Kaposi's sarcoma in patients with and without human immunodeficiency virus infection, in a tertiary referral centre in Kenya

The clinical features of Kaposi's sarcoma (KS), in patients with and without HIV infection, were investigated in a tertiary referral centre in Kenya between 1997 and 1999. Although 186 cases were identified prospectively, the data analysis was restricted to the 91 (49%) cases who had pathological confirmation of Kaposi's sarcoma and documented HIV serostatus. Among these 91 subjects (58% of whom were male), the age-group holding the largest number of KS cases was that of individuals aged 31-40 years; most of the paediatric cases were aged 6-10 years. The ratio of HIV-seropositives to HIV-seronegatives was 8.5:1 for the adult cases and 0.9:1 for the paediatric. Of the signs and symptoms of Kaposi's sarcoma seen at presentation, only peripheral lympadenopathy was found to be significantly associated with underlying HIV infection (P = 0.05). The median survival was 104 days. It is apparent that, as the HIV epidemic advances in regions of the world with endemic KS, the clinical presentation and natural history of the endemic KS are blending with those of the epidemic or AIDS-associated disease, leading to a reduction in the mean age of the cases and a nearly identical incidence in men and women. In regions of the world where patients have ready access to such chemotherapy, the impact of treatment with highly active antiretroviral drugs on the incidence and natural history of KS has been dramatic. It will be important to monitor the clinico-pathological features of KS in the developing world, as more active antiretroviral regimens become available in clinical practice there.

Treatment factors affecting outcomes in HIV-associated non-Hodgkin lymphomas: a pooled analysis of 1546 patients

Limited comparative data exist for the treatment of HIV-associated non-Hodgkin lymphoma. We analyzed pooled individual patient data for 1546 patients from 19 prospective clinical trials to assess treatment-specific factors (type of chemotherapy, rituximab, and concurrent combination antiretroviral [cART] use) and their influence on the outcomes complete response (CR), progression free survival (PFS), and overall survival (OS). In our analysis, rituximab was associated with a higher CR rate (odds ratio [OR] 2.89; P < .001), improved PFS (hazard ratio [HR] 0.50; P < .001), and OS (HR 0.51; P < .0001). Compared with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP), initial therapy with more dose-intense regimens resulted in better CR rates (ACVBP [doxorubicin, cyclophosphamide, vindesine, bleomycin and prednisolone]: OR 1.70; P < .04), PFS (ACVBP: HR 0.72; P = .049; "intensive regimens": HR 0.35; P < .001) and OS ("intensive regimens": HR 0.54; P < .001). Infusional etoposide, prednisone, infusional vincristine, infusional doxorubicin, and cyclophosphamide (EPOCH) was associated with significantly better OS in diffuse large B-cell lymphoma (HR 0.33; P = .03). Concurrent use of cART was associated with improved CR rates (OR 1.89; P = .005) and trended toward improved OS (HR 0.78; P = .07). These findings provide supporting evidence for current patterns of care where definitive evidence is unavailable.

Abstract B71: DNA damage responses to cisplatin and dicycloplatin, a new platinum analog

Background: Dicycloplatin (DCP), a new platinum compound approved by the Chinese FDA in March of 2012, shows better water solubility, greater stability, and lower toxicity, compared to cisplatin and carboplatin. Preclinical in vitro and in vivo studies and a Phase I clinical trial demonstrated that DCP possesses strong antitumor activity and lower adverse events than carboplatin. Phase II clinical trials using dicycloplatin plus paclitaxel in chemotherapy-naïve patients with advanced NSCLC found that efficacy and safety of DCP plus paclitaxel regimen were comparable to those of carboplatin plus paclitaxel regimen, with slightly better tolerance. Materials and Methods: Pharmacokinetic study of DCP characteristics was conducted using AP-4000TM LC-MS/MS System in patient blood samples. Molecular mechanism studies of dicycloplatin-induced gene-signature profiling were determined by Immunoblotting and compared to cisplatin profiling in human ovarian cancer cells. Results: Pharmacokinetic mass spectrometry shows different spectrums of dicycloplatin and of carboplatin in plasma. Two hours after administration, plasma concentration of dicycloplatin prototype is still high (17.1 μg/ml), following a peak concentration of 26.9 µg/ml at 0.5-h. Molecular mechanism investigation showed DCP-induced activation of several kinases including phosphorylations of Chk2 at threonine 68, p53 at serine 15 and BRCA1 at serine 1497. The increases in p-Chk2 and p-BRCA1 showed that the amount of DCP-induced phosphorylation doubled at 48-h and tripled for p-p53 at 24-h, compared to controls. Conclusion: Dicycloplatin appears to activate DNA damage-repair pathways through mechanisms similar to cisplatin.

