Neoadjuvant chemotherapy followed by chemoradiation and surgery with and without cetuximab in patients with resectable esophageal cancer: a randomized, open-label, phase III trial (SAKK 75/08).

Background: This open-label, phase III trial compared chemoradiation followed by surgery with or without neoadjuvant and adjuvant cetuximab in patients with resectable esophageal carcinoma. Patients and methods: Patients were randomly assigned (1 : 1) to two cycles of chemotherapy (docetaxel 75 mg/m2, cisplatin 75 mg/m2) followed by chemoradiation (45 Gy, docetaxel 20 mg/m2 and cisplatin 25 mg/m2, weekly for 5 weeks) and surgery, with or without neoadjuvant cetuximab 250 mg/m2 weekly and adjuvant cetuximab 500 mg/m2 fortnightly for 3 months. The primary end point was progression-free survival (PFS). Results: In total, 300 patients (median age, 61 years; 88% male; 63% adenocarcinoma; 85% cT3/4a, 90% cN+) were assigned to cetuximab (n = 149) or control (n = 151). The R0-resection rate was 95% for cetuximab versus 97% for control. Postoperative treatment-related mortality was 6% in both arms. Median PFS was 2.9 years [95% confidence interval (CI), 2.0 to not reached] with cetuximab and 2.0 years (95% CI, 1.5-2.8) with control [hazard ratio (HR), 0.79; 95% CI, 0.58-1.07; P = 0.13]. Median overall survival (OS) time was 5.1 years (95% CI, 3.7 to not reached) versus 3.0 years (95% CI, 2.2-4.2) for cetuximab and control, respectively (HR, 0.73; 95% CI, 0.52-1.01; P = 0.055). Time to loco-regional failure after R0-resection was significantly longer for cetuximab (HR 0.53; 95% CI, 0.31-0.90; P = 0.017); time to distant failure did not differ between arms (HR, 1.01; 95% CI, 0.64-1.59, P = 0.97). Cetuximab did not increase adverse events in neoadjuvant or postoperative settings. Conclusion: Adding cetuximab to multimodal therapy significantly improved loco-regional control, and led to clinically relevant, but not-significant improvements in PFS and OS in resectable esophageal carcinoma. Clinical trial information: NCT01107639.

Bevacizumab continuation versus no continuation after first-line chemotherapy plus bevacizumab in patients with metastatic colorectal cancer: a randomized phase III non-inferiority trial (SAKK 41/06).

BACKGROUND: Chemotherapy plus bevacizumab is a standard option for first-line treatment in metastatic colorectal cancer (mCRC) patients. We assessed whether no continuation is non-inferior to continuation of bevacizumab after completing first-line chemotherapy. PATIENTS AND METHODS: In an open-label, phase III multicentre trial, patients with mCRC without disease progression after 4-6 months of standard first-line chemotherapy plus bevacizumab were randomly assigned to continuing bevacizumab at a standard dose or no treatment. CT scans were done every 6 weeks until disease progression. The primary end point was time to progression (TTP). A non-inferiority limit for hazard ratio (HR) of 0.727 was chosen to detect a difference in TTP of 6 weeks or less, with a one-sided significance level of 10% and a statistical power of 85%. RESULTS: The intention-to-treat population comprised 262 patients: median follow-up was 36.7 months. The median TTP was 4.1 [95% confidence interval (CI) 3.1-5.4] months for bevacizumab continuation versus 2.9 (95% CI 2.8-3.8) months for no continuation; HR 0.74 (95% CI 0.58-0.96). Non-inferiority could not be demonstrated. The median overall survival was 25.4 months for bevacizumab continuation versus 23.8 months (HR 0.83; 95% CI 0.63-1.1; P = 0.2) for no continuation. Severe adverse events were uncommon in the bevacizumab continuation arm. Costs for bevacizumab continuation were estimated to be ∼30,000 USD per patient. CONCLUSIONS: Non-inferiority could not be demonstrated for treatment holidays versus continuing bevacizumab monotheray, after 4-6 months of standard first-line chemotherapy plus bevacizumab. Based on no impact on overall survival and increased treatment costs, bevacizumab as a single agent is of no meaningful therapeutic value. More efficient treatment approaches are needed to maintain control of stabilized disease following induction therapy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, number NCT00544700.

