Obstructive sleep apnea in Prader-Willi syndrome: risks and advantages of adenotonsillectomy.

Obstructive sleep apnea is a well-known clinical manifestation of Prader-Willi syndrome. The aim of our study is to evaluate the efficacy of adenotonsillectomy for the treatment of the disorder as well as the improvement of their post-operative quality of life. Five patients with moderate to severe obstructive sleep apneas and adenotonsillar hypertrophy of grade III-IV underwent adenotonsillectomy. Pre- and postoperative apneas and Quality of Life were assessed respectively with a polysomnography with multi-sleep latency test and with the pediatric Quality of Life questionnaire, performed before and 6 months after surgery. A decrease of apnea/hypopnea index values has been detected between pre- and post-surgery (t=2.64, P=0.005), as well as oxygen desaturation index values (t=5.51, P=0.005), multi-sleep latency test (t=4.54, P=0.01), and of the values of pediatric Quality of Life questionnaire. No correlation has been detected between body mass index and apnea/hypopnea index, oxygen desaturation index and multi-sleep latency test values pre- and post-adenotonsillectomy. A correlation has been found between multi-sleep latency test and oxygen desaturation index values post-surgery (P=0.04). No post-operative complications were observed. Our data underline the efficacy of surgery in Prader-Willi patients with adenotonsillar hypertrophy in order to improve their quality of life.

Back-and-forth endoscopic septoplasty: analysis of the technique and outcomes.

BACKGROUND: To describe our clinical experience in 218 consecutive patients undergoing endoscopic back-and-forth septoplasty (EBFS), examining surgical indications, technique, and follow-up. METHODS: From January 2005 to November 2008, 218 patients underwent EBFS at the Department of Otorhinolaryngology, San Raffaele Hospital, Milan, Italy. The indication for EBFS in this series was nasal airway obstruction (NAO). Patients were studied with nasal rigid endoscopy and in some cases computed tomography (CT) was used to exclude rhinosinusitis. The most common concomitant diagnoses included allergic rhinitis and turbinate hypertrophy. EBFS facilitates the interruption of perichondrial and periosteal bridges, which are more represented in the anterior portion of the septum between the caudal quadrangular cartilage and the vomeropremaxillary crest. Septal splints were positioned. No nasal packing was required. RESULTS: No cases required conversion to a traditional headlight approach, and no intraoperative complications were encountered. Intraoperative mucosal microlacerations occurred in 77.98% of cases; suturing was required in only 8.25% of cases. Of 218 patients, 74.77% experienced resolution of NAO, while 16.06% experienced only improvement; 9.17% noted the persistence of symptoms. Complications included transient dental pain/hypesthesia (6.88%), septal hematoma (5.04%), synechiae formation (2.29%), epistaxis (1.83%), septal perforation (1.83%), cheek swelling (0.45%), and septal abscess (0.45%). CONCLUSION: EBFS as a variation of endoscopic septoplasty (ES) represents a viable procedure with good outcomes and a low rate of complications. The technique allows lysis of tissue fibers while preserving the integrity of mucosa at the critical area using less force and reduces the probability of mucosal tears, based on embryologic knowledge of anatomical dissection.

Satisfaction and quality of life in laryngectomees after voice prosthesis rehabilitation.

OBJECTIVE/HYPOTHESIS: The purpose of the study was to assess the satisfaction and quality of life in laryngectomees after vocal rehabilitation using voice prostheses. We evaluated the impact on quality of life between laryngectomees with voice prostheses, laryngectomees without them and healthy controls. METHODS: This was a prospective study on a sample of laryngectomees in an Italian university hospital. Our study population was composed of 42 patients who had previously undergone a total laryngectomy; in 24 of them, voice rehabilitation was obtained with a voice prosthesis device (group A), while 18 of them learned oesophageal voice (group B). The results were compared with a group of 25 healthy controls (group C). In order to investigate the quality of life, we administered the Short Form 36-Item Health Survey (SF-36) to the 3 groups. Moreover, self-satisfaction of the subjects in group A was assessed by single questions regarding their use of the voice prosthesis. RESULTS: A statistical difference in the SF-36 was detected for social functioning (SF) between groups A and B. Role physical, SF and role emotional were significantly better in group C than in group A. Group A stated they were very satisfied with voice quality while there were still some problems regarding prosthesis lifetime and communication at the telephone or in noisy environments. CONCLUSIONS: Voice prosthesis implantation in laryngectomees showed positive effects on patients' quality of life; however, there are still some negative aspects. At present, an early diagnosis of larynx cancer with a partial laryngectomy in order to preserve phonatory function is the gold standard.