Citation Information: Mol Cancer Ther 2013;12(11 Suppl):B71.

Citation Format: Jing Jie Yu, Xuqing Yang, Qinhua Song, Michael D. Mueller, Scot C. Remick. DNA damage responses to cisplatin and dicycloplatin, a new platinum analog. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr B71.

Barriers to recruitment of rural patients in cancer clinical trials

PURPOSE

The National Cancer Institute estimates that less than 5% of adult patients with cancer participate in clinical trials. This statistic has to improve in order for clinical trials to be more accurate and generalizable. Several studies have looked into the barriers to accrual among various patient subgroups. However, there are scant data regarding factors that act as barriers to accrual of rural patients. Our study aims to identify these barriers.

PATIENTS AND METHODS

Among patients seen at the Mary Babb Randolph Cancer Center at West Virginia University, 1,000 were randomly selected to receive a questionnaire by mail. Data obtained consisted of demographic and clinical information, as well as awareness about clinical trials, willingness to participate, and factors influencing participation. Patients had 6 weeks to respond.

RESULTS

Two hundred forty-one (24.1%) patients responded to the survey. Of these, 66.9% had heard about clinical trials, 19.6% reported that their health care team had discussed clinical trials, and 9.1% had participated in clinical trials. Respondents were more likely to be willing to participate in cancer prevention/screening trials than therapeutic trials. Regarding the decision not to participate in a clinical trial, patients cited discouragement from their oncologist, monetary burden, discouragement from family physician, commute, and lack of information as strongly or extremely influential factors.

CONCLUSION

Our findings specify the need for patient and physician education through community outreach programs. Oncologists should be trained to discuss clinical trials and to address concerns regarding their availability, utility, and accessibility. Financial counseling may play an important role in improving accrual rates as well.

A pooled analysis of 1,546 patients with AIDS-related lymphoma (ARL): An assessment of prognostic factors by treatment era

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Background: Management of ARL evolved in the last 2 decades. We previously reported prognostic factors in a pooled analysis of 1,546 patients with ARL, and here present analysis of these factors over time to determine if their prognostic significance has changed. Methods: Following a systematic review, we assembled individual patient data from 19 prospective phase 2/3 clinical trials (published 1993-2010) for ARL (n=1,546). Factors analyzed include age, sex, histology, CD4 count, prior history of (h/o) AIDS, & age-adjusted (aa) IPI. The endpoint was overall survival (OS) expressed as the hazard ratio (HR) for death. We used separate Cox proportional hazard models adjusted for the other covariates to determine the significance of each variable in the following time periods: pre-cART [combination antiretroviral therapy] (<1996; n=388), early cART (‘96-‘00; n=694), modern cART (‘01-‘04; n=282) & current era (‘05-‘10; n=182). We also combined all enrollments in one Cox model to test for difference in association with OS over enrollment periods. Results: Rituximab use was limited in the early cART (20%) compared with the modern cART (83%) and current (93%) eras. Histology & sex were not significantly associated with OS in any time period. Increasing age was associated with worse OS in the pre-cART (HR 1.02; p<0.01) and current (HR 1.05, p=0.04) eras. A prior h/o AIDS increased risk of death during early cART (HR 1.31, p=0.047) but was not significant after 2000. Meanwhile, baseline CD4 count <50 was a poor prognostic factor during early (HR 1.78, p<0.01) and modern cART (HR 2.76, p=0.001) eras, but not in the current era. The aaIPI predicted worse OS in each time period (pre-cART: HR 1.54, p<0.0001; early cART: HR 1.49, p<0.0001; modern cART: HR 1.52, p<0.01; current era: HR 2.34, p<0.0001). No significant interaction between each prognostic factor with enrollment was found. Conclusions: In this pooled analysis of 1,546 patients with ARL, aaIPI was the only consistently significant prognostic factor and its effect was magnified in the current era. HIV-related factors gained prognostic relevance in the early and modern cART era but may not be as relevant with current treatment strategies.