[Vertical diplopia after cataract operation]. / Vertikale Diplopie nach Kataraktoperationen.

PURPOSE: Presentation and analysis of patients with vertical diplopia appearing after cataract surgery in retrobulbar anesthesia. SUBJECTS AND METHODS: Between 1990 and 1998 9 Patients with vertical diplopia following cataract surgery in retrobulbar anesthesia were studied in our Orthoptic Department. Each patient had complete orthoptic examination with Hess-screen-test. Additionally, some patients underwent neuroradiologic imaging and forced-duction testing. RESULTS: We subdivided the patients in a group of 4 patients with hypertropia and of 5 patients with hypotropia of the operated eye. All hypotropias were left-sided. Seven patients showed an overaction of the involved muscle without regression. Seven patients underwent surgery of a vertical muscle. Only 1 patient needed prismatic therapy postoperatively. The other 2 non-operated patients were satisfied with prisms alone. CONCLUSIONS: The proposed pathogenesis of vertical diplopia in these cases is fibrosis and contracture of the injured muscle, which could be due to anesthetic myotoxicity after direct injection into the muscle or to an intramuscular hemorrhage. On the other hand hypertropia could be a result of placement of bridle sutures. We discuss prevention and therapy of such complications.

Mechanisms for generating the autonomous cAMP-dependent protein kinase required for long-term facilitation in Aplysia.

The formation of a persistently active cAMP-dependent protein kinase (PKA) is critical for establishing long-term synaptic facilitation (LTF) in Aplysia. The injection of bovine catalytic (C) subunits into sensory neurons is sufficient to produce protein synthesis-dependent LTF. Early in the LTF induced by serotonin (5-HT), an autonomous PKA is generated through the ubiquitin-proteasome-mediated proteolysis of regulatory (R) subunits. The degradation of R occurs during an early time window and appears to be a key function of proteasomes in LTF. Lactacystin, a specific proteasome inhibitor, blocks the facilitation induced by 5-HT, and this block is rescued by injecting C subunits. R is degraded through an allosteric mechanism requiring an elevation of cAMP coincident with the induction of a ubiquitin carboxy-terminal hydrolase.

[Diagnosis of herpetic uveitis and keratouveitis]. / Die Diagnostik der herpetischen Uveitis und Keratouveitis.

BACKGROUND: In epithelial viral keratitis as in viral retinitis, the diagnosis is made on the basis of typical clinical findings. A laboratory confirmation is achieved in over 80% using routine laboratory methods. In contrast, it is almost impossible to confirm the diagnosis of stromal herpetic keratitis in vivo using the currently available laboratory methods. Nothing is known about the situation in cases of viral anterior uveitis. METHODS: Of 52 patients with granulomatous anterior uveitis, 31 were diagnosed on the basis of clinical findings as active herpetic uveitis (group 1), 14 as active granulomatous uveitis of unknown origin (group 2), and 7 had inactive disease after quietening down of herpetic uveitis (group 3). From all patients, aqueous humor was collected at the time of diagnosis and processed for viral culture, Herpes antigen ELISA, and amplification of viral DNA of HSV-1 and VZV. RESULTS: Viral growth in culture was found in only one case in group 3. In this group, viral antigen or viral DNA were detected in no case. Herpes antigen was found in 5/31 cases (16%) in group 1 and in 1/11 cases (9%) in group 2, and viral DNA was found in 8/31 cases from group 1 (5x HSV-1 and 3x VZV) and in 5/14 cases (31%) from group 2. After combination of antigen detection and DNA amplification, the presence of virus was confirmed in 14/45 cases (29%). CONCLUSION: Virus culture has not proven useful in the diagnosis of viral anterior segment disease. Despite their high overall sensitivity, neither antigen ELISA nor the amplification of viral DNA proved sensitive enough to establish a viral etiology. Nevertheless, a laboratory confirmation should be attempted in granulomatous uveitis of unknown origin after preclusion of an underlying systemic disease because of the consequences of a diagnosis of viral anterior segment disease for treatment and prognosis.