Treatment of soft tissue sarcoma: a European approach.

This article discusses the treatment of adult soft tissue sarcoma (excluding gastrointestinal stromal tumor), analyzing the principles underlying treatment and the results of surgery, radiotherapy, and chemotherapy. The focus is on the European approach in particular, and ongoing studies are summarized.

Synergistic antitumor activity of cisplatin, paclitaxel, and gemcitabine with tumor vasculature-targeted tumor necrosis factor-alpha.

PURPOSE: Subnanogram doses of NGR-tumor necrosis factor (TNF), a TNF-alpha derivative able to target tumor neovessels, can enhance the antitumor activity of doxorubicin and melphalan in murine models. We have examined the antitumor activity of NGR-TNF in combination with various chemotherapeutic drugs acting via different mechanisms, including, besides doxorubicin and melphalan, cisplatin, paclitaxel, and gemcitabine. EXPERIMENTAL DESIGN: Chemotherapeutic drugs were tested alone and in combination with NGR-TNF (0.1 ng) in murine lymphoma, fibrosarcoma, and mammary adenocarcinoma models. Different administration schedules have been tested and the effects on tumor growth, animal weight, tumor perfusion, and cell cytotoxicity have been investigated. RESULTS: Pretreatment with NGR-TNF enhanced the response to all these drugs although to a different extent. The increased efficacy was not accompanied by increased toxicity at least as judged from the loss of animal weight. The synergistic effect was transient, maximal synergism being observed with a 2-hour delay between NGR-TNF and drug administrations in all models and with all drugs tested. NGR-TNF did not increase the in vitro cytotoxicity of chemotherapeutic drugs against tumor cells, suggesting that the in vivo synergism depends on NGR-TNF effects on host cells rather than on tumor cells. CONCLUSIONS: Targeted delivery of low doses of NGR-TNF to the tumor vasculature can increase the efficacy of various drugs acting via different mechanisms. Optimal administration schedule requires 2 hours of pretreatment with NGR-TNF independently from the mechanism of drug cytotoxicity. This work could provide important information for designing clinical studies with NGR-TNF in combination with chemotherapeutic drugs.

Suicide gene therapy of graft-versus-host disease induced by central memory human T lymphocytes.

In allogeneic hematopoietic cell transplantation (allo-HCT), the immune recognition of host antigens by donor T lymphocytes leads to a beneficial graft-versus-leukemia (GvL) effect as well as to life-threatening graft-versus-host disease (GvHD). Genetic modification of T lymphocytes with a retroviral vector (RV) expressing the herpes simplex virus-thymidine kinase (TK) suicide gene confers selective sensitivity to the prodrug ganciclovir (GCV). In patients, the infusion of TK+ lymphocytes and the subsequent administration of GCV resulted in a time-wise modulation of antihost reactivity for a GvL effect, while controlling GvHD. Because activation required for genetic modification with RV may reduce antihost reactivity, we investigated the requirements for maximizing the potency of human TK+ lymphocytes. Whereas T-cell receptor triggering alone led to effector memory (EM) TK+ lymphocytes, the addition of CD28 costimulation through cell-sized beads resulted in the generation of central memory (CM) TK+ lymphocytes. In a quantitative model for GvHD using nonobese diabetic/severely combined immunodeficient mice, CM TK+ lymphocytes were more potent than EM TK+ lymphocytes. GCV administration efficiently controlled GvHD induced by CM TK+ lymphocytes. These results warrant the clinical investigation of CM suicide gene-modified human T lymphocytes for safe and effective allo-HCT.

