A Phase II Trial Evaluating Rapid Mid-Treatment Nodal Shrinkage to Select for Adaptive Deescalation in p16+ Oropharyngeal Cancer Patients Undergoing Definitive Chemoradiation

PURPOSE/OBJECTIVE(S)

The purpose of this study is to determine if rapid mid-treatment nodal shrinkage (RMNS) can identify patients with p16+ oropharyngeal cancer (OPC) who can be safely deescalated with reduced dose chemoradiation therapy (CRT). The primary endpoint was 2-year progression free survival (PFS).

MATERIALS/METHODS

Inclusion criteria were as follows: T1-3, N1, M0 (AJCC 8th edition) p16+ OPC with <10 pack-year smoking history. All patients were initially planned for standard dose CRT (70 Gy) and weekly cisplatin. Patients were evaluated with a CT scan at week 4 for RMNS, defined as >40% nodal volumetric reduction from baseline. If RMNS was achieved, they proceeded to deescalated CRT (60 Gy). If not, they received standard CRT. Biomarker correlates were collected at baseline and week 4 of CRT including plasma TTMV (tumor tissue modified viral) HPV DNA and MRI diffusion weighted imaging (DWI). Univariate logistic regression analyses (UVA) were performed to evaluate predictors of RMNS. Odds ratios with 95% CI are reported, using a p<0.05 for statistical significance with a two-sided test. Wilcoxon rank sum tests were used to evaluate differences between the two groups using p < 0.05, 2-sided) for statistical significance. All statistical procedures were performed using R () with no adjustments for multiple testing.

RESULTS

Thirty-six patients were enrolled: median age: 60 years; 81% male; primary site: 36% base of tongue, 53% tonsil, 11% both; T-stage: 39% T1, 50% T2, 11% T3; N-stage: 100% N1; any smoking history: 58% yes, 42% no; 67% (n = 24) had RMNS and received deescalated CRT while the remaining proceeded to standard CRT. At a median follow-up of 32.4 months, 2-year PFS between the standard and deescalated groups were 91.7% vs 90.9%, respectively (p = 0.97). All patients with recurrence underwent successful salvage treatment with 2-year OS 100% for all patients. On UVA, rapid TTMV HPV DNA clearance (baseline to week 4) (OR 12.0 [1.65-250], p = 0.034), lower MRI diffusivity (ADC) at baseline (OR 0.79 [0.61-0.97], p = 0.042) and week 4 (OR 0.76 [0.60-0.91], p = 0.009), and higher MRI diffusional kurtosis at baseline (OR 1.09 [1.01-1.21], p = 0.051) and week 4 (OR 1.24 [1.09-1.52], p = 0.009) were significantly associated with RMNS. When comparing the deescalated and standard cohorts, the mean baseline and week 4 MRI ADC were significantly lower and week 4 MRI diffusional kurtosis was significantly higher in the deescalated group.

CONCLUSION

In this phase II study, rapid mid-treatment nodal shrinkage appeared to select favorable risk p16+ oropharynx cancer patients for treatment de-escalation. Rapid clearance of TTMV HPV DNA at week 4 as well as MRI DWI biomarkers of low ADC and high diffusional kurtosis values were correlated with RMNS. A larger study is planned to incorporate RMNS and biomarkers for further treatment de-escalation. Additional trial information is available at ClinicalTrials.gov (Identifier: NCT03215719).

Cancer treatment-related financial toxicity experienced by patients in low- and middle-income countries: a scoping review

PURPOSE

In the past decade, literature has called attention to financial toxicities experienced by cancer patients. Though studies have addressed research questions in high-income countries, there remains a paucity of in-depth reviews regarding low- and middle-income countries (LMICs). Our scoping review provides an overview of treatment-related financial toxicities experienced by cancer patients in LMICs.

METHODS

A systematic search was conducted in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials. English peer-reviewed articles that (a) explored patients' experience with financial toxicity due to cancer treatment (b) were specific to LMICs as defined by the World Bank and (c) focused on qualitative data were included. Details regarding participants and main findings were extracted and synthesized.

RESULTS

The search yielded 6290 citations, and 42 studies across 3 low-income, 9 lower-middle-income and 8 upper-middle-income countries. Main themes identified included cancer patients encountered various material hardships, managed costs with different coping behaviours and experienced negative psychological responses to their financial burden. Higher levels of financial toxicities were associated with patient characteristics such as lower socio-economic status and lack of insurance, as well as patient outcomes such as lower quality of life.

CONCLUSION

Cancer patients in LMIC experience deleterious financial toxicities as a result of treatment. This comprehensive characterization of financial toxicities will better allow health systems to adopt evidence-based mitigation strategies to reduce the financial burden on patients.

