Intratumor heterogeneity and branched evolution revealed by multiregion sequencing.

BACKGROUND: Intratumor heterogeneity may foster tumor evolution and adaptation and hinder personalized-medicine strategies that depend on results from single tumor-biopsy samples. METHODS: To examine intratumor heterogeneity, we performed exome sequencing, chromosome aberration analysis, and ploidy profiling on multiple spatially separated samples obtained from primary renal carcinomas and associated metastatic sites. We characterized the consequences of intratumor heterogeneity using immunohistochemical analysis, mutation functional analysis, and profiling of messenger RNA expression. RESULTS: Phylogenetic reconstruction revealed branched evolutionary tumor growth, with 63 to 69% of all somatic mutations not detectable across every tumor region. Intratumor heterogeneity was observed for a mutation within an autoinhibitory domain of the mammalian target of rapamycin (mTOR) kinase, correlating with S6 and 4EBP phosphorylation in vivo and constitutive activation of mTOR kinase activity in vitro. Mutational intratumor heterogeneity was seen for multiple tumor-suppressor genes converging on loss of function; SETD2, PTEN, and KDM5C underwent multiple distinct and spatially separated inactivating mutations within a single tumor, suggesting convergent phenotypic evolution. Gene-expression signatures of good and poor prognosis were detected in different regions of the same tumor. Allelic composition and ploidy profiling analysis revealed extensive intratumor heterogeneity, with 26 of 30 tumor samples from four tumors harboring divergent allelic-imbalance profiles and with ploidy heterogeneity in two of four tumors. CONCLUSIONS: Intratumor heterogeneity can lead to underestimation of the tumor genomics landscape portrayed from single tumor-biopsy samples and may present major challenges to personalized-medicine and biomarker development. Intratumor heterogeneity, associated with heterogeneous protein function, may foster tumor adaptation and therapeutic failure through Darwinian selection. (Funded by the Medical Research Council and others.).

Long-term outcome of radical radiation therapy for prostatic carcinoma: 1967-1987.

PURPOSE: This study was done to review long-term results of radical radiotherapy for prostate cancer. METHODS AND MATERIALS: The records of 674 patients with Stage T1a, T1b, T2a, T2b, T3, and any T,N1,M0 disease, treated with external beam radiotherapy between January 1, 1967 and December 1987, were reviewed. These patients were treated to an average total dose of 66 Gy, with an average fractional dose of 2.05 Gy, using megavoltage. The duration of follow-up for surviving patients ranged from a minimum of 7 years to more than 20 years. RESULTS: The survival for 151 Stage T1a,T1b patients was 98.5% at 5 years, 93.6% at 10 years, and 75.2% at 15 years. Survival for 346 Stage T2a,b patients was 94.4% at 5 years, 67.9% at 10 years, and 41.5% at 15 years. Survival for 92 Stage T3 patients was 87.3% at 5 years, 54% at 10 years, and 26.6% at 15 years. The survival for 85 any T,N1,M0 patients was 73.9% at 5 years, 34.4% at 10 years, and 8.5% at 15 years. At 15 years, 75.2% of Stage T1a,b patients, 41.5% of Stage T2a,b patients, 21.7% of Stage T3 patients, and 8.5% of Stage T,N1,M0 patients remained free of local recurrence and distant metastases. The elevation of prostatic acid phosphatase prior to radiotherapy was an unfavorable prognostic factor, with impact on both loco-regional recurrences and survival. CONCLUSIONS: The external beam radiotherapy for localized carcinoma of the prostate produced a good loco-regional control, NED, and overall survival. Patients with smaller tumors and low grade fared better than the ones with more aggressive and/or bulky tumors. The weakness of this study is the absence of serial prostate-specific measurements, which were not available during the period under study. The complication rate requiring surgical intervention was low, i.e. 0.4%.

A population-based study of the use and outcome of radical radiotherapy for invasive bladder cancer.

