Macrocytosis in patients with metastatic renal cell carcinoma (mRCC) treated with tyrosine kinase inhibitors (TKI's)

15583

Background: Sunitinib and sorafenib are TKIs with inhibitory activity against a variety of kinases including VEGFR, PDGFR, and cKIT, as well as significant clinical activity in mRCC. Off target toxicity is frequently seen, and in pts treated with these TKIs the development of anemia ± macrocytosis was noted. Further studies were conducted to clarify the frequency and etiology of these findings. Methods: A retrospective review of mRCC patients treated with sunitinib or sorafenib for = 3 months was undertaken. Complete blood count data including RBC indices was recorded at baseline, 3 months, and at the end of treatment. Thyroid function tests (TFTs) were collected, and in selected patients, bone marrow examination was undertaken. Results: Ninety eight pts were evaluated (61 sunitinib-treated, 37 sorafenib-treated). In sunitinib-treated mRCC patients, median MCV levels increased significantly at 3 months compared to baseline (97.1 fL vs. 90.2 fL; p<0.001) and median Hgb levels decreased from 13.4 to 12.8 (p =0.31). In patients receiving sunitinib >12 months, MCV continued to increase throughout treatment. There was no association between increasing MCV and the development of hypothyroidism. In 10 patients discontinuing sunitinib, MCV returned to baseline within 2 to 4 months. The number of patient receiving sunitinib with an MCV > 100 at the beginning, 3 months, and end of treatment were 2, 14 and 40 respectively. Bone marrow examinations performed during sunitinib therapy (n=3) demonstrated hypocellularity (5–10%) with normal trilineage hematopoiesis and no evidence of dysplastic changes. In contrast, sorafenib- treated mRCC patients showed no effects at 3 months on MCV levels (90.7 fL vs. 90.6 fL) but an increase in hemoglobin level (14.0 g/dL vs. 13.2 g/dL p=0.02) . At the beginning of treatment 2 patients had MCV values more than 100, but at 3 months and 12 months none of the patients had MCV values more than 100. Conclusions: Macrocytosis commonly develops in sunitinib-treated, but not sorafenib- treated mRCC pts. The etiology of this finding is unclear, but studies suggest direct effects on bone marrow precursors. Sunitinib-induced macrocytosis appears reversible with drug discontinuation.

[Table: see text]

Clinical factors associated with outcome in metastatic renal cell carcinoma patients treated with VEGF-targeted therapy

5046

Background: Therapy targeted against the vascular endothelial growth factor (VEGF) pathway is a standard of care in metastatic renal cell carcinoma (RCC). Identification of clinical features of patients more likely to benefit from these agents would aid in patient selection and interpretation of clinical trial results. Methods: We reviewed 120 metastatic RCC patients receiving bevacizumab, sorafenib, sunitinib or axitinib on one of eight prospective clinical trials at the Cleveland Clinic Taussig Cancer Center. Clinical features associated with outcome were identified by univariate analysis, and then a stepwise modeling approach based on Cox proportional hazards regression was used to identify independent prognostic factors and form a model for progression-free survival (PFS). A bootstrap algorithm was used to provide internal validation. Results: Forty-one patients (34%) achieved an objective response by RECIST criteria (95% C.I. 27–44%). The median PFS for the entire group was 13.8 months (m) (95% C.I. 10.7–19.0 m). Multivariate analysis identified the following independent adverse prognostic factors (PF) for PFS: time from diagnosis to current treatment <2 years, baseline platelet count >300 K/μL, baseline neutrophil count >4.5 K/μL, baseline corrected serum calcium <8.5 or >10.0 mg/dL and initial ECOG performance status >0. Using these factors three prognostic subgroups were formed based on the number of adverse PF present . Median PFS in patients with 0 or 1 adverse PF was 20.1 m (95% C.I. 19.0–22.3 m) compared to 13 m (95% C.I. 8.6–17.6 m) in patients with 2 adverse PF and 3.9 m (95% C.I. 1.8–7.2 m) in patients with >2 adverse PF. Conclusions: Five independent prognostic factors for predicting PFS were identified and used to categorize patients with metastatic RCC receiving VEGF-targeted therapies into three risk groups. These factors can be readily incorporated to clinical patient care, stratification schema for clinical trials utilizing these novel agents and for interpretation of clinical trial results using VEGF-targeted agents therapy.

No significant financial relationships to disclose.

