P3-13-07: The TARGIT-A Trial Update Confirms No Increase in Local Recurrence

Introduction: In June 2010, we published the results of the TARGIT-A trial (1) that compared “one-size fits” all radiotherapy (whole breast radiotherapy-EBRT group) with risk -adjusted radiotherapy (TARGIT- group: single dose TARGeted Intraoperative radioTherapy with additional whole breast radiotherapy if adverse prognostic factors were found). These results showed that the risk of local recurrence in the TARGIT group was non-inferior to that of the EBRT group (the difference between the two arms was 0.25% at 4 years). We now report the results analyzed after further follow up of the total trial cohort without unblinding.

Method: As often repeated, unplanned analysis comparing two groups in a randomized trial can result in an increased alpha-spent as well as carry the risk of a false positive result, we have remained blinded to the further recurrences in the trial according to allocated treatment, since the original publication in the Lancet. Instead we proposed and performed a blinded analysis of the local recurrence rate for the whole cohort. We plotted the Kaplan Meier plots and compared the estimated 4-year recurrences.

Results: Amongst the 2232 patients randomized, there were 13 recurrences at the time of Lancet publication and since then, we have had 8 additional recurrences. The number of patients who have completed at least 4 years of follow up has increased from 420 to 717. We found that the 4-year Kaplan Meier estimate of local recurrence was 1.08% (95% CI 0.59 −1.96) at the time of the Lancet publication and it is 1.09% (95% CI 0.65 - 1.85) now.

Conclusion: We found that the overall 4-year recurrence rates of the TARGIT-A trial have remained stable with a longer follow up and therefore; it is statistically implausible, that one particular arm has a significantly higher local recurrence.

References

1. Vaidya JS, Joseph DJ, Tobias JS, Bulsara M, Wenz F, Saunders C, Alvarado M, Flyger HL, Massarut S, Eiermann W, Keshtgar M, Dewar J, Kraus-Tiefenbacher U, Sutterlin M, Esserman L, Holtveg HM, Roncadin M, Pigorsch S, Metaxas M, Falzon M, Matthews A, Corica T, Williams NR, Baum M. Targeted intraoperative radiotherapy versus whole breast radiotherapy for breast cancer (TARGIT-A trial): an international, prospective, randomised, non-inferiority phase 3 trial. Lancet 2010;376(9735):91–102.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-13-07.

A double-blind, randomized, controlled, multicenter study to assess the safety and cardiovascular effects of skeletal myoblast implantation by catheter delivery in patients with chronic heart failure after myocardial infarction

BACKGROUND

We sought to determine the safety and preliminary efficacy of transcatheter intramyocardial administration of myoblasts in patients with heart failure (HF).

METHODS

MARVEL is a randomized placebo-controlled trial of image-guided, catheter-based intramyocardial injection of placebo or myoblasts (400 or 800 million) in patients with class II to IV HF and ejection fraction <35%. Primary end points were frequency of serious adverse events (safety) and changes in 6-minute walk test and Minnesota Living With HF score (efficacy). Of 330 patients intended for enrollment, 23 were randomized (MARVEL-1) before stopping the study for financial reasons.

RESULTS

At 6 months, similar numbers of events occurred in each group: 8 (placebo), 7 (low dose), and 8 (high dose), without deaths. Ventricular tachycardia responsive to amiodarone was more frequent in myoblast-treated patients: 1 (placebo), 3 (low dose), and 4 (high dose). A trend toward improvement in functional capacity was noted in myoblast-treated groups (Δ6-minute walk test of -3.6 vs +95.6 vs +85.5 m [placebo vs low dose vs high dose; P = .50]) without significant changes in Minnesota Living With HF scores.

CONCLUSIONS

In HF patients with chronic postinfarction cardiomyopathy, transcatheter administration of myoblasts in doses of 400 to 800 million cells is feasible and may lead to important clinical benefits. Ventricular tachycardia may be provoked by myoblast injection but appears to be a transient and treatable problem. A large-scale outcome trial of myoblast administration in HF patients with postinfarction cardiomyopathy is feasible and warranted.