PURPOSE: The objective of this study is to describe the use and outcome of radical radiotherapy for bladder cancer in the province of Ontario, Canada, between 1982 and 1994. METHODS: Electronic records of invasive bladder cancer (ICD code 188) from the Ontario Cancer Registry were linked to surgical records from all Ontario hospitals and radiotherapy (RT) records from all Ontario cancer centers. We identified cases receiving radical RT by selecting RT records containing "bladder" or "pelvis" anatomic region codes and a radical or curative intent code (or dose >39.5 Gy if intent missing). We identified cases receiving salvage total cystectomy by selecting total cystectomy procedure codes occurring at any time beyond 4 months from the start of radical RT. We used life table methods to compute the following: the time from diagnosis to radical RT, the time from radical RT to salvage cystectomy, overall and cause-specific survival from radical radiotherapy to death, and overall and cause-specific survival from salvage cystectomy to death. We modeled the factors associated with time to death, time to cystectomy conditional on survival, and time to cystectomy or death, whichever came first, using Cox proportional hazards regression. RESULTS: From the 20,906 new cases of bladder cancer diagnosed in Ontario from 1982 to 1994, we identified 1,372 cases treated by radical radiotherapy (78% male, 22% female; mean age 69.8 years). The median interval to start of radical RT from diagnosis was 13.4 weeks. Ninety-three percent of patients were treated on high-energy linacs, and the most common dose/fractionation scheme was 60 Gy/30 (31% of cases). Five-year survival rates were as follows: bladder cancer cause-specific, 41%; overall, 28%; cystectomy-free, 25%; bladder cancer cause-specific following salvage cystectomy, 36%; overall following salvage cystectomy, 28%. Factors associated with a higher risk of death and a poorer cystectomy-free survival were histology (squamous or nonpapillary transitional cell carcinoma [TCC]) and advanced age. CONCLUSION: This population-based study confirms previous institutional studies and clinical trials and shows that radical RT has a curative role in the management of invasive bladder cancer and allows about one-quarter of patients receiving radiotherapy to survive 5 years while retaining the bladder. Salvage cystectomy following RT provides a chance of cure at the time of bladder relapse.

Reorganization of trigeminal primary afferents following neonatal infraorbital nerve section in hamster.

The infraorbital nerve was sectioned and the ipsilateral whisker follicles were cauterized in hamsters within 12 h of birth. Sixty to ninety days later application of HRP to the proximal stumps of the ipsilateral lingual, inferior alveolar, mylohyoid and auriculotemporal nerves resulted in increased numbers of labeled somata in trigeminal ganglion regions which contain primarily infraorbital cell bodies in normal animals. The labeled central processes of mandibular nerves also occupied portions of the brainstem trigeminal complex normally innervated by infraorbital axons. These findings represent the first anatomical demonstration of trigeminal primary afferent plasticity.

Organization of the infraorbital nerve in rat: a quantitative electron microscopic study.

The normal organization of the rat's infraorbital (IO) nerve was studied using conventional electron microscopic (EM) methods. Just caudal to the infraorbital foramen, at the level of the anterior superior alveolar foramen, the nerve was composed of 18-25 fascicles which ranged from 575 to 87,923 micron2 in cross-sectional area. Complete axon counts from thin sections taken at this level demonstrated that the IO nerve contained an average of 19,740 (S.D. = 2054) myelinated and 13,319 (S.D. = 1159) unmyelinated axons. The average diameter (including the myelin sheath) for medullated fibers was 4.42 micron (S.D. = 1.76) and that for unmyelinated axons was 0.60 micron (S.D. = 0.16). The fiber diameter distributions for both myelinated and unmyelinated axons were essentially unimodal.

Increase in bile secretion after water ingestion in cholecystectomised patients.

The effect of water ingestion on bile secretion was investigated in nine cholecystectomised patients with T-tube biliary drainage. The effect of ingestion of a standard meal on bile secretion was also studied in these patients. Water ingestion produced a significant increase in bile secretion compared with fasting levels. This increase in bile secretion was comparable to that produced by a standard meal. Ingestion of water or meal did not produce any significant change in bile osmolality or sodium and potassium concentrations of bile.

The diagnostic yield of upper gastrointestinal endoscopy in the investigation of anaemia.

