Dynamic changes in RAS gene status in circulating tumour DNA: a phase II trial of first-line FOLFOXIRI plus bevacizumab for RAS-mutant metastatic colorectal cancer (JACCRO CC-11)

Background

Few prospective studies have used liquid biopsy testing in RAS-mutant metastatic colorectal cancer (mCRC), and its clinical significance remains unknown. Therefore, this study aimed to carry out a biomarker analysis by liquid biopsy using updated data of the phase II trial of FOLFOXIRI plus bevacizumab as first-line chemotherapy for RAS-mutant mCRC.

Materials and methods

A total of 64 patients who received modified FOLFOXIRI regimen (irinotecan 150 mg/m², oxaliplatin 85 mg/m², levofolinate 200 mg/m², and fluorouracil 2400 mg/m²) plus bevacizumab biweekly were enrolled. The primary endpoint was the objective response rate (ORR). Plasma samples were collected at pre-treatment, 8 weeks after treatment, and progression in participants included in the biomarker study. The levels of circulating tumour DNA (ctDNA) and specific KRAS and NRAS variants were evaluated using real-time PCR assays.

Results

There were 62 patients (median age: 62.5 years, 92% performance status 0, 27% right side) who were assessable for efficacy and 51 for biomarker analysis. ORR was 75.8% (95% confidence interval 65.1% to 86.5%). The median progression-free survival was 12.1 months, and the median overall survival (OS) was 30.2 months. In 78% of patients, RAS mutations disappeared in the ctDNA at 8 weeks after treatment; these patients tended to have better outcomes than those with RAS mutations. Interestingly, RAS mutations remained undetectable during progression in 62% of patients. Survival analysis indicated that the median OS from progression was significantly longer in patients with RAS mutation clearance than in those with RAS mutation in the ctDNA at disease progression (15.1 versus 7.3 months, hazard ratio: 0.21, P = 0.0046).

Conclusions

Our biomarker study demonstrated no RAS mutations in ctDNA at disease progression in 62% of patients with RAS-mutant mCRC. Both OS and post-progression survival were better in patients with clearance of RAS mutations in ctDNA after triplet-based chemotherapy.

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First-line FOLFOXIRI plus bevacizumab is effective for RAS-mutant mCRC with comparable efficacy in elderly patients.

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RAS mutations disappeared in ctDNA after intensive chemotherapy in 62% of patients with mCRC with RAS-mutant tumours.

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Survival time was longer in patients with RAS mutation clearance than in those with RAS mutations in ctDNA.

Expression of Vincristin-induced Peripheral Neuropathy Related to Different Administration Methods

Vincristine (VCR) is an important drug used in R-CHOP regimens for the treatment of non-Hodgkin's lymphoma. The purpose of this study was to examine whether the administration method affects the incidence of VCR-induced peripheral neuropathy. We investigated the ratio of VCR-induced peripheral neuropathy during rapid intravenous infusion and intravenous drip infusion. A total of 71 patients who had received six or more courses of R-CHOP from January, 2015 to December, 2016 at Komaki City Hospital and Ogaki Municipal Hospital were retrospectively investigated. Peripheral neuropathy was observed in 27/39 patients (69 %) and 24/32 (75 %) in rapid intravenous infusion and intravenous drip infusion of VCR, respectively (P = 0.79). Peripheral neuropathy was observed at a high frequency in this study. Additionally, there was no difference in frequency of peripheral neuropathy due to the difference in administration method. In both groups, the degree of peripheral neuropathy was grade 1 and grade 2 in most patients. However, in rapid intravenous infusion, grade 3 peripheral neuropathy was observed. Some cases required dose reduction and discontinuation in rapid intravenous infusion. In contrast, there were no discontinuing patients in the intravenous drip infusion. Therefore, it was suggested that intravenous drip infusion of VCR reduced serious peripheral neuropathy because the ratio requiring dose reduction and discontinuation was less than that in the rapid group. In conclusion, this study is informative as there are few reports focusing on the administration method of vincristine.

Pulmonary artery pulsatility index and hemolysis during Impella support

Funding Acknowledgements

Type of funding sources: None.

Background

Impella-related hemolysis is a well-known complication, which we sometimes experience in the clinical practice depending on various hemodynamic status including right ventricular impairment.

