Nab-paclitaxel weekly versus dose-dense solvent-based paclitaxel followed by dose-dense epirubicin plus cyclophosphamide in high-risk HR+/HER2- early breast cancer: results from the neoadjuvant part of the WSG-ADAPT-HR+/HER2- trial.

BACKGROUND: In high-risk hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) early breast cancer (EBC), nanoparticle albumin-bound (nab)-paclitaxel showed promising efficacy versus solvent-based (sb)-paclitaxel in neoadjuvant trials; however, optimal patient and therapy selection remains a topic of ongoing research. Here, we investigate the potential of Oncotype DX® recurrence score (RS) and endocrine therapy (ET) response (low post-endocrine Ki67) for therapy selection. PATIENTS AND METHODS: Within the WSG-ADAPT trial (NCT01779206), high-risk HR+/HER2- EBC patients were randomized to (neo)adjuvant 4× sb-paclitaxel 175 mg/m2 q2w or 8× nab-paclitaxel 125 mg/m2 q1w, followed by 4× epirubicin + cyclophosphamide (90 mg + 600 mg) q2w; inclusion criteria: (i) cN0-1, RS 12-25, and post-ET Ki67 >10%; (ii) cN0-1 with RS >25. Patients with cN2-3 or (G3, baseline Ki67 ≥40%, and tumor size >1 cm) were allowed to be included without RS and/or ET response testing. Associations of key factors with pathological complete response (pCR) (primary) and survival (secondary) endpoints were analyzed using statistical mediation and moderation models. RESULTS: Eight hundred and sixty-four patients received neoadjuvant nab-paclitaxel (n= 437) or sb-paclitaxel (n = 427); nab-paclitaxel was superior for pCR (20.8% versus 12.9%, P = 0.002). pCR was higher for RS >25 versus RS ≤25 (16.0% versus 8.4%, P = 0.021) and for ET non-response versus ET response (15.1% versus 6.0%, P = 0.027); no factors were predictive for the relative efficacy of nab-paclitaxel versus sb-paclitaxel. Patients with pCR had longer distant disease-free survival [dDFS; hazard ratio 0.42, 95% confidence interval (CI) 0.20-0.91, P = 0.024]. Despite favorable prognostic association of RS >25 versus RS ≤25 with pCR (odds ratio 3.11, 95% CI 1.71-5.63, P ≤ 0.001), higher RS was unfavorably associated with dDFS (hazard ratio 1.03, 95% CI 1.01-1.05, P = 0.010). CONCLUSIONS: In high-risk HR+/HER2- EBC, neoadjuvant nab-paclitaxel q1w appears superior to sb-paclitaxel q2w regarding pCR. Combining RS and ET response assessment appears to select patients with highest pCR rates. The disadvantage of higher RS for dDFS is reduced in patients with pCR. These are the first results from a large neoadjuvant randomized trial supporting the use of RS to help select patients for neoadjuvant chemotherapy in high-risk HR+/HER2- EBC.

Donor origin of neuroendocrine carcinoma in 2 transplant patients determined by molecular cytogenetics.

Organ transplant recipients have an increased tumor incidence owing to their immunocompromised state. The origin of such tumors, whether donor or recipient, will have a clinical impact on decision-making concerning immunosuppressive therapy, retransplantation, and for recipients of other organs from the same donors. We report molecular cytogenetic determination of donor origin in 2 cases of small-cell neuroendocrine carcinoma developing in sex-mismatched transplant recipients (kidney and liver). Fluorescence in situ hybridization (FISH) analysis was performed on liver core needle biopsy material from the liver transplant patient and on liver fine needle aspiration cytopreparations from the kidney transplant patient. The results for the liver transplant patient were confirmed with microsatellite allelic analysis and with comparative genomic hybridization. In both cases, FISH showed the presence of only X chromosomes within the tumor cells, indicating the donor origin of the neoplasms. FISH is an excellent method to determine neoplastic origin in sex-mismatched transplant patients. HUM PATHOL 31:1425-1429.

Developmental expression of NADPH phagocytic oxidase components in mouse embryos.