Computer records of patients endoscoped over a 34-month period were studied to assess the diagnostic yield of gastrointestinal endoscopy in patients with anaemia. Patients with obvious gastrointestinal bleeding and known gastrointestinal pathology were excluded. On hundred and thirty-six patients were endoscoped for anaemia. Eighty-three of them (61%) had iron deficiency anaemia and 53 (39%) had other types of anaemia. The ages of the patients with iron deficiency anaemia (mean 56 years) were significantly lower than those of other anaemias (means 65 years), (p less than 0.003). Patient characteristics were otherwise comparable. There were significant endoscopic findings (ulcers, carcinoma and haemorrhagic or erosive gastritis) in 26 of 83 patients (31%) with iron deficiency anaemia, in 11 of 53 patients with other anaemias (21%) and 37 of 136 patients (27%) combined. Significant endoscopic findings were found in 506 of 2224 patients (23%) endoscoped during this period who were not anaemic, did not have obvious gastrointestinal haemorrhage and were not known to have gastrointestinal diseases. The diagnostic yield for iron deficiency anaemia was significantly higher than for the non anaemic group (p less than 0.05). There was no difference between the diagnostic yields of iron deficiency and other anaemias, other anaemias and the non anaemic group, or total anaemias and the non anaemic group. Gastrointestinal symptoms and history of analgesic or steroid usage did not appear to increase the incidence of gastrointestinal lesions in either iron deficiency anaemia or other anaemias. Twenty-three of 41 patients (56%) who had no cause for anaemia found at the end of all investigations were colonscoped.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevention of secondary lymphedema.

After some preliminary remarks upon pathophysiologic and anatomo-surgical aspects, the main complications of axillary lymph-nodal dissection for breast cancer treatment are reported. The role of surgical technique is particularly underlined and also the importance of proper management of wound and surgical drainage post-operatively are pointed out. Author describes, finally, the necessity of an adequate knowledge of lymphatic drainage not only of mammary region, but also of surrounding area, in order to prevent lesions to lymphatic pathways, particularly to those draining upper arm at the same site of breast cancer.

The effect of chilli and its pungent ingredient capsaicin on gastrointestinal transit in the rat.

The effect of chilli powder and its pungent ingredient capsaicin on gastrointestinal transit in the rat was studied. Fasted unanaesthetized male Sprague-Dawley rats (n = 144) received by gavage a test meal containing charcoal and cellulose in water or capsaicin solvent plus 51Cr as a radioactive marker. Either 100 or 200 mg of chilli powder (containing 0.13 and 0.26 mg of capsaicin, respectively) or 0.5 or 1 mg of capsaicin were added, the final volume of each meal being 1.5 mL. At 10 and 20 min, animals were killed and the amount of isotope that had left the stomach was measured, together with the distance the charcoal column had travelled along the small intestine. Compared to controls, animals given chilli powder emptied less of their gastric content at 10 and 20 min, an effect partly reproduced by capsaicin. However overall gastric-small intestinal transit was unaffected by chilli powder or capsaicin. Another 12 male Sprague-Dawley rats received, under light ether anaesthesia, on six occasions at 1-2 week intervals, the same six test meals as used in the previous experiment except that charcoal was not used. Total gut transit as measured by the amount of radioactive marker excreted in the stools at 18 and 24 h was unaffected by the use of chilli or capsaicin.

Midazolam as a sedative in esophageal manometry: a study of the effect on esophageal motility.

Midazolam 0.5 mg/kg was given intravenously as a sedative to 19 infants and children undergoing esophageal manometry after oral choral hydrate treatment. The lower esophageal sphincter pressure and motility were measured by manometry before and after midazolam injection. Midazolam did not change the lower esophageal sphincter pressure, blood pressure and respiratory rate of the subjects (p greater than 0.18), and the motility patterns. However, the mean heart rate increased by 5 beats/min after midazolam injection (p less than 0.05). One infant developed transient apnea, reversed promptly by intravenous flumazenil. Sedation occurred within 1 min after intravenous injection of the drug. No other side effects were noted. Midazolam is a relatively safe and effective sedative for accurate lower esophageal sphincter pressure measurement and esophageal manometry when a mild sedative such as choral hydrate does not work.