Development of short-term heterosynaptic facilitation at aplysia sensorimotor synapses in vitro is accompanied by changes in the functional expression of presynaptic serotonin receptors.

1. The sensorimotor synapse of Aplysia expresses various shortlasting changes in synaptic efficacy including homosynaptic depression (HSD) and heterosynaptic facilitation by serotonin (5-HT) either at nondepressed sensory neuron (SN) synaptic connections or at SN synaptic connections first depressed by HSD. We examined the temporal sequence of expression for these three forms of synaptic plasticity as synaptic connections between SN and target motor cell L7 were reestablished and stabilized in cell culture. The same cultures were reexamined at different time points. 2. We found that only HSD and facilitation of nondepressed synapses were expressed at "mature" levels on day 1 in culture, whereas facilitation of depressed connections was significantly weaker on day 1 than the facilitation evoked on day 4. 3. The late expression of 5-HT facilitation of depressed SN synaptic connections was not a result of a reduced capacity of two kinases activated by 5-HT (protein kinase A and protein kinase C) to evoke facilitation. Direct activation of the kinases with either cyclic AMP or phorbol esters evoked the synaptic facilitation both on day 1 and day 4. 4. The late expression of 5-HT facilitation of depressed SN synaptic connections was correlated with the late functional expression of receptors sensitive to 5-HT antagonists cyproheptidine or methiothepin. Both antagonists significantly interfered with 5-HT facilitation on day 4, but both had little effect on 5-HT facilitation of the same cultures examined on day 1. 5. Unlike the properties of SNs in the intact nervous system, both antagonists reduced significantly the excitability changes evoked by 5-HT when the SNs were plated either alone or with target cell L11 that fails to induce synapse formation. When cultured with L7, however, both antagonists evoked little change in 5-HT excitability. In the presence of L7, the SNs expressed the phenotype more typical of SNs in the intact nervous system. 6. The results suggest that target interactions not only influence the formation of chemical connections but they also may regulate the acquisition of specific plastic properties by the presynaptic neuron including the functional expression of receptors for neuromodulators.

Tetanic stimulation and cyclic adenosine monophosphate regulate segregation of presynaptic inputs on a common postsynaptic target neuron in vitro.

Previous studies indicated that Aplysia sensory neurons (SNs) compete when reestablishing synapses with a motor cell target (L7) in vitro. The competition is characterized by a cell number-dependent decrease in the efficacy of each connection, an increase in the elimination of SN varicosities, a reduction in the formation of new SN varicosities, and the segregation of varicosities of each SN to restricted portions of the target axons. The changes do not require spike activity, since both the SNs and L7 do not fire spontaneously. Here, we examined whether adding activity to SNs during the early stages of synapse formation with stimuli known to evoke facilitatory responses in stable SN-L7 connections--tetanic stimulation or increase in intracellular cyclic adenosine monophosphate (cAMP)--would modulate the intrinsic segregatory process. Tetanic stimulation to one SN increased synapse efficacy and the number of varicosities of the stimulated SNs while reducing the functional changes by the nonstimulated SNs in the same cultures. An increase in the stability of preexisting varicosities contributed to the overall increase in varicosities evoked by tetanus. The functional changes evoked by tetanus were not expressed when the same tetanic stimulation was also given to the other SN, or when L7 was hyperpolarized during the tetanus to the SN. Raising cAMP levels in one SN increased synapse efficacy and the rate of new varicosity formation by the injected SNs without affecting the development of the connections formed by the noninjected SNs. These results suggest that different forms of presynaptic and postsynaptic activities in neurons can regulate specific aspects of the competitive process associated with the fine-tuning of connections formed by converging presynaptic inputs.