Increasing liver transplantation waiting list mortality: a report from the Australian National Liver Transplantation Unit, Sydney

BACKGROUND

We aimed to describe the demand for liver transplantation (LTx) and patient outcomes on the waiting list at the Australian National Liver Transplantation Unit, Sydney over the last 20 years.

METHODS

We performed a retrospective analysis with the data divided into three eras: 1985-1993, 1994-2000 and 2001-2008.

RESULTS

The number of patients accepted for LTx increased from 320 to 372 and 548 (P < 0.001) with the number of LTx being performed increasing from 262 to 312 and 452 respectively (P < 0.001). The median adult recipient age increased from 45 to 48 and 52 years (P < 0.001) while it decreased in children from 4 to 2 and 1 years respectively (P = 0.001). In parallel, the deceased donor offers decreased from 1003 to 720 and 717 (P < 0.001). Methods to improve access to donor livers have been used with the use of split livers, extended criteria and non-heart beating donors, resulting in increased acceptance of deceased donor offers by 65% and 115% in the second and third eras when compared with the first era (P < 0.001). However, the adult median waiting time has increased from 23 to 41 and 120 days respectively (P < 0.001). This was associated with increased adult mortality on the waiting list from 23 to 40 and 122 respectively (P < 0.001).

CONCLUSIONS

Despite the increasing proportion of donor offers being used, the waiting list mortality is increasing. A solution to this problem is an increase in organ donation to keep pace with the escalating demand for LTx.

The hexosamine biosynthetic pathway can mediate myocardial apoptosis in a rat model of diet-induced insulin resistance

AIMS

Type 2 diabetes is characterized by deranged metabolic pathways that may result in cardiovascular complications. For example, hyperglycaemia promotes flux through the hexosamine biosynthetic pathway (HBP) leading to greater O-GlcNAcylation of target proteins, with pathophysiological outcomes. This study investigated mechanisms whereby increased HBP flux elicits myocardial apoptosis in a rat model of diet-induced hyperglycaemia/insulin resistance.

METHODS

Four-week-old male Wistar rats were fed a high-fat diet (86 days) after which insulin resistance was assessed vs. matched controls. Oxidative stress was evaluated, and apoptotic peptide levels, BAD phosphorylation and overall O-GlcNAcylation assessed by immunoblotting. Protein-specific O-GlcNAcylation and BAD-Bcl-2 dimerization were determined by immunoprecipitation and Western blotting.

RESULTS

Rats consuming the high-fat diet exhibited a moderate elevation in body weight, higher fasting insulin and glucose levels, and insulin resistance vs. controls. Overall protein O-GlcNAcylation was increased in hyperglycaemic/insulin-resistant hearts. In parallel, myocardial peptide levels of apoptotic markers (caspase-3, cytochrome-c, BAD) were significantly higher with insulin resistance. To gain mechanistic insight into our findings, we evaluated O-GlcNAcylation of BAD, a pro-apoptotic Bcl-2 homolog. Here we found increased BAD O-GlcNAcylation and decreased BAD phosphorylation (Ser136) in hyperglycaemic/insulin-resistant rat hearts. These data are in agreement with competition by phosphorylation and O-GlcNAcylation for the same or neighbouring site(s) on target proteins. Moreover, we observed increased BAD-Bcl-2 dimerization in hyperglycaemic/insulin-resistant hearts.

CONCLUSION

The main finding of this study is that increased apoptosis in hyperglycaemic/insulin-resistant hearts can also be mediated through HBP-induced BAD O-GlcNAcylation and greater formation of BAD-Bcl-2 dimers (pro-apoptotic).