We wished to determine when each of the four NADPH oxidase components p22 phagocytic oxidase (phox), gp91 phox, p47 phox, p67 phox is first expressed embryologically and whether the expression pattern occurs in a consistent temporal sequence or whether the four genes are expressed simultaneously. A deficiency of any one of them results in chronic granulomatous disease (CGD). mRNA transcripts and protein expression for p22 phox, gp91 phox, p47 phox, p67 phox was monitored in murine embryos at time of implantation (E5.5) until E 11.5, and in fetal liver, spleen, and limb bone marrow from E 14 until term (E 19). We observed that mRNA was first expressed for p22 phox at E 5.5, for p67 phox at E 7.0 and for p47 phox at E 7.5 before the onset of yolk sac hematopoiesis (E 8.0). gp91 Phox mRNA was first expressed at E 9.0. However, only p22 phox protein was expressed in circulating hemocytoblast by E 9.0. No other embryonic tissue contained phox proteins either before or after the establishment of hemocytoblastic circulation. The four specific mRNA transcripts and phox proteins were expressed in nests of developing granulocytes in liver by E 14 and the expression continued in the liver at E 16 and E 19. Spleen and limb bone marrow showed inconsistent results. Cord blood neutrophils contained all phox proteins. These studies confirm that the four CGD-related phox mRNA components of NADPH oxidase are expressed early in embryonic development and the expression occurs in a consistent sequential fashion but only p22 phox protein appears in embryonic hemocytoblast.

Problem-based learning at the University of Southern California School of Dentistry.

Responding to the recent Institute of Medicine report on dental education, the Center for Craniofacial Molecular Biology (CCMB) of the University of Southern California School of Dentistry has developed a parallel track program in dental education leading to the D.D.S. degree. This program was proposed in May of 1995, and the first class of twelve students was admitted in September of that year. Currently two classes are enrolled and plans to admit a further twelve students (Class of 2001) are in place. The educational strategy for this program is totally problem-based. Students work in groups of six with a faculty facilitator, not necessarily a content expert. Facilitators are largely drawn from the multidisciplinary pool of research faculty at the center. All learning is mediated through biomedical and biodental problem cases. No formal lectures or classes are scheduled. The learning of clinical dental skills is promoted through focussed dental patient simulations in which students review clinical charts, radiographs, medical reports and then explore identified, hands-on learning needs using patient simulators in a clinical context. Early patient exposure is obtained through dental office visits and other special patient clinics. Initial experience with this program suggests that the problem-based learning (PBL) students learn as well (if not better) than their traditional program peers and develop excellent group and cognitive analytical skills. The absence of a pool of dentally related biomedical cases suitable for a PBL program has necessitated the use of innovative approaches to their development and presentation. It is believed that this educational approach will produce dental clinicians equipped with the self-motivated, life-long learning skills required in the ever-changing world of bio-dental sciences in the twenty-first century.

Chronic granulomatous disease of childhood: clinical, pathological, biochemical, molecular, and genetic aspects of the disease.

The pathobiology of chronic granulomatous disease (CGD) of childhood, a heterogeneous phenotypic disorder characterized by chronic and recurrent infection, has become more completely understood over the past three decades. Blood neutrophils, monocytes, and eosinophils lack a respiratory burst required for effective killing of catalase positive bacteria by reduced by-products of oxygen. The disease is transmitted in at least two genetic forms: X-linked and autosomal recessive. In the X-linked form, a gene coding for a beta subunit protein required for cytochrome b presence on the plasma membrane of phagocytic cells is not expressed. The protein appears to be a constituent of the cytochrome b complex that requires an additional alpha subunit for complete expression. Cytochrome b is likely a component of leukocyte oxidase, which catalyzes the respiratory burst. The autosomal recessive form of the disorder appears to be controlled by a set of genes coding for soluble cofactors essential for oxidase expression. One or more of these cofactors have recently been shown to be deficient in several patients with autosomal recessive CGD. Optional therapy for CGD patients is presently not available. Long-term use of antibiotics may be helpful. The cloned product interferon gamma has been reported to improve superoxide generation, bactericidal activity, and immunoreactive cytochrome b in some CGD neutrophils and monocytes, both in vitro and in vivo. Currently a prospective clinical evaluation of the efficacy of interferon gamma is in progress. Molecular studies of expression and function of the X-CGD gene in phagocytic cells are in progress as well.

