Prognostic significance of absolute lymphocyte count in patients with metastatic renal cell carcinoma receiving first-line combination immunotherapies: results from the International Metastatic Renal Cell Carcinoma Database Consortium.

BACKGROUND: Lymphocytes are closely linked to mechanisms of action of immuno-oncology (IO) agents. We aimed to assess the prognostic significance of absolute lymphocyte count (ALC) in patients with metastatic renal cell carcinoma (mRCC). PATIENTS AND METHODS: Using the International mRCC Database Consortium (IMDC), patients receiving first-line IO-based combination therapy were analysed. Baseline patient characteristics, objective response rates (ORRs), time to next treatment (TTNT), and overall survival (OS) were compared. RESULTS: Of 966 patients included, 195 (20%) had lymphopenia at baseline, and they had a lower ORR (37% versus 45%; P < 0.001), shorter TTNT (10.1 months versus 24.3 months; P < 0.001), and shorter OS (30.4 months versus 48.2 months; P < 0.001). Among 125 patients with lymphopenia at baseline, 52 (42%) experienced ALC recovery at 3 months, and they had longer OS (not reached versus 30.4 months; P = 0.012). On multivariable analysis for OS, lymphopenia was an independent adverse prognostic factor (hazard ratio 1.68; P < 0.001). Incorporation of lymphopenia into the IMDC criteria improved OS prediction accuracy (C-index from 0.688 to 0.707). CONCLUSIONS: Lymphopenia was observed in one-fifth of treatment-naive patients with mRCC and may serve as an indicator of unfavourable oncologic outcomes in the contemporary IO era.

Cabazitaxel versus abiraterone or enzalutamide in poor prognosis metastatic castration-resistant prostate cancer: a multicentre, randomised, open-label, phase II trial.

BACKGROUND: Treatment of poor prognosis metastatic castration-resistant prostate cancer (mCRPC) includes taxane chemotherapy and androgen receptor pathway inhibitors (ARPI). We sought to determine optimal treatment in this setting. PATIENTS AND METHODS: This multicentre, randomised, open-label, phase II trial recruited patients with ARPI-naive mCRPC and poor prognosis features (presence of liver metastases, progression to mCRPC after <12 months of androgen deprivation therapy, or ≥4 of 6 clinical criteria). Patients were randomly assigned 1 : 1 to receive cabazitaxel plus prednisone (group A) or physician's choice of enzalutamide or abiraterone plus prednisone (group B) at standard doses. Patients could cross over at progression. The primary endpoint was clinical benefit rate for first-line treatment (defined as prostate-specific antigen response ≥50%, radiographic response, or stable disease ≥12 weeks). RESULTS: Ninety-five patients were accrued (median follow-up 21.9 months). First-line clinical benefit rate was greater in group A versus group B (80% versus 62%, P = 0.039). Overall survival was not different between groups A and B (median 37.0 versus 15.5 months, hazard ratio (HR) = 0.58, P = 0.073) nor was time to progression (median 5.3 versus 2.8 months, HR = 0.87, P = 0.52). The most common first-line treatment-related grade ≥3 adverse events were neutropenia (cabazitaxel 32% versus ARPI 0%), diarrhoea (9% versus 0%), infection (9% versus 0%), and fatigue (7% versus 5%). Baseline circulating tumour DNA (ctDNA) fraction above the cohort median and on-treatment ctDNA increase were associated with shorter time to progression (HR = 2.38, P < 0.001; HR = 4.03, P < 0.001). Patients with >30% ctDNA fraction at baseline had markedly shorter overall survival than those with undetectable ctDNA (HR = 38.22, P < 0.001). CONCLUSIONS: Cabazitaxel was associated with a higher clinical benefit rate in patients with ARPI-naive poor prognosis mCRPC. ctDNA abundance was prognostic independent of clinical features, and holds promise as a stratification biomarker.

Renal medullary carcinoma and its association with sickle cell trait: a case report and literature review.

Renal medullary carcinoma (rmc) is a rare and aggressive renal malignancy that usually presents at an advanced stage, has a poor prognosis, and is associated with sickle cell trait. We present a case of rmc including radiologic and pathology findings, treatment, and outcome. A review of the literature is also presented, with an emphasis on the association of rmc with sickle cell trait, which was an unknown diagnosis in our patient preoperatively.

