A man in his forties with anal tumour and inguinal lymphadenopathy. / En mann i 40-årene med analtumor og lymfeknutesvulst i lysken.

A man in his late forties was examined for suspected cancer of the anal canal with spreading to inguinal lymph nodes. When biopsies failed to confirm malignant disease, other differential diagnoses had to be considered.

Tumor phosphatidylinositol 3-kinase signaling in therapy resistance and metastatic dissemination of rectal cancer: opportunities for signaling-adapted therapies.

Locally advanced rectal cancer (LARC) comprises heterogeneous tumors with predominant hypoxic components, a hallmark of the tumor microenvironment and determinant of resistance to cytotoxic therapies, local recurrence, and metastatic progression. A rational integration of molecularly targeted agents in established combined-modality treatment regimens may improve local and systemic disease control, but will require a clear definition of functional biomarkers for patient stratification. In a prospective study of LARC patients given neoadjuvant chemotherapy and radiation, we applied a kinase substrate array technology to analyze the patients' tumor biopsies sampled at the time of diagnosis, and observed that receptor tyrosine kinase activities integrated by high phosphatidylinositol 3-kinase signaling were correlated both with poor tumor response to the neoadjuvant treatment and adverse progression-free survival. Conceptually, the specific tumor signature of phosphatidylinositol 3-kinase signaling activity may point to actionable therapy targets in LARC patients with unfavorable disease features. Clinical trial registration number NCT00278694.

Tumor kinase activity in locally advanced rectal cancer: angiogenic signaling and early systemic dissemination.

Tumor hypoxia is a common determinant of resistance to cytotoxic therapies and metastatic behavior. In rectal cancer patients receiving preoperative chemoradiotherapy, tyrosine kinase activities in tumors with poor and good treatment responses were found to differ. Given that tyrosine kinase signaling mediates hypoxic tissue adaptation, the present study examined whether tumor kinase activity might also correlate with systemic dissemination of rectal cancer. Immunomagnetic selection of disseminated tumor cells (DTC) from bone marrow aspirates was undertaken in 55 patients with locally advanced rectal cancer. Using peptide arrays with 144 tyrosine kinase substrates, phosphopeptide signatures were generated from patients' baseline tumor biopsies, to study association between DTC and tumor tyrosine kinase activity regulated ex vivo by sunitinib. Disseminated tumor cells were detected in 60% of cases, and these patients had significantly poorer metastasis-free survival than patients without DTC. Phosphorylation of 31 array tyrosine kinase substrates by tumor samples was significantly more strongly inhibited by sunitinib in the DTC-negative patients, with a number of phosphosubstrates representing angiogenic factors. In this cohort of rectal cancer patients, tumor phenotypes defined by a subset of tyrosine kinase activities correlating with weak ex vivo inhibition by sunitinib, was associated with early systemic dissemination.

Prediction of response to preoperative chemoradiotherapy in rectal cancer by multiplex kinase activity profiling.

PURPOSE: Tumor response of rectal cancer to preoperative chemoradiotherapy (CRT) varies considerably. In experimental tumor models and clinical radiotherapy, activity of particular subsets of kinase signaling pathways seems to predict radiation response. This study aimed to determine whether tumor kinase activity profiles might predict tumor response to preoperative CRT in locally advanced rectal cancer (LARC). METHODS AND MATERIALS: Sixty-seven LARC patients were treated with a CRT regimen consisting of radiotherapy, fluorouracil, and, where possible, oxaliplatin. Pretreatment tumor biopsy specimens were analyzed using microarrays with kinase substrates, and the resulting substrate phosphorylation patterns were correlated with tumor response to preoperative treatment as assessed by histomorphologic tumor regression grade (TRG). A predictive model for TRG scores from phosphosubstrate signatures was obtained by partial-least-squares discriminant analysis. Prediction performance was evaluated by leave-one-out cross-validation and use of an independent test set. RESULTS: In the patient population, 73% and 15% were scored as good responders (TRG 1-2) or intermediate responders (TRG 3), whereas 12% were assessed as poor responders (TRG 4-5). In a subset of 7 poor responders and 12 good responders, treatment outcome was correctly predicted for 95%. Application of the prediction model on the remaining patient samples resulted in correct prediction for 85%. Phosphosubstrate signatures generated by poor-responding tumors indicated high kinase activity, which was inhibited by the kinase inhibitor sunitinib, and several discriminating phosphosubstrates represented proteins derived from signaling pathways implicated in radioresistance. CONCLUSIONS: Multiplex kinase activity profiling may identify functional biomarkers predictive of tumor response to preoperative CRT in LARC.