Clinical significance of MUC1, MUC2 and CK17 expression patterns for diagnosis of pancreatobiliary arcinoma

Pancreatic cancer is characterized by aggressive growth and resistance to treatment. Identification of unique biomarkers for diagnosis and prognosis is important for treatment of this disease. We investigated the expression patterns of mucin 1 (MUC1), mucin 2 (MUC2) and cytokeratin 17 (CK17) in both normal tissues and metastatic adenocarcinomas using immunohistochemistry (IHC). We have shown that MUC1 (pan-epithelial membrane mucin), MUC2 (intestinal-type secretory mucin) and CK17 can be used as a panel of markers to distinguish collectively pancreatobiliary carcinoma from other primary site carcinomas. Tumors originating in the pancreatobiliary system showed an expression pattern of MUC1 (+), MUC2 (-) and CK17 (+). By contrast, tumors arising from the colorectal region were MUC1 (-), MUC2 (+) and CK17 (-), while tumors originating from non-pancreatobiliary system tissue expressed a MUC1 (+), MUC2 (-) and CK17 (-) profile. More importantly, the MUC1 (+), MUC2 (-) and CK17 (+) result showed greater sensitivity than CA19-9 by IHC, which is the currently accepted and widely used pancreatic tumor marker for diagnosing pancreatic cancer. Thirteen of 51 cases (25%) of pancreatobiliary adenocarcinomas with the pattern MUC1 (+), MUC2 (-) and CK17 (+) showed no immunoreactivity for CA19-9, while 34/51 (67%) cases having MUC1 (+), MUC2 (-) and CK17 (+) were correlated with positive CA19-9 staining. Our data support using an antibody panel of MUC1, MUC2 and CK17 to enhance current methods for pancreatic cancer diagnosis by identifying specifically the primary tissue of origin.

Prostate cancer screening and incidence among men younger than age 50

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Background: Prostate cancer has long been considered as a disease of older men. However, age at diagnosis with prostate cancer has continued to decline. Since the introduction of prostate-specific antigen (PSA) test in 1986, the prostate cancer incidence rate has steadily and dramatically increased in men under age 50. This study aims to better understand demographic variations in prostate cancer screening and incidence, and clinical characteristics of prostate cancers in men under age 50.

Methods: We examined prostate cancer testing data from the Behavioral Risk Factor Surveillance System (2002, 2004, 2006, and 2008) and prostate cancer incidence data from the CDC's National Program of Cancer Registries and the NCI's Surveillance, Epidemiology, and End Results programs (2001-2006). We estimated the weighted percentage of self-reported cancer testing using SUDAAN and age-adjusted cancer incidence rates and trends using SEER-STAT. Statistical significance for trends was determined by the annual percentage change (APC) differing form zero.

Results: A total of 29,176 prostate cancer cases were identified from 2001-2006 among men under age 50. Of these, 551 (1.9%) were among men under age 40. Incidence rates remained stable from 2001-2006; however the incidence of well-differentiated tumors decreased significantly (APC=−24.7) during this time period. About 44% of men aged 40-49 years old reported having a prostate cancer test in the past two years. Prostate cancer testing and incidence rates were highest among men who were black, non-Hispanic, or lived in the northeast. Black men had more than a 2-fold increase in cancer incidence than white men.

Conclusions: The magnitude of prostate cancer testing and incidence in men under age 50 reveals significant health/public health problems in this younger population. This study demonstrates substantial regional differences in prostate cancer testing and incidence in men under age 50. It also confirms that prostate cancer testing and incidence varies by race and ethnicity. We observed a large disparity in prostate cancer incidence between blacks and whites. The incidence rate remained stable over time; the dramatic decrease occurred in well-differentiated cancers.

No significant financial relationships to disclose.