Methods

We enrolled consecutive patients with cardiogenic shock who received Impella support between March 2018 and December 2020. The association between pulmonary artery pulsatility index (PAPi) immediately after Impella insertion and the occurrence of hemolysis was investigated. Hemolytic event was defined as detection of hemoglobinuria and elevated lactate dehydrogenase level over 2.5 folds of upper normal range.

Results

Among 38 patients (median 71 y; men 61%; LVEF 29%) included in this study, hemolysis occurred in 18 patients (47%). Incidence of hemolysis was significantly higher in the low PAPi group (< 1.3) compared with the normal PAPi group (≥ 1.3) (67% vs. 33%, p = 0.0176; Figure 1). The low PAPi (<1.3) was significantly associated with the occurrence of hemolysis with a hazard ratio of 5.71 (95% confidence interval 1.09–29.91, p = 0.0313) adjusted for other clinically significant variables.

Conclusions

In patients with right ventricular impairment with lower PAPi, it might be encouraged to be aware of the risk of hemolysis, maintaining volume status and considering inotropes administration. Abstract Figure.

A novel method of evaluating changes in intrinsic motivation during cognitive rehabilitation

Motivation is one of the most important affecting rehabilitation outcomes. In present study, we propose a novel method to evaluate intrinsic motivation. We conducted experiments of simulated cognitive rehabilitation exercises. The results of these experiments demonstrate that intrinsic motivation is correlated to valence. Furthermore, CIM (Changes in intrinsic motivation) can be detected with up to 80% accuracy, using physiological states. The result showed that this method more precisely detects CIM than occupational therapists.Clinical Relevance-The proposed method enables to evaluate changes in intrinsic motivation during cognitive rehabilitation without disturbing or suspending rehabilitation.

Aspirin vs. P2Y12 inhibitors with anticoagulation therapy for atrial fibrillation: insights from the AFIRE trial

Background

Patients with coronary artery disease (CAD) and atrial fibrillation (AF) can be treated with multiple antithrombotic therapies including antiplatelets and oral anticoagulants; however, this has the potential to increase bleeding risk.

Purpose

This sub-analysis aimed to evaluate the efficacy and safety of P2Y12 inhibitors and aspirin in patients also receiving oral anticoagulant therapy.

Methods

We evaluated patients from the Atrial Fibrillation and Ischemic Events with Rivaroxaban in Patients with Stable Coronary Artery Disease (AFIRE) trial who received combination therapy (rivaroxaban plus a single antiplatelet agent). The choice of antiplatelets was left to the physician's discretion. The primary efficacy endpoint was a composite of stroke, systemic embolism, myocardial infarction, unstable angina requiring revascularization, and death from any cause. The primary safety endpoint was major bleeding according to the International Society on Thrombosis and Haemostasis criteria.

Results

A total of 1,075 patients were included (P2Y12 inhibitor group, n=297; aspirin group, n=778). Approximately 60% of patients were administered proton pump inhibitors (PPIs), and there was no significant difference in PPI use in the P2Y12 inhibitor and aspirin groups. Regarding the primary efficacy endpoint, there was no significant difference between the P2Y12 inhibitor and aspirin groups (hazard ratio, 1.31; 95% confidence interval, 0.88–1.94; p=0.178). Likewise, the primary safety endpoint was not different between the groups (hazard ratio, 0.79; 95% confidence interval, 0.43–1.47; p=0.456). In the detailed subgroup analysis, there were no differences in the efficacy and safety endpoints.

Conclusions

There were no significant differences between P2Y12 inhibitors and aspirin in cardiovascular events in patients with AF and stable CAD taking rivaroxaban in the chronic phase.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Japan Cardiovascular Research Foundation based on a contract with Bayer Yakuhin, Ltd. Summary of this study

A study of the association between seasonal influenza vaccines and the increased risk of Guillain-Barré syndrome using Vaccine Adverse Event Reporting System, 2018-2019