Vorinostat, a histone deacetylase inhibitor, combined with pelvic palliative radiotherapy for gastrointestinal carcinoma: the Pelvic Radiation and Vorinostat (PRAVO) phase 1 study.

BACKGROUND: Histone deacetylase (HDAC) inhibitors have shown radiosensitising activity in preclinical tumour models. This phase 1 study assessed the use of vorinostat combined with pelvic palliative radiotherapy for gastrointestinal carcinoma. METHODS: Between Feb 14, 2007, and May 18, 2009, eligible patients with histologically confirmed carcinoma, scheduled to receive pelvic palliative radiation to 30 Gy in 3 Gy daily fractions over 2 weeks, were enrolled into cohorts of escalating vorinostat dose. Vorinostat was administered orally once daily, 3 h before each radiotherapy fraction, at the following dose levels: 100 mg (n=1), 200 mg (n=4), 300 mg (n=6), and 400 mg (n=6). Endpoints included safety, tolerability, and biological activity (tumour histone acetylation). This study is registered with ClinicalTrials.gov, number NCT00455351. FINDINGS: One patient withdrew consent after one treatment day, leaving 16 patients evaluable for tolerability. Most recorded adverse events were grade 1 and 2, among which fatigue (all patients) and gastrointestinal events (all patients) were most common. Grade 3 adverse events included fatigue (n=5), anorexia (n=3), diarrhoea (n=2), hyponatraemia (n=1), hypokalaemia (n=1), and acneiform rash (n=1). Of these, treatment-related grade 3 events (ie, dose-limiting toxicities) were observed in one of six patients at vorinostat 300 mg once daily (fatigue and anorexia), and in two of six patients at vorinostat 400 mg once daily (two events of diarrhoea and one each of fatigue, anorexia, hyponatraemia, and hypokalaemia). The maximum-tolerated dose of vorinostat in combination with palliative radiotherapy was thus determined to be 300 mg once daily. Histone hyperacetylation was detected, indicating biological activity of vorinostat. INTERPRETATION: Vorinostat can be safely combined with short-term pelvic palliative radiotherapy. This study highlights the potential use of HDAC inhibitors with radiation, and suggests investigation of vorinostat in long-term curative pelvic radiotherapy--eg, as a component of preoperative chemoradiotherapy for rectal cancer. FUNDING: Merck & Co, Inc, Norwegian Cancer Society, Norwegian Health and Rehabilitation Foundation.

Radiosensitization by SAHA in experimental colorectal carcinoma models-in vivo effects and relevance of histone acetylation status.

