Phase I study of RAD001 (everolimus), cetuximab, and irinotecan as second-line therapy in metastatic colorectal cancer (mCRC)

e15115

Background: The PI3K/AKT/mTOR pathway is frequently dysregulated in colorectal cancer (Cancer Res 2005;65:11227). In a phase I study in patients with advanced solid tumors, everolimus an oral mTOR inhibitor demonstrated clinical benefit including a partial response in pts with colorectal cancer (J Clin Oncol 2008;26:1603–10; J Clin Oncol 2008; 26:1588–95). Methods: This open-label, multicenter phase I study uses a Bayesian logistic model to identify feasible doses of everolimus + irinotecan + cetuximab. Adult pts with mCRC progressing despite prior 5-FU/oxaliplatin (FOLFOX) or capecitabine/oxaliplatin (XELOX) plus bevacizumab (if standard practice) were treated using a sequential dose escalation scheme (Table). Dose decisions were driven by the probability of dose-limiting toxicity (DLT) in the first 2 cycles. Dose level decisions were based on maximizing the probability that end-of-cycle-2 DLT rate would be within the targeted toxicity interval (20% to <35%) and minimizing the risk of over-dosing (< 5% risk of unacceptable toxicity and < 25% risk of excessive/unacceptable toxicity). Results: 18 pts were treated from April ‘07 to August ‘08, 5 pts at dose level A1 and 13 pts at dose level B1. Two DLTs (G3 rash on cycle 2 day 1 lasting > 7 days and G3 mucositis on cycle 1 day 14 lasting > 7 days, 1 pt each) were reported in 4 evaluable pts at dose level A1. No DLTs were reported in 7 evaluable patients at dose level B1. Conclusions: At dose level B1 everolimus in combination with irinotecan and cetuximab was generally well tolerated. The study was stopped due to changes in clinical practice based on emerging data indicating that cetuximab has limited efficacy in mCRC patients with KRAS mutations and that efficacy data favors daily RAD001 over weekly dosing. Patients in this study were treated with cetuximab irrespective of KRAS status.

[Table: see text]

[Table: see text]

Associations between andrological measures, hormones and semen quality in fertile Australian men: inverse relationship between obesity and sperm output

BACKGROUND

The World Health Organization developed a time to pregnancy (TTP) study (number of menstrual cycles taken to conceive) to determine whether the average TTP is increasing and semen quality decreasing with time. The present study describes clinical, semen and hormone characteristics obtained from male partners of pregnant women in Melbourne, Australia, and examines the associations between these characteristics.

METHODS

Male partners (n = 225) of pregnant women (16-32 weeks) who conceived naturally had physical examination, health and lifestyle questionnaires, semen and hormone (FSH, LH, sex hormone-binding globulin, testosterone and Inhibin B) analyses.

RESULTS

Previously known associations between semen, hormone and clinical variables were confirmed as significant: sperm numbers (concentration and total sperm count) correlated positively with Inhibin B and inversely with FSH and left varicocele, while total testicular volume correlated positively with sperm numbers and Inhibin B and inversely with FSH. However, only abstinence, total testicular volume, varicocele grade and obesity (BMI > 30 kg/m2) were independently significantly related to total sperm count. Compared with those with BMI < 30 (n = 188), obese subjects (n = 35) had significantly lower total sperm count (mean 324 versus 231 million, P = 0.013) and Inhibin B (187 versus 140 pg/ml, P < 0.001) but not FSH (3.4 versus 4.0 IU/l, P = 0.6).

CONCLUSIONS

Obese fertile men appear to have reduced testicular function. Whether this is cause or effect, i.e. adiposity impairing spermatogenesis or reduced testicular function promoting fat deposition, remains to be determined.

Sexual Health in Parkinson’s Disease

Introduction:

The changes in sexual health of patients with Parkinson's disease must be a concern to the clinicians. The effects in sexual health of patients submitted to functional cirurgy is still a matter of debate.

Objectives:

To describe and evaluate the sexual health of patients with Parkinson's disease following deep brain stimulation (DBS) of the subthalamic nucleus (STN).