Phase II trial of sorafenib in patients with advanced anaplastic carcinoma of the thyroid

BACKGROUND

Anaplastic thyroid cancer (ATC) is a rare but highly aggressive malignancy with a median survival of 3-5 months. The BRAF oncogene is mutated to its active form in up to 24% of ATC cases. Sorafenib is a tyrosine kinase inhibitor that acts on the RAF-1 serine/threonine kinase. In preclinical mouse models, sorafenib inhibits the growth of ATC xenografts and improves survival. No study of sorafenib in ATC has been conducted. We conducted a multi-institutional phase II trial of sorafenib in patients with ATC who had failed up to two previous therapies.

METHODS

The primary endpoint of the trial was the Response Evaluation Criteria In Solid Tumors (RECIST)-defined imaging response rate. Twenty patients with ATC were treated with sorafenib 400 mg twice daily.

RESULTS

Two of the 20 patients had a partial response (10%) and an additional 5 of 20 (25%) had stable disease. The duration of response in the two responders was 10 and 27 months, respectively. For the patients with stable disease, the median duration was 4 months (range 3-11 months). The overall median progression-free survival was 1.9 months with a median and a 1-year survival of 3.9 months and 20%, respectively. Toxicity was manageable and as previously described for sorafenib, including hypertension and skin rash.

CONCLUSION

Sorafenib has activity in ATC, but at a low frequency and similar to our previous experience with fosbretabulin. One patient with a response had previously progressed on fosbretabulin. Toxicities were both predictable and manageable.

Phase I clinical trial of O6-benzylguanine and topical carmustine in the treatment of cutaneous T-cell lymphoma, mycosis fungoides type

OBJECTIVES

To evaluate the toxic effects and maximum tolerated dose of topical carmustine [1,3-bis(2-chloroethyl)-1-nitrosourea] following intravenous O6-benzylguanine in the treatment of cutaneous T-cell lymphoma (CTCL), and to determine pharmacodynamics of O6-alkylguanine DNA alkyltransferase activity in treated CTCL lesions.

DESIGN

Open-label, dose-escalation, phase I trial.

SETTING

Dermatology outpatient clinic and clinical research unit at a university teaching hospital.

PATIENTS

A total of 21 adult patients (11 male, 10 female)with early-stage (IA-IIA) refractory CTCL, mycosis fungoides type, treated with topical carmustine following intravenous O6-benzylguanine.

INTERVENTION

Treatment once every 2 weeks with 120 mg/m(2) intravenous O6-benzylguanine followed 1 hour later by whole-body, low-dose topical carmustine starting at 10 mg, with 10-mg incremental dose-escalation in 3 patient cohorts. Cutaneous T-cell lymphoma lesional skin biopsy specimens were taken at baseline and 6 hours, 24 hours, and 1 week after the first O6-benzylguanine infusion for analysis of O6-alkylguanine-DNA alkyltransferase activity.

MAIN OUTCOME MEASURES

Clinical response measured by physical examination and severity-weighted assessment tool measurements, safety data acquired by review of adverse events at study visits, and O6-alkylguanine-DNA alkyltransferase activity in treated lesion skin biopsy specimens.