Durable complete responses and near complete responses to sunitinib in metastatic renal cell carcinoma

15514

Introduction: Sunitinib is a tyrosine kinase inhibitor with activity against VEGFR and PDGFR recently approved by the FDA for the treatment of advanced renal cell carcinoma (RCC). There is no existing literature that details complete responses (CRs) in patients taking sunitinib for metastatic RCC. Methods: Seventy-four patients with metastatic RCC receiving sunitinib at the Cleveland Clinic Taussig Cancer Center on clinical trials were reviewed to determine the number of patients with RECIST-defined CRs. Additionally, patients who achieved near-CRs defined as a greater than 90% reduction in composite tumor volume or residual disease of less than or equal to 1 cm were reviewed. Results: Two patients (2.7%) achieved a RECIST-defined CR lasting >15 months. The patients who obtained CRs had non-bulky pulmonary metastases, favorable or intermediate MSKCC risk profiles, were treated with sunitinib in the first-line setting and had a significant reduction in composite tumor measurements within the first two cycles. An additional 2 patients achieved near-CRs, including one patient that previously progressed on bevacizumab. These 2 near-CR patients remain progression-free for more than 19 months. Finally, 1 patient achieved sufficient downstaging and reduction of tumor volume such that the remaining lesion could be excised, resulting in a surgical CR. This patient is currently off sunitinib and remains progression-free 4 months after surgery. Conclusion: Sunitinib is capable of producing durable CRs in cytokine-naïve metastatic RCC patients with non-bulky pulmonary metastases. Additionally, near-CRs can be seen despite non-pulmonary metastatic sites and prior VEGF-targeted therapy.

No significant financial relationships to disclose.

Gene modulatory effects, pharmacokinetics, and clinical tolerance of interferon-alpha1b: a second member of the interferon-alpha family

Interferon-alpha1 (IFN-alpha1), which may have a primary role in innate immunity, differs significantly in amino-acid sequence from IFN-alpha2, the only recombinant IFN-alpha with substantial clinical evaluation. Patients with metastatic malignancies received daily subcutaneous doses of 1.5-270 mug/m(2) of recombinant IFN-alpha1b. Gene modulation, pharmacokinetics, tolerability, and disease response were determined. Significant (P<0.01) dose and gene-dependent increases of 2-10 fold occurred in IFN-stimulated genes, including four (tumor necrosis factor-related apoptosis-inducing ligand, cig 5, p56, GEM) never previously identified as increased in patients; significant increases (P<0.01) resulted at the lowest dose (1.5 microg/m(2); 1.5 x 10(4) human antiviral units/m(2)). Increases (P<0.01) were sustainable for >4 weeks. Peak levels of IFN-alpha1b were at 3 h; an increase of approximately eightfold in both C(max) and AUC occurred between 15 microg/m(2) and 270 microg/m(2). Chronic toxicities of anorexia, weight loss, and fatigue were relatively uncommon. Eighteen patients were treated for >8 weeks; none experienced >grade 1 weight loss. Three patients at the highest dose developed grade 3 fatigue after > or =3 months, which required dose reduction or discontinuation. Patient acceptability of fatigue defined a dose for initiation of Phase II trials, 270 microg/m(2). Six patients (five with renal cell carcinoma) had progression-free survival for >1 year, including two who had partial responses. IFN-alpha1b resulted in potent stimulation of IFN-regulated genes and tumor regressions in renal cell carcinoma. Unique gene modulatory effects, when coupled with the moderate severity of side effects and a potentially central role in innate immunity, provide rationale for further clinical evaluation of IFN-alpha1 in virus infections and cancer.

The effects of transcutaneous electrical nerve stimulation (TENS) on spasticity in multiple sclerosis

Spasticity is a common and often disabling symptom associated with multiple sclerosis (MS). Transcutaneous electrical nerve stimulation (TENS) has been found effective in reducing spasticity in conditions such as stroke, but there is little evidence to support its use in MS. The aim of this study was to evaluate the effectiveness of TENS on spasticity in MS and, furthermore, to compare two different application times. Thirty-two subjects were randomized into two groups, and a single, blind, crossover design was used to compare two weeks of 60 minutes and 8 hours daily of TENS applications (100 Hz and 0.125 ms pulse width). Outcomes were examined using the Global Spasticity Score (GSS), the Penn Spasm Score (PSS), and a visual analogue scale (VAS) for pain. The results of the study demonstrated that there were no statistically significant differences in the GSS following either 60 minutes or 8 hours daily of TENS (P=0.433 and 0.217, respectively). The 8-hour application time led to a significant reduction in muscle spasm (P=0.038) and pain (P = 0.008). Thus, this study suggests that, whilst TENS does not appear to be effective in reducing spasticity, longer applications may be useful in treating MS patients with pain and muscle spasm. Multiple Sclerosis 2007; 13: 527-533. http://msj.sagepub.com

