Plasma Epstein-Barr viral DNA load at midpoint of radiotherapy course predicts outcome in advanced-stage nasopharyngeal carcinoma

BACKGROUND

To test the hypothesis that prognostication of treatment outcome is feasible by biomarker response at midcourse of chemoradiotherapy (CRT)/radiotherapy (RT), with respect to the plasma load of Epstein-Barr viral (EBV) DNA in nasopharyngeal carcinoma (NPC).

PATIENTS AND METHODS

One hundred seven patients with stage IIB-IV NPC were prospectively studied. Plasma EBV DNA load was measured by quantitative PCR before therapy (pre-DNA), at completion of 4 weeks of CRT/RT (mid-DNA), and within 3 months of completion of therapy (post-DNA). The end points are post-DNA load, a recognized surrogate of survival, and clinical outcome.

RESULTS

Ninety-three percent of patients had detectable EBV DNA before therapy (median load = 972 copies/ml). EBV DNA became undetectable in 55 (51%) patients at the end of week 4 of therapy. Detectable mid-DNA was associated with worse clinical outcome (median follow-up time, 6.2 years), for distant failure [hazard ratio (HR) 12.02, 95% confidence interval (CI) 2.78-51.93; P < 0.0001], progression-free survival (PFS; HR 4.05, 95% CI 1.89-8.67, P < 0.0001), and overall survival (OS; HR 3.29, 95% CI 1.37-7.90, P = 0.0077). Seventy-four percent of all failures were associated with detectable mid-DNA, whereas 34% of all failures were associated with detectable post-DNA. Stratification by tumor stage (IIB, III, IV) has no significant prognostic effect.

CONCLUSIONS

Unfavorable EBV DNA response at midcourse of RT/CRT is an adverse prognosticator for treatment outcome, is linked to majority of all failures, and discriminates outcome better than tumor stage. The data could provide a basis for trial design that addresses alteration of therapy intensity during the latter phase of CRT, and adjuvant therapy. Validation studies are awaited.

Injuries related to consumer products in Canada--a systematic literature review

OBJECTIVES

To conduct a systematic literature review of injury related to certain consumer products.

METHODS

Forty-six empirical research reports along with 32 surveillance reports from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) were examined to determine the approximate number of injuries associated with a given product per year and any trends in frequency. Percentages of injuries that: (1) resulted in hospitalization, (2) appeared to result from the product itself and (3) were associated with risky or inappropriate use and/or non-use of a helmet were also extracted from the reports.

RESULTS

Outdoor play and sports equipment appear to be associated with the greatest numbers of injuries. A relatively high proportion of injuries appear to result from inappropriate or risky use of a product and/or inadequate safety precautions.

CONCLUSION

This review identified the following areas of concern regarding consumer products and injuries: lack of helmet use by people using in-line skates, sleds, snowboards, downhill skis and personal-powered watercraft; operation of all-terrain vehicles (ATVs) and snowmobiles by alcohol-impaired people; operation of snowmobiles at excessive speeds; poor design of playground equipment; and unsafe storage and use of matches.

Injuries related to consumer products in Canada–a systematic literature review

Objectives

To conduct a systematic literature review of injury related to certain consumer products.

Methods

Forty-six empirical research reports along with 32 surveillance reports from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) were examined to determine the approximate number of injuries associated with a given product per year and any trends in frequency. Percentages of injuries that: (1) resulted in hospitalization, (2) appeared to result from the product itself and (3) were associated with risky or inappropriate use and/or non-use of a helmet were also extracted from the reports.

Results

Outdoor play and sports equipment appear to be associated with the greatest numbers of injuries. A relatively high proportion of injuries appear to result from inappropriate or risky use of a product and/or inadequate safety precautions.

Conclusion

This review identified the following areas of concern regarding consumer products and injuries: lack of helmet use by people using in-line skates, sleds, snowboards, downhill skis and personal-powered watercraft; operation of all-terrain vehicles (ATVs) and snowmobiles by alcohol-impaired people; operation of snowmobiles at excessive speeds; poor design of playground equipment; and unsafe storage and use of matches.

Unintentional injury mortality and external causes in Canada from 2001 to 2007

Introduction

To understand the distribution pattern and time trend of unintentional injury mortalities is crucial in order to develop prevention strategies.

Methods

We analyzed vital statistics data from Canada (excluding Quebec) for 2001 to 2007. Mortality rates were age- and sex-standardized to the 2001 Canadian population. An autoregressive model was used for time-series analysis.