Methods:

Patients with Parkinson's disease bilaterally implanted for DBS of STN and those only pharmacologically treated, will be evaluated. Sexual functioning will be assessed using the international erectile function indices (IEFI) and the female sexual function indices (FSFI). Depression and anxiety will be evaluated using the Beck depression inventory and the brief symptom indices. Relations between sexual functioning and modifications in the severity of disease (Hoehn and Yahr stage), reduction in levodopa equivalent daily dosage (LEDD), age, and duration of disease will be analyzed.

Results and conlusions:

We expect to find positive changes in the sexual health of these patients, given the fact of the procedure improve the overall burden of the disease by reduction of medication and motor symptoms.

Factors affecting low birthweight after assisted reproduction technology: difference between transfer of fresh and cryopreserved embryos suggests an adverse effect of oocyte collection

BACKGROUND

Data show that differences exist in the birthweight of singletons after frozen embryo transfer (FET) compared with fresh transfer or gamete intra-Fallopian transfer (GIFT). Factors associated with low birthweight (LBW) after assisted reproduction technology (ART) were studied.

METHODS

Birthweight, distribution of birthweight, z-score, LBW (<2500 g), gestation and percentage preterm (<37 weeks) for singleton births >19 weeks gestation, conceived by ART or non-ART treatments (ovulation induction and artificial insemination) between 1978 and 2005 were analysed for one large Australian clinic.

RESULTS

For first births, the mean birthweight was significantly (P < 0.005) lower, and LBW and preterm birth more frequent for GIFT (mean = 3133 g, SD = 549, n = 109, LBW = 10.9% and preterm = 10.0%), IVF (3166, 676, 1615, 11.7, 12.5) and ICSI (3206, 697, 1472, 11.5, 11.9) than for FET (3352, 615, 2383, 6.5, 9.2) and non-ART conceptions (3341, 634, 940, 7.1, 8.6). Regression modelling showed ART treatment before 1993 and fresh embryo transfer were negatively related to birthweight after including other covariates: gestation, male sex, parity, birth defects, Caesarean section, perinatal death and socio-economic status.

CONCLUSIONS

Birthweights were lower and LBW rates higher after GIFT or fresh embryo transfer than after FET. Results for FET were similar to those for non-ART conceptions. This suggests IVF and ICSI laboratory procedures affecting the embryos are not causal but other factors operating in the woman, perhaps associated with oocyte collection itself, which affect endometrial receptivity, implantation or early pregnancy, may be responsible for LBW with ART.

Melanoma of the anal canal: a case series

PURPOSE

Anal melanoma is an uncommon and aggressive cancer. Different surgical modalities have been used in managing the disease with no clear evidence to favor one approach over another.

METHODS

The medical records of patients with anal melanoma treated at the H. Lee Moffitt Cancer and Research Institute between 1987 and 2004 were reviewed. Published anal melanoma studies, including more than ten patients with outcome data, also were reviewed.

RESULTS

Twelve patients were identified (8 percent of all cancer of the anal canal). Nine were females with a median age of 67 (range, 27-86) years. Four patients had nodal involvement, and one had bone metastases at the time of diagnosis. Five patients had abdominoperineal resection, and six had local excision. Adjuvant radiation therapy with or without interferon was used. Five of the 11 patients without metastatic disease relapsed or died within the first year of diagnosis (4 had local excision and 1 had abdominoperineal resection). Median time to relapse was 6.5 (range, 4-31) months. The liver was the most common site for relapse. Only one patient treated with local excision followed by interferon was a long survivor (no evidence of recurrence at 54 months).

CONCLUSIONS

Anorectal melanoma is a rare and challenging disease. The preoperative staging influences the treatment schedule. In the absence of strong survival benefit of abdominoperineal resection in managing the nonmetastatic form of the disease, it is reasonable to consider local excision as the initial treatment of choice. Adjuvant radiation therapy is well tolerated and is promising in improving locoregional control.

Phase I trial of histone deacetylase inhibition by valproic acid followed by the topoisomerase II inhibitor epirubicin in advanced solid tumors: a clinical and translational study

PURPOSE

To determine the safety, toxicity, and maximum-tolerated dose of a sequence-specific combination of the histone deacetylase inhibitor (HDACi), valproic acid (VPA), and epirubicin in solid tumor malignancies and to define the clinical feasibility of VPA as an HDACi.

