Anastrozole (‘Arimidex’) versus tamoxifen as first-line therapy in postmenopausal women with advanced breast cancer: Results of the double-blind cross-over SAKK trial 21/95 - a sub-study of the TARGET (Tamoxifen or ‘Arimidex’ Randomized Group Efficacy and Tolerability) trial

It is desirable to identify the most effective sequence of endocrine therapies for the treatment of postmenopausal women with advanced, hormone-responsive breast cancer. In a retrospective analysis of two large, randomized, comparative Phase III trials in this patient population, the Tamoxifen or Arimidex Randomized Group Efficacy and Tolerability (TARGET) trial and the North American trial, we ascertained that tumors responding to anastrozole as first-line therapy may subsequently respond to tamoxifen as second-line therapy. In a double-blind cross-over trial, the SAKK 21/95 sub-trial (including patients from the Swiss centres in the TARGET trial), we further investigated the clinical impact of anastrozole followed by tamoxifen compared with that of tamoxifen followed by anastrozole. Patients with locally advanced or metastatic breast cancer who had continued on randomized treatment until objective disease progression and were still considered suitable for endocrine therapy, could continue on blinded therapy crossing-over to the alternative treatment. They were assessed for time to progression (TTP) from treatment randomization, TTP after crossing-over treatments, time from randomization to progression after crossing-over treatments and overall survival. Median TTP from randomization for patients receiving first-line treatment with anastrozole (n= 31) and tamoxifen (n= 29) was 11.3 and 8.3 months, respectively, p= 0.75. Median TTP from treatment cross-over was 6.7 months for tamoxifen after progression on anastrozole (n= 19) and 5.7 months for anastrozole after progression on tamoxifen (n= 18), while median time from randomization to second progression was 28.2 and 19.5 months, respectively. Overall survival from randomization for the anastrozole-tamoxifen sequence and the tamoxifen-anastrozole sequence was 69.7 versus 59.3 months, respectively, p= 0.10. The relative risk of death was higher for the tamoxifen followed by anastrozole sequence (1.63; 95% confidence interval [CI] 0.89–2.98). Tamoxifen is an effective second-line therapy after anastrozole. Our data, together with the better tolerability profile of anastrozole compared with tamoxifen, support the use of anastrozole as first-line therapy for advanced breast cancer in postmenopausal women with hormone receptor-positive tumors. Treatment with tamoxifen may still be useful upon subsequent progression.     

Magnetic resonance imaging provides accurate and precise volume determination of the regenerating mouse liver

Direct and repetitive noninvasive determination of the time course and the strain-specific hepatic regenerative capacity after partial hepatectomy can extend our knowledge about the basic mechanisms of liver regeneration and repair. The aim of this study was to develop a magnetic resonance (MR)-based volumetric procedure to measure the hepatic volume in the regenerating mouse liver. In Balb-C mice (n = 14), varying amounts of liver tissue were resected and MR imaging was performed 24 hours later in a 1.5 TeslaMagnet Unit. Three dimensional (3D) T1- (volumetric interpolated breath-hold examination [VIBE] sequence) and T2-weighted images were acquired with continuous 1-mm thin slices. Animals with and without intravenous administration of paramagnetic contrast agents were compared. Immediately after MR examination, mice were euthanized and livers were weighted. The liver volume was determined on MR images using Cavalieri’s method and linear regression analysis was performed from the data obtained. Correlation coefficients between the liver volume measured by MR and the liver weight were 0.98 (T1) and 0.94 (T2) in the group without paramagnetic contrast injection and 0.70 (T1) and 0.96 (T2) after paramagnetic contrast application. We conclude that MR-based liver volumetry allows precise liver volume measurement during hepatic regeneration after partial hepatectomy in mice and can be a valuable tool with regard to experimental hepatology. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 (poster presentation).     