Capture probability of released males of two Bactrocera species (Diptera: Tephritidae) in detection traps in California

The genus Bactrocera (Diptera: Tephritidae) includes approximately 70 polyphagous species that are major pests of fruit and vegetable crops. Most Bactrocera species have limited geographic distributions, but several species are invasive, and many countries operate continuous trapping programs to detect infestations. In the United States, California maintains approximately 25,000 traps (baited with male lures) specifically for Bactrocera detection distributed over an area of approximately 6,400 km2 (2,500 miles2) in the Los Angeles area. Although prior studies have used male lures to describe movement of Bactrocera males, they do not explicitly relate capture probability with fly distance from lure-baited traps; consequently, they do not address the relative effectiveness of male lures in detecting incipient populations of Bactrocera species. The objective of this study was to measure the distance-dependent capture probability of marked, released males of Bactrocera dorsalis (Hendel) and Bactrocera cucurbitae (Coquillett) (methyl eugenol- and cue lure-responding species, respectively) within the detection trapping grid operating in southern California. These data were then used to compute simple probability estimates for detecting populations of different sizes of the two species. Methyl eugenol was the more powerful attractant, and based on the mark-recapture data, we estimated that B. dorsalis populations with as few as approximately 50 males would always (>99.9%) be detected using the current trap density of five methyl eugenol-baited traps per 2.6 km2 (1 mile2). By contrast, we estimated that certain detection of B. cucurbitae populations would not occur until these contained approximately 350 males. The implications of the results for the California trapping system are discussed, and the findings are compared with mark-release-recapture data obtained for the same two species in Hawaii.

Arterial Occlusion Precipitated by Cisplatinbased Chemotherapy

Cisplatin-based therapy is curative in testicular cancer. Adverse effects of cisplatin-based chemotherapy include dose-dependent myelosuppression, nephrotoxicity, neurotoxicity, and ototoxicity. By contrast, chemotherapy-associated vascular complications are unpredictable. Few incidents of digital gangrene with cisplatin have been reported. Here, we present a patient who developed arterial occlusion leading to gangrene of the toe after cisplatinbased chemotherapy.

Arterial occlusion precipitated by cisplatinbased chemotherapy

Cisplatin-based therapy is curative in testicular cancer. Adverse effects of cisplatin-based chemotherapy include dose-dependent myelosuppression, nephrotoxicity, neurotoxicity, and ototoxicity. By contrast, chemotherapy-associated vascular complications are unpredictable. Few incidents of digital gangrene with cisplatin have been reported. Here, we present a patient who developed arterial occlusion leading to gangrene of the toe after cisplatinbased chemotherapy.

In vitro susceptibility of Plasmodium falciparum isolates from Abidjan, Côte d'Ivoire, to artemisinin, chloroquine, dihydroartemisinin and pyronaridine

Côte d'Ivoire is an endemic area for Plasmodium falciparum malaria, with perennial transmission in the southern forest and seasonal transmission in the northern savannah. Change of first-line treatment of uncomplicated malaria to artemisinin-combination therapy (ACT) is widespread in the country as elsewhere in Africa. The present study was conducted to assess the in vitro response of Plasmodium falciparum to antimalarial drugs currently used in the country (chloroquine, artemisinin and dihydroartemisinin) and new drugs that could be used in the near future (pyronaridine) and to analyse the pattern of cross-resistance between these drugs. The standard in vitro drug sensitivity microtechnique recommended by the World Health Organization was used to assess the sensitivity of Plasmodium falciparum isolates collected in Abidjan (Côte d'Ivoire) between April and December 2006. Of 128 in vitro tests performed, 112 (87.5%) were successful. Among them, 32, 27, 25, and 28 P. falciparum isolates grew satisfactorily and yield interpretable results for chloroquine, pyronaridine, artemisinin, and dihydroartemisinin respectively. The proportions of resistant isolates were 56.2% for chloroquine, 48% for pyronaridine, 36% for artemisinin and 3.6% for dihydroartemisinin. The most potent drug was dihydroartemisinin with a geometric mean IC50 of 2.72 nM ranged from 1.45 to 3.99 nM. No multi-resistant isolates (showing resistance to more than three drugs) were found. A positive correlation was found between the IC50 values for the following drugs: chloroquine and pyronaridine (r=0.45), pyronaridine and dihydroartemisinin (r=0.40), chloroquine and artemisinin (r=0.68), artemisinin and dihydroartemisinin (r=0.62). Data suggested cross-resistance between these drugs and warrant an improved surveillance programme for drug resistance to malaria in Côte d'Ivoire.