Results

Overall mortality rate steadily decreased but unintentional injury mortality rate was stable over the study period. The three territories had the highest mortality rates. Unintentional injury deaths were less common in children than in youths/adults. After 60, the mortality rate increased steadily with age. Males were more likely to die of unintentional injury, and the male/female ratio peaked in the 25- to 29-year age group. Motor vehicle crashes, falls and poisoning were the three major causes. There was a substantial year after year increase in mortality due to falls. Deaths due to motor vehicle crashes and drowning were more common in summer months, and deaths caused by falls and burns were more common in winter months.

Conclusion

The share of unintentional injury among all-cause mortality and the mortality from falls increased in Canada during the period 2001 to 2007.

Unintentional injury mortality and external causes in Canada from 2001 to 2007

INTRODUCTION

To understand the distribution pattern and time trend of unintentional injury mortalities is crucial in order to develop prevention strategies.

METHODS

We analyzed vital statistics data from Canada (excluding Quebec) for 2001 to 2007. Mortality rates were age- and sex-standardized to the 2001 Canadian population. An autoregressive model was used for time-series analysis.

RESULTS

Overall mortality rate steadily decreased but unintentional injury mortality rate was stable over the study period. The three territories had the highest mortality rates. Unintentional injury deaths were less common in children than in youths/adults. After 60, the mortality rate increased steadily with age. Males were more likely to die of unintentional injury, and the male/female ratio peaked in the 25- to 29-year age group. Motor vehicle crashes, falls and poisoning were the three major causes. There was a substantial year after year increase in mortality due to falls. Deaths due to motor vehicle crashes and drowning were more common in summer months, and deaths caused by falls and burns were more common in winter months.

CONCLUSION

The share of unintentional injury among all-cause mortality and the mortality from falls increased in Canada during the period 2001 to 2007.

A phase II study of concurrent cetuximab-cisplatin and intensity-modulated radiotherapy in locoregionally advanced nasopharyngeal carcinoma

BACKGROUND

Based on our previous work on the clinical activity of cetuximab in recurrent nasopharyngeal carcinoma (NPC), we evaluated the feasibility of adding cetuximab to concurrent cisplatin and intensity-modulated radiotherapy (IMRT) in locoregionally advanced NPC.

PATIENTS AND METHODS

Patients with American Joint Committee on Cancer stage III-IVB NPC were given an initial dose of cetuximab (400 mg/m(2)) 7-10 days before receiving concurrent IMRT, weekly cisplatin (30 mg/m(2)/week) and cetuximab (250 mg/m(2)/week).

RESULTS

Thirty patients (median age of 45 years) with stage III (67%), IVA (30%) and IVB (3%) nonkeratinizing NPC were enrolled. Grade 3-4 oropharyngeal mucositis occurred in 26 (87%) patients and 10 (33%) patients required short-term nasogastric feeding. Grade 3 radiotherapy-related dermatitis occurred in six patients (20%) and three patients (10%) had grade 3 cetuximab-related acneiform rash. These grade 3-4 skin and mucosal toxic effects were manageable and reversible. At a median follow-up of 31.8 months [95% confidence interval (CI) 26.2-32.1 months], the 2-year progression-free survival was 86.5% (95% CI 74.3% to 98.8%).

CONCLUSIONS

Concurrent administration of cetuximab, weekly cisplatin and IMRT is a feasible strategy against locoregionally advanced NPC. Preliminary survival data compare favorably with historic data and further follow-up is warranted.

The significance of serum interleukin-10 on the outcome of unresectable hepatocellular carcinoma (HCC)

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Background: Serum interleukin-10 (IL-10) is associated with active hepatitis in patients (pts) with hepatitis B viral (HBV) infection. In HBV-related HCC, elevation of serum IL-10 is frequently observed but its significance on the outcome of HCC is unclear.

Methods: A prospective cohort of newly diagnosed and inoperable HCC was recruited from a multidisciplinary clinic from Prince of Wales Hospital from 2006 to 2008. The baseline demographics, tumor characteristics/stage, laboratory parameters, virologic factors (HBV DNA, antiviral therapy) and first-line treatment modality were documented at the time of diagnosis. Serum IL-10 was measured by enzyme-linked immunosorbent essay. Univariate and multivariate analyses were conducted. Overall survival (OS) was the primary endpoint.

