Severe neutropenia during cabazitaxel treatment is associated with survival benefit in men with metastatic castration-resistant prostate cancer (mCRPC): A post-hoc analysis of the TROPIC phase III trial

BACKGROUND

Cabazitaxel significantly improves overall survival (OS) in men with metastatic castration-resistant prostate cancer (mCRPC) progressing during or after docetaxel, but is associated with a higher rate of grade ≥3 neutropenia compared with docetaxel. We thus examined the relationship between cabazitaxel-induced grade ≥3 neutropenia, baseline neutrophil-lymphocyte ratio (NLR) and treatment outcomes.

METHODS

Data from the experimental arm of the TROPIC phase 3 trial which randomly assigned men with mCRPC to cabazitaxel or mitoxantrone every 3 weeks, both combined with daily prednisone, were analysed. The influence on OS (primary end-point) and progression-free survival (PFS) of at least one episode of grade ≥3 neutropenia during cabazitaxel therapy was investigated using Cox regression models, adjusted for pain at baseline. The relationships with prostate-specific antigen (PSA) responses during cabazitaxel therapy and baseline NLR were also analysed.

FINDINGS

The occurrence of grade ≥3 neutropenia during cabazitaxel therapy was associated with a prolonged OS (median 16.3 versus 14.0 months, hazard ratio (HR) [95% confidence interval] = 0.65 [0.43-0.97], p = 0.035), a twice longer PFS (median 5.3 versus 2.6 months, HR = 0.56 [0.40-0.79], p = 0.001) and a higher confirmed PSA response ≥50% (49.8% versus 24.4%, p = 0.005), as compared with patients who did not develop grade ≥3 neutropenia. Grade ≥3 neutropenia was more common in case of NLR <3 as compared with NLR ≥3 at baseline (88.8% versus 75.3%, p = 0.002). Combining low NLR at baseline and grade ≥3 neutropenia during therapy was associated with the longest OS (median 19.2 months) while high NLR at baseline and no grade ≥3 neutropenia was associated with a poor OS (median 12.9 months, HR 0.46 [0.28-0.76], p = 0.002). In the subgroup of neutropenic patients the median OS was 19.7 months in those treated with granulocyte colony-stimulating factor (G-CSF) and 16 months on those without G-CSF support.

INTERPRETATION

This post-hoc analysis of TROPIC suggests that the occurrence of grade ≥3 neutropenia with cabazitaxel is associated with improved OS and PFS. Patients with a low NLR at baseline were more likely to develop grade ≥3 neutropenia during cabazitaxel therapy and showed the longest OS. High NLR at baseline and no grade ≥3 neutropenia during therapy was associated with poor outcomes which may suggest insufficient drug exposure or a limited impact on the tumour-associated immune response. Primary or secondary prophylactic use of G-CSF had no adverse impact for outcome. If prospectively confirmed, these results would justify maintaining the intended cabazitaxel dose of 25 mg/m(2) whenever possible.

Glucocorticoids in myasthenia gravis - if, when, how, and how much?

Glucocorticoids (GC) are the most commonly used immune-directed therapy in myasthenia gravis (MG). However, to date, GC have not proven their effectiveness in the setting of a randomized clinical trial that complies with currently accepted standards. The rationale for the use of GC in MG is the autoimmune nature of the disease, which is supported by consistent positive results from retrospective studies. Well-defined recommendations for treatment of MG with GC are lacking and further hampered by inter- and intra-individual differences in the disease course and responses to GC treatment. Uncertainties concerning GC treatment in MG encompass the indication for treatment initiation, exact dosage, dose adjustment in specific conditions (e.g., pregnancy, thymectomy), mode of tapering, and surveillance of adverse events (AE). This review illustrates the mode of action of GC in the treatment for MG, presents the currently available data on GC treatment in MG, and attempts to translate the currently available information into clinical recommendations.

[Thymectomy in myasthenia and/or thymoma]

Thymectomy, the surgical removal of the thymic gland, is essential in cases of thymoma. The majority of cases of a myasthenia gravis (MG) represent a relative indication for thymectomy which requires cooperation with specialized neurologists. Patients with MG may present with a tumor of the thymic gland. In case of suspicious thymoma, the resectability of the tumor has to be evaluated in the preoperative diagnostic. The clinical condition of patients with MG has to be stabilized preoperatively. The aim of thymectomy is the radical removal of thymoma and/or maximal improvement of MG symptoms. This requires the complete extirpation of the thymic gland including all ectopic thymic tissue in the anterior mediastinum. There is a variety of surgical techniques for performing a complete thymectomy. In addition to the conventional techniques with sternotomy, the significance of minimally-invasive approaches is increasing rapidly. Despite the ongoing scarcity of data of higher evidence concerning the procedure of thymectomy an increasing number of equivalent results with minimally-invasive operation techniques for MG and for thymoma are available. The successful surgical performance of a thymectomy is part of an interdisciplinary cooperation in the perioperative treatment of MG as well as the postoperative long-term care for patients with MG and/or thymoma.