Thyroid function tests (TFTs) abnormalities in patients (pts) with metastatic renal cell carcinoma (mRCC) treated with sunitinib

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Background: Sunitinib is a multi-targeted receptor tyrosine kinase inhibitor of vascular endothelial growth factor and platelet-derived growth factor receptors. It has anti-tumor activity in mRCC pts with toxicity including fatigue. We investigated TFTs abnormalities and related signs and symptoms in pts with mRCC receiving sunitinib. Methods: The medical records of pts with mRCC enrolled in 4 ongoing clinical trials of sunitinib were reviewed. TFTs assessment (TSH, T3 and T4) was undertaken based on the clinical suspicion of treating physicians. Patient demographics, frequency and values of TFTs and any signs and symptoms of thyroid dysfunction were collected. Abnormal TFTs and treatment outcome were correlated. Results: Between 5/2004 and 12/2005, 62 pts (43 males, 19 females) were treated with sunitinib. The median age was 58 years (range, 23–72). Fifty-five pts had TFTs assessed while on treatment and 40 pts (65% of total) had one or more abnormality. Two pts had well-controlled hypothyroidism prior to initiation of sunitinib. TFTs abnormalities were consistent with hypothyroidism in all pts including one who initially developed transient hyperthyroidism. Signs and symptoms possibly related to hypothyroidism were found in 33 pts (53% of total) with abnormal TFTs and were initially attributed to sunitinib. Signs and symptoms included fatigue in 33 pts, anorexia in 20 pts, fluid retention in 17 pts, and skin/hair changes in 13 pts. Thyroid hormone replacement was undertaken in 12 pts and resulted in improvement of symptoms in 6 pts. Among the 40 pts with abnormal TFTs 29 pts had tumor evaluation; 13 had SD, 8 had PR, 2 had CR. There was no correlation between abnormal TFTs and treatment outcome. Conclusions: TFTs abnormalities are common in pts with mRCC treated with sunitinib. Thyroid hormone replacement is indicated in such pts to improve hypothyroidism-related symptoms and possibly to improve treatment tolerance.

[Table: see text]

T regulatory cells (Treg) in patients with metastatic renal cell carcinoma (mRCC) decrease during sunitinib treatment: Correlations with clinical responses and T helper 1/T helper 2 (Th1/Th2) bias

2526

Background: High numbers of regulatory T cells (Treg) and high expression of forkhead box transcription factor (FoxP3) in Treg are associated with decreased survival in various malignancies, likely via immunosuppression. Studies demonstrate Th1 suppression (IFN-γ) and Th2 (Il-4) promotion in metastatic renal cell carcinoma (mRCC) patients (pts). The aim of the present study was to determine the profile of Th1, Th2, and Treg at baseline and after 28 days of therapy with the multi-targeted tyrosine kinase inhibitor, sunitinib malate (SU11248). Further, correlation of changes in these parameters and tumor shrinkage (TS) was examined. Methods: Blood was obtained from cytokine-refractory, clear cell mRCC pts on day 1 (pre-treatment) and after 28 days of sunitinib 50mg daily. T cell cytokine expression (IL-4, IFN-γ), percentage in peripheral blood mononuclear cells of CD3+/CD4+/CD25hi+/FoxP3+ cells, and percentage of Treg that were FoxP3+ were evaluated using flow cytometry. Tumor measurements were performed after 2 cycles of therapy. Correlations between immune parameters and TS were assessed with Spearman rank correlations. Results: Ten pts were evaluable for Th1/Th2 responses; 9 for Treg. At baseline 7/10 had Th2 bias and 3/10 had Th1 bias. On day 28, pts maintained Th1 bias (n=3), switched to Th1 bias (n=3), or had decrease in magnitude of Th2 response (n=4). Additionally, a median 74.5% decrease occurred after 28 days of sunitinib in the percentage of CD3/CD4/CD25hi+/FoxP3+ in peripheral blood mononuclear cells, with a median 68.0% decrease of FoxP3+ Treg (CD3/CD4/CD25hi+) cells. Decrease in number of Treg correlated with relative change in Th1 response and Th2 bias (p<.05 for all correlations). All pts had TS including 2 pts with partial response. Degree of TS correlated with relative change in Th1 response (p=.03), and Th2 bias (p=.06), as well as the relative change in FoxP3+ Treg (p=.06). Conclusions: Our results suggest that sunitinib promotes an immunostimulatory Th1 bias and reduces Treg. This immunostimulatory mechanism may contribute to the anti-tumor effect in mRCC. Further studies are on-going.