Improvement in outcome for children with acute nonlymphocytic leukemia. A report from the Childrens Cancer Study Group.

The Childrens Cancer Study Group conducted four therapeutic studies on a total of 1006 children with acute nonlymphocytic leukemia from 1972 to 1983. This report describes the therapeutic strategies of these studies and examines trends in induction rates and long-term outcome over this period. The remission induction rate has changed from 58% in 1972 to 1975 to 80% for the period 1980 to 1983, and the induction mortality dropped from 20% to 6%. Four-year survival probabilities from time of diagnosis have almost doubled from 19% to 36%. Few deaths occurred more than 5 years after diagnosis: children surviving in first remission beyond 5 years had a 92% survival rate and an 86% relapse-free survival rate over the next 5 years. In contrast, median survival after a marrow relapse was less than 6 months and the 6-year survival probability was 4%. The leukocyte count was a significant prognostic factor, and although the mortality for infants was high initially, long-term survival was not decreased.

Interferon-alpha n1 in children with recurrent acute lymphocytic leukemia: a phase I study of pharmacokinetics and tolerance.

Twelve children ages 3-15 years with relapsed acute lymphocyte leukemia (ALL) were treated over 25 days by intravenous or intramuscular administration of interferon-alpha n1 (IFN-alpha n1). Single doses ranged from 2.5 to 15 MU/m2, total doses from 60 to 200 MU/m2. Serum pharmacokinetics were determined following administration of two different doses. Calculation of area under serum concentration curve (AUC) values showed increased AUC with increased dose. Mean AUC (h x U/ml) ranged from 735 to 3986 at doses of 2.5 and 15 MU/m2, respectively, when given intramuscularly. AUC for i.v. and i.m. administration were similar. Side effects reported most commonly were fever and chills in 11 of 12 patients, nausea/vomiting in 7, mild lethargy in 3, and injection site pain in 4 of 9 treated i.m. Reversible hepatotoxicity occurred in the 3 patients receiving the highest doses, 10 then 15 MU/m2. Three patients had clinically significant bleeding associated with mildly increased coagulation studies and an additional three patients had increased coagulation parameters without bleeding. Four patients were considered to have stable disease; one treated at the highest dose level had clearance of peripheral blasts but remained in bone marrow relapse. IFN-alpha n1 as used in this study produced detectable blood levels with associated side effects. A Phase II intramuscular trial is recommended.

Comparison of in vivo effects of intravenous infusion of N-formyl-methionyl-leucyl-phenylalanine and phorbol myristate acetate in rabbits.

Comparison of the physiologic responses in rabbits to the intravenous infusion of two polymorphonuclear neutrophil (PMN) activators, N-formyl-methionyl-leucyl-phenylalanine (FMLP) and phorbol myristate acetate (PMA), has revealed marked differences in kinetics for activation between these agents. FMLP infusion was associated with maximally increased respiratory rates (RR), a maximally decreased mean blood pressure (MBP), and a maximally decreased absolute granulocyte count (AGC), all within the first 5 min after infusion. However, there were no significant differences between RR, MBP, and AGC of FMLP-treated animals and controls, 15 min postinfusion and after. On the other hand, PMA did not cause significant changes in RR or MBP until 30 min and 2 h postinfusion, respectively. Previous work has demonstrated that both FMLP and PMA stimulate the PMN metabolically in vitro via the same respiratory burst enzyme, NADPH oxidase, but that each of these activators demonstrates kinetics which are different from the other. Thus, these data from an in vivo study support previous in vitro findings and offer further evidence that the neutropenia and cardiopulmonary alterations following intravenous infusion of FMLP and PMA may be caused by metabolic activation of the blood PMN.

Effect of vitamin E on FMLP-induced activation of rabbit polymorphonuclear leukocytes.

