Predictors of radiation necrosis in long-term survivors after Gamma Knife stereotactic radiosurgery for brain metastases.

BACKGROUND: The long-term risk of necrosis after radiosurgery for brain metastases is uncertain. We aimed to investigate incidence and predictors of radiation necrosis for individuals with more than 1 year of survival after radiosurgery for brain metastases. METHODS: Patients who had a diagnosis of brain metastases treated between December 2006 and December 2014, who had at least 1 year of survival after first radiosurgery were retrospectively reviewed. Survival was analyzed using the Kaplan-Meier estimator, and the incidence of radiation necrosis was estimated with death or surgical resection as competing risks. Patient and treatment factors associated with radiation necrosis were also analyzed. RESULTS: A total of 198 patients with 732 lesions were analyzed. Thirty-four lesions required salvage radiosurgery and 10 required salvage surgical resection. Median follow-up was 24 months. The estimated median survival for this population was 25.4 months. The estimated per-lesion incidence of radiation necrosis at 4 years was 6.8%. Medical or surgical therapy was required for 60% of necrosis events. Tumor volume and male sex were significant factors associated with radiation necrosis. The per-lesions incidence of necrosis for patients undergoing repeat radiosurgery was 33.3% at 4 years. CONCLUSIONS: In this large series of patients undergoing radiosurgery for brain metastases, patients continued to be at risk for radiation necrosis throughout their first 4 years of survival. Repeat radiosurgery of recurrent lesions greatly exacerbates the risk of radiation necrosis, whereas treatment of larger target volumes increases the risk modestly.

Pulsed Radiation Therapy With Concurrent Cisplatin Results in Superior Tumor Growth Delay in a Head and Neck Squamous Cell Carcinoma Murine Model.

PURPOSE: To assess the efficacy of 3-week schedules of low-dose pulsed radiation treatment (PRT) and standard radiation therapy (SRT), with concurrent cisplatin (CDDP) in a head and neck squamous cell carcinoma xenograft model. METHODS AND MATERIALS: Subcutaneous UT-SCC-14 tumors were established in athymic NIH III HO female mice. A total of 30 Gy was administered as 2 Gy/d, 5 d/wk for 3 weeks, either by PRT (10 × 0.2 Gy/d, with a 3-minute break between each 0.2-Gy dose) or SRT (2 Gy/d, uninterrupted delivery) in combination with concurrent 2 mg/kg CDDP 3 times per week in the final 2 weeks of radiation therapy. Treatment-induced growth delays were defined from twice-weekly tumor volume measurements. Tumor hypoxia was assessed by (18)F-fluoromisonidazole positron emission tomography imaging, and calculated maximum standardized uptake values compared with tumor histology. Tumor vessel density and hypoxia were measured by quantitative immunohistochemistry. Normal tissues effects were evaluated in gut and skin. RESULTS: Untreated tumors grew to 1000 mm(3) in 25.4 days (±1.2), compared with delays of 62.3 days (±3.5) for SRT + CDDP and 80.2 days (±5.0) for PRT + CDDP. Time to reach 2× pretreatment volume ranged from 8.2 days (±1.8) for untreated tumors to 67.1 days (±4.7) after PRT + CDDP. Significant differences in tumor growth delay were observed for SRT versus SRT + CDDP (P=.04), PRT versus PRT + CDDP (P=.035), and SRT + CDDP versus PRT + CDDP (P=.033), and for survival between PRT versus PRT + CDDP (P=.017) and SRT + CDDP versus PRT + CDDP (P=.008). Differences in tumor hypoxia were evident by (18)F-fluoromisonidazole positron emission tomography imaging between SRT and PRT (P=.025), although not with concurrent CDDP. Tumor vessel density differed between SRT + CDDP and PRT + CDDP (P=.011). No differences in normal tissue parameters were seen. CONCLUSIONS: Concurrent CDDP was more effective in combination PRT than SRT at restricting tumor growth. Significant differences in tumor vascular density were evident between PRT and SRT, suggesting a preservation of vascular network with PRT.

Surgical Resection of Brain Metastases and the Risk of Leptomeningeal Recurrence in Patients Treated With Stereotactic Radiosurgery.