[Table: see text]

Antitumor effects of sorafenib and sunitinib in patients (pts) with metastatic renal cell carcinoma (mRCC) who had prior therapy with anti-angiogenic agents

4597

Background: Sorafenib and sunitinib are multi-targeted kinase inhibitors (TKI’s) with clinical activity in mRCC. Their effect in mRCC pts refractory to prior anti-angiogenic agents is unclear. We investigated the anti-tumor effect of sorafenib and sunitinib in patients with mRCC who failed prior treatment with anti-angiogenic agents. Methods: Pts with mRCC receiving sorafenib and sunitinib on compassionate use trials were identified. Those pts who had received prior treatment with anti-angiogenic agents defined as thalidomide, lenalidomide, M200 (anti-α5β1 integrin monoclonal antibody), bevacizumab, AG013736, sunitinib or sorafenib were selected and their treatment response to current sorafenib or sunitinib evaluated. Results: Seventy-two pts (39 receiving sorafenib and 33 receiving sunitinib) were identified. Of these 72 pts, 23 pts (32%) had received prior anti-angiogenic therapy as defined above. Demographics included: 19 male and 4 female, median age 61 years (range 44 to 77). Thirteen pts (57%) are currently evaluable; the remainder are too early for assessment. Twelve pts (92%) demonstrated tumor reduction including 4 pts with objective partial response (PR); 8 pts had stable disease with tumor shrinkage ranging from 4 to 27% and 1 pt had disease progression. Of the 4 PR pts, prior therapy included M200 (1 pt), lenalidomide (2 pts) and sorafenib (1 pt). Of the 13 evaluable pts 4 had failed a prior TKI and received a subsequent TKI and all had evidence of tumor shrinkage to subsequent therapy (sunitinib followed by sorafenib, 1pt - 16% shrinkage, sorafenib followed by sunitinib 2 pts - 33.4% and 24% and AG013736 followed by sunitinib 1 pt - 12% ). Conclusion: Sorafenib and sunitinib have anti-tumor activity in mRCC pts who have received prior anti-angiogenic agents.

[Table: see text]

Clinical classification criteria for knee osteoarthritis: performance in the general population and primary care

BACKGROUND

Doubts have been expressed about the performance of the American College of Rheumatology (ACR) clinical classification criteria for osteoarthritis when applied in the general population.

OBJECTIVE

To investigate whether the distribution of population subgroups and underlying disease severity might explain the performance of these criteria in the population setting.

METHODS

Population-based cross-sectional study. 819 adults aged > or = 50 years reporting knee pain in the last 12 months were clinically assessed by research therapists using standardised protocols and blinded to radiographic status. All participants underwent plain radiography of the knees, scored by a single reader blinded to clinical status. The relationship between fulfilling the ACR clinical classification criteria for knee osteoarthritis and the presence of symptomatic radiographic knee osteoarthritis was summarised for the sample as a whole and within subgroups.

RESULTS

Radiographic osteoarthritis was present in 539 participants (68%) and symptomatic radiographic knee osteoarthritis in 259 (33%). 238 participants (30%) fulfilled the ACR clinical criteria for knee osteoarthritis. Agreement between the ACR clinical criteria and symptomatic radiographic knee osteoarthritis was low (sensitivity 41%; specificity 75%; positive predictive value 44%; negative predictive value 72%). Sensitivity and specificity did not vary markedly between population subgroups, although they were influenced by the underlying severity of radiographic osteoarthritis.

CONCLUSION

The ACR clinical criteria seem to reflect later signs in advanced disease. Other approaches may be needed to identify early, mild osteoarthritis in the general population and primary care.

2-MeOE2bisMATE induces caspase-dependent apoptosis in CAL51 breast cancer cells and overcomes resistance to TRAIL via cooperative activation of caspases