Real-world outcomes of nivolumab and cabozantinib in metastatic renal cell carcinoma: results from the International Metastatic Renal Cell Carcinoma Database Consortium.

Objectives: In the present study, we explored the real-world efficacy of the immuno-oncology checkpoint inhibitor nivolumab and the tyrosine kinase inhibitor cabozantinib in the second-line setting. Methods: Using the International Metastatic Renal Cell Carcinoma Database Consortium (imdc) dataset, a retrospective analysis of patients with metastatic renal cell carcinoma (mrcc) treated with nivolumab or cabozantinib in the second line after prior therapy targeted to the vascular endothelial growth factor receptor (vegfr) was performed. Baseline characteristics and imdc risk factors were collected. Overall survival (os) and time to treatment failure (ttf) were calculated using Kaplan-Meier curves. Overall response rates (orrs) were determined for each therapy. Multivariable Cox regression analysis was performed to determine survival differences between cabozantinib and nivolumab treatment. Results: The analysis included 225 patients treated with nivolumab and 53 treated with cabozantinib. No significant difference in median os was observed: 22.10 months [95% confidence interval (ci): 17.18 months to not reached] with nivolumab and 23.70 months (95% ci: 15.52 months to not reached) with cabozantinib (p = 0.61). The ttf was also similar at 6.90 months (95% ci: 4.60 months to 9.20 months) with nivolumab and 7.39 months (95% ci: 5.52 months to 12.85 months) with cabozantinib (p = 0.20). The adjusted hazard ratio (hr) for nivolumab compared with cabozantinib was 1.30 (95% ci: 0.73 to 2.3), p = 0.38. When adjusted by imdc criteria and age, the hr was 1.32 (95% ci: 0.74 to 2.38), p = 0.35. Conclusions: Real-world imdc data indicate comparable os and ttf for nivolumab and cabozantinib. Both agents are reasonable therapeutic options for patients progressing after initial first-line vegfr-targeted therapy.

Measuring quality care in localized renal cell cancer: use of appropriate preoperative investigations in a population-based cohort.

INTRODUCTION: Obtaining appropriate preoperative risk-specific staging investigations for localized renal cell carcinoma (rcc) is a recognized quality indicator. The goal of the present work was to determine the use and appropriateness of preoperative investigations in patients undergoing curative surgery for rcc. METHODS: This population-based retrospective study of patients having surgery for localized rcc recorded the use of preoperative imaging and laboratory investigations within 6 months of surgery. "Appropriate" stage-specific investigations were determined using recognized published guidelines. RESULTS: The study cohort consisted of 544 patients with 72.8% being stage i, 18.4% being stage ii, and 8.8% being stage iii by clinical TNM (2002) criteria. In 61.6%, chest imaging was obtained by chest radiography or computed tomography (ct) within 3 months preoperatively; in 75.6%, such imaging was obtained within 6 months. Abdominal ct imaging was obtained in 97.1% of patients before surgery, with 77.5% of patients receiving such imaging within 3 months of surgery. Complete blood count, electrolytes, and creatinine were measured in 99.1% of patients, but those tests plus other recommended blood tests including calcium, alkaline phosphatase, and liver function were measured in only 17.7%. CONCLUSIONS: In this study, most patients received appropriate abdominal imaging, but chest imaging was underutilized in the overall cohort. Despite being recommended, blood tests such as liver function, alkaline phosphatase, and calcium were completed in fewer than 2 of 10 patients. This analysis provides the groundwork for quality improvement initiatives directed to the use of preoperative investigations in localized rcc.

Outcomes of patients with metastatic renal cell carcinoma that do not meet eligibility criteria for clinical trials.