Immunogenic and structural properties of the Asn-Gly-Arg (NGR) tumor neovasculature-homing motif.

Tumor homing peptides containing the NGR motif, such as CNGRC and GNGRG, have been used for delivering cytokines, chemotherapeutic drugs, apoptotic peptides, and liposomes to a CD13 isoform expressed in tumor blood vessels. In view of the potential clinical applications of these drugs and considering the risk that NGR peptides could elicit blocking antibodies we have investigated the immunogenic properties of CNGRC and GNGRG in mice and rabbits, using various products containing these residues and different administration schedules. The results suggest that the immunogenicity of the NGR motif is very low, even when it is conjugated to tumor necrosis factor-alpha or to highly immunogenic carrier proteins. Molecular dynamics simulation experiments showed that both peptides have a strong propensity to populate a turn conformation. Superposition of predicted structures to the CTGNGRGEWKC loop of the 5th type I repeat of human fibronectin, a protein that contains four NGR motives, showed that the root mean square deviation of backbones was 0.7A for GNGRG and 0.5A for NGR. These results suggest that NGR peptides could mimic from an immunological point of view a "self" structure, likely the GNGRG loop of fibronectin, with important implications for the use of these targeting peptides in patients.

HIC1 promoter methylation and 17p13.3 allelic loss in invasive ductal carcinoma of the breast.

The HIC1 gene is a transcriptional regulator commonly methylated in a variety of human cancer. Thirty-three invasive ductal carcinomas of the breast and 21 matched normal breast tissues were analysed for HIC1 promoter methylation, and allelic loss of a 700 kb region spanning the gene locus. At least one genetic or epigenetic abnormality was found in 27 of the carcinomas tested (82%). Promoter methylation was demonstrated in 21 carcinomas (64%), and nine normal tissues (43%), whereas 18 malignant tumors (54%) showed allelic loss. Concomitant loss of heterozigosity and promoter hypermethylation in the region spanning HIC1 was detected in eight carcinomas (24%) suggesting that in this subset of tumors both copies of the gene are functionally lost. These observations support a role for the HIC1 gene in the pathogenesis of breast ductal carcinomas.

Retinoids and human breast cancer: in vivo effects of an antagonist for RAR-alpha.

The aim of the present study was to evaluate the in vivo effects of the RAR-alpha selective antagonist Ro 41-5253 on a xenograft animal model for breast cancer. Our observations indicate a lack of toxic side effects of the drug, even when used at high dosages. It is interesting to note that using Ro 41-5253 at dosages of 10, 30 and 100 mg/kg/die resulted in a slight, but significant inhibition of cell growth. The data obtained in this study represents the basis for a further evaluation of Ro 41-5253 anti-neoplastic activity on transgenic breast cancer animal models.

Treatment with all-trans retinoic acid plus tamoxifen and vitamin E in advanced hepatocellular carcinoma.

BACKGROUND: Low serum retinol and hepatic tocopherol levels correlate with hepatocellular carcinoma (HCC) risk. Antiestrogen tamoxifen seems useful in HCC patients. A pilot study was performed to evaluate the effect of all-trans retinoic acid associated with tamoxifen and vitamin E on patients with advanced HCC. PATIENTS AND METHODS: Fifteen consecutive patients with advanced HCC were included in the study. Patients were evaluated for survival, quality of life, liver function, tumor mass, toxicity related to the treatment and retinoid receptors in liver biopsies. RESULTS: The median survival of our patients was 22 months. Pain and asthenia were improved in the majority of patients. Every patient with baseline elevated liver enzymes showed an improvement in liver function. RAR-alpha, RXR-alpha, RAR-beta and RAR-gamma receptors were demonstrated in 100%, 73%, 47% and 40%, respectively. CONCLUSION: A combination therapy of all-trans retinoic acid, tamoxifen and vitamin E increases the survival rate and ameliorates the clinical outcome in patients with inoperable HCC.

