses hardship. Correlation analysis indicated convergent validity for the global, role, emotional, pain and nausea dimensions, but not the social dimension. Both instruments indicated that groups 1 and 2 had better QOL than group 4 in at least one dimension. However, different dimension-specific results meant that qualitatively different conclusions would have been drawn if either instrument had been used singly: FLIC indicated that group 1 had better role function that group 4 and suffered less hardship and that group 1 suffered less nausea than group 3, while the QLQ-C30 data indicated that group 2 had better physical function than group 4. The only consistent result was for pain: both instruments indicated group 4 had more pain than either groups 1 or 2. Thus the choice of QOL instrument for use in a particular trial will affect both the results and conclusions. It is important, therefore, to consider carefully which instrument is most likely to detect important differences relevant to the patients' lives in that setting.

Establishment of an in vitro model for cisplatin resistance in human neuroblastoma cell lines.

Two unique cisplatin-resistant neuroblastoma (NB) cell lines have been derived from the established lines IMR-32 and SK-N-SH by treatment with escalating doses of cisplatin. IMR/CP.20 was 6.6-fold and SK/CP.15 was 3.8-fold more resistant to the cytotoxic effects of cisplatin than the parent lines. The parent SK-N-SH cells were 16.6-fold more resistant to the effects of cisplatin than IMR-32 cells. The cisplatin-resistant cell lines demonstrated alterations to their morphology, but there was no change in the cell growth characteristics of the resistant compared to the sensitive lines. Cytogenetic analysis revealed that clonal selection of parental subclones had occurred with additional chromosomal changes in both resistant lines. Both IMR/CP.20 and SK/CP.15 lines were cross-resistant to aphidicolin and to L-phenylalanine mustard. The IMR/CP.20 line was 7.3-fold more resistant to mitomycin C than the parent line. Neither cisplatin-resistant NB line was cross-resistant to 5-fluorouracil, etoposide or doxorubicin. All NB lines had low levels of DNA repair compared to HeLa or CHO-K1 cells. However, the IMR/CP.20 cell line showed a significantly higher ability to effect DNA repair than the parent IMR-32 line, indicating that the increased resistance to cisplatin observed in this line may, in part, be due to an enhanced DNA repair capacity.

Repair of cisplatin-DNA adducts by protein extracts from human ovarian carcinoma.

Human ovarian carcinoma exhibits a spectrum of responses to treatment with cisplatin, ranging from marked sensitivity to relative resistance. Variations in the efficiency with which cells repair cisplatin-DNA adducts may in part determine cisplatin sensitivity. We have investigated the use of a novel cell-free assay of nucleotide excision repair of platinated DNA to assess the DNA repair capacity of direct biopsies of untreated human ovarian carcinoma. In this pilot study, ovarian carcinoma extracts performed in vitro excision repair of platinated DNA. Moreover, tumors from different individuals varied as much as 10-fold in their repair capacity in this assay.

Heterogeneous repair of platinum-DNA adducts by protein extracts from mammalian tissues.

Cis-diamminedichloroplatinum (II) (cisplatin) is a mainstay of human cancer chemotherapy. In addition to its antitumour effects however, cisplatin is toxic to normal tissues, causing dose-limiting nephrotoxicity and neurotoxicity. On the other hand, myelosuppression is uncommon. In the light of data suggesting a role for DNA repair mechanisms as determinants of cellular cisplatin sensitivity, we postulated that varying DNA repair capacities between tissues could explain the patterns of organ toxicity seen in clinical practice. Using a novel cell-free assay of repair of cisplatin-DNA adducts, we find that the DNA repair capacity of protein extracts from different tissues varies significantly in our assay, but does not directly correlate with the organ toxicity profile of cisplatin.

A cost-utility approach to the use of 5-fluorouracil and levamisole as adjuvant chemotherapy for Dukes' C colonic carcinoma.

OBJECTIVE: To perform an economic evaluation of the joint use of 5-fluorouracil and levamisole as adjuvant chemotherapy in patients with fully resected Dukes' Stage C carcinoma of the colon, compared with resection and no chemotherapy. The evaluation was prompted by a study (N Engl J Med 1990; 322: 352-358) which recommended a new treatment standard for colon cancer: a 52-week course of fluorouracil, with levamisole every second week, as adjuvant chemotherapy. This recommendation raised several concerns, particularly about the quality of life of patients undergoing such a long course of chemotherapy and the costs to the health care system. METHODS: The cost of the surgery plus chemotherapy was estimated and compared with the cost of surgery alone. Descriptions of quality of life were developed from interviews with patients and health professionals, and the time trade off technique was then used to derive utility weights from a small sample (16) which were used to adjust length of life to reflect quality, in terms of a "quality adjusted life year" (QALY). RESULTS: Chemotherapy increases the total cost of treating a patient with colon cancer by $7000, from $6000 to $13,000. Incorporating quality of life reduced the extra benefit gained from the chemotherapy from 2.4 life years to 0.4 QALYs. Thus the result is a cost of $17,500 to achieve an extra QALY from this particular treatment. CONCLUSIONS: The results of this analysis are only tentative, as the quality of life descriptions were not measured over time but from a cross-sectional survey of patients, and the valuations of health states were derived from a small sample. However, we believe them to be indicative, and conclude that it is perhaps more appropriate for the use of chemotherapy to be an option rather than standard treatment until further research on these aspects is complete.

Loss of allelic heterozygosity on distal chromosome 1p in Merkel cell carcinoma. A marker of neural crest origins?

The location of genes involved in tumor evolution has been inferred from experiments in which loss of constitutional heterozygosity has been detected in tumor DNA at high frequency in specific chromosome regions. For example, cytogenetic and molecular abnormalities on chromosome 1p have been reported in tumors such as malignant melanoma and neuroblastoma which arise in cells derived from embryonic neural crest tissue. To extend these observations, we have examined tumor DNA from three cases of Merkel cell carcinoma for evidence of loss of constitutional heterozygosity on the short arm of chromosome 1. In all three cases, heterozygous allelic deletions of varying extent on distal chromosome 1p were detected in tumor DNA. Comparisons with neural crest tumors suggest that loss of heterozygosity on distal chromosome 1p in Merkel cell tumors may be a marker of neural crest origin.