Results: Total 180 new cases of inoperable HCC were evaluated. The median follow-up time was 15.5 months. Median age was 60.5 years. Most (159 pts; 88.3%) were males. 81.1% of them were positive for HBsAg. Total 120 (66.7%) had radiologic evidence of cirrhosis. 20 (11.1%), 85 (47.2%) and 75 (41.7%) received locoablative, trans- arterial/systemic therapy and supportive care respectively. The mean level of serum IL-10 was 18.1pg/ml (range: 2.8-11.7). 114 (63.3%) had log IL-10 higher than 1.0 pg/ml. Pts with log IL-10 >1.0 pg/ml had significantly worse OS than those with log IL-10≤ 1.0 pg/ml (14.8 vs. 4.5 months; HR 2.39; p<.0001). Multivariate analysis found log IL-10 (HR=2.57; p=0.005), CLIP score, TNM stage, treatment modality and the use of anti-viral therapy for HBV infection be the independent prognostic factors. Exploratory analyses showed that pts with Log IL-10>1.0pg/ml had higher ALT and HBV DNA, lower albumin, higher chance of ascites, worse Child-Pugh stage and worse tumor stage (Table).

Conclusions: Serum IL-10 is an independent prognostic factor for inoperable HCC. Pts with high IL-10 level have poorer liver reserves and worse tumor staging.

[Table: see text]

No significant financial relationships to disclose.

Can diffusion-weighted imaging distinguish between normal and squamous cell carcinoma of the palatine tonsil?

The utility of diffusion-weighted imaging (DWI) in the detection of squamous cell carcinoma (SCC) of the tonsils has not been previously investigated. This preliminary study compared DWI of apparent SCC tonsillar tumours with normal tonsils. DWI of the tonsils was performed in 10 patients with newly diagnosed tonsil SCC that was evident on conventional MRI and in 17 patients undergoing cranial MRI for other indications. Regions of interest (ROI) were drawn around each identifiable tonsil on the apparent diffusion coefficient (ADC) map and the mean ADC value for each tonsil was calculated. ADC values for normal and SCC tonsils were compared using the Mann-Whitney U-test. The median ADC and range (x10(-3) mm(2) s(-1)) were found to be 0.814 and 0.548-1.312, respectively, for normal tonsils compared with 0.933 and 0.789-1.175, respectively, for SCC tonsils. ADC values were significantly higher for SCC tonsils than for normal tonsils (p = 0.009). No SCC tonsil had an ADC less than 0.82 x 10(-3) mm(2) s(-1) compared with 58% of normal tonsils. We conclude that there is a difference in the ADC between normal tonsils and SCC tonsils where the cancer is apparent on conventional MRI. These results are promising, although further studies are now required to determine whether DWI can be used to identify or exclude smaller foci of SCC within tonsils where the cancer is not evident on conventional MRI.

X-Ray induced radiation damage in taurine: a combined X-ray diffraction and Raman study

The impact of X-radiation on crystalline taurine has been investigated by time resolved synchrotron X-ray powder and single crystal diffraction and Raman spectroscopy. Multiple data sets have been collected at 120 and 296 K. All the observed effects of radiation, i.e. broadening and shifts of Raman and diffraction lines, a dose dependent irreversible increase in the atomic displacement parameters (ADPs) as well as in one of the unit-cell axes, and an apparent enhancement of electron density in the SO(3) group can be tentatively attributed to primary radical formation predominantly involving the SO(3) group. In secondary reactions molecular species that are distinct from taurine are created in minute quantities, thereby introducing local departure from crystalline order, i.e. enhanced static disorder and a build-up of local strain. Our study provides evidence for ascribing the linear increase in ADPs as well as the expansion of the c axis to the accumulation of foreign species in the crystal, and not to a thermal effect. Once initiated, this process appears to continue also without radiation, however, then at a much reduced rate.