PURPOSE: Recent prospective data have shown that patients with solitary or oligometastatic disease to the brain may be treated with upfront stereotactic radiosurgery (SRS) with deferral of whole-brain radiation therapy (WBRT). This has been extrapolated to the treatment of patients with resected lesions. The aim of this study was to assess the risk of leptomeningeal disease (LMD) in patients treated with SRS to the postsurgical resection cavity for brain metastases compared with patients treated with SRS to intact metastases. METHODS AND MATERIALS: Four hundred sixty-five patients treated with SRS without upfront WBRT at a single institution were identified; 330 of these with at least 3 months' follow-up were included in this analysis. One hundred twelve patients had undergone surgical resection of at least 1 lesion before SRS compared with 218 treated for intact metastases. Time to LMD and overall survival (OS) time were estimated from date of radiosurgery, and LMD was analyzed by the use of cumulative incidence method with death as a competing risk. Univariate and multivariate analyses were performed with competing risk regression to determine whether various clinical factors predicted for LMD. RESULTS: With a median follow-up time of 9.0 months, 39 patients (12%) experienced LMD at a median of 6.0 months after SRS. At 1 year, the cumulative incidence of LMD, with death as a competing risk, was 5.2% for the patients without surgical resection versus 16.9% for those treated with surgery (Gray test, P<.01). On multivariate analysis, prior surgical resection (P<.01) and breast cancer primary (P=.03) were significant predictors of LMD development. The median OS times for patients undergoing surgery compared with SRS alone were 12.9 and 10.6 months, respectively (log-rank P=.06). CONCLUSIONS: In patients undergoing SRS with deferral of upfront WBRT for intracranial metastatic disease, prior surgical resection and breast cancer primary are associated with an increased risk for the development of LMD.

Tumor volume as a predictor of survival and local control in patients with brain metastases treated with Gamma Knife surgery.

OBJECT: The aim of this study was to examine tumor volume as a prognostic factor for patients with brain metastases treated with Gamma Knife surgery (GKS). METHODS: Two hundred fifty patients with 1-14 brain metastases who had initially undergone GKS alone at a single institution were retrospectively reviewed. Patients who received upfront whole brain radiation therapy were excluded. Survival times were estimated using the Kaplan-Meier method. Univariate and multivariate analyses using Cox proportional hazard regression models were used to determine if various prognostic factors could predict overall survival, distant brain failure, and local control. RESULTS: Median overall survival was 7.1 months and the 1-year local control rate was 91.5%. Median time to distant brain failure was 8.0 months. On univariate analysis an increasing total tumor volume was significantly associated with worse survival (p = 0.031) whereas the number of brain metastases, analyzed as a continuous variable, was not (p = 0.082). After adjusting for age, Karnofsky Performance Scale score, and extracranial disease on multivariate analysis, total tumor volume was found to be a better predictor of overall survival (p = 0.046) than number of brain metastases analyzed as a continuous variable (p = 0.098). A total tumor volume cutoff value of ≥ 2 cm(3) (p = 0.008) was a stronger predictor of overall survival than the number of brain metastases (p = 0.098). Larger tumor volume and extracranial disease, but not the number of brain metastases, were predictive of distant brain failure on multivariate analysis. Local tumor control at 1 year was 97% for lesions < 2 cm(3) compared with 75% for lesions ≥ 2 cm(3) (p < 0.001). CONCLUSIONS: After adjusting for other factors, a total brain metastasis volume was a strong and independent predictor for overall survival, distant brain failure, and local control, even when considering the number of metastases.

Direct effect of cocaine on epigenetic regulation of PKCepsilon gene repression in the fetal rat heart.

Maternal cocaine administration during gestation caused a down-regulation of PKCepsilon expression in the heart of adult offspring resulting in an increased sensitivity to ischemia and reperfusion injury. The present study investigated the direct effect of cocaine in epigenetic modification of PKCepsilon gene repression in the fetal heart. Hearts were isolated from gestational day 17 fetal rats and treated with cocaine in an ex vivo organ culture system. Cocaine treatment for 48 h resulted in significant decreases in PKCepsilon protein and mRNA abundance and increases in CpG methylation at two SP1 binding sites in the PKCepsilon promoter region (-346 and -268). Electrophoretic mobility shift assays demonstrated that CpG methylation of both SP1 sites inhibited SP1 binding. Consistently, chromatin immunoprecipitation assays showed that cocaine treatment significantly decreased binding of SP1 to the SP1 sites in the intact fetal heart. Reporter gene assays revealed that site-directed mutations of CpG methylation at both SP1 sites significantly reduced the PKCepsilon promoter activity while methylation of a single site at either -346 or -268 did not have a significant effect. The causal effect of increased methylation in the cocaine-induced down-regulation of PKCepsilon was demonstrated with the use of DNA methylation inhibitors. The presence of either 5-aza-2'-deoxycytodine or procainamide blocked the cocaine-induced increase in SP1 sites methylation and decrease in PKCepsilon mRNA. The results demonstrate a direct effect of cocaine in epigenetic modification of DNA methylation and programming of cardiac PKCepsilon gene repression linking prenatal cocaine exposure and pathophysiological consequences in the heart of adult offspring.