13-cis retinoic acid in head and neck cancer chemoprevention: results of a randomized trial from the Italian Head and Neck Chemoprevention Study Group.

Patients with squamous cell carcinoma of the head and neck (HNSCC) after being treated radically remain at high risk for both recurrent and second primary tumours. 13-cis retinoic acid (13-cRA) was demonstrated to reverse pre-malignant lesions of the oral cavity and to reduce the incidence of second primary tumours in patients treated radically for HNSCC. Synergism between retinoids and interferon in tumoural cell lines have been demonstrated. Based on these data, the Italian Head and Neck Chemoprevention Study Group started a randomized chemoprevention study in patients radically treated for stage III and IV HNSCC. From February 1992 to January 1996, 267 patients were randomized: 126 were allocated to the control group, 126 were randomized to receive 13-cRA at a dose of 0.5 mg/kg per day per os and 15 patients have been assigned to the group of 13-cRA plus interferon alpha2a (IFN-alpha2a) at a dose of 3,000,000 UI 3 times a week (randomization in this arm interrupted due to administrative financial problems). The mean follow-up was 39 months. The 5-year actuarial survival was 58.9% for patients of the 13-cRA group and 57.2% for those of the control group (P=0.94). Among evaluable patients, disease progression was observed in 45 of 123 patients (36.6%) of the 13-cRA group and in 42 of 124 (33.9%) of the control group. The 5-year actuarial relapse-free survival was 48.9% for the 13-cRA group and 55.6% for the control group (P=0.62). Adverse effects, mostly of grade I were reported in 69.4% of treated patients (haematologic disorders, mucositis, conjunctivitis, cutaneous toxicity, hypertriglyceridemia and hypercholesterolemia). Only 5 patients (4.1%) reported grade III-IV toxicity. Low-dose of 13-cRA given for 1 year is ineffective as chemoprevention in patients with radically treated HNSCC.

Histone deacetylase inhibitors enhance retinoid response in human breast cancer cell lines.

Solid tumors develop resistance to retinoids during carcinogenesis. One of the strategies to overcome this resistance may include the combination of these molecules with other differentiating, cytotoxic or chromatin-remodelling agents. We analysed the anti-proliferative activity of two histone-deacetylase inhibitors (HDACIs), Trichostatin A (TSA) and sodium phenylbutyrate (PB), alone or combined with retinoids, all-trans retinoic acid (ATRA) and Ro 41-5253, on two human breast cancer cell lines: the hormone-dependent MCF-7 and the hormone-independent MDA-MB-231. These lines responded differently to retinoids: MCF-7 were sensitive, whilst MDA-MB-231 were rather resistant. When the retinoids were combined with HDACIs, these molecules potentiated the retinoid activity on growth inhibition, especially for the association Ro 41-5253 and TSA. By FACS analysis, we observed that the anti-proliferative effects were only partially due to pro-apopotic mechanisms, suggesting a cell-cycle block. The efficacy of the retinoids/HDACIs combinations could represent a new strategy in breast cancer chemotherapy, allowing inhibition of both ER + and ER- cell populations.

beta-carotene supplementation in patients radically treated for stage I-II head and neck cancer: results of a randomized trial.

