Strangulated Gastric Hernia Following a Missed Traumatic Diaphragmatic Injury: A Case Report.

Traumatic diaphragmatic injuries (TDIs) are rare and can be life-threatening, depending on the size of the injury and the contents herniating through it. They usually result from blunt or penetrating trauma to the thoracoabdominal area, with an incidence of 0.8-5% and up to 30% presenting late. A high index of suspicion should be maintained when evaluating patients with a history of trauma (severe blunt or thoracoabdominal penetrating trauma) and upper abdominal symptoms. We present a case of a missed TDI after a left posterior thoracoabdominal stab injury, which was evaluated with a diagnostic laparoscopy at an outside hospital. He presented to our emergency department (ED) with sudden onset left-sided chest pain and uncontrollable vomiting. A CT scan was obtained and showed a distended stomach herniating through a defect in the left hemidiaphragm. The patient was immediately taken for laparoscopic exploration and repair. There was a 5 cm defect in the left posterolateral diaphragm containing a strangulated stomach (approximately ⅔) and necrotic omentum. Complete reduction was achieved and the diaphragmatic defect was repaired primarily. His postoperative course was uncomplicated. This case illustrates the importance of maintaining a high index of suspicion for TDI, despite reports of previous exploration. Missed TDI can present with herniated intra-abdominal organs, which can become strangulated and increase morbidity and mortality.

A Rare Cause of Popliteal Artery and Vein Transection: A Case Report and Literature Review.

We present a rare occurrence of popliteal vascular injury due to blunt trauma. The patient had an isolated blunt lower extremity trauma. The patient subsequently experienced moderate tenderness and non-expanding hematoma at the popliteal fossa, reduced range of motion at the knee, and diminished distal pulses. X-rays showed a patella dislocation and tibial plateau non-displaced fracture but no knee dislocation. CT angiography showed an abrupt non-opacification of the distal portion of the popliteal artery with an overlying large hematoma. Surgical exploration was performed which revealed a concomitant transection of the popliteal artery and vein with a 5 cm defect. It was repaired with an interposition graft, and a fasciotomy was also performed. Literature has noted that although the overall incidence of popliteal injuries is low, when present due to blunt trauma there is increased morbidity. A high index of suspicion is recommended for vascular injuries in all patients with blunt trauma to the lower extremities. Minimizing time to diagnosis and intervention for limb salvage and improved outcomes.

Antitumor effects of regorafenib and sorafenib in preclinical models of hepatocellular carcinoma.

The purpose of this study was to investigate the antitumor activity of regorafenib and sorafenib in preclinical models of HCC and to assess their mechanism of action by associated changes in protein expression in a HCC-PDX mouse model. Both drugs were administered orally once daily at 10 mg/kg (regorafenib) or 30 mg/kg (sorafenib), which recapitulate the human exposure at the maximally tolerated dose in mice. In a H129 hepatoma model, survival times differed significantly between regorafenib versus vehicle (p=0.0269; median survival times 36 vs 27 days), but not between sorafenib versus vehicle (p=0.1961; 33 vs 28 days). Effects on tumor growth were assessed in 10 patient-derived HCC xenograft (HCC-PDX) models. Significant tumor growth inhibition was observed in 8/10 models with regorafenib and 7/10 with sorafenib; in four models, superior response was observed with regorafenib versus sorafenib which was deemed not to be due to lower sorafenib exposure. Bead-based multiplex western blot analysis was performed with total protein lysates from drug- and vehicle-treated HCC-PDX xenografts. Protein expression was substantially different in regorafenib- and sorafenib-treated samples compared with vehicle. The pattern of upregulated proteins was similar with both drugs and indicates an activated RAF/MEK/ERK pathway, but more proteins were downregulated with sorafenib versus regorafenib. Overall, both regorafenib and sorafenib were effective in mouse models of HCC, although several cases showed better regorafenib activity which may explain the observed efficacy of regorafenib in sorafenib-refractory patients.

Allosteric MEK1/2 inhibitor refametinib (BAY 86-9766) in combination with sorafenib exhibits antitumor activity in preclinical murine and rat models of hepatocellular carcinoma.