A phase I study of intra-arterial (IA) cisplatin (C) and accelerated fractionation (AF) radiotherapy (RT) for locally advanced head and neck squamous cell carcinoma (HNSCC)

16512

Background: Concurrent IAC and conventional fractionation (CF) RT is an effective treatment for locally advanced HNSCC. AF RT with 2 late concurrent IAC doses may be equally effective since AF RT produces better local tumor control compared with CF RT and late chemotherapy boost may counteract accelerated repopulation of tumor cells. The maximum-tolerated dose (MTD) of IAC given concurrently with AF RT is not known. Methods: A phase I study was conducted in patients with locally advanced stage III/IV HNSCC to determine the MTD of C that was given as 2 selective IA infusions 1 week apart during the last 2 weeks of AF RT (70 Gy/35 fractions/6 weeks) using 6 fractions/week. IV sodium thiosulfate was used to neutralize the systemic toxicity of C. Starting at 100 mg/m2, cohorts of 3 to 6 patients were treated with escalating doses of IAC, in 25 mg/m2 increments, up to the highest level of 200 mg/m2 per infusion. Dose-limiting toxicity (DLT) was defined as the occurrence in 2 patients at a dose level of grade 3 acute mucositis or skin reactions lasting more than 8 weeks after completion of treatment; grade 4 hematologic, infective, metabolic or hearing toxicity; or grade 3 renal, hepatic or neurological toxicity. The MTD was defined as the dose level immediately lower than that resulting in DLT. Results: Ten patients were recruited with a mean age of 56 years. Two patients had stage III; 1, stage IVa; and 7, stage IVb disease. The T-stages were T1 (n = 2), T2 (n = 1), T3 (n = 2), and T4 (n = 5). The N-stages were N0 (n = 2), N1 (n = 1), N2 (n = 4), and N3 (n = 3). Three patients received IAC at a dose level of 100 mg/m2, 3 at 125 mg/m2, and 4 at 150 mg/m2. All patients had the 2 planned doses except one in the lowest dose level who developed grade 3 hyponatremia after the first dose. There was no treatment-related mortality. DLT occurred in 2 patients at the 150 mg/m2 dose level. One of them had grade 4 leukopenia, and the other had grade 3 acute skin reactions lasting 9 weeks after RT. Thus, MTD was 125 mg/m2. At a median follow-up of 24 months, 6 patients remained alive and disease-free. Conclusions: In patients with locally advanced HNSCC, AF RT with 2 doses of late IAC boost was feasible. The MTD of IAC was 125 mg/m2.

No significant financial relationships to disclose.

High incidence of symptomatic methemoglobinemia (metHb) in Asian patients (pts) treated with 3-Aminopyridine-2-carboxaldehyde thiosemicarbazone (3-AP, triapine) and gemcitabine (GEM) in a second-line phase II trial of metastatic non-small cell lung cancer

18207

Background: Triapine (Vion Pharmaceuticals) is an inhibitor of ribonucleotide reductase that can enhance GEM uptake in GEM- resistant cell lines. Clinically significant metHb has been rarely reported with triapine & G6PD-deficient pts maybe more susceptible. This multicenter study evaluated the activity & safety of combined triapine-GEM in pts with metastatic NSCLC who had progressed despite prior response or disease stabilization to 1st line platinum-GEM regimen. Methods: Eligible pts were treated with triapine (105mg/m2) as 4-hr IV infusion, followed by GEM (1g/m2) over 30-min on days 1, 8 & 15, repeating every 28 days for 6 cycles. G6PD-deficient pts were excluded. Results: 6 males & 6 female Asian pts (median age: 65 yrs) received a median no. of 2 cycles (range 1–6 cycles). At a median follow-up of 4.6 mos, no response was seen. 4 pts had stable disease. Median time to progression was 3 mos (95% CI: 1.7–9.1 mos). Gr 3–4 toxicities included neutropenia (gr 3, 2 pts), hypoxia (gr 3, 3 pts) & dyspnea (gr 3, 1 pt). There were no treatment-related deaths & all pts remained alive at analysis. 4 pts developed symptomatic metHb during, or ≤ 4 hrs of stopping triapine. This was manifested as dyspnea &/or hypoxia, associated with an oxygen saturation of ≤90% at room air. Arterial metHb assay performed during the hypoxic episode showed a metHb level of up to 15% of total concentration of hemoglobin ([Hb]), which fell to < 5% of [Hb] within 4–6 hrs of stopping triapine. All pts recovered with conservative treatment & none required reversal with methylene blue. 3 out of the 4 pts were able to continue treatment after dose-reduction of triapine. Conclusions: The cause of the relatively high incidence of triapine-related symptomatic metHb was unclear in this Asian cohort. This study was terminated prematurely due to lack of response.

No significant financial relationships to disclose.