PURPOSE: Histone deacetylase inhibitors are being evaluated as antitumor agents in ongoing clinical trials, and promising preclinical results, combined with favorable toxicity profiles, have rendered the drugs as interesting candidates for combination with other treatment modalities, such as radiotherapy. The aim of the present study was to evaluate the radiosensitizing properties of suberoylanilide hydroxamic acid (SAHA) and the possible requirement of histone hyperacetylation at radiation exposure. METHODS AND MATERIALS: Radiosensitization by SAHA was assessed in a colorectal carcinoma cell line and in two colorectal xenograft models by analysis of clonogenic survival and tumor growth delay, respectively. Histone acetylation status at radiation exposure was evaluated by Western blot. RESULTS: In vitro, radiosensitization was demonstrated when cells were preincubated with SAHA, and, in the xenografts, tumor growth was delayed when the mice were treated with fractionated radiation combined with daily SAHA injections compared with radiation alone. Surprisingly, the SAHA-dependent growth delay was still present when radiation was delivered at restored baseline acetylation levels compared with maximal histone hyperacetylation. CONCLUSION: SAHA was an effective radiosensitizer in experimental colorectal carcinoma models, suggesting that histone deacetylase inhibition might constitute a valuable supplement to current multimodal treatment strategies in rectal cancer. The presence of histone hyperacetylation at radiation was not required to obtain an increased radiation response, questioning the validity of using histone hyperacetylation as a molecular marker for radiosensitivity.

Inhibitory effects of oxaliplatin in experimental radiation treatment of colorectal carcinoma: does oxaliplatin improve 5-fluorouracil-dependent radiosensitivity?

BACKGROUND AND PURPOSE: New chemoradiotherapy regimens for rectal cancer with integration of oxaliplatin with 5-fluorouracil-based therapy are being actively investigated. However, only limited preclinical data are available on oxaliplatin as radiosensitizer in colorectal carcinoma. MATERIALS AND METHODS: A human colorectal carcinoma cell line (HT29) was exposed to ionizing radiation with or without oxaliplatin and/or 5-fluorouracil, upon which clonogenicity and cell cycle profiles were analyzed. HT29 xenografts were treated for two weeks with daily radiation and/or the oral 5-fluorouracil analog capecitabine with or without oxaliplatin once weekly, and tumor volumes were followed for up to 60 days. RESULTS: Pretreatment of HT29 cells with oxaliplatin for 2h, followed by radiation and a 48-h exposure to 5-fluorouracil, resulted in increased radiocytotoxicity, and combination index analysis indicated synergistic effects. Ionizing radiation and oxaliplatin induced cell cycle G(2)/M phase arrest in HT29 cells at distinctly different time points. Growth of HT29 xenografts was clearly inhibited by radiation. Capecitabine and oxaliplatin together significantly improved the inhibitory effect, but oxaliplatin did not add to the growth inhibitory response induced by radiation plus capecitabine. CONCLUSIONS: The combination of oxaliplatin and 5-fluorouracil sensitized colorectal carcinoma cells to ionizing radiation in vitro. In vivo, however, oxaliplatin did not convincingly improve the increased radiocytotoxicity conferred by capecitabine treatment. In the absence of conclusive clinical evidence, the integration of OXA into combined-modality treatment of rectal cancer must remain controversial.

Early changes in apparent diffusion coefficient predict the quantitative antitumoral activity of capecitabine, oxaliplatin, and irradiation in HT29 xenografts in athymic nude mice.

PURPOSE: The purpose of this study was to evaluate the possible use of changes in apparent diffusion coefficient (ADC) measured by magnetic resonance imaging for pretreatment prediction and early detection of tumor response in a mouse model during fractionated chemoradiotherapy. MATERIALS AND METHODS: Athymic mice with bilateral HT29 xenografts on rear flanks were allocated into three groups: control, capecitabine, and capecitabine and oxaliplatin. The left flanks of the mice received daily irradiation. T2 and diffusion images were acquired before therapy and weekly for the following 9 weeks. Pretreatment and changes in ADC were calculated and compared with tumor doubling growth delay. RESULTS: No correlations between pretreatment ADC and changes in tumor volumes after therapy were seen. All treated tumors, except those receiving capecitabine (P = .06), showed increased mean tumor ADC values 11 days after initialization of therapy (P < .05) before returning to pretreatment values within 5 days posttherapy (day 18 after onset of therapy). This increase in mean tumor ADC showed a strong positive correlation (r = 0.92, P < .01) with mean tumor doubling growth delay. CONCLUSIONS: Pretreatment ADC values did not predict the effectiveness of therapy, whereas early changes in mean ADC quantitatively correlated with treatment outcome.