OBJECTIVE: The objectives of the study were to evaluate the allosteric mitogen-activated protein kinase kinase (MEK) inhibitor BAY 86-9766 in monotherapy and in combination with sorafenib in orthotopic and subcutaneous hepatocellular carcinoma (HCC) models with different underlying etiologies in two species. DESIGN: Antiproliferative potential of BAY 86-9766 and synergistic effects with sorafenib were studied in several HCC cell lines. Relevant pathway signaling was studied in MH3924a cells. For in vivo testing, the HCC cells were implanted subcutaneously or orthotopically. Survival and mode of action (MoA) were analyzed. RESULTS: BAY 86-9766 exhibited potent antiproliferative activity in HCC cell lines with half-maximal inhibitory concentration values ranging from 33 to 762 nM. BAY 86-9766 was strongly synergistic with sorafenib in suppressing tumor cell proliferation and inhibiting phosphorylation of the extracellular signal-regulated kinase (ERK). BAY 86-9766 prolonged survival in Hep3B xenografts, murine Hepa129 allografts, and MH3924A rat allografts. Additionally, tumor growth, ascites formation, and serum alpha-fetoprotein levels were reduced. Synergistic effects in combination with sorafenib were shown in Huh-7, Hep3B xenografts, and MH3924A allografts. On the signaling pathway level, the combination of BAY 86-9766 and sorafenib led to inhibition of the upregulatory feedback loop toward MEK phosphorylation observed after BAY 86-9766 monotreatment. With regard to the underlying MoA, inhibition of ERK phosphorylation, tumor cell proliferation, and microvessel density was observed in vivo. CONCLUSION: BAY 86-9766 shows potent single-agent antitumor activity and acts synergistically in combination with sorafenib in preclinical HCC models. These results support the ongoing clinical development of BAY 86-9766 and sorafenib in advanced HCC.

SC68896, a novel small molecule proteasome inhibitor, exerts antiglioma activity in vitro and in vivo.

PURPOSE: Glioblastomas are among the most lethal neoplasms, with a median survival of <1 year. Modulation of the proteasome function has emerged as a novel approach to cancer pharmacotherapy. Here, we characterized the antitumor properties of SC68896, a novel small molecule proteasome inhibitor. EXPERIMENTAL DESIGN: Different tumor cell lines were tested by crystal violet staining for sensitivity to SC68896, given alone or in combination with death ligands. The molecular mechanisms mediating SC68896-induced cell death and changes in cell cycle progression were assessed by immunoblot and flow cytometry. An orthotopic human glioma xenograft model in nude mice was used to examine the in vivo activity of SC68896. RESULTS: SC68896 inhibits the proliferation of cell lines of different types of cancer, including malignant glioma. Exposure of LNT-229 glioma cells to SC68896 results in a concentration- and time-dependent inhibition of the proteasome, with a consequent accumulation of p21 and p27 proteins, cell cycle arrest, caspase cleavage, and induction of apoptosis. Using RNA interference, we show that the effect of SC68896 on glioma cells is facilitated by wild-type p53. SC68896 sensitizes glioma cells to tumor necrosis factor-related apoptosis-inducing ligand and CD95 ligand and up-regulates the cell surface expression of the tumor necrosis factor-related apoptosis-inducing ligand receptor cell death receptors 4 and 5, which may contribute to this sensitization. Intracerebral glioma-bearing nude mice treated either i.p. or intratumorally with SC68896 experience prolonged survival. CONCLUSIONS: SC68896 is the first proteasome inhibitor that exerts antiglioma activity in vivo. It may represent a novel prototype agent for the treatment of malignant gliomas and warrants clinical evaluation.

Effect of physicochemical modification on the biodistribution and tumor accumulation of HPMA copolymers.