RESULTS

A minimal toxic effect was observed through the 40-mg carmustine dose level with 76% of adverse events being grade 1 based on the National Cancer Institute Common Terminology Criteria for Adverse Events. Mean baseline O6-alkylguanine-DNA alkyltransferase activity in CTCL lesions was 3 times greater than in normal controls and was diminished by a median of 100% at 6 and 24 hours following O6-benzylguanine with recovery at 1 week. Clinical disease reduction correlated positively with O6-alkylguanine-DNA alkyltransferase activity at 168 hours (P=.02) and inversely with area under the curve of O6-alkylguanine-DNA alkyltransferase over 1 week (P=.01). Twelve partial responses and 4 complete responses were observed (overall response, 76% [95% CI, 0.55-0.89]). Five patients discontinued therapy owing to adverse events with a possible, probable, or definite relationship to the study drug.

CONCLUSION

O6-benzylguanine significantly depletes O6-alkylguanine-DNA alkyltransferase in CTCL lesions and in combination with topical carmustine is well tolerated and shows meaningful clinical responses in CTCL at markedly reduced total carmustine treatment doses.

Declining mammography screening in a state Medicaid Fee-for-Service program: 1999-2008

OBJECTIVE

To evaluate and compare annual and biennial mammography screening rates across age, race, and geographic location (rural-urban) and to determine mammography screening persistence over 10 years among women enrolled in the West Virginia (WV) Medicaid Fee-for-Service (FFS) program.

METHODS

The WV Medicaid FFS administrative claims data for women recipients aged 40-64 from 1999 to 2008 were used for study purposes. Annual and biennial screening rates and persistence with screening were determined for women who were continuously enrolled in the WV Medicaid FFS program for respective calendar years.

RESULTS

A steady decline in the annual and biennial screening rates over a 10-year period (1999-2008) was observed among women recipients aged 40-64 years in the WV Medicaid FFS program, and screening persistence was also lower. Both annual and biennial screening rates and persistence varied by different demographic characteristics.

CONCLUSIONS

Although mammography screening services are covered under Medicaid programs, underuse persists as a major concern. The results of this study emphasize the need to identify and address barriers to mammography screening in low-income rural populations.

A comparative investigation of methods for longitudinal data with limits of detection through a case study

The statistical analysis of continuous longitudinal data may be complicated since quantitative levels of bioassay cannot always be determined. Values beyond the limits of detection (LOD) in the assays may not be observed and thus censored, rendering complexity to the analysis of such data. This article examines how both left-censoring and right censoring of HIV-1 plasma RNA measurements, collected for the study on AIDS-related Non-Hodgkin’s lymphoma (AR-NHL) in East Africa, affects the quantification of viral load and explores the natural history of viral load measurements over time in AR-NHL patients receiving anticancer chemotherapy. Data analyses using Monte Carlo EM algorithm (MCEM) are compared to analyses where the LOD or LOD/2 (left censoring) value is substituted for the censored observations, and also to other methods such as multiple imputation, and maximum likelihood estimation for censored data (generalized Tobit regression). Simulations are used to explore the sensitivity of the results to changes in the model parameters. In conclusion, the antiretroviral treatment was associated with a significant decrease in viral load after controlling the effects of other covariates. A simulation study with finite sample size shows MCEM is the least biased method and the estimates are least sensitive to the censoring mechanism.

AIDS-Related Non-Hodgkin's Lymphoma in Sub-Saharan Africa: Current Status and Realities of Therapeutic Approach