Chronic early-life social isolation affects NMDA and TrkB receptor expression in a sex-specific manner

Exposing mammals to adverse social environments early in life can affect brain development in ways that alter adult behaviour. For example, chronic, early-life social isolation (CELSI) has been found to cause novelty-induced hyperactivity, impaired pre-pulse inhibition, and enhanced anxiety-related behaviour. Although the molecular mechanism(s) underlying the embedding of CELSI have not been fully elucidated, evidence suggests changes in the level of excitatory neurotransmission and neurotrophic factor signalling may be quite important. Since much of the work in this area has focused upon mRNA-level analyses, and has shown variable responses across both brain region and animal sex, our study aimed to explore the impact of CELSI on the expression of two important plasticity-related proteins (Tropomyosin receptor kinase B and the GluN2B subunit of the NMDA receptor) in the pre-frontal cortex and hippocampus of both male and female rats. We observed that the expression of both proteins was clearly changed by CELSI, but that the effect occurred in a sex (but not region) specific manner. Our results support the growing view that early-life adversity can cause structural changes reasonably associated with adult behaviour, and emphasise that the study of such changes benefits from a sex-based analysis.

Role of the biomarkers for the diagnosis of Creutzfeldt-Jakob disease

OBJECTIVE

Sporadic Creutzfeldt-Jakob disease (CJD) is a human prion disease, rapidly progressive and fatal, characterized by spongiform encephalopathy. The characteristic triad of signs - rapidly progressive dementia, myoclonus and periodic sharp wave complexes (PSWC) on electroencephalography (EEG) - usually appear in the late stages of the disease. The clinical diagnosis of CJD ante-mortem involves the exclusion of the rapidly progressive non-prionic dementias, the definitive diagnosis requiring brain tissue confirmation. Authors evaluated the methods of clinical diagnosis for sporadic CJD.

METHODS

This study retrospectively reviewed the medical records of patients diagnosed with probable sporadic CJD, based on brain magnetic resonance imaging (MRI), EEG, cerebrospinal fluid (CSF) analysis and extensive laboratory work-up.

RESULTS

Four patients with a mean age of 67 years were included in our study. The mean duration from diagnosis until death was of 3.2 weeks. The clinical features of the disease at onset were atypical. In the final stage of the disease, all patients presented rapidly progressive dementia and myoclonus. High levels of 14-3-3 protein and tau protein and normal levels of amyloid β1-42 were found at CSF analysis, in all patients. PSWC on EEG were present in 3 out of 4 patients at different moments of the disease. MRI showed hyperintense lesions in brain cortex, caudate nucleus, and putamen on T2, FLAIR, and DWI.

CONCLUSION

CJD may present various clinical features and, since brain biopsy is usually difficult to perform, a combination of biomarkers is useful in order to establish the diagnosis in the early phase of the disease.

Biallelic mutation of MSH2 in primary human cells is associated with sensitivity to irradiation and altered RAD51 foci kinetics

BACKGROUND

Reports of differential mutagen sensitivity conferred by a defect in the mismatch repair (MMR) pathway are inconsistent in their conclusions. Previous studies have investigated cells established from immortalised human colorectal tumour lines or cells from animal models.

METHODS

We examined primary human MSH2-deficient neonatal cells, bearing a biallelic truncating mutation in MSH2, for viability and chromosomal damage after exposure to DNA-damaging agents.

RESULTS

MSH2-deficient cells exhibit no response to interstrand DNA cross-linking agents but do show reduced viability in response to irradiation. They also show increased chromosome damage and exhibit altered RAD51 foci kinetics after irradiation exposure, indicating defective homologous recombinational repair.

DISCUSSION

The cellular features and sensitivity of MSH2-deficient primary human cells are broadly in agreement with observations of primary murine cells lacking the same gene. The data therefore support the view that the murine model recapitulates early features of MMR deficiency in humans, and implies that the variable data reported for MMR-deficient immortalised human cells may be due to further genetic or epigenetic lesions. We suggest caution in the use of radiotherapy for treatment of malignancies in individuals with functional loss of MSH2.

Genetic, functional, and histopathological evaluation of two C-terminal BRCA1 missense variants

BACKGROUND

The vast majority of BRCA1 missense sequence variants remain uncharacterized for their possible effect on protein expression and function, and therefore are unclassified in terms of their pathogenicity. BRCA1 plays diverse cellular roles and it is unlikely that any single functional assay will accurately reflect the total cellular implications of missense mutations in this gene.

OBJECTIVE

To elucidate the effect of two BRCA1 variants, 5236G>C (G1706A) and 5242C>A (A1708E) on BRCA1 function, and to survey the relative usefulness of several assays to direct the characterisation of other unclassified variants in BRCA genes.

METHODS AND RESULTS

Data from a range of bioinformatic, genetic, and histopathological analyses, and in vitro functional assays indicated that the 1708E variant was associated with the disruption of different cellular functions of BRCA1. In transient transfection experiments in T47D and 293T cells, the 1708E product was mislocalised to the cytoplasm and induced centrosome amplification in 293T cells. The 1708E variant also failed to transactivate transcription of reporter constructs in mammalian transcriptional transactivation assays. In contrast, the 1706A variant displayed a phenotype comparable to wildtype BRCA1 in these assays. Consistent with functional data, tumours from 1708E carriers showed typical BRCA1 pathology, while tumour material from 1706A carriers displayed few histopathological features associated with BRCA1 related tumours.