This study was aimed at evaluating the efficacy of beta-carotene in improving survival (S) and in disease-free survival (DFS) and reducing the incidence of second primary tumors (SPT) in patients with a radically treated stage I-II squamous head and neck tumors. Eligible patients were randomly allocated to receive beta-carotene (n=104) or no treatment (n=110). beta-carotene was administered at the dose of 75 mg/day for 3-month cycles within one month intercycle intervals for a 3-year period. The 3-year compliance to the beta-carotene was 68.7%. Only eight patients reported drug-related toxicity (7.8%). The median follow-up of all patients was 59 months. The median follow-up was 61 months (range 1-116 months) in the beta-carotene and 58 months (1-123 months) in the control group. The 10-year DFS was 75.7% for the patients in the beta-carotene and 74.3% for those in the control group (P=0.56). The 10-year S was 85.9% in the beta-carotene group and 80.9% in the control group (P=0.20). beta-carotene supplementation had no significant effect on the incidence of second primary tumors (RR=0.99; 95% C.I. 0.28-3.44). A statistically non-significant 40% reduction in the risk of death among subjects assigned to the beta-carotene compared to the controls was observed (RR=0.60; 95% C.I. 0.26-1.38). No increase in the death from cardiovascular diseases was observed among patients treated with beta-carotene. Our results might support the hypothesis that an adequate beta-carotene treatment could be potentially associated with a decreased risk of death in these patients.

Tissue expression and translational control of rat kynurenine aminotransferase/glutamine transaminase K mRNAs.

Kynurenic acid (KA) is an endogenous glutamate receptor antagonist at the level of the different ionotropic glutamate receptors. One of the enzymes responsible for the production of KA, kynurenine aminotransferase I (KATI), also catalyses the reversible transamination of glutamine to oxoglutaramic acid (GTK, EC 2.6.1.15). The enzyme exists in a cytosolic and in a mitochondrial form because of the presence of two different KATI mRNAs coding for a protein respectively with and without leader sequence targeting the protein into mitochondria. We have cloned from a phage library of rat kidney cDNA four new KATI cDNAs containing different 5' untranslated regions (UTRs). One of the transcripts (+14KATI cDNA) contains an alternative site of initiation of translation. The tissue distribution of the different transcripts was studied by RT-PCR. The study demonstrated that several KATI mRNAs are constitutively expressed in ubiquitous manner, while +14KATI mRNA is present only in kidney. The translational efficiency of the different transcripts was studied in vitro and enzymatic activities were measured in transiently transfected Cos-1 cells. Each KATI mRNA exhibits a different in vitro translational efficiency, which corresponds to different levels of KAT enzymatic activity in transfected cells. Both findings correlate with the predicted accessibility of the ribosomal binding sites of the different mRNAs. The structure of the rat KATI/GTK gene was also studied. The expression of several KATI mRNAs with different 5'UTRs represents an interesting example of transcriptional/translational control on the expression of pyridoxal phosphate (PLP)-dependent aminotransferases.

Retinoids and malignant melanoma: a pathway of proliferation inhibition on SK MEL28 cell line.

BACKGROUND: It has been observed, in preclinical and clinical studies, that retinoids may interfere with the carcinogenic process in different ways such as the control of proliferation, differentiation and apoptosis. MATERIALS AND METHODS: We evaluated the in vitro efficacy of some synthetic retinoids (RAR-alpha, beta and gamma; RXR-alpha agonists and RAR-alpha antagonist) and compared these to the panagonist all-trans retinoic acid in inhibiting growth of the human melanoma cell line, SK MEL 28. We estimated, in parallel, apoptosis as a function of the treatment and, by RT-PCR, we analysed the effects of retinoids on the transcriptional profile of relevant genes, such as retinoid receptors and regulatory proteins. RESULTS: We observed a marked antiproliferative rate with the RAR-gamma selective agonist RO 44-4753 and the RAR-alpha selective antagonist RO 41-5253; on the contrary, the other synthetic retinoids exhibited a rather low efficacy. All the tested retinoids appeared to activate the RAR-beta gene and major expression was evidenced following RO 44-4753 and RO 41-5253 treatment. CONCLUSION: Among the tested retinoids, RO 41-5253 exhibited marked effects on proliferation and RARs mRNA expression and its action appeared mainly related to a cell-cycle arrest rather than an apoptotic mechanism.

Concomitant chemo-radiotherapy in the treatment of locally advanced and/or metastatic soft tissue sarcomas: experience of the National Cancer Institute of Genoa.