Today AIDS-related non-Hodgkin's lymphoma (AR-NHL) is a significant cause of morbidity and mortality in HIV-infected patients the world over, and especially in sub-Saharan Africa. While the overall incidence of AR-NHL since the emergence of combination antiretroviral therapy (cART) era has declined, the occurrence of this disease appears to have stabilized. In regions of the world where access to cART is challenging, the impact on disease incidence is less clear. In the resource-rich environment it is clinically well recognized that it is no longer appropriate to consider AR-NHL as a single disease entity and rather treatment of AIDS lymphoma needs to be tailored to lymphoma subtype. While intensive therapeutic strategies in the resource-rich world are clearly improving outcome, in AIDS epicenters of the world and especially in sub-Saharan Africa there is a paucity of data on treatment and outcomes. In fact, only one prospective study of dose-modified oral chemotherapy and limited retrospective studies with sufficient details provide a window into the natural history and clinical management of this disease. The scarcities and challenges of treatment in this setting provide a backdrop to review the current status and realities of the therapeutic approach to AR-NHL in sub-Saharan Africa. More pragmatic and risk-adapted therapeutic approaches are needed.

Correlations among ERCC1, XPB, UBE2I, EGF, TAL2 and ILF3 revealed by gene signatures of histological subtypes of patients with epithelial ovarian cancer

The aim of this study was to better understand the mechanisms of tumor development and disease progression in human epithelial ovarian cancer. Fifty genes were screened for gene signature; 20 expressed genes were assessed in tumor and normal samples of EOC patients by RT-PCR. Expression of UBE2I, EGF, TAL2 and ILF3 was validated by qPCR on the ABI Prism 7000 Detection System. ERCC1 and XPB expression was previously determined by RT-PCR in these specimens. Statistical analyses include two-sided Kruskal-Wallis test, pairwise comparison, Pearson correlation coefficient and paired t-test. In comparison to normal samples, 6 genes demonstrated distinct expression patterns in tumor tissues, with high expression observed for ERCC1, XPB and ILF3 (p=0.001, 0.0007 and 0.002, respectively) and low expression observed for TAL2 and EGF (both p<0.0001). This differential expression pattern between normal and tumor tissues may reflect in part the development of ovarian cancer. Significant differences in expression patterns of these genes in clear cell, endometrioid, mucinous and serous ovarian cancer were observed. Comparison of expression of any two EOC subtypes revealed multiple gene involvement in histopathological differentiation and cancer progression. A positive association was found between ERCC1 and XPB expression (r=0.53, p<0.0001) and between TAL2 and EGF expression (r=0.817, p<0.0001) suggesting the existence of gene linkage in these tumors. The differences in expression patterns of studied genes between tumors and normal specimens, between histological subtypes and correlations among studied genes, may indicate their involvement in tumor growth and disease progression in human epithelial ovarian cancer. Further investigation of these genes may enable better understanding of the molecular mechanism of tumorigenesis and identification of potential biomarkers.

Preliminary clinical and pharmacologic investigation of photodynamic therapy with the silicon phthalocyanine photosensitizer pc 4 for primary or metastatic cutaneous cancers

Photodynamic therapy (PDT) for cutaneous malignancies has been found to be an effective treatment with a range of photosensitizers. The phthalocyanine Pc 4 was developed initially for PDT of primary or metastatic cancers in the skin. A Phase I trial was initiated to evaluate the safety and pharmacokinetic profiles of systemically administered Pc 4 followed by red light (Pc 4-PDT) in cutaneous malignancies. A dose-escalation study of Pc 4 (starting dose 0.135 mg/m(2)) at a fixed light fluence (135 J/cm(2) of 675-nm light) was initiated in patients with primary or metastatic cutaneous malignancies with the aim of establishing the maximum tolerated dose (MTD). Blood samples were taken at intervals over the first 60 h post-PDT for pharmacokinetic analysis, and patients were evaluated for toxicity and tumor response. A total of three patients (two females with breast cancer and one male with cutaneous T-cell lymphoma) were enrolled and treated over the dose range of 0.135 mg/m(2) (first dose level) to 0.54 mg/m(2) (third dose level). Grade 3 erythema within the photoirradiated area was induced in patient 2, and transient tumor regression in patient 3, in spite of the low photosensitizer doses. Pharmacokinetic observations fit a three-compartment exponential elimination model with an initial rapid distribution phase (∼0.2 h) and relatively long terminal elimination phase (∼28 h), Because of restrictive exclusion criteria and resultant poor accrual, the trial was closed before MTD could be reached. While the limited accrual to this initial Phase I study did not establish the MTD nor establish a complete pharmacokinetic and safety profile of intravenous Pc 4-PDT, these preliminary data support further Phase I testing of this new photosensitizer.