Granulocytes of vitamin E-treated rabbits were compared to granulocytes from placebo-treated rabbits. Granulocytes were isolated from rabbit peripheral blood by a new method employing Percoll and gelatin sedimentation. Vitamin E-treated cells showed less adherence to rabbit aortic endothelium when stimulated with FMLP. FMLP receptor numbers and affinity were not significantly different. Resting cell surface and baseline transmembrane potential were similar in both cell types. Decrease in cell surface potential with FMLP was comparable in vitamin E- and placebo-treated cells. Vitamin E-treated PMN depolarized more and hyperpolarized more rapidly than placebo cells. Thus vitamin E-treated PMNs show differences in the early events of PMN activation. These may contribute to the lower stimulated adherence observed with vitamin E-treated cells.

In vitro and in vivo effects of treatment by platelet-activating factor on N-formyl-met-leu-phe-mediated responses of polymorphonuclear leucocytes.

Two chemoattractants, the peptide N-formyl-met-leu-phe (FMLP), and the ether phospholipid, platelet activating factor (PAF), each stimulate a variety of in vitro responses in polymorphonuclear leucocytes (PMN). Because often more than one inflammatory mediator is active during inflammation, we determined the effect on PMN of sequential stimulation with these two agents. Before FMLP stimulation, human PMN were exposed to PAF, at concentrations which gave little or no response when administered alone. PAF enhanced FMLP-elicited superoxide release in a dose-dependent fashion. Likewise, release of granular lysozyme from the cells was increased in PAF treated cells. Similar treatment with other phospholipids, including the lyso derivation of PAF, failed to produced these effects. Incubation with nordihydroguaiaretic acid, an inhibitor of arachidonic acid metabolism, had little effect on the enhancement of lysozyme release by PAF. To determine if enhancing effects by PAF might occur also in vivo, we studied rabbits receiving PAF and/or FMLP intravenously. When rabbits received 0.01 micrograms PAF (a dose which does not elicit the sustained neutropenia observed with higher doses of PAF) followed by 0.05 micrograms FMLP the absolute granulocyte count (AGC) dropped at 1 min (46 +/- 11% of original value), and continued to fall (24 +/- 12% at 10 min). Controls, treated with the suspending fluid for PAF, and then 0.05 micrograms FMLP, had a similar 1 min AGC value, but at 10 min AGC returned to 65 +/- 6.1% (P less than 0.001 for comparison of 10 min values). Thus PAF pretreatment enhanced FMLP-elicited granulocytopenia in vivo. Study of in vitro human PMN aggregation revealed that, at certain relative concentrations of PAF and FMLP, aggregation was enhanced. These studies show that both in vitro and in vivo responses of FMLP-stimulated PMN may be exaggerated by pre-exposure to PAF.

Advances in nutrition care of children with neoplastic diseases: a review of treatment, research, and application.

Within the last decade, significant advances have been made both in treating children with cancer and in providing proper nutrition support. Oncologic treatment and nutrition research and their application to the nutrition care of children with cancer are reviewed. Quality nutrition care is now possible because of an improved understanding of (a) the prevalence and significance of protein-energy malnutrition (PEM) in high-risk groups, (b) the staging and assessment of nutritional status, and (c) the efficacy and limitations of nutrition support options. Nutrition staging, assessment, and support should be integrated into treatment protocols for children with neoplastic diseases. Common risk factors for the development of PEM have been identified from serial monitoring of newly diagnosed children with a variety of tumors. Certain tumor types and their treatment can be classified within either low or high nutritional risk groups. A comprehensive nutrition program (intense nutrition counseling, favorite nutritious foods) is preferred for low nutritional risk groups but is ineffective in preventing or reversing PEM in high-risk groups. For high-risk patients, central parenteral nutrition (CPN) is the method of choice as a relatively short-term but important support measure that allows children to withstand long intervals of intense treatment during periods of growth and development. Current data suggest that bone marrow suppression may be attenuated and treatment tolerance improved with the use of CPN in selected children with advanced cancer (e.g., acute nonlymphocytic leukemia or advanced neuroblastoma).

The value of nutrition support in children with cancer.

