[HER-2 and TOP 2A gene amplifications in urinary bladder carcinoma]. / HER-2 und TOP 2A Genamplifikationen beim Harnblasenkarzinom.

The HER-2/neu gene is frequently amplified in bladder cancer. Topoisomerase 2 Alpha (TOP2A) which is located nearby the HER-2/neu gene is an important molecular target for several anti cancer drugs. The frequency of TOP2A amplification in urinary bladder cancer is unknown. It was the aim of this study to determine the frequency of HER-2 and TOP2A amplification in urinary bladder cancer and to evaluate the association of these amplifications with tumor phenotype. For this purpose a tissue microarray containing 768 pTa, 425 pT1 and 571 pT2-4 carcinomas was analyzed by fluorescence in situ hybridization (FISH). Amplifications of both genes were significantly associated with advanced tumor stage and high grade. HER-2 amplification was found in 1.6% of pTa, 7.2% of pT1 and 13.8% of pT2-4 carcinomas (p < 0.0001). HER-2 amplification was present in only 1.1% of grade 1 and 0.8% of grade 2 tumors but in 14.2% of grade 3 tumors (p < 0.0001). TOP2A amplification was present in 0.7% pTa, 1.8% pT1 and 3.4% pT2-4 carcinomas (p < 0.0001). TOP2A was found in none of the grade 1, in 0.2% of grade 2 and 3.8% of grade 3 tumors (p < 0.0001). 1% of all analyzed tumors had simultaneously high level amplification of TOP2A and HER-2. Amplification of both genes were significantly associated with tumor specific survival if all tumors were analyzed together. Given the high frequency of HER-2 amplification in urinary bladder cancer, some of these tumors may respond favorable to Herceptin therapy. The TOP2A amplification status may influence response to anthracyclin treatment.

Outcomes among orthopedic patients in skilled nursing facilities: does managed care make a difference?

The use of rehabilitative care has increased greatly. This study evaluates whether managed care affects health outcomes among Medicare orthopedic patients receiving rehabilitative treatments. Managed care versus fee-for-service patients had better outcomes at four months following discharge from skilled nursing facilities. It is important to address predictive factors, such as age, length of hospital stay, debilitation and social living arrangements, which can also influence health outcomes when planning rehabilitative treatment for older patients.

Comparison of older adult subject and proxy responses on the SF-36 health-related quality of life instrument.

Studies of older adults' health status and health-related quality of life (HRQoL) often rely on proxy responses when subjects have problems that affect their ability to respond. With the increased interest in outcomes research in health care, it is important to examine proxy reliability on HRQoL instruments. This study compares 32 pairs of subject-andproxy responses on the eight subscales and two summary scales of the Short Form 36 (SF-36). Subjects and their proxies, recruited from senior centers and residential facilities, were interviewed face-to-face within a seven-day period. Subjects were 60 years of age or older and had passed a brief cognitive screen, and proxies were geographically proximate and had seen the subject during the past week. Results showed that although moderate intra-class correlations were found on six of the eight measures, an item-level kappa statistic indicated poor to fair agreement on all subscales except items of Physical Functioning and Role Physical. Moreover, paired t-tests revealed proxy mean scores that were significantly lower on the Physical Functioning, Vitality, and Mental Health subscales. Given the mixed findings, until further research is done, researchers and clinicians should exercise caution when using proxy responses for older adults with the SF-36.

Patterns of her-2/neu amplification and overexpression in primary and metastatic breast cancer.

BACKGROUND: Only 25% of patients with HER-2/neu-positive metastatic breast tumors respond favorably to trastuzamab (Herceptin) treatment. We hypothesized that a high failure rate of patients on trastuzamab could result if some of the metastases were HER-2 negative and these metastases ultimately determine the course of the disease. METHODS: We used tissue microarrays (TMAs) containing four samples each from 196 lymph node-negative primary tumors, 196 lymph node-positive primary tumors, and three different lymph node metastases from each lymph node-positive tumor to estimate HER-2 gene amplification by fluorescence in situ hybridization (FISH) and Her-2 protein overexpression by immunohistochemistry (IHC). RESULTS: FISH and IHC analyses gave the same result with respect to HER-2 status for 93.7% of the tissues contained in the TMAs. Tissue samples were, therefore, considered to be HER-2 positive if they were positive for either HER-2 DNA amplification or Her-2 protein expression and HER-2 negative if both FISH and IHC gave a negative result. The HER-2 status of lymph node-positive primary tumors was maintained in the majority of their metastases. For HER-2-positive primary tumors, 77% (95% confidence interval [CI] = 59% to 90%) had entirely HER-2-positive metastases, 6.5% (95% CI = 8% to 21%) had entirely HER-2-negative metastases, and 16.3% (95% CI = 5% to 34%) had a mixture of HER-2-positive and HER-2-negative metastases. For HER-2-negative primary tumors, 95% (95% CI = 88% to 98%) had metastases that were entirely negative for HER-2. CONCLUSIONS: Our data suggest that differences in HER-2 expression between primary tumors and their lymph node metastases cannot explain the high fraction of nonresponders to trastuzamab therapy.