The evolving role of statins in hematopoietic stem and progenitor cell transplantation

Allogeneic hematopoietic stem cell transplantation is the sole curative modality for a variety of malignant and benign hematological disorders. Despite advances in supportive care and transplant conditioning regimens graft-versus-host disease (GVHD), infectious complications and end organ toxicity remain the leading causes of transplant related mortality (TRM). Development of safe and effective strategies to mitigate these significant complications associated with HSCT, are urgently needed. Statins are lipid lowering drugs, which reduce cholesterol production by inhibiting HMG-CoA reductase, with a well defined toxicity profile. Statins have pleiotropic immunomodulatory effects which are relevant in the context of treating and preventing GVHD. In addition to GVHD statins may possess several other effects that might have clinical benefit in the setting of hematopoietic cell transplantation, such as treatment of bronchiolitis obliterans and antineoplastic activity. Herein we review the emerging role of statins in improving the outcomes of patients undergoing HSCT.

The importance of clinical grading of heart failure and other cardiac toxicities during chemotherapy: updating the common terminology criteria for clinical trial reporting

Although the use of chemotherapy and targeted therapy has improved the clinical benefit, progression-free survival, and overall survival of various cancers in recent years, old and new toxicities have limited their use. To balance the risk with the benefit of treatment, Common Toxicity Criteria and now Common Terminology Criteria for Adverse Events (CTCAE) have been used by the oncology community for more than 20 years to assess toxicity from cancer treatment. This article details the description and grading of cardiac toxicities reported in association with cancer treatment and the use of CTCAE to assess them.

Dose-escalating and pharmacological study of bortezomib in adult cancer patients with impaired renal function: a National Cancer Institute Organ Dysfunction Working Group Study

PURPOSE

To determine the toxicities, pharmacokinetics, pharmacodynamics, and maximum tolerated dose of bortezomib in patients with renal impairment and to develop dosing guidelines for such a patient population.

PATIENTS AND METHODS

Sixty-two adult cancer patients received intravenous bortezomib at 0.7-1.5 mg/m(2) on days 1, 4, 8, and 11 every 3 weeks. Patients were stratified by 24-h creatinine clearance (CrCl) normalized to body surface area (BSA) 1.73 m(2) into five cohorts: normal renal function (≥ 60 ml/min/1.73 m(2)); mild dysfunction (40-59 ml/min/1.73 m(2)); moderate dysfunction (20-39 ml/min/1.73 m(2)); severe dysfunction (<20 ml/min/1.73 m(2)); and dialysis. Dose escalation was planned for the four cohorts with renal dysfunction. Plasma bortezomib concentrations and blood 20S proteasome inhibition were assayed.

RESULTS

Bortezomib escalation to the standard 1.3 mg/m(2) dose was well tolerated in all patients with CrCl ≥ 20 ml/min/1.73 m(2); 0.7 mg/m(2) was tolerated in three patients with severe renal dysfunction (<20 ml/min/1.73 m(2)). Bortezomib dose escalation was well tolerated in nine dialysis patients, including to 1.3 mg/m(2) in four patients. Decreased CrCl did not affect bortezomib pharmacokinetics or pharmacodynamics. Bortezomib-related side-effects were neither more common nor severe in patients with renal dysfunction versus those with normal renal function.

CONCLUSION

Bortezomib 1.3 mg/m(2) is well tolerated, and dose reductions are not necessary in patients with renal dysfunction. Extrapolation from clinical and pharmacologic data suggests patients with severe renal dysfunction, including dialysis patients, can receive bortezomib at the full dose established to be clinically effective in the general patient population.