Prenatal cocaine exposure abolished ischemic preconditioning-induced protection in adult male rat hearts: role of PKCepsilon.

Prenatal cocaine exposure in rats resulted in decreased PKCepsilon protein expression in the heart of adult male but not female offspring. The present study determined its functional consequence of inhibiting cardioprotection mediated by ischemic preconditioning. Pregnant Sprague-Dawley rats were administered intraperitoneally saline or cocaine (30 mg.kg(-1).day(-1)) from day 15 to day 21 of gestational age. Hearts were isolated from 3-mo-old offspring and were subjected to ischemia and reperfusion injury in a Langendorff preparation, with or without prior ischemic preconditioning. Preischemic values of left ventricular function were the same between the saline control and cocaine-treated animals. Ischemic preconditioning of two episodes of 5-min ischemia significantly decreased infarct size and enhanced postischemic functional recovery of the left ventricle in the saline control animals. This ischemic preconditioning was associated with increased phospho-PKCepsilon, but not phospho-PKCdelta, levels and was blocked by a PKCepsilon translocation inhibitor peptide. Prenatal cocaine treatment abolished the ischemic preconditioning-mediated increase in phospho-PKCepsilon and cardioprotection in the heart of male offspring. In contrast, the cardioprotective effect was fully maintained in female offspring that were exposed to cocaine before birth. The results suggest that prenatal cocaine exposure causes a sex-specific loss of cardioprotection by ischemic preconditioning in adult offspring, which is most likely due to fetal programming of PKCepsilon gene repression, resulting in a downregulation of PKCepsilon function in the heart of adult male offspring.

A new approach for exploring functional development of fetal brain pathways.

Study of functional development of central pathways in fetuses is challenging due to the lack of methods available. In this article, we present a novel approach to test if and when central functional pathways are established by a combination of mapping with c-fos and chronically cannulated fetuses in utero. This approach is based on brain structures such as circumventricular organs (CVOs) that lack the blood-brain barrier (BBB), but are rich in sensors to peripheral signals and contain projections to other brain regions. If signaling molecules in the blood that are too large to cross the BBB induced c-fos expression in both the CVOs and other nuclei inside the fetal brain, this can be evidence that projections from the CVOs to those nuclei are established and functional. This is a useful real-time method to explore the status of functional maturation of pathways between the CVOs and other brain areas in developing fetuses. Notably, at the moment, this is the first and only in vivo method that can detect functional projections in the fetal brain in vitro.

Short- and long-term adverse effects of cocaine abuse during pregnancy on the heart development.

The effect of cocaine on the developing fetus is a topic of considerable interest and debate. One of the potential effects of fetal cocaine exposure is damage to the developing heart. This review provides an overview of the current understanding of the short- and long-term effects of fetal cocaine exposure on the heart in both humans and animal models. Human studies are still preliminary but have suggested that fetal cocaine exposure impacts on the developing heart. Studies in animal models provide strong evidence for a programming effect resulting in detrimental long-term changes to the heart induced by fetal cocaine exposure. In the rat model, fetal cocaine results in apoptosis in the term heart, left ventricular remodeling and myocyte hypertrophy, as well as increased sensitivity to ischemia/reperfusion injury in the adult male offspring. The rat model has also shown evidence of epigenetic modifications in response to intrauterine cocaine. Increased DNA methylation of promoter regions leads to a long-term decrease in the expression of the cardioprotective gene, PKCepsilon. The current data shows fetal cocaine exposure has significant immediate and long-term cardiac consequences in animal models and while human studies are still incomplete they suggest this phenomenon may also be significant in humans exposed to cocaine during development.

Fetal exposure to cocaine causes programming of Prkce gene repression in the left ventricle of adult rat offspring.

Previous studies demonstrated that maternal cocaine administration caused a significant decrease in protein kinase C epsilon (PRKCE) abundance in the left ventricle and an increase in susceptibility of the heart to ischemic injury in adult male offspring. The present study tested the hypothesis that epigenetic modification has a key role in cocaine-mediated programming of cardiac Prkce gene repression. Pregnant Sprague-Dawley rats were administered saline or cocaine (30 mg/kg/day i.p.) from Days 15 to 21 of gestational age, and hearts of 3-mo-old adult offspring were studied. Cocaine exposure significantly decreased Prkce mRNA levels in the left ventricle of male but not female offspring. CpG dinucleotides identified in Bhlhb2, Pparg, E2f, and Egr1 binding sites at the Prkce gene promoter were densely methylated in males and females and were unaffected by cocaine exposure. In contrast, methylation of CpGs in the two Sp1 binding sites (-346 and -268) was low and was significantly increased by cocaine exposure in male offspring. In females, methylation of the Sp1 binding site at -268 but not -346 was increased. Reporter gene assays showed that both Sp1 binding sites had a strong stimulatory role in Prkce gene activity. Methylation of the Sp1 binding sites significantly decreased SP1 binding to the Prkce promoter. Cocaine exposure did not affect nuclear SP1 protein levels but decreased the SP1 binding affinity to its binding site at -268. The results demonstrate an epigenetic mechanism of DNA methylation in programming of cardiac Prkce gene repression, linking fetal cocaine exposure and pathophysiological consequences in the heart of adult male offspring in a gender-dependent manner.