Postpericardiotomy syndrome after minimally invasive repair of pectus excavatum

Minimally invasive repair of pectus excavatum (MIRPE) was first reported in 1998 and has gained wide acceptance since then. A 17-year-old girl who had undergone thoracotomy and cardiac surgery for transposition of great vessels at the age of 18 months presented with a deep, long pectus excavatum with asymmetry. After initial uneventful postoperative clinical course after MIRPE, the patient had bilateral pleural and pericardial effusion on the sixth postoperative day. Suspecting postpericardiotomy syndrome, systemic steroids were administered, and the symptoms resolved without affecting wound healing. Manifestation of a pericardial effusion combined with bilateral pleural effusion after MIRPE, especially in patients after cardiac surgery, may indicate a postpericardiotomy syndrome that can be treated successfully by intravenous steroids.     

Thrombin binding to GPIbalpha induces integrin alphaIIbbeta3 dependent platelet adhesion to fibrin in ex vivo flowing whole blood

We have investigated the role of the thrombin/GPIbalpha interaction in the adhesion of platelets to fibrin in a whole blood ex vivo perfusion model at a shear rate of 280 s(-1). Blood was perfused through parallel-plate chambers containing coverslips coated with cells expressing tissue factor, leading to the generation of thrombin and thus, deposition of fibrin onto the exposed cells. Adhesion of platelets to fibrin and thrombus growth were analyzed. Interestingly, when GPIbalpha was removed from the platelet surface by action of mocarhagin, platelet adhesion on fibrin was inhibited. Furthermore, a monoclonal antibody, VM16d, directed against the thrombin binding site on GPIbalpha also inhibited platelet adhesion on fibrin, showing the importance of the thrombin/GPIbalpha interaction.We then looked at the involvement of alphaIIbbeta3 and showed that platelet adhesion and thrombus growth on fibrin were inhibited by the dodecapeptide, whereas lamifiban only inhibited the growth of the platelet thrombus. These results indicated that binding of thrombin to GPIbalpha induced an intracellular signaling leading to the interaction of the platelet integrin alphaIIbbeta3 with the fibrin-dodecapeptide sequence.     

Involvement of brain-derived neurotrophic factor in cannabinoid receptor-dependent protection against excitotoxicity

Cannabinoid type 1 (CB1) receptors play a central role in the protection against excitotoxicity induced by treatment of mice with kainic acid (KA). As inactivation of CB1 receptor function in mice blocks KA-induced increase of brain-derived neurotrophic factor (BDNF) mRNA levels in hippocampus, the notion was put forward that BDNF might be a mediator, at least in part, of CB1 receptor-dependent neuroprotection [Marsicano et al. (2003) Science, 302, 84-88]. To assess this signalling cascade in more detail, organotypic hippocampal slice cultures were used, as this in vitro system conserves morphological and functional properties of the hippocampus. Here, we show that both genetic ablation of CB1 receptors and pharmacological blockade with the specific CB1 receptor antagonist SR141716A increased the susceptibility of the in vitro cultures to KA-induced excitotoxicity, leading to extensive neuronal death. Next, we found that the application of SR141716A to hippocampal cultures from wild-type mice abolished the KA-induced increase in BDNF protein levels. Therefore, we tried to rescue these organotypic cultures from neuronal death by exogenously applied BDNF. Indeed, BDNF was sufficient to prevent KA-induced neuronal death after blockade of CB1 receptor signalling. In conclusion, our results strongly suggest that BDNF is a key mediator in CB1 receptor-dependent protection against excitotoxicity, and further underline the physiological importance of the endogenous cannabinoid system in neuroprotection.     

The fate of intravenously administered tetrahydrobiopterin and its implications for heterologous gene therapy of phenylketonuria

