Combined treatment with pemetrexed and vinflunine in patients with metastatic urothelial cell carcinoma after prior platinum-containing chemotherapy - results of an exploratory phase I study.

Vinflunine is to date the only registered agent for second-line treatment of metastatic urothelial cell carcinoma (UCC) in Europe. However, the effect is modest. Pemetrexed has demonstrated some single-agent activity in this disease entity. In order to improve treatment possibilities for UCC patients, a phase I trial (VINTREX) was undertaken to assess the safety of vinflunine and pemetrexed in metastatic UCC patients. A dose escalation design was planned to determine the dose-limiting toxicity (DLT) and maximum tolerated dose (MTD) of a vinflunine/pemetrexed combination. Pemetrexed was added to vinflunine dosed at 280 mg/m2 on day 1 of a 21-day cycle. Three levels of pemetrexed were planned starting at 400 mg/m2. Four patients were enrolled with a mean age of 66 years and with a mean number of prior GC-cycles of 6,8. Two DLT's were observed at the lowest dose-level in cohort 1. One patient experienced grade 4 thrombocytopenia and a second demonstrated hepatobiliary toxicity grade 3 with an increase in alanine aminotransaminase. Most common grade 3 and 4 adverse events were anemia, thrombocytopenia and neutropenia. Three out of four patients received 3 cycles of pemetrexed and vinflunine, all had progressive disease. Based on these observations and due to protocol design, the study was interrupted at dose level 1 for safety reasons. The combined therapy of vinflunine (Javlor®, Pierre Fabre Pharma) and pemetrexed (Alimta®, Eli Lilly) is poorly tolerated in metastatic UCC patients. The combination cannot be recommended for further investigations in metastatic UCC.

Renal impairment and late toxicity in germ-cell cancer survivors.

BACKGROUND: Treatment with bleomycin-etoposide-cisplatin (BEP) impairs renal function and increases the risk of late cardiovascular disease (CVD) and death. We investigated the influence of BEP on glomerular filtration rate (GFR) and assessed the importance of GFR changes on CVD and death in a large cohort of germ-cell cancer survivors. PATIENTS AND METHODS: BEP-treated patients (N = 1206) were identified in the Danish DaTeCa database, and merged with national registers to identify late toxicity. GFR were measured (51Cr-EDTA clearance) before and after treatment and at 1, 3 and 5-year follow-up. The influence of BEP on GFR was evaluated with a linear mixed model. Risk factors for late toxicity were identified by a landmark analysis adjusting for covariates. The cohort was compared with the background population with standardized hospitalization/mortality rates. RESULTS: GFR changed (ΔGFR) -11.3%, -15.4% and -25.9% after three, four and five+ cycles of BEP. For patients with impaired renal function before treatment the changes were 4.3%, 0.0% and -12.8%, respectively. During follow-up a significant rebound of GFR was documented. Compared with the background population, all patients, irrespective of renal function, had an increased risk of CVD and death. This risk depended on chronic kidney disease stage before treatment but not after treatment. ΔGFR had no influence on risk of late toxicity [death: hazard ratio (HR) 1.06, P = 0.50; CVD: HR 0.97, P = 0.61]. CONCLUSIONS: Renal function after BEP is closely related to number of cycles, but the changes in GFR are partly reversible and have no impact on risk of CVD or death.

Screening for carcinoma in situ in the contralateral testicle in patients with testicular cancer: a population-based study.

BACKGROUND: Screening programmes for contralateral carcinoma in situ (CIS) testis in patients with unilateral germ-cell cancer (GCC) have never been evaluated. We investigated the effect of screening for contralateral CIS in a large nation-wide, population-based study. PATIENTS AND METHODS: A contralateral single-site biopsy was offered to 4130 patients in whom GCC had been diagnosed in 1984-2007 (screened cohort); 462 patients in whom GCC was diagnosed in 1984-1988 comprised the unscreened cohort. Cases with CIS were offered radiotherapy. Initially CIS-negative biopsies in patients with metachronous GCC were revised according to today's standards. Risk for metachronous GCC was estimated using cumulative incidence and the Cox proportional hazards model. RESULTS: In the screened cohort, contralateral CIS was found in 181 (4.4%) patients. The cumulative incidence of metachronous GCC after 20 years was 1.9% in the screened cohort and 3.1% in the unscreened cohort (P = 0.097), hazard ratio (HR) for the unscreened cohort: 1.59 (P = 0.144). Expert revision with contemporary methodology of CIS-negative biopsy samples from patients with metachronous cancer revealed CIS in 17 out of 45 (38%) cases. Decreased risks for metachronous GCC were related to older age at diagnosis (HR 0.52 per 10 years, P < 0.001) and chemotherapy (HR 0.35, P = 0.002). Limitations include the small number of patients in the unscreened cohort and the retrospective study design. CONCLUSIONS: Our evaluation of a national population-based screening programme for contralateral CIS in patients with testicular cancer showed no significant difference in the risk for metachronous GCC between a screened and an unscreened cohort. Single-site biopsy including modern immunohistochemistry does not identify all cases of CIS.