High-throughput tissue microarray analysis of 3p25 (RAF1) and 8p12 (FGFR1) copy number alterations in urinary bladder cancer.

Studies by comparative genomic hybridization revealed that the chromosomal regions 3p25 and 8p11-p12 are recurrently amplified in bladder cancer. To investigate the prevalence of DNA copy number alterations in these chromosomal regions and study their clinical significance, we used probes for the RAF1 (3p25) and FGFR1 (8p12) genes for fluorescence in situ hybridization. A tissue microarray containing 2317 tumors was analyzed. The analysis revealed RAF1 amplification in 4.0% and FGFR1 amplification in 3.4% of interpretable tumors. In addition, deletions were found at the 3p25 locus in 2.2% and at the 8p11-12 locus in 9.9% of interpretable tumors. Both amplifications and deletions of RAF1 and FGFR1 were significantly associated with high tumor grade (P < 0.0001), advanced stage (P < 0.0001), and poor survival (P < 0.05) if tumors of all of the stages where analyzed together. RAF1 amplifications were associated with subsequent tumor progression in pT1 carcinomas (P < 0.05). The marked differences in the frequency of all of the analyzed changes between pTa grade 1/grade 2 and pT1-4 carcinomas support the concept of these tumor groups representing different tumor entities.

Apparent diffusion coefficients in the evaluation of high-grade cerebral gliomas.

BACKGROUND AND PURPOSE: Preliminary data indicate that apparent diffusion coefficient (ADC) values may be useful in identifying and grading primary cerebral tumors. We tested the hypothesis that ADC values can be used to differentiate tumor, edema, and normal brain tissue. METHODS: Fifteen patients with high-grade cerebral astrocytomas underwent conventional MR imaging, diffusion-weighted MR imaging, and proton MR spectroscopy. We defined tumor as an area containing the highest choline/creatine and choline/N-actetyl aspartate ratios, contrast enhancement, and abnormal T2 signal intensity. Edema was defined as tissue with normal proton MR spectra, no enhancement, and high T2 signal intensity. Normal brain was assumed if tissue had normal proton MR spectra, no enhancement, and normal T2 signal intensity in the hemispheres ipsilateral or contralateral to tumor. ADC maps were calculated and regions of interest were manually placed over areas of tumor, edema, and normal tissue. Comparisons were made by analysis of variance. For post hoc testing, the Tukey method was used to correct for the effect of multiple comparisons, and significance was accepted if P was less than .05. RESULTS: When ADC values were analyzed as a group, significant differences were found between tumor (131 + 45) and normal brain tissue (ipsilateral to tumor, 92 + 22; contralateral to tumor, 78 + 5) but not between tumor and adjacent edema (129 + 45). A plot of individual data points showed considerable overlapping among the three types of tissue sampled. CONCLUSION: As a group, ADC values helped to distinguish high-grade glioma from normal tissue but could not be used to separate high-grade glioma from surrounding edema. Individually, ADC values overlapped considerably and were not useful in our patients. The utility of ADC values (as obtained in this relatively small study) is questionable in patients with high-grade cerebral astrocytomas.

CDKNA2A mutation analysis, protein expression, and deletion mapping of chromosome 9p in conventional clear-cell renal carcinomas: evidence for a second tumor suppressor gene proximal to CDKN2A.