A positive stance towards nutrition support of the child with cancer assures potential for normal growth, development, and quality of life during extended oncologic treatment. Data from recent studies of children with cancer (advanced neuroblastoma, Wilms' tumor) demonstrate the importance of integrating nutrition staging, assessment, and support into treatment protocols. Patients with solid tumors and lymphomas who are malnourished at diagnosis have a poor outcome when compared to nourished counterparts. Enteral nutrition (intensive nutrition counseling and favorite, nutritious foods) is effective in low nutritional risk groups but ineffective in preventing or reversing protein-energy malnutrition in high nutritional risk groups. For high-risk groups, central parenteral nutrition is a relatively short-term, but important, support measure which allows children to grow despite extended periods of intense oncologic treatment. The patient's nutritional course may affect bone marrow suppression and the ability to tolerate aggressive chemotherapeutic treatment. Although treatment tolerance may be improved with nutrition support, adequacy of primary oncologic treatment outweighs other supportive factors as a determinant of ultimate survival.

Cloning the gene for an inherited human disorder--chronic granulomatous disease--on the basis of its chromosomal location.

The gene that is abnormal in the X-linked form of the phagocytic disorder chronic granulomatous disease has been cloned without reference to a specific protein by relying on its chromosomal map position. The transcript of the gene is expressed in the phagocytic lineage of haematopoietic cells and is absent or structurally abnormal in four patients with the disorder. The nucleotide sequence of complementary DNA clones predicts a polypeptide of at least 468 amino acids with no homology to proteins described previously.

DNA linkage analysis of X chromosome-linked chronic granulomatous disease.

Chronic granulomatous disease (CGD) is a disorder of phagocytes that is usually inherited as an X chromosome-linked trait. Previous family studies suggested that the CGD locus resides on the distal short arm (Xp22-Xpter). Using cloned, polymorphic DNA probes we have performed a linkage analysis within CGD families that suggests a more proximal location (Xp21). In addition, the CGD locus is proximal to the Duchenne muscular dystrophy locus and lies within a broad region of Xp in which recombination appears to be greater than anticipated on the basis of physical distance between markers. Regional localization of the X chromosome CGD locus should facilitate molecular cloning of the CGD gene and molecular dissection of the phagocyte oxidase system.

In vitro detection of endothelial cell damage using 2-deoxy-D-3H-glucose: comparison with chromium 51, 3H-leucine, 3H-adenine, and lactate dehydrogenase.

To develop a sensitive in vitro assay for detecting endothelial cell damage, we radiolabeled endothelial cell monolayers with tracer amounts of 2-deoxy-D-[1-3H]-glucose (3HDOG). We damaged identical cohorts of endothelial cells radiolabeled with 3HDOG or chromium 51 by exposing monolayers to toxic oxygen radicals generated by xanthine-xanthine oxidase or phorbol myristate acetate (PMA)-activated polymorphonuclear leukocytes (PMNs), a surface active agent (Triton X-100), and anti-HLA antibodies and complement. With each mechanism of injury, the 3HDOG assay detected significant (P less than 0.01) endothelial cell damage at lower concentrations of the injurious agent than the 51Cr assay. When endothelial monolayers were damaged by xanthine-xanthine oxidase or PMA-activated PMNs, efflux of 3HDOG was reduced (range 71% to 94% reduction) by superoxide dismutase and catalase, indicating that efflux of 3HDOG was mediated by toxic oxygen radicals. When monolayers were damaged with xanthine oxidase in the absence of glucose, a much lower concentration of xanthine oxidase was required to initiate efflux of 3HDOG as compared with xanthine oxidase injury in the presence of glucose. Additional studies compared the 3HDOG assay with 3H-adenine, 3H-leucine, and lactate dehydrogenase (LDH) release when endothelial cells were exposed to toxic oxygen radicals generated by PMA-activated PMNs and xanthine-xanthine oxidase. Again, the 3HDOG assay was more sensitive in detecting in vitro endothelial cell damage. We conclude that the 3HDOG assay is more sensitive than the 51Cr, 3H-adenine, 3H-leucine, or LDH release assays in detecting endothelial cell damage in vitro.

Platelet-derived growth factor promotes human peripheral monocyte activation.