Tetrahydrobiopterin (BH(4)) is a required cofactor for the enzymatic activity of phenylalanine hydroxylase (PAH) and is synthesized de novo from GTP in several tissues. Heterologous expression of PAH in tissues other than liver is a potential novel therapy for human phenylketonuria that is completely dependent upon BH(4) supply in the PAH-expressing tissue. Previous experiments with liver PAH-deficient transgenic mice that expressed PAH in skeletal muscle demonstrated transient correction of hyperphenylalaninemia only with hourly parenteral BH(4) administration. In this report, the fate of intravenously administered BH(4) is examined. The conclusions are that (1) BH(4) administered intravenously is rapidly taken up by liver and kidney, and (2) uptake of BH(4) into muscle is relatively low. The levels of BH(4) achieved in skeletal muscle following IV injection are only 10% of the amount expected were BH(4) freely and equally distributed across all tissues. The half-life of BH(4) in muscle is approximately 30 min, necessitating repeated injections to maintain muscle BH(4) content sufficient to support phenylalanine hydroxylation. The efficacy of heterologous muscle-directed gene therapy for the treatment of PKU will likely be limited by the BH(4) supply in PAH-expressing muscle.     

Exploring amyloid formation by a de novo design

Protein deposition as amyloid fibrils underlies many debilitating human disorders. The complexity and size of disease-related polypeptides, however, often hinders a detailed rational approach to study effects that contribute to the process of amyloid formation. We report here a simplified peptide sequence successfully designed de novo to fold into a coiled-coil conformation under ambient conditions but to transform into amyloid fibrils at elevated temperatures. We have determined the crystal structure of the coiled-coil form and propose a detailed molecular model for the peptide in its fibrillar state. The relative stabilities of the two structural forms and the kinetics of their interconversion were found to be highly sensitive to small sequence changes. The results reveal the importance of specific packing interactions on the kinetics of amyloid formation and show the potential of this exceptionally favorable system for probing details of the molecular origins of amyloid disease.     

Medial ankle instability

Medial instability is suspected on the basis of a patient's ankle feeling like it is "giving way," especially medially, when walking on uneven ground, downhill, or down stairs, pain at the anteromedial aspect of the ankle, and sometimes pain in the lateral ankle, especially during dorsiflexion of the foot. A history of a chronically unstable feeling that is manifested by recurrent injuries with pain, tenderness, and sometimes bruising over the medial and lateral ligaments, is considered to indicate combined medial and lateral instability that is believed to result in rotational instability of the talus in the ankle mortise. Pain on the medial gutter of the ankle and a valgus and pronation deformity of the foot are hallmarks of the disorder. The deformity typically can be corrected by the activation of the posterior tibial muscle. In contrast to stress radiographs, arthroscopy is a helpful diagnostic tool in verifying medial instability; it proved that the lateral ankle ligaments also can be involved. The treatment for symptomatic medial instability of the ankle might include reconstruction of all involved ligaments at the medial, and, if necessary, the lateral ankle. In the case of progressed foot deformity or bilateral long-standing valgus and pronation deformity of the foot, an additional calcaneal lengthening osteotomy might be considered. A classification of the instability into three types has been helpful for determining surgical treatment and the after treatment. This treatment concept provides high patient satisfaction and reliable clinical results.     

Unexpected Clobetasol Propionate Profile in Human Stratum Corneum After Topical Application in Vitro

PURPOSE: The validity of using drug amount-depth profiles in stratum corneum to predict uptake of clobetasol propionate into stratum corneum and its transport into deeper skin layers was investigated. METHODS: In vitro diffusion experiments through human epidermis were carried out using Franz-type glass diffusion cells. A saturated solution of clobetasol propionate in 20% (V/V) aqueous propylene glycol was topically applied for 48 h. Steady state flux was calculated from the cumulative amount of drug permeated vs. time profile. Epidermal partitioning was conducted by applying a saturated drug solution to both sides of the epidermis and allowing time to equilibrate. The tape stripping technique was used to define drug concentration-depth profiles in stratum corneum for both the diffusion and equilibrium experiments. RESULTS: The concentration-depth profile of clobetasol propionate in stratum corneum for the diffusion experiment is biphasic. A logarithmic decline of the drug concentration over the first four to five tape strips flattens to a relatively constant low concentration level in deeper layers. The drug concentration-depth profile for the equilibrium studies displays a similar shape. CONCLUSIONS: The shape of the concentration-depth profile of clobetasol propionate is mainly because of the variable partitioning coefficient in different stratum corneum layers.