BACKGROUND: Targeted therapies in metastatic renal cell carcinoma (mRCC) have been approved based on registration clinical trials that have strict eligibility criteria. The clinical outcomes of patients treated with targeted agents but are ineligible for trials are unknown. PATIENTS AND METHODS: mRCC patients treated with vascular endothelial growth factor-targeted therapy were retrospectively deemed ineligible for clinical trials (according to commonly used inclusion/exclusion criteria) if they had a Karnofsky performance status (KPS) <70%, nonclear-cell histology, brain metastases, hemoglobin ≤9 g/dl, creatinine >2× the upper limit of normal, corrected calcium ≥12 mg/dl, platelet count of <100 × 10(3)/uL, or neutrophil count <1500/mm(3). RESULTS: Overall, 768 of 2210 (35%) patients in the International Metastatic RCC Database Consortium (IMDC) were deemed ineligible for clinical trials by the above criteria. Between ineligible versus eligible patients, the response rate, median progression-free survival (PFS) and median overall survival of first-line targeted therapy were 22% versus 29% (P = 0.0005), 5.2 versus 8.6 months, and 12.5 versus 28.4 months (both P < 0.0001), respectively. Second-line PFS (if applicable) was 2.8 months in the trial ineligible versus 4.3 months in the trial eligible patients (P = 0.0039). When adjusted by the IMDC prognostic categories, the HR for death between trial ineligible and trial eligible patients was 1.55 (95% confidence interval 1.378-1.751, P < 0.0001). CONCLUSIONS: The number of patients that are ineligible for clinical trials is substantial and their outcomes are inferior. Specific trials addressing the unmet needs of protocol ineligible patients are warranted.

Chemotherapy in metastatic gastric cancer: population-based perceptions and practice patterns of medical oncologists.

Although randomised trials in metastatic gastric cancer have shown a survival benefit from chemotherapy, a significant proportion of medical oncologists do not believe that it prolongs survival or improves quality of life, including those who routinely treat metastatic gastric cancer. There was wide variation in what was considered to be 'standard therapy' and a statistically significant difference between what medical oncologists consider 'standard therapy' and what they use in every day practice.

Ligand-induced recruitment of a histone deacetylase in the negative-feedback regulation of the thyrotropin beta gene.

We have investigated ligand-dependent negative regulation of the thyroid-stimulating hormone beta (TSHbeta) gene. Thyroid hormone (T3) markedly repressed activity of the TSHbeta promoter that had been stably integrated into GH(3 )pituitary cells, through the conserved negative regulatory element (NRE) in the promoter. By DNA affinity binding assay, we show that the NRE constitutively binds to the histone deacetylase 1 (HDAC1) present in GH(3 )cells. Significantly, upon addition of T3, the NRE further recruited the thyroid hormone receptor (TRbeta) and another deacetylase, HDAC2. This recruitment coincided with an alteration of in vivo chromatin structure, as revealed by changes in restriction site accessibility. Supporting the direct interaction between TR and HDAC, in vitro assays showed that TR, through its DNA binding domain, strongly bound to HDAC2. Consistent with the role for HDACs in negative regulation, an inhibitor of the enzymes, trichostatin A, attenuated T3-dependent promoter repression. We suggest that ligand-dependent histone deacetylase recruitment is a mechanism of the negative-feedback regulation, a critical function of the pituitary-thyroid axis.

Use of technology to facilitate language skills in school-age children.

Technology offers numerous possibilities for facilitating language and literacy skills in school-age children and adolescents. Narrative skills can be addressed by the use of specialized programs as well as generic word processing software. Writing skills can be targeted due to the variety of possibilities for input as well as options for supporting spelling and syntax. Reading skills might be improved by the use of programs that focus on decoding, as well as hypertext tools that highlight the use of text patterns or signals.

An analysis of falls in the hospital: can we do without bedrails?

OBJECTIVES: To determine the effects of introduction of a bedrail policy, and an educational program, on patient falls and fall-related injuries. DESIGN: A prospective "Before and After" design. PARTICIPANTS AND SETTING: All patients admitted during 1 calendar year in an assessment, treatment, and rehabilitation unit for older people. INTERVENTION: A policy change for the use of bedrails (restricting their use) and an educational program about their effects. MEASUREMENTS: Patient fall rates -- all falls and around the bed falls -- and patient and staff injuries. RESULTS: There was a significant reduction in the number of beds with bedrails attached after the policy introduction (mean of 40/135 vs 18.5/135, respectively, P = .02), but the fall rate (either total or around the bed) did not change significantly. Serious injuries were significantly less common after the bedrail policy was introduced (P = .008), with fewer head injuries. CONCLUSIONS: Reducing the use of bedrails did not alter patient fall rates significantly, but it was associated with a reduction in serious injuries. Unless it can be shown that bedrails are beneficial, their continued use in older patients must be seriously questioned.

Outcome of advanced stage low grade follicular lymphomas in a population-based retrospective cohort.