2-Methoxyoestradiol (2-MeOE2) is an endogenous oestrogen metabolite which inhibits tubulin polymerisation and has anti-tumour and anti-angiogenic activity. 2-MeOE2 induces apoptosis in a wide range of cancer cell types and has recently been demonstrated to cooperate with TRAIL to induce apoptosis in breast cancer cells. 2-Methoxyoestradiol-3,17-bis-O,O-sulphamate (2-MeOE2bisMATE) is a sulfamoylated derivative of 2-MeOE2 with enhanced activity and improved pharmacokinetic properties, and 2-MeOE2bisMATE is a promising candidate for early clinical trials. It is important, therefore, to understand the mechanisms by which 2-MeOE2bisMATE acts, and whether it retains the ability to cooperate with TRAIL. We demonstrate that 2-MeOE2bisMATE-induced apoptosis of CAL51 breast cancer cells was associated with rapid activation of caspase 3 and 9, but not caspase 8 (as measured by BID cleavage) and was completely prevented by the caspase inhibitor zVADfmk. Interfering with Fas- or TRAIL-receptor function did not prevent 2-MeOE2bisMATE-induced apoptosis. Whereas CAL51 cells were resistant to TRAIL-induced apoptosis, 2-MeOE2bisMATE and TRAIL cooperated to induce cell death. This apoptosis was associated with enhanced activation of caspases, but not increased expression of the DR5 TRAIL receptor, previously demonstrated to be induced by 2-MeOE2. Therefore, 2-MeOE2bisMATE-induced apoptosis is dependent on caspases and like 2-MeOE2, 2-MeOE2bisMATE can overcome resistance to TRAIL by stimulating activation of downstream caspases. Our results suggest that 2-MeOE2bisMATE and TRAIL might be a particularly effective combination of anti-cancer agents.

Clinical service organisation for heart failure

BACKGROUND

Chronic heart failure (CHF) is a serious, common condition associated with frequent hospitalisation. Several different disease management interventions (clinical service organisation interventions) for patients with CHF have been proposed.

OBJECTIVES

To assess the effectiveness of disease management interventions for patients with CHF.

SEARCH STRATEGY

We searched: Cochrane CENTRAL Register of Controlled Trials (to June 2003); MEDLINE (January 1966 to July 2003); EMBASE (January 1980 to July 2003); CINAHL (January 1982 to July 2003); AMED (January 1985 to July 2003); Science Citation Index Expanded (searched January 1981 to March 2001); SIGLE (January 1980 to July 2003); DARE (July 2003); National Research Register (July 2003); NHS Economic Evaluations Database (March 2001); reference lists of articles and asked experts in the field.

SELECTION CRITERIA

Randomised controlled trials comparing disease management interventions specifically directed at patients with CHF to usual care.

DATA COLLECTION AND ANALYSIS

At least two reviewers independently extracted data information and assessed study quality. Study authors were contacted for further information where necessary.

MAIN RESULTS

Sixteen trials involving 1,627 people were included. We classified the interventions into three models: multidisciplinary interventions (a holistic approach bridging the gap between hospital admission and discharge home delivered by a team); case management interventions (intense monitoring of patients following discharge often involving telephone follow up and home visits); and clinic interventions (follow up in a CHF clinic). There was considerable overlap within these categories, however the components, intensity and duration of the interventions varied. Case management interventions tended to be associated with reduced all cause mortality but these findings were not statistically significant (odds ratio 0.86, 95% confidence interval 0.67 to 1.10, P = 0.23), although the evidence was stronger when analysis was limited to the better quality studies (odds ratio 0.68, 95% confidence interval 0.46 to 0.98, P = 0.04). There was weak evidence that case management interventions may be associated with a reduction in admissions for heart failure. It is unclear what the effective components of the case management interventions are. The single RCT of a multidisciplinary intervention showed reduced heart-failure related re-admissions in the short term. At present there is little available evidence to support clinic based interventions.

AUTHORS' CONCLUSIONS

The data from this review are insufficient for forming recommendations. Further research should include adequately powered, multi-centre studies. Future studies should also investigate the effect of interventions on patients' and carers' quality of life, their satisfaction with the interventions and cost effectiveness.

Near-threshold production of the multistrange Xi- hyperon

The yield for the multistrange Xi(-) hyperon has been measured in 6A GeV Au+Au collisions via reconstruction of its decay products pi(-) and Lambda, the latter also being reconstructed from its daughter tracks of pi(-) and p. The measurement is rather close to the threshold for Xi(-) production and therefore provides an important test of model predictions. The measured yield for Xi(-) and Lambda are compared for several centralities. In central collisions the Xi(-) yield is found to be in excellent agreement with statistical and transport model predictions, suggesting that multistrange hadron production approaches chemical equilibrium in high baryon density nuclear matter.

Comparison of source images for protons, pi-'s, and lambda's in 6A GeV Au+Au collisions

Source images are extracted from two-particle correlations constructed from strange and nonstrange hadrons produced in 6A GeV Au+Au collisions. Very different source images result from pp vs p Lambda vs pi(-)pi(-) correlations. Scaling by transverse mass can describe the apparent source size ratio for p/pi(-) but not for Lambda/pi(-) or Lambda/p. These observations suggest important differences in the space-time emission histories for protons, pions, and neutral strange baryons produced in the same events.