Prevalence, healthcare utilization, and costs of breast cancer in a state Medicaid fee-for-service program

OBJECTIVE

The purpose of this study was to determine the prevalence, medical services and treatment utilization, and costs associated with breast cancer in a socioeconomically underprivileged population covered by a state Medicaid fee-for-service (FFS) program.

METHODS

We analyzed the West Virginia (WV) Medicaid FFS administrative claims data for women recipients 21-64 years of age enrolled continuously in the program during the calendar year 2005. Breast cancer-related medical services and treatment use and costs were calculated for women recipients with breast cancer. The excess burden of breast cancer was calculated by comparing the all-cause healthcare utilization and costs among women recipients with breast cancer to a matched control group of women recipients without breast cancer. Healthcare costs incurred during the 1-year study period were calculated from the perspective of state Medicaid. Cost estimates in the study excluded out-of-pocket expenses and indirect costs of breast cancer.

RESULTS

In 2005, the prevalence of breast cancer in the WV Medicaid FFS program was 22.7/1000. More than 98% of breast cancer-related medical services utilization occurred in the office setting. Approximately 73% of women recipients with breast cancer had at least one claim for breast cancer treatment, with hormone therapy being the most common (55.1%) treatment. The all-cause healthcare costs were significantly higher for women recipients with breast cancer compared to those without breast cancer ($16,345 vs. $13,027, p<0.001).

CONCLUSIONS

Consistent with our expectations, breast cancer diagnosis among women recipients in the WV Medicaid FFS program was found to be associated with higher all-cause healthcare use and costs compared to women recipients in the matched control group. The excess cost burden associated with breast cancer could be attributed to higher office visit, emergency room visit, and prescription medication use among recipients with breast cancer.

Higher busulfan dose intensity does not improve outcomes of patients undergoing allogeneic haematopoietic cell transplantation following fludarabine, busulfan-based reduced toxicity conditioning

We evaluated the impact of busulfan dose intensity in patients undergoing reduced toxicity/intensity conditioning allogeneic transplantation in a multicenter retrospective study of 112 consecutive patients. Seventy-five patients were conditioned with busulfan (0.8 mg/kg/dose IV × 8 doses), fludarabine (30 mg/m(2) /day, days -7 to -3), and 6 mg/kg of ATG [reduced intensity conditioning (RIC) group], while 37 patients received a more-intense conditioning with busulfan (130 mg/m(2) /day IV, days -6 to -3), fludarabine (40 mg/m(2) /day, days -6 to -3) and 6 mg/kg of ATG [reduced toxicity conditioning (RTC) group]. At baseline both groups were matched for median age, unrelated donor allografts, and human leukocyte antigen-mismatched allografts. More patients in RIC group had high-risk disease, and higher median comorbidity index. There were no graft rejections. Median time to neutrophil (17 days vs. 15 days; p = 0.003) and platelet engraftment (16 days vs. 11 days; p < 0.001) was significantly longer in the RIC group. RTC group had significantly more bacterial (62.2% vs. 32%; p = 0.004) and fungal infections (13.5% vs. 1.3% p = 0.01). For RIC and RTC groups rates of grades II-IV acute GVHD (34% vs. 40%; p-value = 0.54), and chronic GVHD (45% vs. 57%; p-value = 0.30) were not significantly different. In similar order at 1 year the cumulative-incidence of non-relapse mortality (NRM; 12% vs. 21%; p-value = 0.21) and relapse rates (38% vs. 39%; p = 0.96) were not significantly different. Patients in RIC and RTC groups had similar 1-year overall survival (61% vs. 50%, p = 0.11) and progression-free survival (50% vs. 36%, p-value = 0.39). Our data suggest that the merits of higher busulfan dose intensity in the context of fludarabine/busulfan-based RTC may be offset by higher early morbidity.

Combining clinical, pathological, and demographic factors refines prognosis of lung cancer: a population-based study

Background

In the treatment of lung cancer, an accurate estimation of patient clinical outcome is essential for choosing an appropriate course of therapy. It is important to develop a prognostic stratification model which combines clinical, pathological and demographic factors for individualized clinical decision making.