Inactivation of tumor suppressor genes on chromosome 9p is considered a critical event in renal cell carcinoma pathogenesis. Alterations of CDKN2A on 9p21 have been reported in renal cancer cell lines, but their relevance for primary renal carcinomas is unclear. Loss of heterozygosity (LOH) was analyzed by using four polymorphic microsatellites at D9S970 (9p12-9p13), D9S171 (9p13), D9S1748 (9p21), and D9S156 (9p21) in 113 primary conventional clear-cell renal cell carcinomas (CRCCs). Allelic deletion was detected in 21 of 88 informative CRCCs (24%) with the highest rate of LOH being observed at D9S171 on 9p13 (20%). Chromosome 9p LOH was associated with short tumor-specific survival in stage pT3 RCC (P = 0.01). Fluorescence in situ hybridization analysis of 54 CRCCs revealed no homozygous CDKN2A deletions indicating that this mechanism of CDKN2A inactivation is rare in CRCC. Sequencing of 113 CRCCs showed that 13 tumors (12%) had a 24-bp deletion abrogating codons 4 through 11 of CDKN2A. Immunohistochemical CDKN2A expression was absent in normal renal tissue and was only detected in six of 382 CRCCs (1.5%) on a renal tumor microarray. These data suggest that CDKN2A alterations are present in a small subset of CRCCs and a second, yet unknown tumor suppressor gene proximal to the CDKN2A locus, may play a role in CRCC development.

A comparison of skilled nursing facility rehabilitation treatment and outcomes under Medicare managed care and Medicare fee-for-service reimbursement.

PURPOSE: This article compares the rehabilitation treatment and outcomes of Medicare managed care organization (MCO) and fee-for-service (FFS) patients in skilled nursing facilities (SNFs). DESIGN AND METHODS: Data on 514 MCO patients and 420 FFS patients treated in four for-profit Southern California-based SNFs between June 1996 and September 1998 were analyzed with bivariate and multivariate regression models. RESULTS: After controlling for time since onset and other sociodemographic and health status characteristics, Medicare MCO patients were found to receive significantly fewer therapy units and have significantly shorter lengths of stay in rehabilitation programs. IMPLICATIONS: The findings may be the result of more global differences in the trajectories of care among MCO and FFS patients treated in SNFs, yet they highlight critical issues related to the spread of Medicare managed care in nursing homes and the dynamic between MCO and FFS reimbursement systems.

Sequential use of gadolinium chelate and mangafodipir trisodium for the assessment of focal liver lesions: initial observations.

The purpose of this study was to assess the feasibility of sequential administration of 2 different MR imaging contrast agents using a single visit protocol to image focal liver abnormalities. Twenty-one patients with known or suspected liver lesions were included in the study. All patients received a bolus intravenous injection of gadolinium chelate (Gd) and dynamically enhanced imaging performed. The patients then received an injection of mangafodipir trisodium (Mn) contrast and a second scan performed with an average delay of 62 min after the Gd bolus injection. The images were evaluated to determine the appearance of liver lesions after administration of each contrast agent, and for evidence of prior Gd administration adversely affecting evaluation of images acquired after Mn administration. Focal liver lesions were present in 19 patients, including 8 with liver metastases, 1 with liver lymphoma, 6 with hemangiomas, 3 with focal nodular hyperplasia (FNH), and 1 with hepatic abscess. In 2 other patients no liver lesions were identified in either the post-Gd or post-Gd-post-Mn scans. All malignant lesions identified on the post-Gd scan were also identified on post-Gd-post-Mn scans. Although the potential benefit for increasing detection sensitivity for hepatic metastases was not demonstrated, this is a preliminary series. This study does demonstrate the practicality for use a single visit sequential Gd-Mn protocol described here, with possible application of this technique for further assessment of the utility of combining Gd and Mn for detection of liver metastases.

High-throughput tissue microarray analysis of cyclin E gene amplification and overexpression in urinary bladder cancer.