BACKGROUND: To the authors' knowledge previous reports of patient outcome for advanced stage low grade follicular lymphomas (LGFL) have not been population-based. This is the first report describing the outcome of these patients based on a population-based cohort. METHODS: A retrospective chart review was performed for all patients diagnosed with advanced stage LGFL between 1987-1995 for the adult population of central and northern Alberta, Canada. RESULTS: One hundred and fifty-seven patients were diagnosed with advanced stage LGFL. Approximately 45% of patients had died at last follow-up. Treatment was initiated at the time of diagnosis in 87 patients (55%), with alkylating agents used in 66% of them. Of the 70 patients not treated at the initial diagnosis, 69% had been treated at a median of 16.3 months. The overall median survival was 5.9 years. On univariate analysis, significant variables (P < 0.20) included age, B symptoms, symptomatic lymphadenopathy, symptomatic splenomegaly, splenomegaly, Eastern Cooperative Oncology Group performance status, baseline lactate dehydrogenase (LDH), diffuse component on histology, and treatment at the time of diagnosis. By multivariate analysis, the only factors that influenced survival significantly and independently were baseline LDH and B symptoms. An elevated baseline LDH had a hazard ratio of 2.80 (95% confidence interval [CI], 1.65, 4.74) and a median survival of 8.0 years versus 3.6 years (P < 0.0001). B symptoms had a hazard ratio of 2.30 (95% CI, 1.23, 4.30) and a median survival of 6.5 years versus 3.1 years (P < 0.0067). CONCLUSIONS: Although some patients with advanced stage LGFL enjoy a prolonged survival, 80% of deaths in this cohort were attributable to lymphoma. The median overall survival of 5.9 years offers a less positive perspective on the outcome of these patients than in previous nonpopulation-based reports. This emphasizes the need for further population-based studies as well as new therapeutic approaches, especially those directed toward patients with poor prognostic features such as elevated baseline LDH and B symptoms.

Enhancement of methylcholanthrene-induced neoplastic transformation in murine C3H 10T1/2 fibroblasts by antisense phosphorothioate oligodeoxynucleotide sequences.

Antisense phosphorothioate oligodeoxynucleotides (ODNs) are increasingly used to target specific proteins for inhibition. Previous reports of antisense inhibition of the inducible nitric oxide synthase (iNOS) gene suggested its utility in defining the role of nitric oxide (NO) in carcinogenesis, as NO is mutagenic and chemical inhibitors of iNOS block neoplastic transformation in C3H 10T1/2 fibroblasts. Treatment with ODNs (0.025-25 microM) directed against 15mer sequences in the iNOS coding region decreased NO production consistent with a reduction of iNOS protein and iNOS mRNA, however, control ODNs (2.5 microM) also showed considerable nonspecific inhibition of NO synthesis. Treatment with both iNOS antisense and missense ODNs during the promotional phase of the C3H10T1/2 transformation assay significantly increased the number of neoplastic foci in 3-methylcholanthrene (MCA) treated cells which corresponded with the ability of the ODN to inhibit NO production. Enhanced neoplastic transformation and non-specific inhibition of NO synthesis resulting from exposure to antisense ODNs suggest limitations to their long-term use in humans at higher doses.

Characterization of the heat shock response in the gills of sea lampreys and a brook lamprey at different intervals of their life cycles.

The heat shock response (HSR) was characterized in the gills of two lamprey species that differ with respect to their adult life history. In vivo labelling with [35S]methionine revealed an enhanced synthesis of heat shock proteins (HSPs) having approximate molecular weights of 70 kDa (HSP70) and 90 kDa (HSP90) following heat treatment. Induction of the HSR occurred in larval lampreys (ammocoetes) following temperature elevations of 13-16 degrees C for the parasitic species, the sea lamprey (Petromyzon marinus) and 16-20 degrees C for the nonparasitic species, the brook lamprey (Lampetra appendix). The case in L. appendix represents the greatest increase in temperature required to induce the HSR in gill tissue among aquatic poikilotherms studied to data and induction occurs within a temperature range (25-29 degrees C) not normally experienced by these animals. Western blotting detected the presence of 70 and 90 kDa HSPs and HSP70 levels were greater in post-metamorphic L. appendix than in ammocoetes both before and after heat shock. The HSR of lampreys appears to be induced during times of emergency when large, rapid temperature increases are experienced. The high set-point temperature for induction of the response may be a consequence of both the environments they presently inhabit and their experiences during evolution.

Buckling of redundant expansile stent distal to an oesophageal cancer: endoscopic management.