PATIENTS AND METHODS

Patients were treated with increasing doses of VPA (days 1 through 3) followed by epirubicin (day 3) in 3-week cycles. The study evaluated pharmacokinetic and pharmacodynamic end points, toxicities, and tumor response.

RESULTS

Forty-eight patients were enrolled, and 44 received at least one cycle of therapy. Patients (median age, 54 years; range, 39 to 78 years) received the following doses of VPA: 15, 30, 45, 60, 75, 90, 100, 120, 140, and 160 mg/kg/d. Dose-limiting toxicities were somnolence (n = 1), confusion (n = 3), and febrile neutropenia (n = 1). No exacerbation of epirubicin-related toxicities was observed. Partial responses were seen across different tumor types in nine patients (22%), and stable disease/minor responses were seen in 16 patients (39%), despite a median number of three prior regimens (range, zero to 10 prior regimens). Patients received a median number of four treatment cycles (range, one to 10 cycles), and treatment was stopped after reaching maximal epirubicin doses rather than progression in 13 (32%) of 41 patients patients. Total and free VPA plasma concentrations increased linearly with dose and correlated with histone acetylation in peripheral-blood mononuclear cells.

CONCLUSION

The maximum-tolerated dose and recommended phase II dose was VPA 140 mg/kg/d for 48 hours followed by epirubicin 100 mg/m2. Sustained plasma concentrations of VPA exceeding those required for in vitro synergy were achieved with acceptable toxicity. Noteworthy antitumor activity was observed in heavily pretreated patients and historically anthracycline-resistant tumors.

Comparison of human sperm morphometry assessment models based on zona pellucida selectivity

Computer image analysis improves the objectivity and reproducibility of conventional assessments of sperm morphology. We have extended this objectivity by using the physiological process of sperm-zona pellucida (ZP) binding to classify 'normal' sperm morphometry. Linear regression analysis of the morphometric differences between sperm in semen, swim-up and ZP bound samples (n=53) was used to establish 12 "zona preferred" morphometric parameters from which two different morphometric evaluations of an individual sperm's potential for motility and ability to bind to the ZP of human oocytes were calculated. The two models, %Z and %ZB, were then tested, together with conventional morphometry assessments of percent "normal" and other semen variables, against experimental sperm-ZP binding rates (n=64) and natural pregnancy rates in sub-fertile couples (n= 1191). Although %ZB was the most significantly related semen variable to sperm-ZP binding rate, the simpler %Z was more significant in the Cox regression model for natural pregnancy rates in sub-fertile couples. In multivariate analysis, the only additional significant covariates were sperm straight line velocity and female age. %Z is therefore the most appropriate and also easiest of our morphometry assessments to be applied to commercial CASA systems which offer a morphometry module with stain density analysis.

Multiple mechanisms are implicated in the generation of 5q35 microdeletions in Sotos syndrome

BACKGROUND

Sotos syndrome is characterised by learning difficulties, overgrowth, and a typical facial appearance. Microdeletions at 5q35.3, encompassing NSD1, are responsible for approximately 10% of non-Japanese cases of Sotos. In contrast, a recurrent approximately 2 Mb microdeletion has been reported as responsible for approximately 50% of Japanese cases of Sotos.

METHODS

We screened 471 cases for NSD1 mutations and deletions and identified 23 with 5q35 microdeletions. We investigated the deletion size, parent of origin, and mechanism of generation in these and a further 10 cases identified from published reports. We used "in silico" analyses to investigate whether repetitive elements that could generate microdeletions flank NSD1.

RESULTS

Three repetitive elements flanking NSD1, designated REPcen, REPmid, and REPtel, were identified. Up to 18 cases may have the same sized deletion, but at least eight unique deletion sizes were identified, ranging from 0.4 to 5 Mb. In most instances, the microdeletion arose through interchromosomal rearrangements of the paternally inherited chromosome.