Previous in vitro and in vivo studies showed a synergistic effect of concomitant doxorubicin and radiotherapy in a variety of solid tumors. From 1988 to 2000, we have investigated in a pilot study and then in a phase II study the efficacy of a concomitant doxorubicin radiotherapy treatment in patients with advanced and/or metastatic soft tissue sarcomas (STS). We enrolled and treated a group of 115 patients with advanced STS, with metastases (61%), frequently pretreated (59%), predominantly G2/G3 (84%). Doxorubicin was administered by continuous infusion at a dose of 12 mg/m(2)/day over 5 consecutive days concomitantly with radiotherapy; treatment was given on ambulatory basis at 2-week intervals with support of granulocytes colony stimulating factors (GCSF). In the whole group of 115 patients a clinical objective response (ORs) rate of 67% was obtained, with 11% complete and 56% partial responses. No patient progressed while on therapy, except one who progressed in non-irradiated metastatic tumor. Treatment (median 3 cycles) was well tolerated with no WHO grade 3 toxicity (apart from alopecia) and no acute or chronic cardiotoxicity. Thirty-nine responder patients underwent surgery (24 primary tumors, 10 relapses, 5 relapses plus isolated lung metastases). The median survival time(s) was 29 months in the whole series and over 50 months in responder patients. A multivariate analysis showed a positive association between survival and sex (HR=1.8; CI 95%, 1.0-3.4), performance status (HR=2.1; CI 95%, 1.1-4.0), ORs (HR=7.9; CI 95%, 3.5-18.1) and surgery (HR=8.8; CI 95%, 2.1-35.9). Low toxicity, high OR rate and positive survival time trend make the concomitant chemo-radiotherapy an efficacious approach for advanced STS.

Synergistic effect of the anti-HER-2/neu antibody and cisplatin in immortalized and primary mesothelioma cell lines.

Malignant mesothelioma (MM) still remains a therapeutic and diagnostic problem to which new therapeutic perspectives are being continuously tried and tested. Three different primary cultures (MMGe-1, MES MM 98, and MES 1) and one immortalized cell line (MSTO 211 H) of human MM were studied in order to evaluate the HER-2/neu expression. Three out of four cell lines showed a different level of c-erbB-2 expression, the highest being detected on the MSTO 211 H cell line (fibroblastic phenotype), whereas MMGe-1 resulted negative. The effect of the anti-HER-2/neu antibody (Trastuzumab) alone, and in combination with cisplatin (CDDP) at different doses (ranging from 0.1 to 100 microg/ml), was studied on all the c-erB-2 positive cell lines. Trastuzumab was able to inhibit cell proliferation in a time-dependent manner, with growth inhibition also obtained at low concentrations (0.1-1 microg/ml). Combined treatment with Trastuzumab (10 microg/ml) and CDDP (1 microg/ml) showed synergism. Our results were encouraging, and suggest a rationale for further investigations in a clinical setting.

Endogenous reactivation of the RARbeta2 tumor suppressor gene epigenetically silenced in breast cancer.

Loss of expression of retinoic acid receptor beta2 (RARbeta2), a potent tumor suppressor gene, is commonly observed during breast carcinogenesis. RARbeta2 silencing can be traced to epigenetic chromatin changes affecting the RARbeta P2 promoter. Here we show that retinoic acid therapy fails to induce RARbeta2 in primary breast tumors, which carry a methylated RARbeta P2 promoter. DNA methylation leads to repressive chromatin deacetylation at RARbeta P2. By inducing an appropriate level of histone reacetylation at RARbeta P2 we could reactivate endogenous RARbeta2 transcription from unmethylated as well as methylated RARbeta P2 in breast cancer cell lines and xenograft tumors, and obtain significant growth inhibition both in vitro and in vivo. This study may have translational implications for breast cancer and other cancers carrying an epigenetically silenced RARbeta P2 promoter.