The G protein-coupled estrogen receptor (GPER) is expressed in two different subcellular localizations reflecting distinct tumor properties in breast cancer

INTRODUCTION

The G protein-coupled estrogen receptor (GPER) is a novel estrogen receptor that mediates proliferative effects induced by estrogen but also by tamoxifen. The aim of our study was to analyze the frequency of GPER in a large collective of primary invasive breast carcinomas, with special emphasis on the subcellular expression and to evaluate the association with clinicopathological parameters and patient overall survival.

METHODS

The tissue microarrays from formalin-fixed, paraffin embedded samples of primary invasive breast carcinomas (n = 981) were analyzed for GPER expression using immunohistochemistry. Expression data were compared to the clinicopathological parameters and overall survival. GPER localization was also analyzed in two immortalized breast cancer cell lines T47D and MCF7 by confocal immunofluorescence microscopy.

RESULTS

A predominantly cytoplasmic GPER expression was found in 189 carcinomas (19.3%), whereas a predominantly nuclear expression was observed in 529 cases (53.9%). A simultaneous comparable positive expression of both patterns was found in 32 of 981 cases (3.2%), and negative staining was detected in 295 cases (30%). Confocal microscopy confirmed the occurrence of cytoplasmic and nuclear GPER expression in T47D and MCF7. Cytoplasmic GPER expression was significantly associated with non-ductal histologic subtypes, low tumor stage, better histologic differentiation, as well as Luminal A and B subtypes. In contrast, nuclear GPER expression was significantly associated with poorly differentiated carcinomas and the triple-negative subtype. In univariate analysis, cytoplasmic GPER expression was associated with better overall survival (p = 0.012).

CONCLUSION

Our data suggest that predominantly cytoplasmic and/or nuclear GPER expression are two distinct immunohistochemical patterns in breast carcinomas and may reflect different biological features, reason why these patterns should be clearly distinguished in histological evaluations. Prospective studies will be needed to assess whether the expression status of GPER in breast carcinomas should be routinely observed by clinicians, for instance, before implementing endocrine breast cancer treatment.

Predicting post-stroke pneumonia: the PANTHERIS score

OBJECTIVES

Stroke-associated pneumonia (SAP) is a common complication with a known negative impact on neurological outcome. We developed a score to identify patients at highest risk of SAP in order to promote prophylactic measures.

MATERIALS AND METHODS

We conducted a cohort study on a neurological intensive care unit in patients suffering from acute ischemic MCA infarction. Association of predefined demographics, comorbidities, and clinical characteristics with SAP was investigated using logistic regression analysis.

RESULTS

Between 2003 and 2010, a total of 335 patients were included in this analysis. Frequency of SAP was 31.3%. A 12-point scoring system was developed based on the following factors: Glasgow Coma Scale (GCS) [GCS < 9 = 5, GCS 9-12 = 2, GCS > 12 = 0], age [<60 = 0, 60-80 = 1, >80 = 2], increase in systolic arterial blood pressure >200 mmHg within the first 24 h after admission [no = 0, yes = 2], and white blood cell count >11.000/μl [no = 0, yes = 3]. The score revealed excellent discrimination (AUC = 0.85) and calibration (Nagelkerke's R² = 0.46) properties. Predictive properties were reproduced in an internal validation group.

CONCLUSIONS

The PANTHERIS score is a simple scoring system for the prediction of SAP based on easy-to-assess parameters. By identifying patients at high risk, it may guide intense monitoring or prophylactic measures. This score needs to be validated within external datasets.

Temsirolimus is highly effective as third-line treatment in chromophobe renal cell cancer

We report unexpectedly high efficacy of temsirolimus as third-line treatment in a patient with metastatic chromophobe renal cell carcinoma. After failure of two sequentially administered tyrosine kinase inhibitors, treatment with temsirolimus resulted in a prolonged partial remission of 14 months, and the response is still continuing. Up to now, no data from randomized clinical studies have been published addressing the question of efficacy of temsirolimus as third-line treatment after failure of tyrosine kinase inhibitors. The case presented here implies that temsirolimus could be a viable option for patients with metastatic chromophobe renal cell carcinoma.