CONCLUSIONS

Frequency, size, and mechanism of generation of 5q35 microdeletions differ between Japanese and non-Japanese cases of Sotos. Our microdeletions were identified from a large case series with a broad range of phenotypes, suggesting that sample selection variability is unlikely as a sole explanation for these differences and that variation in genomic architecture might be a contributory factor. Non-allelic homologous recombination between REPcen and REPtel may have generated up to 18 microdeletion cases in our series. However, at least 15 cannot be mediated by these repeats, including at least seven deletions of different sizes, implicating multiple mechanisms in the generation of 5q35 microdeletions.

Phase I trial of CT-2106 (polyglutamated camptothecin) administered weekly in patients (pts) with advanced solid tumors

2015

Background: CT-2106, a camptothecin (CPT) conjugate, is a topoisomerase I inhibitor. Covalent binding through the hydroxyl group of CPT to polyglutamate, a biodegradable polymer of glutamic acid, enhances CPT aqueous solubility and prevents opening of the lactone ring and subsequent CPT binding to albumin. Responses were observed in a Q3 week dosing study in which the maximum tolerated dose (MTD) was 75 mg/m2. Objectives of this study are to determine the MTD and pharmacokinetics (PK) of CT-2106 given weekly to pts with advanced cancer. Methods: Pts received CT-2106 (10 min IV infusion) on days 1, 8, and 15 of each 28 day cycle. Toxicity (NCI CTC v3) and tumor response (RECIST) were assessed. Plasma was analyzed for conjugated and unconjugated CPT by liquid chromatography and tandem mass spectrometry. Results: Enrollment is complete with 21 evualuable pts. Dose limiting toxicities (DLT) are shown in the table . Median age = 60 years (range 36–83), median doses = 6 (1–9), median prior therapies = 3 (1–6). Most pts (12) had melanoma. In a Q3 week study assessments of conjugated and unconjugated CPT demonstrated that CT-2106 provides prolonged exposure to conjugated CPT and slow, progressive release of active CPT from the polymeric backbone. The PK of unconjugated CPT is dependent on the disposition profile of conjugated CPT; unconjugated CPT elimination is formation rate limited. The distribution of conjugated CPT appears to be restricted to extracellular body fluids. Total clearance includes renal excretion documented by substantial urinary excretion levels and CPT cleavage via metabolic pathways. Accumulation of conjugated or unconjugated CPT was not observed with repeated Q3 week dosing. PK in this weekly dosing study will be presented. Conclusions: CT-2106 is generally well tolerated without the toxicities normally associated with CPT, specifically hemorrhagic cystitis and severe diarrhea. The MTD is 25–35 mg/m2 in these heavily pretreated pts.

[Table: see text]

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Sunitinib treatment of pediatric metastatic GIST after failure of imatinib

9519

Background: The genotype of most GIST in pediatric patients (pts) is “wild type” (WT-GIST), with no detectable KIT or PDGFR-α mutations. Adults with metastatic WT-GIST often have suboptimal results and primary resistance to imatinib (IM) therapy. Treatment with sunitinib malate (SU11248), an oral, multitargeted tyrosine kinase inhibitor with antiangiogenic and antitumor activities, results in significant clinical benefit, such as improved survival, for adult pts with IM-resistant GIST, including WT-GIST. We report here the treatment of 3 pediatric pts with IM-resistant, metastatic GIST using sunitinib. Methods and Patients: Pt 1 presented at age 17 with numerous abdominal and hepatic GIST metastases. Following surgical debulking and 6 wks of IM treatment, objective progression was noted due to growth of omental masses and a new hepatic lesion. Pt 2 presented at age 8 with an isolated gastric GIST, fully resected, followed by adjuvant IM that continued until resection of a local recurrence 14 mos later. She had 2 more local recurrences and developed lung metastases. Pt 3 presented at age 13 with a large gastric GIST and a retroperitoneal metastasis, both fully resected and followed by adjuvant IM for 18 mos. Six mos after discontinuing IM, recurrent metastatic GIST was noted in the liver and retroperitoneum; IM therapy was resumed with stable disease for 1 yr when new hepatic lesions appeared with progression of the retroperitoneal mass. Pts 1 and 2 had WT-GIST, while genotyping of Pt 3 is pending. Sunitinib, obtained via an expanded-access protocol, was administered in 6-wk cycles, orally QD for 4 wks followed by 2 wks off dosing. Results: All pts have received 5 cycles of sunitinib. All GIST lesions have stabilized or decreased in size by CT imaging, with complete regression of 2 lung nodules in Pt 2. 18FDG-PET imaging obtained in 2 pts showed significant decreases in tumor-associated activity at all disease sites. Side effects with sunitinib have been manageable, including grade 2 GI and hematologic toxicities in pt 1, grade 3 fatigue in pt 2 and grade 3 hematologic toxicity in pt 3. Conclusions: Sunitinib shows important antitumor activity in pediatric pts with IM-resistant GIST. An expanded phase I/II trial of sunitinib in pediatric GIST is warranted.