Like in the polymorphonuclear leukocyte (PMN), the platelet-derived growth factor (PDGF) purified to homogeneity is capable of inducing monocyte activation responses as evaluated by generation of superoxide anion (O-.2) from membrane-associated oxidase system, release of granule enzymes, and enhanced cell adherence and cell aggregation. Superoxide anion release was maximized at 10 ng/mL PDGF and was comparable to that induced by 10(-7) mol/L formyl-methionyl-leucyl-phenylalanine. The potency of PDGF to induce this response in monocytes was of the same magnitude as that observed in PMNs. Similarly, lysozyme release and monocyte adherence were also increased in a dose-dependent manner and achieved maximal responses at 40 ng/mL concentration of PDGF. The PDGF concentration required to achieve maximal monocyte aggregation was two-fold (60 ng/mL) of that found for PMNs. In contrast to PMNs, a positive correlation (gamma = .93; P less than .01) was observed between the increases of PDGF concentration and beta-glucuronidase release. These findings indicate that PDGF can induce the full sequence of cell activation events in human monocytes similar to human PMNs.

Karyotypic and clinical findings in a consecutive series of children with acute lymphocytic leukemia.

Detailed karyotypic findings and clinical data on 70 consecutive newly diagnosed children with acute lymphocytic leukemia (ALL), primarily from Indiana, are presented. These children fall into five karyotypic groups: (a) normal chromosomes; (b) hyperdiploid I, with chromosome numbers greater than 50, frequently with multiple copies of the same chromosome, and often lacking a consistent abnormal clone; (c) hyperdiploid II, with karyotypes having 47-49 chromosomes and usually with all of the karyotypically abnormal cells identical; (d) pseudodiploids, with either translocations or deletions of specific chromosomes; and (e) hypodiploids. Because few of this series of children have expired or relapsed, patients in the karyotypic groups have been considered in relation to those clinical factors that have been found to be of prognostic significance by the Children's Cancer Study Group. Age, white blood cell count, and platelet count were significantly different in patients among the five karyotypic groups. A significantly greater number of pseudodiploid patients had white blood cell counts greater than 50,000 X 10(6)/L and were not in the infant age group, as has been the case for other series. Specifically, the 4;11 translocation was associated with a higher risk of early death compared with other patients. Among those with normal karyotypes, platelet levels of greater than 100 X 10(9)/L occurred more frequently than among those with abnormal karyotypes.

Glycoprotein-180 deficiency: genetics and abnormal neutrophil activation.

Neutrophil function was studied in a patient with polymorphonuclear leukocyte (PMN) glycoprotein-180 deficiency and in her parents. PMNs of the patient had abnormal chemotaxis, phagocytosis, adherence, surface charge, and membrane-associated events of activation. Selective defects to C3b, immunoglobulin G (IgG), phorbol myristate acetate (PMA) and N-formyl-methionyl-leucyl-phenylalanine (FMLP) are described, although C3b receptor density was normal. The parents were found to have abnormal adherence to nylon-wool fibers, abnormal transmembrane potential depolarization with PMA, and reduced amounts of glycoprotein-180 in their PMNs. These studies provide further evidence that the oxidative burst has several different pathways for activation. They demonstrate that the absence of a single PMN surface glycoprotein is associated with a broad spectrum of PMN functional abnormalities. Finally, the observations made in the parents support an autosomal recessive mode of inheritance.

Volume-dependent human blood polymorphonuclear leukocyte heterogeneity demonstrated with counterflow centrifugal elutriation.

Human peripheral blood polymorphonuclear leukocytes (PMNs) have recently been recognized as a heterogeneous population of cells. Consideration has not been given to the possibility that size may be an additional physical characteristic demonstrating heterogeneity. Using counterflow centrifugal elutriation, we have demonstrated that PMNs can be isolated into at least six volume-dependent fractions. A positive correlation exists for PMN size and superoxide anion release upon stimulation with f-Met-Leu-Phe or phorbol myristate acetate. Total granule contents were also noted to be greater in larger PMN fractions, with a constant percent of release upon stimulation. The implications of these findings are discussed.