Summary Assessment of response of skeletal metastases to systemic therapy is currently dependent on radiological evidence of bone healing. We have performed a prospective study of additional response criteria in patients with progressive bone metastases from breast cancer. Changes in these potential markers of response were correlated with the radiological response and the time to treatment failure (TTF).Successful systemic therapy typically led to a transient increase in osteoblast activity ('flare'), a reduction in osteoclast activity and symptomatic improvement. After 1 month a > 10% rise in serum osteocalcin (BGP) Osteoblast activity was monitored by serial measurements of alkaline phosphatase bone isoenzyme (ALP-BI) and osteocalcin (BGP). Serum calcium, tartrate resistant acid phosphatase (TRP) and urinary excretion of calcium and hydroxyproline were measured to assess osteoclast activity. Serum for measurement of BGP, ALP-BI and TRP was obtained from a morning blood sample following centrifugation. The aliquot for TRP was acidified with 20 p1 of 5 M acetate buffer (pH 5) per ml of serum. All samples were frozen within 6 h and stored at -20°C. A morning spot urine sample was collected for measurement of calcium and hydroxyproline excretion after an overnight fast and stored at -20°C. Foods rich in collagen were avoided for 18 h prior to urine collection for hydroxyproline. Following pretreatment estimations measurements of serum calcium, BGP, and urinary calcium excretion were performed monthly, ALP-BI at 1, 3 and 6 months during treatment and TRP and urinary hydroxyproline excretion 3 monthly.Bone scans, with plain radiographs of abnormal areas, were performed before treatment and repeated three monthly. Standard overlapping views were taken 3-4h after injection of 500 megabecquerels of technetium99m labelled methylene diphosphonate (MDP). Symptomatic response was assessed by a questionnaire completed by the patient. Severity of pain and mobility were rated by the patient and combined with a scoring of analgesic consumption and the UICC performance status to produce an overall symptom score which was expressed as a percentage of the maximum possible score. (Details of pain and activity questionnaire available from the authors on request).ALP-BI was measured by the modified heat-inactivation technique described by Moss & Whitby (1975). This method utilises the different heat stability characteristics of the bone and liver isoenzymes. The total enzyme activity is measured and the presence of significant amounts of ALP from other sources (e.g. gut) excluded by electrophoresis. Serum is incubated at 56°C and at this temperature more than 99% of the bone isoenzyme decays within 15 min. The residual activity of the sample is measured after 15 and 25 min incubation and reflects the inactivation rate of the liver component. The total liver component can be determined by extrapolation from these two measurement and ALP-BI Br.

We measured serum alkaline phosphatase isoenzymes and osteocalcin levels in 40 healthy women at 4-week intervals throughout uncomplicated pregnancies and 6 weeks after delivery in 17 women. Serum bone alkaline phosphatase was significantly higher in the third trimester than in early pregnancy (P less than 0.001), and this elevation was still apparent at the end of the puerperium, suggesting increased bone turnover. Serum osteocalcin was not detected (less than 0.2 micrograms/L) after the first trimester in the majority of women, and it reappeared within 48 h after delivery. The disappearance of osteocalcin after the first trimester and its rapid reappearance after delivery suggest placental clearance of this peptide. We conclude that serum osteocalcin measurements cannot be used as a marker of bone metabolism during pregnancy.

Sepsis-associated encephalopathy (SAE) induces neuroinflammation, which is associated with cognitive impairment (CI). CI is also correlated with aging. We used contrast-enhanced magnetic resonance imaging (MRI), perfusion MRI, and MR spectroscopy to assess long-term alterations in BBB permeability, microvascularity, and metabolism, respectively, in a rat lipopolysaccharide-induced SAE model. Free radical-targeted molecular MRI was used to detect brain radical levels at 24 h and 1 week post-LPS injection. CE-MRI showed increased Gd-DTPA uptake in LPS rat brains at 24 h in cerebral cortex, hippocampus, thalamus, and perirhinal cortex regions. Increased MRI signal intensities were observed in LPS rat brains in cerebral cortex, perirhinal cortex, and hippocampus regions 1 week post-LPS. Long-term BBB dysfunction was detected in the cerebral cortex at 6 weeks post-LPS. Increased relative cerebral blood flow (rCBF) in cortex and thalamus regions at 24 h, decreased cortical and hippocampal rCBF at 6 weeks, decreased cortical rCBF at 3 and 12 weeks, and increased thalamus rCBF at 6 weeks post-LPS, were detected. MRS indicated that LPS-exposed rat brains had decreased: NAA/Cho metabolite ratios at 1, 3, 6, and 12 weeks; Cr/Cho at 1, 3, and 12 weeks; and Myo-Ins/Cho at 1, 3, and 6 weeks post-LPS. Free radical imaging detected increased radical levels in LPS rat brains at 24 h and 1 week post-LPS. LPS-exposed rats were compared to saline-treated controls. We clearly demonstrated BBB dysfunction, impaired vascularity, and decreased brain metabolites, as measures of long-term neuroinflammatory indicators, as well as increased free radicals in a LPS-induced rat SAE model.

Bi-annual MRI performed well for early detection of invasive breast cancer in genomically stratified high-risk women. No benefit was associated with annual MG screening plus bi-annual MRI screening.