Low ANXA10 expression is associated with disease aggressiveness in bladder cancer.

BACKGROUND: Markers for outcome prediction in bladder cancer are urgently needed. We have previously identified a molecular signature for predicting progression in non-muscle-invasive bladder cancer. ANXA10 was one of the markers included in the signature and we now validated the prognostic relevance of ANXA10 at the protein level. METHODS: We investigated ANXA10 expression by immunohistochemistry using a tissue microarray with 249 Ta and T1 urothelial carcinomas. The expression of ANXA10 was also investigated in an additional set of 97 more advanced tumours. The functional role of ANXA10 in cell lines was investigated by siRNA-mediated ANXA10 knockdown using wound-healing assays, proliferation assays, and ingenuity pathway analysis. RESULTS: Low expression of ANXA10 correlated with shorter progression-free survival in patients with stage Ta and T1 tumours (P<0.00001). Furthermore, patients with more advanced tumours and low ANXA10 expression had an unfavourable prognosis (P<0.00001). We found that ANXA10 siRNA transfected cells grew significantly faster compared with control siRNA transfected cells. Furthermore, a wound-healing assay showed that ANXA10 siRNA transfected cells spread along wound edges faster than control transfected cells. CONCLUSION: We conclude that ANXA10 may be a clinical relevant marker for predicting outcome in both early and advanced stages of bladder cancer.

Retinoblastoma protein expression is an independent predictor of both radiation response and survival in muscle-invasive bladder cancer.

The objective of the study was to investigate the predictive value of various clinical, biochemical, and histopathological parameters, with special emphasis on the expression of the retinoblastoma protein (pRB), on the radiation response in bladder cancer. In order to obtain a truly objective response measure, patients receiving preoperative radiotherapy followed by cystectomy were studied. Pretreatment tumour samples and clinical data from 108 consecutive patients were collected. End points were complete response (CR) to radiotherapy, relapse-free survival time and overall survival time. Expression of pRB was assessed by immunohistochemical staining as present or absent. Complete response to radiotherapy was obtained in 42 of 106 evaluable patients (40%). Predictive for CR to radiotherapy, in univariate analysis, was transurethral resection (as opposed to biopsy), B-haemoglobin, no upper urinary retention, and loss of pRB staining. Loss of pRB staining was the strongest independent predictor of radiation response in multivariate logistic regression analysis and absence of upper urinary retention was the only other significant factor. Loss of pRB was the only parameter showing statistically significant, independent association with relapse-free survival, whereas B-haemoglobin was also independently associated with overall survival. Loss of pRB expression seems to indicate a phenotype displaying enhanced radiosensivity and may be of benefit by denoting patients who would selectively benefit from a treatment schedule containing radiotherapy.

Distribution of early atherosclerotic lesions in the human abdominal aorta correlates with wall shear stresses measured in vivo.

OBJECTIVES: to study the relationship between wall shear stresses measured in vivo and early atherosclerotic lesions in the abdominal aorta. MATERIALS: eight young volunteers for in vivo wall shear-stress measurements. Abdominal aortas from 10 young adults without signs or history of atherosclerotic disease were obtained by autopsy for histomorphometric measurements. METHODS: wall shear stresses were measured in the abdominal aorta above and below the renal arteries using a magnetic resonance technique with high resolution for imaging and blood velocity mapping. At identical abdominal aortic locations, intimal thickness was measured blindly using histomorphometric techniques and correlated to wall shear-stress variables using linear-regression analysis. RESULTS: intimal thickness showed a linear decrease with mean wall shear stress (r=-0.90, p<0.01) and with maximum wall shear stress (r=-0.86, p<0.01). CONCLUSIONS: intimal thickness in the normal abdominal aorta is associated with mean, maximum and oscillating wall shear stresses. These in vivo data corroborate previous in vitro studies suggesting that low and oscillating wall shear stresses are localising factors for intimal thickening and hence the early development of atherosclerosis.

A histomorphometric method for evaluating topographic differences in degree of early atherosclerosis within the human aorta.