Transient versus persistent functional and structural changes associated with facilitation of Aplysia sensorimotor synapses are second messenger dependent.

Increases in activity of both protein kinase A (PKA) and protein kinase C (PKC) contribute to short-term facilitation of Aplysia sensorimotor synapses evoked by serotonin (5-HT). We report here that increasing levels of cAMP in sensory neurons evokes increases in both synaptic efficacy and in the number of sensory neuron varicosities contacting the major axons of motor cell L7 at intermediate times (3 hr) that persist for 24 hr. Treatment with phorbol esters results in a large transient increase in synaptic efficacy that is accompanied by a large transient increase in the number of sensory neuron varicosities with the newest varicosities most susceptible to elimination. The reversal of the synaptic facilitation and the structural changes does not appear to be the result of long-term inhibitory actions of persistent PKC activation by phorbol esters, since changes in synaptic efficacy can be evoked by additional applications of either phorbol esters or 5-HT. The short-lived changes in structure evoked by phorbol esters occur in preexisting sensory neurites and not by new growth, since increases in PKC activity with phorbol esters lead to reductions in neurite extension and to retractions by sensory neuron growth cones. The action of phorbol esters on growth cone extension is reversible with washout. The results suggest that increases in PKA and PKC activities by 5-HT contribute to short (minutes) and intermediate (hours) forms of facilitation of sensorimotor synapses while increases in PKA activity also mediate long-term (days) maintenance of synaptic facilitation.

Pre- and postsynaptic changes mediated by two second messengers contribute to expression of Aplysia long-term heterosynaptic inhibition.

FMRFamide evokes long-term inhibition of the sensorimotor connection of Aplysia that includes structural alterations in the presynaptic sensory cell. FMRFamide also evokes a down-regulation of the adhesion molecule apCAM from the surface of the postsynaptic motor cell L7. We examined the second messenger pathways mediating the long-term actions of FMRFamide on both the pre- and postsynaptic cells and determined whether the activation of each pathway is required for the expression of long-term functional and structural plasticity. Inhibition of the lipoxygenase pathway of arachidonic acid metabolism, but not the cyclooxygenase pathway, blocks the long-term changes in the presynaptic sensory cell evoked by FMRFamide. The down-regulation of apCAM in L7 appears to be mediated by cAMP-dependent activation of protein kinase A. Blocking the cAMP-dependent changes also blocks FMRFamide-induced long-term functional and structural changes. These results suggest that the expression of long-term heterosynaptic inhibition in Aplysia may require concomitant presynaptic and postsynaptic changes, each transduced by specific second messenger systems.

Pairing-specific, activity-dependent presynaptic facilitation at Aplysia sensory-motor neuron synapses in isolated cell culture.

Synapses made by Aplysia sensory neurons onto motor- and interneuron followers in the intact nervous system exhibit an associative form of synaptic facilitation that is thought to contribute to classical conditioning of the animal's gill and siphon withdrawal reflex (Hawkins et al., 1983; Walters and Byrne, 1983). Here we demonstrate that a similar associative facilitation can be induced between individual sensory and motor neurons isolated in culture. Pairing tetanic stimulation with either of two facilitatory transmitters, 5-HT or small cardioactive peptide, considerably prolongs facilitation compared to either tetanus or transmitter alone. When corrected for the depression that occurs simply in response to low-frequency testing, the facilitation produced by one pairing trial does not decay for more than 20 min after training. This facilitation requires the temporal pairing (0.5 sec forward interstimulus interval) of the two stimuli, tetanus and 5-HT. Delivering the same two stimuli in an unpaired fashion (1 min forward interval) fails to produce the long-lasting effect. Measurements of spontaneous transmitter release during either paired or unpaired training reveal no changes in unitary mEPSP or mEPSC ("mini") amplitude, indicating that the facilitation involves a presynaptic mechanism. While both forms of training dramatically increase the initial frequency of spontaneous release, mini frequency does not remain elevated as long as the evoked EPSP following paired training, nor does paired training specifically enhance spontaneous release frequency. Pairing-specific facilitation was not blocked by the protein kinase C inhibitor H7. In contrast, the same training procedure produced pairing-specific increases of sensory neuron excitability and action potential width, suggesting that cAMP-mediated processes are involved in the paired effect. Although Ca2+ influx is necessary for the associative effect (Abrams, 1985), we find that the facilitation does not require influx through L-type voltage-gated Ca2+ channels, since the effect was not blocked by the dihydropyridine antagonist nitrendipine. Together, these findings indicate that the mechanism underlying associative, activity-dependent facilitation is intrinsic to the sensory neuron synapse, that it is presynaptically mediated by processes unique to evoked synaptic transmission, and that it appears to involve a pairing-specific broadening of the presynaptic action potential, allowing enhanced Ca2+ influx through the dihydropyridine-insensitive channels responsible for release.