Fetal programming of cardiac function and disease.

Fetal programming describes long-term adaptive changes that an organism undergoes in response to an intrauterine insult. This term was coined to describe the increased incidence of adult disease, such as cardiovascular disease, seen among populations that suffered an intrauterine insult. While changes induced by such an insult may be initially beneficial, they can have deleterious long-term effects. Cardiac programming effects can be induced by maternal diet alterations, fetal exposure to increased levels of corticosteroids, chronic fetal hypoxia and anemia, and maternal use of nicotine or cocaine. These stimuli result in a variety of changes in cardiac function and gene expression, many of which persist into adulthood. A possible mediator of these changes is an alteration in the DNA methylation pattern of the cardiomyocytes. This review gives an overview of the changes that have been observed in the heart in response to various programming stimuli and potential programming mechanisms.

Adsorption of liquid-phase alkane mixtures in silicalite: simulations and experiment.

A combination of experimental and computational studies of adsorption from liquid-phase mixtures of linear alkanes in the zeolite silicalite is presented here. Configurational biased grand canonical Monte Carlo simulations combined with identity-swap moves are used to equilibrate the simulations in reasonable times. Interesting trends observed in experiments have been captured quantitatively by simulations. A siting analysis of the simulation data reveals that, during adsorption from a liquid mixture, shorter alkanes prefer the zigzag channels and longer alkanes concentrate in the straight channels of silicalite.

Morphometric analysis of cytolysis in cultured cell monolayers: a simple and versatile method for the evaluation of the lytic activity and the fate of LAK cells.

The assessment of cytolytic activity of killer cells may not only be useful to improve routine analysis, e.g., in clinical settings, but may also offer new opportunities for the fundamental analysis of the mutual interaction between cytotoxic cells and their targets. We have developed a morphometric method to estimate cytolytic activity of activated natural killer (NK) cells by measuring the clearance of a precultured confluent monolayer of adherent target cells, e.g., immortalized fibroblasts. Cytotoxic cells are inoculated on top of confluent monolayers of target cells and after 2 h, nonadherent cells are washed off and intact adherent cells are fixed and stained with a Coomassie blue solution. Elementary computer-assisted analysis of the resulting microscopic images and measurement of the cleared area provide us with a sensitive and reproducible parameter of target cell lysis. We found that the assay can be used with targets of very different origin, as long as they form confluent monolayers, and with different populations of killer cells. The morphometric cytotoxicity assay (MoCA) offers several advantages: storage of samples for postponed analysis, increased sensitivity as compared to radioactive assays, continuous visualization during assay, availability of targets and effectors for subsequent analysis after interaction.

Morphometric analysis of cytolysis in cultured cell monolayers: a simple and versatile method for the evaluation of the cytotoxic activity and the fate of LAK cells.

In vitro techniques for the evaluation of the cytotoxicity of immune cells are important both for the routine assessment of the cytolytic activity in samples for clinical or experimental use and for basic studies of the interaction between killer and target cells. Especially in the latter case, it is important not only to quantify target cell death as an endpoint, but also to observe the interaction and to recover effectors and targets for further analysis. We present a new method that offers considerable improvements for both types of applications, in comparison with the standard radioactivity release assays used today. The morphometric cytotoxicity assay (Mo.C.A.) estimates the extent of target cell lysis by measuring the openings that appear in a confluent monolayer of adherent cells as killed cells detach from the plastic on which they were spread. Two hours after the inoculation of the effector cells, nonadherent killer and dead target cells are washed off and the remaining monolayer is fixed and stained with Coomassie blue. Elementary computer-assisted image analysis allows then to calculate the percentage of open space, which is a parameter for the extent of lysis. As the Mo.C.A. is easy, and does not rely on the use of radioactive compounds or sophisticated equipment, we provide evidence that it should be valuable for the routine analysis of cytotoxicity in various cell samples. In addition, the method offers great flexibility in the choice of target cells and allows for continuous microscopic observation of the live cultures. The interaction can also be stopped at any time, and the effector and (unlabeled) target cells can be recovered separately. Therefore, the method should also offer new possibilities for the basic study of killer cell biology.