CONCLUSIONS

A comprehensive range of genetic, bioinformatic, and functional analyses have been combined for the characterisation of BRCA1 unclassified sequence variants. Consistent with the functional analyses, the combined odds of causality calculated for the 1706A variant after multifactorial likelihood analysis (1:142) indicates a definitive classification of this variant as "benign". In contrast, functional assays of the 1708E variant indicate that it is pathogenic, possibly through subcellular mislocalisation. However, the combined odds of 262:1 in favour of causality of this variant does not meet the minimal ratio of 1000:1 for classification as pathogenic, and A1708E remains formally designated as unclassified. Our findings highlight the importance of comprehensive genetic information, together with detailed functional analysis for the definitive categorisation of unclassified sequence variants. This combination of analyses may have direct application to the characterisation of other unclassified variants in BRCA1 and BRCA2.

Association between polymorphisms of the GPX1 gene and second primary tumours after index squamous cell cancer of the head and neck

We investigated the association between genetic polymorphisms in GPX1 gene amongst patients who had index squamous cell carcinoma (SCCHN) and a second primary tumour (SPT) after a primary SCCHN in a case-control study. GPX1 genotypes were determined for 61 patients with SPT and for 259 control subjects by a PCR technique using a fluorescent-labelled primer. Analysis was by an ABI automated fluorescent sequencer. The associations between specific genotypes and the development of SPT were examined by logistic regression. A significant difference was found between the control group and the SPT cases in allele frequencies of GPX1 ALA( *)6 and ALA( *)7 (p(trend)=0.04). These results suggest that polymorphisms in the GPX1 gene may be a marker for SPT development and further studies are indicated.

Phase III, randomized, double-blind study of clarithromycin extended-release and immediate-release formulations in the treatment of adult patients with acute maxillary sinusitis

BACKGROUND

Clarithromycin has an established bacteriologic efficacy and safety profile in the treatment of respiratory tract infections.

OBJECTIVE

This study compares the efficacy and tolerability of extended-release and immediate-release formulations of clarithromycin in patients with acute maxillary sinusitis.

METHODS

Fourteen days' treatment with once-daily clarithromycin was compared with the immediate-release, twice-daily formulation in a phase III, randomized, double-blind, parallel-group, multicenter study. Patients aged > or =12 years with signs, symptoms, and a radiologically confirmed diagnosis of acute maxillary sinusitis were eligible. Patients were assessed before treatment, within 48 hours after treatment, on study days 16 to 18, and at the test-of-cure visit on study days 24 to 31. Patients who received > or =1 dose of study drug were included in the safety analysis.

RESULTS

Of 283 patients treated, 245 were included in the efficacy analysis (122 in the extended-release group, 123 in the immediate-release group). Treatment groups were well matched with respect to demographic characteristics and medical condition and history. At the test-of-cure visit, 85% of patients in the clarithromycin extended-release group and 79% in the immediate-release group were deemed clinical cures; 89% and 91% in the extended-release and immediate-release groups, respectively, demonstrated radiographic success. Overall incidences of study drug-related adverse events were similar in the 2 treatment groups (32% in the extended-release group and 28% in the immediate-release group); however, significantly fewer patients receiving extended-release clarithromycin (2/142 11%]), compared with those receiving the immediate-release formulation (10/141 [7%]: P = 0.02) discontinued therapy because of drug-related gastrointestinal symptoms or abnormal taste. No clinically meaningful changes in laboratory values or vital signs were observed during the study.

CONCLUSION

Although the efficacy of the 2 formulations was comparable, once-daily clarithromycin extended-release was better tolerated than the twice-daily immediate-release formulation by patients with acute maxillary sinusitis.

Tumor suppressor p53 is required to modulate BRCA1 expression

Individuals carrying mutations in BRCA1 or p53 genes are predisposed to a variety of cancers, and both tumor suppressor genes have been implicated in DNA damage response pathways. We have analyzed a possible functional link between p53 and BRCA1 genes. Here we show that BRCA1 expression levels are down-regulated in response to p53 induction in cells that undergo either growth arrest, senescence, or apoptosis. Physiological stimuli, such as exposure to DNA-damaging agents, also result in negative regulation of BRCA1 levels in a p53-dependent manner prior to causing cell cycle arrest. Nuclear run-on experiments and luciferase reporter assays demonstrate that the changes in BRCA1 expression are mainly due to transcriptional repression induced by p53. In conclusion, the data show that BRCA1 expression levels are controlled by the presence and activity of wild-type p53 and suggest the existence of an intracellular p53/BRCA1 pathway in the response of cells to stress conditions.