This report describes a complication that occurred as a result of deploying an Ultraflex stent too low in relation to a stenosing carcinoma of the gastro-oesophageal junction. Intermittent kinking of the redundant lower end of the stent caused frequent episodes of total dysphagia. A percutaneous endoscopic gastrostomy was deployed to anchor the redundant portion of the stent within the stomach, allowing it to be shortened with endoscopic stitch cutters. This procedure relieved the episodic dysphagia, and was well tolerated.

Effects of tamoxifen on nitric oxide synthesis and neoplastic transformation in C3H 10T1/2 fibroblasts.

Tamoxifen (TAM) is used in the prevention and treatment of breast cancer, however, its mechanisms of therapeutic action as well as its pathologic effects are not fully understood. We report that TAM (10(-7)-10(-5) M) inhibits 3-methylcholanthrene-induced transformation of C3H 10T1/2 murine fibroblasts in a dose-responsive manner. Over this concentration range, TAM (>10(-6) M) potentiates inducible nitric oxide synthase (iNOS) activity in 10T1/2 cells. This increase in NO synthase activity was mediated through an increase in iNOS protein for cells stimulated with interferon-gamma (IFN-gamma) and bacterial lipopolysaccharide (LPS). Significant increases in NO formation were observed when TAM (10(-5)) was added prior to or simultaneously with IFN-gamma/LPS treatment, whereas the addition of TAM 48 h after IFN-gamma/LPS treatment had no effect on NO synthesis. The morphologic changes seen with cells treated with TAM are similar to those observed in cells treated with TGF-beta1. TGF-beta1 inhibited NO production at high doses and slightly enhanced NO formation at low doses in IFN-gamma/LPS-stimulated cells. The transformation inhibitory effects of TAM did not appear to be related to the effects on cellular proliferation of neoplastic cells as TAM did not inhibit the growth of neoplastic cells into foci in the presence of normal confluent C3H 10T1/2 fibroblasts.

A soluble transcription factor, Oct-1, is also found in the insoluble nuclear matrix and possesses silencing activity in its alanine-rich domain.

Expression of the human thyrotropin beta (hTSHbeta) gene is restricted to thyrotrophs, at least in part, by silencing. Using transient-transfection assays, we have localized a silencer element to a region between -128 and -480 bp upstream of the transcription initiation site. The silencing activity was overcome in a thyrotroph-specific manner by an unknown enhancer located in the sequences at -approximately 10000 to -1200 bp. The ubiquitous POU homeodomain protein Oct-1 recognized the A/T-rich silencer element at multiple sites in gel mobility shift assays and in vitro footprinting analyses. The silencing activity of Oct-1 was localized in its C-terminal alanine-rich domain, suggesting that Oct-1 plays a role in silencing of the hTSHbeta promoter. Further, a significant fraction of Oct-1 was shown to be associated with the nuclear matrix, and the hTSHbeta silencer region was tethered to a nuclear matrix of human cells in vivo, suggesting a possible role of the Oct-1-hTSHbeta silencer region interaction in chromatin organization.

Systemic gene therapy with p53 reduces growth and metastases of a malignant human breast cancer in nude mice.

We report on an in vivo delivery system that attenuates the growth, in nude mice, of a malignant human breast cancer cell line containing a p53 mutation. Nude mice, inoculated with breast carcinoma cells, were injected every 10-12 days with a liposome-p53 complex via the tail vein. A significant reduction of greater than 60% in primary tumor volume was observed as compared to the control groups. Furthermore, when individual growth patterns of the tumors were assessed, we found that primary tumor size regressed in the majority of p53-treated animals (8/15), whereas only one tumor in the control groups (1/22) regressed. The eight tumors that regressed with the liposome-p53 complex showed no evidence of relapse for 1 month after the cessation of treatment. We also determined that the administration of the liposome-p53 complex reduced the incidence of metastases. The MDA-MB-435 tumor cells, transduced with the lacZ gene, facilitated quantitation of beta-galactosidase activity and tumor burden in the lungs. The number of metastatic cells in the lung was significantly lower in the p53-treated group (0.53 +/- 0.43 x 10(6), p < 0.01) than in either the vector-treated (8.1 +/- 3.7 x 10(6)) or untreated control groups (15.8 +/- 5.9 x 10(6)). Thus, systemic administration of the liposome-p53 complex reduced not only the size of the primary tumors but, more importantly, prevented the relapse and metastases of these tumors.