[Table: see text]

Phase I trial of a sequence-specific combination of the HDAC inhibitor, valproic acid (VPA), and the topoisomerase II inhibitor, epirubicin, in advanced solid tumors: Clinical results and correlative studies

3068

Background: Multiple lines of evidence indicate that histone deacetylase inhibitors (HDACi) potentiate topoisomerase (topo) inhibitors. The HDACi-induced histone acetylation and chromatin modulation facilitates DNA access and target recruitment for topo II inhibitors. Methods: This Phase I trial explored a sequence-specific combination of VPA and epirubicin in solid tumors. A VPA loading dose and 6 oral doses (q12h) were given prior to epirubicin in 3-week cycles. Histone acetylation and topo II expression were evaluated in pre-and post-VPA peripheral blood mononuclear cells and tumor samples. Results: To date, 42 patients [median age 53 (39–78)] have been treated in 12 cohorts: IV VPA loading (mg/kg)/epirubicin (mg/m2): 15/75, 30/75, 45/75, 60/75, 75/75 and 75/100, oral loading: 75/100, 90/100, 100/100, 120/100, 140/100 and 160/100. Tumor types included: breast (10), melanoma (11), lung (6), sarcoma (2), GYN (2), GI (5) and others (6). Dose-limiting toxicities included somnolence (1) and neutropenia (1). No exacerbation of epirubicin-related toxicities was observed. Objective responses were seen across different tumor types in anthracycline-resistant and -refractory tumors, despite a median number of 3 (0–6) prior regimens: Partial response; 7/37 (19%), stable disease/minor response: 16/37 (43%). Patients received a median number of 4 (1–10) treatment cycles. Study treatment was stopped despite a clinical benefit or response in 4/33 patients after reaching maximal epirubicin doses (≤750 mg/m2). VPA peak and trough plasma concentrations increased linearly up to 120 mg/m2. MTD is being defined at 160/100 mg/kg/d VPA. H3 and H4 histone acetylation and topo II expression have been correlated with VPA dose, plasma concentration and response. Conclusion: A sequence-specific combination of VPA and epirubicin is active without exacerbation of epirubicin toxicity. VPA plasma peak and trough levels exceeding concentrations needed for biological effects and in vitro synergy are easily achievable with minimal toxicity. The noteworthy anti-tumor activity seen in this heavily pretreated Phase I population warrants further exploration.

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[Disability and quality of life of stroke survivors: evaluation nine months after discharge]

INTRODUCTION AND AIM

After acute episode, a great number of individuals who survive a stroke have impairments that impede them to carry out with autonomy a set of basic activities of daily life and instrumental activities of daily life. The clinical evaluation health self perception is a useful element on patient's recovering process. The purpose of this study was to evaluate post-stroke functional health status and quality of life.

PATIENTS AND METHODS

After identification of a cohort of admitted patients at a general hospital, those were contacted by phone nine months after discharge. The collected tool sent by mail included the COOP WONCA charts, Frenchay Activities Index, Barthel Index, Rankin scale and a set of socio-demographic variables.

RESULTS

Participants survival rate was of 81%. The physical functioning and the capacity to perform daily activities were the most affected ones, impairing the patients of making a set of basic and instrumental daily activities. The emotional state and health self-perception are also correlated to disability.

CONCLUSIONS

The results suggest a significative percentage of stroke survivors maintaining a moderate or severe disability (47.8%) requiring the presence of caregiver helping self-care. Collected data enhances that stroke survivors have severe physical dysfunction associated to emotional and psychological disturbances.