The aim of the study was to develop an unbiased topographically oriented method of evaluating early atherosclerotic lesions in the aorta and to apply this to a series of human aortas from young adults. A systematic sampling procedure and histomorphometric analysis of intimal thickening is described. Results from a group of 15 young adults (aged 18-40 years) showed a characteristic pattern with increasing intimal thickening when moving distally from the thoracic to the upper and finally to the lower abdominal aorta, but also a shift in the localization of the most pronounced intimal thickening from the posterior to the anterior and back to the posterior aspect. This pattern was found in aortas both with minimal and with more pronounced atherosclerosis, and supports the view that the early intimal thickening precedes the atherosclerotic lesions and marks the sites of predilection for the more advanced disease processes. An increase in intimal thickness with age could be demonstrated in the aortas without overt atherosclerosis. The simple sampling procedure, well-defined sampling sites, and ability to demonstrate and quantitate differences in intimal thickening and plaque morphology make this method well suited for relating morphometric data to other parameters of interest when studying the etiology and dynamics of atherosclerotic disease.

Comparison of rhG--CSF primed bone marrow and blood stem cell autografts: an analysis of engraftment in malignant lymphomas and solid tumours.

Many studies have documented faster engraftment after transplantation with peripheral blood stem cells (PBSC) compared to bone marrow (BM) stem cells. Most comparisons, however, have been between unprimed BM and primed PBSC. We have collected engraftment data on 39 patients from 4 Danish centres and compared G-CSF primed BM with G-CSF primed PBSC in malignant lymphoma and solid tumours. In the lymphoma group 6 BM transplants were compared with 8 PBSC transplants, whereas in the testicular cancer group 16 BM transplants were compared with 9 PBSC transplants. In the lymphoma group, the time to platelet engraftment (platelets >20x10(9)/l unsupported) was median 15 d in PBSC transplants and median 34 d in BM transplants (p=0.003). In the solid tumour patients the difference in time to platelet engraftment was 11 and 18 d in PBSC and BM transplants, respectively (p<0.0001). In an attempt to explain this difference we performed CD34+ subset analysis of BM and PBSC. This analysis revealed a higher content of lineage restricted cells (CD34+CD61+ and CD34+GlyA+) in PBSC compared to BM. In conclusion, G-CSF mobilized PBSC seems to result in faster engraftment than G-CSF primed BM, which could be explained by an increased number of lineage specific progenitors in PBSC compared to BM.

Wall shear stress and early atherosclerotic lesions in the abdominal aorta in young adults.

OBJECTIVES: To study the correlation between wall shear stress and early atherosclerotic lesions in the abdominal aorta. DESIGN: Blinded histomorphometric studies. Comparison with in vitro data. MATERIALS: Abdominal aortic haemodynamics were simulated in a realistic pulsatile flow model. Abdominal aortas from 10 young adults with no signs of atherosclerotic disease were obtained during autopsy. METHODS: Quantitative wall shear stresses were measured at rest and exercise in one suprarenal and two infrarenal positions using laser Doppler anemometry. Intimal thickening indices were measured blindly at the corresponding locations using histomorphometric methods, and compared to wall shear stress variables using linear regression analysis. RESULTS: Intimal thickness index increased significantly with age. Intimal thickness index was significantly lower in the suprarenal than the infrarenal aorta, and higher at the distal posterior vessel wall compared to the anterior wall. Intimal thickness index correlated significantly with mean, minimum and oscillating wall shear stresses measured at rest. CONCLUSION: Intimal thickness in the undiseased abdominal aorta correlated significantly with mean, minimum and oscillating wall shear stresses at rest measured in a pulsatile flow model. No correlations were found with maximum shear stress parameters. Exercise changed the local wall shear stresses away from the characteristics associated with intimal thickness index.

Hypocholesterolaemic effect of a new fermented milk product in healthy middle-aged men.