cAMP and arachidonic acid simulate long-term structural and functional changes produced by neurotransmitters in Aplysia sensory neurons.

The efficacy of the synapses between the sensory and motor cells of Aplysia, as well as the number of presynaptic sensory cell varicosities in vitro, can undergo long-term increases and decreases, respectively, following application of the facilitatory modulator serotonin or the inhibitory modulator FMRFamide. We here report that cAMP and arachidonic acid, two second messenger systems mediating some of the short-term actions of serotonin and FMRFamide on sensory cells, reproduce some of the long-term changes in the structure of the sensory cells, and these structural changes in turn parallel the long-term changes in the functional effectiveness of the synapses. cAMP enhances the strength of the connections between the sensory and motor cells and increases the number of sensory varicosities. Conversely, arachidonic acid decreases the strength of the connections and decreases the number of sensory varicosities. Thus, each of the modulatory neurotransmitters may activate the same intracellular second messenger system to establish both short and long lasting functional changes in synaptic efficacy, as well as to produce enduring structural changes in neuron connectivity.

cAMP evokes long-term facilitation in Aplysia sensory neurons that requires new protein synthesis.

Behavioral sensitization leads to both short- and long-term enhancement of synaptic transmission between the sensory and motor neurons of the gill-withdrawal reflex in Aplysia. Serotonin (5-HT), a transmitter important for short-term sensitization, can evoke long-term enhancement of synaptic strength detected 1 day later. Because 5-HT mediates short-term facilitation through adenosine 3',5'-monophosphate (cAMP)-dependent protein phosphorylation, the role of cAMP in the long-term modulation of this identified synapse was examined. Like 5-HT, cAMP can also evoke long-term facilitation lasting 24 hours. Unlike the short-term change, the long-lasting change is blocked by anisomycin, a reversible inhibitor of protein synthesis, and therefore must involve the synthesis of gene products not required for the short-term change.

Additional component in the cellular mechanism of presynaptic facilitation contributes to behavioral dishabituation in Aplysia.

Sensitization of defensive gill and siphon withdrawal reflexes in Aplysia results, in part, from presynaptic facilitation of transmitter release from mechanoreceptor sensory neurons that innervate the siphon skin and synapse with interneurons and motor neurons. Presynaptic facilitation also can be elicited by application of serotonin. This facilitation is associated with two phenomena, a prolongation of the presynaptic action potential resulting from a decrease in a specific K+ current and an enhancement of the Ca2+ transients elicited by depolarization. Previous work has shown that prolongation of the action potential enhances synaptic transmission at normal levels of release. Here we report that an additional set of processes also contributes to facilitation. When repeated activation of the sensory neurons induces profound homosynaptic depression, prolonging the duration of action potentials (or of depolarizing commands under voltage clamp) has little effect on transmitter release. Nonetheless, serotonin is still capable of enhancing release. Since homosynaptic depression underlies the behavioral process of habituation, the second set of processes, by counteracting the consequences of the depression, seems to mediate the effects of dishabituation in the sensory neuron. Prolongation of the action potential by closure of the K+ channel seems to mediate the effects of sensitization.