Studies by comparative genomic hybridization revealed that the 19q13 chromosomal region is frequently amplified in bladder cancer. The cyclin E gene (CCNE), coding for a regulatory subunit of cyclin-dependent kinase 2, has been mapped to 19q13. To investigate the role of cyclin E alterations in bladder cancer, a tissue microarray of 2,317 specimens from 1,842 bladder cancer patients was constructed and analyzed for CCNE amplification by fluorescence in situ hybridization and for cyclin-E protein overexpression by immunohistochemistry. Fluorescence in situ hybridization analysis showed amplification in only 30 of the 1,561 evaluable tumors (1.9%). Amplification was significantly associated with stage and grade (P: < 0.0005 each). Immunohistochemically detectable cyclin E expression was strong in 233 (12.4%), weak in 354 (18.9%), and negative in 1, 286 of the 1,873 interpretable tumors. The majority (62.1%) of CCNE-amplified tumors were strongly immunohistochemistry-positive (P: < 0.0001). The frequency of protein expression increased from stage pTa (22.2%) to pT1 (45.5%; P: < 0.0001) but then decreased for stage pT2-4 (29.4%; P: < 0.0001 for pT1 versus pT2-4). Low cyclin E expression was associated with poor overall survival in all patients (P: < 0.0001), but had no prognostic impact independent of stage. It is concluded that cyclin E overexpression is characteristic to a subset of bladder carcinomas, especially at the stage of early invasion. This analysis of the prognostic impact of CCNE gene amplification and protein expression in >1,500 arrayed bladder cancers was accomplished in a period of 2 weeks, illustrating how the tissue microarray technology remarkably facilitates the evaluation of the clinical relevance of molecular alterations in cancer.

Breath-hold 3D gradient-echo MR imaging of the lung parenchyma: evaluation of reproducibility of image quality in normals and preliminary observations in patients with disease.

This study evaluates the reproducibility and image quality of a three-dimensional (3D) gradient-echo sequence for imaging the lung parenchyma, with and without gadolinium administration, using a 2D spoiled gradient-echo sequence for comparison. Twenty patients without lung disease (normals) and five patients with lung disease (lung disease) underwent paired 2D and 3D gradient-echo sequences, without contrast (24 patients) and with contrast (18 patients). Images were retrospectively reviewed independently in a blinded fashion by two investigators. Artifacts and demonstration of central lung, peripheral lung, heart, pulmonary arteries, and esophagus were evaluated. Image quality of the central lung was rated as fair or good in 5 and 4 (reader one and two) patients with non-contrast 2D gradient-echo, 24 and 25 patients with non-contrast 3D gradient-echo, 3 and 1 patient(s) with contrast-enhanced 2D gradient-echo, and 19 and 19 patients with contrast-enhanced 3D gradient-echo imaging. Differences in image quality between 2D and 3D sequences were significant (P < 0.001). Heart-related phase artifacts were negligible in 2 and 0 patients with non-contrast 2D gradient-echo, 23 and 25 patients with non-contrast 3D gradient-echo, 0 and 0 patients with contrast-enhanced 2D gradient-echo, and 17 and 19 patients with contrast-enhanced 3D gradient-echo imaging. Differences in heart-related phase artifact in the central lung between 2D and 3D sequences were significant (P = 0.001). Infiltrates, lung cancer, and pulmonary metastasis were better shown on the gadolinium-enhanced 3D gradient-echo sequences than on the other sequences. Breath-hold 3D gradient-echo imaging results in good image quality and negligible image artifacts and is superior to 2D spoiled gradient-echo imaging. Preliminary results in patients with disease appear promising.

Correlates of open- and locked-facility placement in a population of decisionally impaired adults.

OBJECTIVES: This study compares characteristics of public conservatees placed in locked facilities with those in less restrictive settings. Given the principle of the least restrictive alternative, the study seeks to identify factors, including the role of aging and advanced age, associated with restrictive placement within conservatorship. METHODS: Management Information Systems data on 1,534 adult conservatees in Los Angeles County in July, 1993, are examined in cross-section. Models exploring individual and environmental characteristics of conservatees and linear, curvilinear, and multiplicative aging effects are tested on the probability that adults are placed in locked facilities versus all other placement types. RESULTS: Locked facility placement is associated with being female, receiving SSI, a diagnosis of dementia, and being identified as a danger to oneself and to others. Locked-facility placement is associated with increasing age until age 60, when the effect becomes inversely related; the multiplicative effect of older age and impaired functioning is also inversely related. DISCUSSION: The curvilinear nature of age and the interaction effect of Age x Functioning implies that increasing frailty in older adults makes locked facility-placement less likely. Further research is needed on whether alternative placement types, such as special care units with secured perimeters, can further reduce the need for locked facilities.

FRA7G extends over a broad region: coincidence of human endogenous retroviral sequences (HERV-H) and small polydispersed circular DNAs (spcDNA) and fragile sites.