Radiosensitization of colorectal carcinoma cell lines by histone deacetylase inhibition.

BACKGROUND: The tumor response to preoperative radiotherapy of locally advanced rectal cancer varies greatly, warranting the use of experimental models to assay the efficacy of molecular targeting agents in rectal cancer radiosensitization. Histone deacetylase (HDAC) inhibitors, agents that cause hyperacetylation of histone proteins and thereby remodeling of chromatin structure, may override cell cycle checkpoint responses to DNA damage and amplify radiation-induced tumor cell death. METHODS: Human colorectal carcinoma cell lines were exposed to ionizing radiation and HDAC inhibitors, and cell cycle profiles and regulatory factors, as well as clonogenicity, were analyzed. RESULTS: In addition to G(2)/M phase arrest following irradiation, the cell lines displayed cell cycle responses typical for either intact or defective p53 function (the presence or absence, respectively, of radiation-induced expression of the cell cycle inhibitor p21 and subsequent accumulation of G(1) phase cells). In contrast, histone acetylation was associated with complete depletion of the G1 population of cells with functional p53 but accumulation of both G(1) and G(2)/M populations of cells with defective p53. The cellular phenotypes upon HDAC inhibition were consistent with the observed repression of Polo-like kinase-1, a regulatory G(2)/M phase kinase. Following pre-treatment with HDAC inhibitors currently undergoing clinical investigation, the inhibitory effect of ionizing radiation on clonogenicity was significantly amplified. CONCLUSION: In these experimental models, HDAC inhibition sensitized the tumor cells to ionizing radiation, which is in accordance with the concept of increased probability of tumor cell death when chromatin structure is modified.

DNA damage responses in cell cycle G2 phase and mitosis--tracking and targeting.

BACKGROUND: In order to determine temporal responses of cell cycle populations to DNA damage, a rational combination of cell cycle analyses is critical. Moreover, the targeting of cell cycle checkpoint responses may modify the cytotoxic effect of DNA damage. MATERIALS AND METHODS: The characteristics of cell cycle populations (DNA content, cell cycle transitioning of S phase cells and size of mitotic cell fraction within the total G2/M phase population) in HeLa cells exposed to ionizing radiation were analyzed using three individual flow cytometry-based assays. The potential radiosensitization from inhibiting DNA damage responses was assessed by the colony formation assay. RESULTS: Irradiation resulted in an initial accumulation of S phase cells in G2 phase, from which the arrested cells were subsequently released to enter mitosis. Upon drug inhibition of G2 checkpoint signaling or mitotic progression, the cytotoxic effect of ionizing radiation on the HeLa cells was amplified. CONCLUSION: DNA damage-induced cell cycle responses, analyzed by selected cytometry assays and modified by specific targeting, might contribute to an understanding of how to improve radiotherapy outcome.

Male infertility in Zimbabwe.

OBJECTIVES: There are very few studies on male infertility in sub-Saharan Africa. Sub-Saharan countries tend not to research male infertility because of economic reasons and, possibly, the psychological denial of the problem. METHODS: The participants in the present study were 311 men with infertility problems who had been referred to the Andrology Clinic of the University of Zimbabwe. They were investigated by means of a clinical interview, a clinical examination, semen analysis and various endocrine tests. RESULTS: It was found that 78% of the respondents had ever had a sexually transmitted disease. Most of the respondents reported that their infertility caused them stress and reported signs of mild depression. Most men mentioned also to seek treatment based on traditional methods. Men blamed that their wife was the reason of their childlessness. CONCLUSION: This study shows the importance of understanding both the cultural and the medical aspects of male infertility. Male infertility is a significant medical and psychological problem in Zimbabwe. PRACTICE IMPLICATION: Men should promptly be diagnosed and treated for STIs. Health education and teaching people about STDs and HIV in general about this are essential to the process of preventing male infertility.