The long and the short of long-term memory--a molecular framework.

A single learning event initiates several memory processes with different time courses of retention. While short term memory involves covalent modification of pre-existing proteins, the finding that long-term memory requires the expression, during learning, of additional genes, makes it possible to analyse in molecular terms the induction and retention of long-term memory.

Action potentials, macroscopic and single channel currents recorded from growth cones of Aplysia neurones in culture.

Action potentials, macroscopic ionic currents and single channel currents were recorded from growth cones of Aplysia right upper quadrant (r.u.q.) cells in culture, using the patch-clamp technique. Recordings were obtained from both intact growth cones and from growth cones that had been mechanically isolated from the rest of the neurone. In current-clamp mode, greater than half of the isolated growth cones display an all-or-none action potential when depolarized above 0 mV with outward current pulses. The remaining growth cones display only a graded depolarization that is unaffected by tetrodotoxin (TTX). In whole-cell voltage clamp almost all isolated growth cones display a rapidly activating and inactivating inward current followed by a delayed outward current in response to depolarizations positive to -20 mV. The rapid inward current reverses direction at around +70 to +80 mV and is completely suppressed by 100 microM-TTX, which suggests that this current is carried by the fast Hodgkin-Huxley sodium current channels. The delayed outward current appears to result from the activation of both the delayed rectifier potassium current, IK, and the calcium-activated potassium current, IC. The growth cones do not display any prominent early transient outward current, IA. The sodium current, INA, was studied in isolation by substituting caesium for potassium ions in the pipette solution. INa is half-inactivated at a holding potential of -36 mV, reaches half-maximal activation with a depolarization to 0 mV, and has a mean peak current density of 13 microA/cm2. The time course of inactivation is well described by a single exponential (tau = 3 ms at 0 mV). In cell-attached patches, a rapidly activating and inactivating inward current channel was recorded with an average unit conductance of 6.9 pS. The activation and inactivation parameters of the ensemble averaged current closely match the measured values from the macroscopic sodium current. At very positive potentials we recorded a voltage-dependent outward current channel with a conductance of around 35 pS. No significant inward calcium current was observed in whole-cell measurements and few single calcium channel currents were measured in cell-attached patches, suggesting a sparse distribution of calcium channels in the r.u.q. growth cones.

Synaptogenesis by single identified neurons in vitro: contribution of rapidly transported and newly synthesized proteins.

The object of these studies is to define the molecular events that occur during synaptogenesis. Our approach is to use single identified Aplysia neurons grown in culture under conditions where chemical synapses are formed. In this report we studied synapses established by R2, a giant cholinergic neuron, onto neurons R15 and L11, and a group of left upper quadrant (LUQ) cells. The detailed electrophysiology of these contacts was described in the preceding paper (Schacher, S., S. G. Rayport, and R. T. Ambron (1985) (J. Neurosci. 5: 2851-2856). Within the animal, R2 synapses on thousands of unicellular mucus glands in the skin. R2 growing in vitro will establish contacts with isolated mucus glands. Although we do not know whether a functional synapse is formed, electron microscopy shows that the membrane in the area of contact is differentiated and that the ending is filled with various types of vesicles. A single R2 regenerating neurites in vitro synthesizes more than 300 polypeptides containing [35S]methionine. Many of these are subsequently transported into the growing neurites. We compared the newly synthesized proteins made by R2 before and after synapse formation and found that the expression of a 68-kilodalton (kd) and 72-kd protein was markedly enhanced after synaptogenesis. The finding that only two proteins were affected implies that many of the proteins required for synapse formation are present in R2 prior to contacting a target cell. Support for this idea was obtained when we compared the proteins present in R2's neurites in vitro with those that are rapidly transported to R2's mature synapses in vivo (Ambron, R. T., S. Schacher, and S. G. Rayport (1985) J. Neurosci. 5: 2866-2873).(ABSTRACT TRUNCATED AT 250 WORDS)