FRA7G is an aphidicolin-inducible common fragile site at human chromosomal band 7q31.2. This region is frequently altered in a number of different tumor types including prostate, breast, and ovarian cancer. It has also been hypothesized that this region contains an important tumor suppressor gene which is mutated during the development of these cancers or an oncogene which is amplified. We previously used a FISH-based approach to isolate YAC clones which spanned FRA7G. In this report, we describe the isolation and restriction endonuclease mapping of three overlapping P1 clones which cover FRA7G and the region frequently altered in the different cancers. FISH-based analysis of these clones reveals that aphidicolin-induced breakage in the FRA7G region occurs over a region of at least 300 Kb in length. We have also localized a previously sequenced BAC clone to this region. The sequence obtained from this clone reveals the presence of an endogenous retroviral sequence (HERV-H) in the midst of the FRA7G region as well as sequences with homology to small polydispersed circular DNAs (spcDNAs). Thus for the first two cloned common fragile sites, FRA7G and FRA3B, there is an association with both spcDNAs and hot-spots for viral integration.

A molecular cytogenetic analysis of 7q31 in prostate cancer.

Gains of chromosome 7 and alterations of the 7q-arm have been frequently observed in multiple cancers using various cytogenetic and molecular genetic techniques. Using PCR analysis of microsatellite markers, we have previously reported that allelic imbalance of 7q31 is common in prostate cancer and is associated with higher tumor grade and advanced pathological stage. In an effort to better understand the chromosome 7 alterations in prostate cancer, we undertook a molecular cytogenetic study of 25 prostate specimens using fluorescence in situ hybridization (FISH) with DNA probes for the chromosome 7 centromere and for 5 loci mapped to 7q31 (D7S523, D7S486, D7S522, D7S480, and D7S490) and 1 locus at 7q11.23 (ELN). Six tumors had no apparent anomaly for any chromosome 7 probe. Nine tumors showed apparent simple gain of a whole chromosome 7, whereas one tumor had apparent simple loss of a whole chromosome 7. Four tumors had gain of the chromosome 7 centromere and additional overrepresentation of the 7q-arm. One tumor had overrepresentation of 7q31 without any apparent anomaly of the chromosome 7 centromere, and one tumor had apparent loss of the chromosome 7 centromere with no apparent anomaly of the 7q-arm. Three tumors had gain of the chromosome 7 centromere and loss of the 7q31 region. Gain of 7q31 was strongly correlated with tumor Gleason score. Multiplex PCR studies of these specimens supported these FISH observations. Mutation screening and DNA sequencing of the MET gene, which is mapped to 7q31, revealed only the presence of simple sequence polymorphisms but no apparent acquired disease-associated mutations. FISH analysis of metaphases from an aphidicolin-induced, chromosome 7 only, somatic cell hybrid demonstrated that the DNA probe for D7S522 spans the common fragile site FRA7G at 7q31. Our data indicate that the 7q-arm, particularly the 7q31 region, is genetically unstable in prostate cancer, and some of the gene dosage differences observed may be due to fragility at FRA7G.

Improving service delivery: provider perspectives on building community-based systems of care.

This article examines the views of service providers toward different public policy efforts to improve service delivery to elders requiring multiple services from an array of organizations. The authors examine the relationship between provider assessments of the adequacy of their community-based systems of care and community resource levels, coordination strategies, and client characteristics. Findings, based on responses from managers of programs serving older adults (n = 250) to a mailed survey, were that two-thirds (69.4%) evaluated their service delivery systems as adequate or better. A regression model used to explain system adequacy indicated that 22% of the variance was accounted for by community resource level, information and service availability, attention to specific need clients, and percentage of minority clients served by the respondents' programs. Findings suggest that community resource level appears to be an important factor in respondents' evaluation of system adequacy. While respondents indicated that improved coordination could enhance their efforts to deliver services, this strategy was not one they favored in improving their community-based system of care. Instead, they preferred strategies which expanded or improved the services that were available.

Rethinking alternatives to guardianship.

This article describes, compares, and analyzes the roles and functions of guardianship and several decision-making interventions previously identified as potential alternatives to guardianship. An analytical framework, comprised of capacity, risk, complexity, and support, is developed to assess performance expectations and identify limitations of four types of decision-making interventions. Using case examples to illustrate how the framework applies to practice, the capacity of different types of interventions to address needs and to substitute or divert older adults from guardianship is examined. The article concludes with propositions introduced to guide future research.