OBJECTIVE: There are still controversies as to the potential beneficial effects of milk and fermented milk products on the level of lipoproteins. The objective of the present investigation was to test the effect of a moderate daily intake of a new fermented milk product, which was based on a bacterial culture obtained from the intestinal flora of inhabitants of Abkhasia, on the lipoprotein levels of a homogeneous group of middle-aged Danish men. DESIGN: The study was randomised, double-blind, and placebo-controlled, and the intervention was performed for a period of 6 weeks. SUBJECTS: Fifty-eight healthy, non-obese, normocholesterolaemic, male volunteers born in 1949 of Danish descent participated (i.e. all were 44 years old). INTERVENTIONS: During the intervention period the subjects' habitual diets were supplemented with 200 ml/day of either the new fermented milk product or a placebo product (chemically fermented). The biologically fermented milk product contained Enterococcus faecium and two strains of Streptococcus termophilus. Fasting blood samples were drawn initially and after 3 and 6 weeks and analysed for plasma values of total cholesterol, high-density lipoprotein (HDL)-cholesterol and triglyceride. In addition, LDL-cholesterol was estimated. RESULTS: After these 6 weeks total cholesterol was reduced significantly in the group given biologically fermented milk (-0.37 mmol/l, confidence interval: -0.51 to -0.23) while no changes were observed in the placebo group (-0.02 mmol/l) (P < 0.01). This reduction in total cholesterol could be completely ascribed to a fall in LDL-cholesterol by 10% (i.e. -0.42 mmol/l) since HDL-cholesterol and triglyceride were unchanged in both groups. CONCLUSIONS: Thus, this short-term study (6 weeks) demonstrated an LDL-cholesterol-lowering effect (10% reduction) of a new fermented milk product in middle-aged Danish men.

[Cholesterol-lowering effect of a new fermented milk product in healthy 44-year old Danish men]. / Kolesterolsaenkende effekt af et nyt surmaelksprodukt hos raske 44-årige danske maend.

The potential cholesterol-lowering effect of a new fermented milk product was tested in a homogeneous group of Danish men (all 44-year-old; n = 58) in a randomised, double blinded and placebo-controlled study. Two hundred ml of the fremented milk or placebo (chemically acidified) was taken daily for six weeks. After these six weeks total cholesterol decreased significantly in the fermented milk group by -0.37 mmol/l (confidence interval: -0.51 to -0.23 mmol/l) and no changes were observed in the placebo group (-0.02 mmol/l) (p < 0.01). This decrement in total cholesterol could be completely ascribed to a reduction of LDL-cholesterol by 10% (i.e. -0.42 mmol/l), since HDL-cholesterol and triglyceride were unchanged in both groups during the study. Thus, in the present short term study, the tested fermented milk product was able to reduce LDL-cholesterol in middle-aged men.

A reconstruction of the remodelling cycle in normal human cortical iliac bone.

This paper describes the reconstruction of the remodelling cycle in normal iliac crest cortical bone from static and dynamic variables after double labelling with tetracycline in 10 young normal individuals. The average duration of the resorptive period was 27 days during which the average rate of resorption was 4.7 microns/day. The final resorption depth was 76 microns. The diameter of osteoclast containing cutting cones was significantly smaller (P less than 0.05) than cutting cones containing mononuclear cells, indicating an initial osteoclastic resorption phase preceding a mononuclear resorption phase. The average mineralization lag-time was 8 days and the formative period 89 days. Osteoid thickness during this period averaged 5.8 microns. The seam thickness varied with the underlying uncompleted wall thickness, i.e., during the course of the formative period, with matrix deposition initially exceeding, later equalling and finally lower than the rate of mineralization. The mineral appositional rate (MAR) was 1.2 microns/day and the adjusted mineral appositional rate (Aj.AR) 0.9 micron/day. Both MAR and Aj.AR decreased during the formative period. A completed wall thickness of 62 microns left a Haversian canal with a diameter of 29 microns. After a quiescent period of 438 days the osteon (or parts of it) was reactivated. The average activation frequency was 0.93 per year.

Stereologic estimators of cortical bone remodeling including a kinetic model.

The purpose of this study was to describe cortical bone remodeling by means of a new stereologic model, which is based on isotropic uniform (IUR) histological sections and two fluorochrome tissue time markers (tetracycline and calcein) given with a 15-day interval. From each of five pigs two samples of cortical bone were sawed out from the middle part of the diaphysis of the left femoral bone and fixed in absolute methanol. Specimens were embedded undecalcified in methylmethacrylate, and the plane of sectioning was sampled by a new procedure, which produce IUR-sections. The extent of remodeling was estimated by length densities, that is, length of Haversian system undergoing resorption or formation per unit volume of bone. These estimates made it possible to express the activation rate and the remodeling rate at tissue level in absolute three-dimensional terms. Such estimates have not previously been published. The shortest diameter of osteon cross-sections was used for obtaining three-dimensional measures of osteons dimensions. The estimated true variance between animals as percentage of the observed variance was above 68% for all morphometric parameters except the length density of resorptive osteons (35%). It was concluded that the proposed stereologic methods enable a detailed description in three-dimensional terms of the remodeling process in cortical bone, and further information may be obtained by combining measurements with observations of cell morphology.