Copolymers of N-(2-hydroxypropyl)methacrylamide (HPMA) are prototypic and well-characterized polymeric drug carriers that are being broadly implemented in the delivery of anticancer therapeutics. To better predict the in vivo potential of the copolymers and to describe the biodistributional consequences of functionalization, 13 physicochemically different HPMA copolymers were synthesized, varying in molecular weight and in the nature and amount of functional groups introduced. Upon radiolabeling, the copolymers were injected i.v., and their circulation kinetics, tissue distribution and tumor accumulation were monitored in rats bearing subcutaneous Dunning AT1 tumors. It was found that increasing the average molecular weight of HPMA copolymers resulted in prolonged circulation times and in increased tumor concentrations. Conjugation of carboxyl and hydrazide groups, as well as introduction of spacer, drug and peptide moieties reduced the long-circulating properties of the copolymers and as a result, lower levels were found in tumors and in all organs other than kidney. Interestingly, however, in spite of the reduced (absolute) tumor concentrations, hardly any reduction in the relative levels localizing to tumors was found. Tumor-to-organ ratios were comparable to unmodified control for the majority of chemically modified copolymers, indicating that functionalization does not necessarily affect the tumor targeting ability of the copolymers and suggesting that HPMA copolymer-based drug delivery systems may prove to be attractive tools for more effectively treating various forms of advanced solid malignancy.

Increased MIBG uptake after transfer of the human norepinephrine transporter gene in rat hepatoma.

UNLABELLED: The transport of MIBG by the human norepinephrine transporter (hNET) seems to be the critical step in the treatment of MIBG-concentrating tumors. Therefore, we investigated whether the accumulation of MIBG may be induced by retroviral transfection of the hNET gene in Morris hepatoma cells. METHODS: A bicistronic retroviral vector for the transfer of the hNET coding sequence and the hygromycin resistance gene was generated. Morris hepatoma cells (MH3924A) were infected with the respective retroviral particles, and hNET-expressing cell lines MHhNEThyg1 to MHhNEThyg9 were obtained through hygromycin selection. The uptake of (3)H-norepinephrine or (131)I-MIBG and the efflux of (131)I-MIBG were determined in transfected and wild-type cells. In addition, the (131)I-MIBG distribution was monitored in nude mice and rats bearing wild-type and hNET-expressing hepatomas. RESULTS: hNET-expressing hepatoma cell lines accumulated up to 36 times more norepinephrine than did wild-type cells and 8 times more than did hNET-expressing neuroblastoma cell line SK-N-SH. The addition of nisoxetine, a selective inhibitor of noradrenaline uptake, inhibited norepinephrine uptake. Maximal (131)I-MIBG accumulation was observed 2 h after incubation and was followed by 43% efflux within 4 h after the (131)I-MIBG-containing medium had been removed. In vivo experiments performed with nude mice bearing both hNET-expressing and wild-type tumors showed a 10-fold-higher accumulation of (131)I-MIBG in transfected tumors than in wild-type tumors. The ex vivo calculations revealed doses of 605 and 75 mGy in hNET-expressing and wild-type tumor tissues, respectively. CONCLUSION: Transduction of the hNET gene enables Morris hepatoma cells to accumulate norepinephrine and MIBG. However, the retention of MIBG is brief; therefore, the absorbed dose of radiation in vivo is not expected to be therapeutically effective.

Detection and cellular localisation of the synthetic soluble macromolecular drug carrier pHPMA.

Synthetic macromolecules such as copolymers of N-(2-hydroxypropyl)methacrylamide (pHPMA) are potential carriers for the delivery of drugs owing to their ability to passively accumulate in solid tumours [enhanced permeation and retention (EPR) effect]. To gain further knowledge about the biodistribution and the cellular localisation, poly(HPMA) was prepared for labelling by introducing biotin molecules. Biotinylated pHPMA (5 mol%) was intravenously injected into tumour-bearing rats and the accumulation of biotin-pHPMA was visualised using a streptavidin-alkaline phosphatase technique at day 7 post injection. In spite of the high solubility of pHPMA copolymers and the lack of attachment to cell structures, the biotinylated polymer could be easily detected in tissues fixed in 10% paraformaldehyde-phosphate buffer at 4 degrees C for 48 h. While biotin-pHPMA could be detected intracytoplasmically in liver and spleen, a predominantly interstitial localisation was observed within the anaplastic prostate carcinoma (Dunning R3327-AT1). How biotin as a label influences the biodistribution of poly(HPMA) was assessed by scintigraphy, autoradiography and histology comparing homopolymer poly(HPMA) with biotin-pHPMA. The organ distribution patterns of the two polymers correlated well, except with respect to kidney. It is assumed that the accumulation of biotin-pHPMA in the distal tubuli is due to a biotin transporter in the brush border membrane. The technique presented is useful for a more comprehensive understanding of the biodistribution of soluble macromolecules.