Methodology/Principal Findings

A total of 234,412 patients diagnosed with adenocarcinomas or squamous cell carcinomas of the lung or bronchus between 1988 and 2006 were retrieved from the SEER database to construct a prognostic model. A model was developed by estimating a Cox proportional hazards model on 500 bootstrapped samples. Two models, one using stage alone and another comprehensive model using additional covariates, were constructed. The comprehensive model consistently outperformed the model using stage alone in prognostic stratification and on Harrell's C, Nagelkerke's R², and Brier Scores in the whole patient population as well as in specific treatment modalities. Specifically, the comprehensive model generated different prognostic groups with distinct post-operative survival (log-rank P<0.001) within surgical stage IA and IB patients in Kaplan-Meier analyses. Two additional patient cohorts (n = 1,991) were used as an external validation, with the comprehensive model again outperforming the model using stage alone with regards to prognostic stratification and the three evaluated metrics.

Conclusion/Significance

These results demonstrate the feasibility of constructing a precise prognostic model combining multiple clinical, pathologic, and demographic factors. The comprehensive model significantly improves individualized prognosis upon AJCC tumor staging and is robust across a range of treatment modalities, the spectrum of patient risk, and in novel patient cohorts.

Combretastatin A4 phosphate: a novel vascular disrupting agent

Combretastatin A4 phosphate (CA4P) is the lead compound of a relatively new class of agents termed vascular disrupting agents that target existing tumor blood vessels. Rapid tumor blood flow shutdown has been demonstrated in preclinical models and patients by various techniques such as dynamic contrast-enhanced MRI, perfusion computed tomography and PET scans following CA4P infusion. CA4P typically induces rapid tumor necrosis in the center of the tumor and leaves a rim of viable cells in the periphery. In oncology, CA4P does not appear to be that active by itself, but may be more efficacious when combined with chemotherapy, antiangiogenic therapy and radiation therapy. Studies are currently underway, which combine CA4P with antiangiogenic agents. Side effects have included hypertension, tumor pain and occasional cardiovascular toxicity, without any significant myelosuppression or disabling systemic symptoms. The utility of CA4P for conditions other than cancer, which involves neovascularization such as macular degeneration, is also being explored.

Initial assessment, surveillance, and management of blood pressure in patients receiving vascular endothelial growth factor signaling pathway inhibitors

Hypertension is a mechanism-based toxic effect of drugs that inhibit the vascular endothelial growth factor signaling pathway (VSP). Substantial evidence exists for managing hypertension as a chronic condition, but there are few prospectively collected data on managing acute hypertension caused by VSP inhibitors. The Investigational Drug Steering Committee of the National Cancer Institute convened an interdisciplinary cardiovascular toxicities expert panel to evaluate this problem, to make recommendations to the Cancer Therapy Evaluation Program on further study, and to structure an approach for safe management by treating physicians. The panel reviewed: the published literature on blood pressure (BP), hypertension, and specific VSP inhibitors; abstracts from major meetings; shared experience with the development of VSP inhibitors; and established principles of hypertension care. The panel generated a consensus report including the recommendations on clinical concerns summarized here. To support the greatest possible number of patients to receive VSP inhibitors safely and effectively, the panel had four recommendations: 1) conduct and document a formal risk assessment for potential cardiovascular complications, 2) recognize that preexisting hypertension will be common in cancer patients and should be identified and addressed before initiation of VSP inhibitor therapy, 3) actively monitor BP throughout treatment with more frequent assessments during the first cycle of treatment, and 4) manage BP with a goal of less than 140/90 mmHg for most patients (and to lower, prespecified goals in patients with specific preexisting cardiovascular risk factors). Proper agent selection, dosing, and scheduling of follow-up should enable maintaining VSP inhibition while avoiding the complications associated with excessive or prolonged elevation in BP.