The aim of this study was to investigate the association between the incidence of Guillain-Barré syndrome (GBS) and seasonal influenza vaccines using the United States Vaccine Adverse Event Reporting System. Using multiple logistic regression analysis, we calculated the adjusted reporting odds ratio (ROR) of GBS cases associated with seasonal influenza vaccines administered from August 2018 to July 2019. Additionally, we analyzed the time-to-onset profile. The total number of adverse events reported following vaccination during this period was 43,235. Most of the GBS patients received a cell culture-based quadrivalent inactivated influenza vaccine (42.2%), quadrivalent inactivated influenza vaccine (26.6%), or high-dose trivalent inactivated influenza vaccine (15.6%). The adjusted ROR of seasonal influenza vaccines for GBS was 3.44 (2.40-4.95). The adjusted ROR of sex (male) (as reference female) and 0.5-59 years (as reference ≥ 60 years) were 1.90 (0.73-4.95) and 1.57 (0.88-2.78). Male sex and advanced age were not risk factors for GBS. The median duration of GBS was 9.5 (4.0-21.5) days. GBS following seasonal influenza vaccination developed mainly within 14 days and 42 days at most. In sex-stratified analyses, the median durations of GBS in females and males were 12.0 (8.3-28.5) and 5.0 (3.0-15.5) days (P = 0.050). Therefore, our findings indicate that the incidence of GBS is associated with seasonal influenza vaccines, and careful monitoring of GBS is required for up to 42 days, especially in the first 14 days. Moreover, GBS may occur slightly earlier in males than in females.

OPERA tau neutrino charged current interactions

The OPERA experiment was designed to discover the vτ appearance in a vμ beam, due to neutrino oscillations. The detector, located in the underground Gran Sasso Laboratory, consisted of a nuclear photographic emulsion/lead target with a mass of about 1.25 kt, complemented by electronic detectors. It was exposed from 2008 to 2012 to the CNGS beam: an almost pure vμ beam with a baseline of 730 km, collecting a total of 1.8·1020 protons on target. The OPERA Collaboration eventually assessed the discovery of vμ→vτ oscillations with a statistical significance of 6.1 σ by observing ten vτ CC interaction candidates. These events have been published on the Open Data Portal at CERN. This paper provides a detailed description of the vτ data sample to make it usable by the whole community.

POS1255 REACTOGENICITY OF SARS-COV-2 VACCINES IN PATIENTS WITH AUTOIMMUNE AND INFLAMMATORY DISEASE

Background:

Patients with autoimmune disease often require immunosuppressive medications that may increase their risk of developing severe illness from COVID-19. The importance of immunization in this population is particularly high. While the studied vaccines show efficacy in the general population, nothing is known regarding the immune response or safety profile in patients with autoimmune disease and those taking immunomodulatory medications.

Objectives:

To assess the safety profile and degree of adverse events from SARS-CoV-2 vaccines in patients with autoimmune and inflammatory disease.

Methods:

This study is part of a larger prospective observational study examining the immunogenicity and safety profile of the SARS-CoV-2 vaccine in patients with immune-mediated diseases taking immunomodulatory medications. Adults with an immune-mediated disease scheduled to receive either a Pfizer or Moderna SARS-COV-2 vaccine were enrolled in this study. Subjects participated in 3 study visits (pre-vaccine, dose 1 (D1) and dose 2 (D2)) where blood, for immunologic assays, and clinical data were collected. Assessments of adverse events (AE), including local and systemic symptoms and validated degree of AE severity were solicited within 7 days of receiving each vaccine dose.

Results:

To date, 70 patients with autoimmune and inflammatory disease have been enrolled. Demographic and clinical characteristics are shown in Table 1. Distribution of current immunomodulatory medications included prednisone 18.6%, conventional synthetic DMARD 55.7%, targeted synthetic DMARD 4.3%, and biologic DMARD 68.5%. Almost all participants experienced an adverse event following vaccination (D1 96%, D2 100%). Following D1 AEs were generally mild (76.5%) whereas following D2 a large portion of patients experienced AEs that were moderate (47.8%) and severe (30.5%). Injection site pain was the most common AE following both doses followed by arthralgias (D1 21.6%, D2 78.2%), fever (D1 21.6%, D2 70%) and fatigue (D1 21.6%, D2 65.2%) (Figure 1).

Figure 1.

Solicited Local and Systemic Adverse Events. Percentage of participants who had endorsed an adverse event within 7 days of first or second dose of SARS-CoV-2 Vaccine. ‘Other’ symptoms included chills, blurry vision, brain fog and dizziness.

Conclusion:

Patients with autoimmune and inflammatory disease experience a significant burden of adverse events following SARS-CoV-2 vaccination with both frequency and severity appearing greater than that of the reported results from the vaccine clinical trials. Several of the endorsed AEs such as fever, fatigue and arthralgias can also be commonly seen in rheumatologic diseases, mimicking flares. While SARS-CoV-2 immunization is crucial in patients with autoimmune diseases, this study demonstrates the importance of understanding the AEs experienced by this patient population to better inform patients of possible expected side effects of SARS-CoV-2 vaccination and further management in the future.

Table 1.

Demographic and Clinical Characteristics of Participants

Parameter N (%)N=70Age [years], mean (SD)Age group48.3 ± 16.4 < 6553 (75.7) 65+17 (24.3)Gender Female48 (68.6) Male20 (38.5) Other2 (2.9)Race White47 (67.1) Asian14 (20.0) Hispanic8 (11.4) Black1 (1.4) BMI [kg/m2], mean (SD)25.0 ± 5.4Immunologic Diagnosis Rheumatoid Arthritis21 (30.0) Spondyloarthritis*21 (30.0) Systemic Lupus Erythematous8 (11.4) Connective Tissue Disease, Other‡12 (17.1) Vasculitis3 (4.2) Inflammatory Bowel Disease7 (10.0) Autoinflammatory Syndrome5 (7.1) Multiple Sclerosis2 (2.9) IgG4 Related Disease2 (2.9)Disease Duration [years], mean (SD)9.0 ± 5Medications Prednisone13 (18.6)DMARDs Hydroxychloroquine16 (22.9) Methotrexate15 (21.4) Sulfasalazine6 (8.6) Tofacitinib3 (4.3) Azathioprine2 (2.9)Biologics TNF inhibitor33 (47.1) Rituximab7 (10) Abatacept6 (8.6) IL-23 inhibitor2 (2.9)

* Spondyloarthritis includes Axial Spondyloarthritis and Psoriatic Arthritis. ‡ Other Connective Tissue Disease includes scleroderma, Sjogren’s syndrome, polymyositis, and UCTD.

Disclosure of Interests:

Monica Yang: None declared, Patti Katz: None declared, Diana Paez: None declared, Alexander Carvidi: None declared, Mehrdad Matloubian: None declared, Mary Nakamura: None declared, Lianne S. Gensler Consultant of: AbbVie, Eli Lilly, Gilead, GSK, and Novartis, Grant/research support from: Pfizer and UCB

Securing the surgical field for mobilization of right-sided colon cancer using the duodenum-first multidirectional approach in laparoscopic surgery

Background

The aim of this study was to compare the short-term outcomes of the duodenum-first multidirectional approach (DMA) in laparoscopic right colectomy with those of the conventional medial approach to assess its safety and feasibility.

Methods

This retrospective study enrolled 120 patients who had laparoscopic surgery for right-sided colon cancer in our institution between April 2013 and December 2019. Fifty-four patients underwent colectomy using the multidirectional approach; among these, 20 underwent the DMA and 34 underwent the caudal-first multidirectional approach (CMA). Sixty-six patients underwent the conventional medial approach. Complications within 30 days of surgery were compared between the groups.

Results

There were 54 patients in the multidirectional group [29 females, median age 72 years (range 36–91 years)] and 66 in the medial group [42 females, median age 72 years (range 41–91 years)]. Total operative time was significantly shorter in multidirectional approach patients than conventional medial approach patients (208 min vs. 271 min; p = 0.01) and significantly shorter in patients who underwent the DMA compared to the CMA (201 min vs. 269 min; p < 0.001). Operative time for the mobilization procedure was also significantly shorter in patients who underwent the DMA (131 min vs. 181 min; p < 0.001). Blood loss and incidence of postoperative complications did not differ. In 77 patients with advanced T3/T4 tumors, the DMA, CMA, and conventional medial approach were performed in 13, 21, and 43 patients, respectively. Total operative time and operative time of the mobilization procedure were significantly shorter in patients undergoing DMA. Blood loss and incidence of postoperative complications did not differ. R0 resection was achieved in all patients with advanced tumors.

Conclusions

The DMA in laparoscopic right colectomy is safe and feasible and can achieve R0 resection with a shorter operative time than the conventional medial approach, even in patients with advanced tumors.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-021-02444-5.