Efficacy of neoadjuvant docetaxel and cisplatin followed by concurrent cisplatin-radiotherapy in locally advanced nasopharyngeal carcinoma (NPC): A randomized phase II study

6037

Background: The current standard treatment for locally advanced NPC is chemoradiation (CRT) ± adjuvant chemotherapy. However, adjuvant chemotherapy is often poorly tolerated after intensive CRT. Our previous study of neoadjuvant chemotherapy followed by CRT showed encouraging toxicity profile and disease control in advanced NPC (JCO 2004: 22: 3053–60). The current study compared the safety and efficacy of neoadjuvant chemotherapy (neoadj) followed by CRT. Methods: Newly diagnosed patients (pts) with stage III to IVB NPC were randomized (stratified by stage III vs IV) to: (1) Neoadj-CRT: docetaxel 75 mg/m2 D1, cisplatin 75 mg/m2 D1, q3w × 2 cycles, followed by cisplatin 40 mg/m2 weekly × 6–8 cycles concurrent with RT (= 66 Gy in 2-Gy fractions), or (2) CRT: cisplatin-RT (same as arm 1) without neoadj. The primary endpoint was toxicity. Secondary endpoints included survival and quality of life. Planned accrual was 30 pts per arm to detect a 20% difference in toxicity on one side of a 95% confidence interval (CI). Results: From 11/2002 to 11/2004, 65 pts were recruited. Five pts were excluded after randomization but before treatment started (three pts were subsequently found ineligible, and two pts withdrew consent). There was a higher rate of G3–4 neutropenia (100% vs 16%, p<0.001), but not neutropenic fever (3% vs 4%) or other non-hematologic toxicity in the neoadj-CRT vs CRT arm. The proportion of pts progressing at 2-yrs by group was compared by Fisher’s Exact Test (p=0.158). At median follow-up of 2.74 yrs, there were 10 deaths and 13 progressions. The 2-yr progression free survival for neoadj-CRT vs CRT was 80% vs 71% (hazard ratio 0.42; CI 0.14− 1.27; p=0.11). The 2-yr overall survival was 93% vs 76% (hazard ratio 0.17; CI 0.037–0.82; p=0.013). Conclusions: Neoadjuvant docetaxel and cisplatin followed by CRT was well tolerated with a manageable toxicity profile and allowed subsequent delivery of full dose CRT. Preliminary result suggested improved survival. A phase 3 study to definitively test this strategy is warranted. Acknowledgement: Sanofi-Aventis Hong Kong Ltd supported this study in part.

No significant financial relationships to disclose.

A double-blind placebo-controlled randomized study of Chinese herbal medicine as complementary therapy for reduction of chemotherapy-induced toxicity

BACKGROUND

Chinese herbal medicine (CHM) is a common complementary therapy used by patients with cancer for reduction of chemotherapy-induced toxic effects. This study applied the highest standard of clinical trial methodology to examine the role of CHM in reducing chemotherapy-induced toxicity, while maintaining a tailored approach to therapy.

PATIENTS AND METHODS

Patients with early-stage breast or colon cancer who required postoperative adjuvant chemotherapy were eligible for the study. Enrolled patients were randomly assigned to one of three Chinese herbalists who evaluated and prescribed a combination of single-item packaged herbal extract granules. Patients received either CHM or placebo packages with a corresponding serial number. The placebo package contained nontherapeutic herbs with an artificial smell and taste similar to a typical herbal tea. The primary end points were hematologic and non-hematologic toxicity according to the National Cancer Institute Common Toxicity Criteria Version 2.

RESULTS

One hundred and twenty patients were accrued at the time of premature study termination. Patient characteristics of the two groups were similar. The incidence of grade 3/4 anemia, leukopenia, neutropenia, and thrombocytopenia for the CHM and placebo groups were 5.4%, 47.3%, 52.7%, and 1.8% and 1.8%, 32.2%, 44.7%, and 3.6%, respectively (P = 0.27, 0.37, 0.63, and 0.13, respectively). Incidence of grade 2 nausea was the only non-hematologic toxicity that was significantly reduced in the CHM group (14.6% versus 35.7%, P = 0.04).

CONCLUSIONS

Traditional CHM does not reduce the hematologic toxicity associated with chemotherapy. CHM, however, does have a significant impact on control of nausea.

Transarterial ethanol ablation of unresectable hepatocellular carcinoma with lipiodol-ethanol mixture (LEM): A phase II study

14054

Background: Transarterial ablation with lipiodol-ethanol mixture (LEM) induced potent dual embolization of arterioles and portal venules in preclinical studies, and extensive tumor necrosis in clinical studies. It is potentially an effective treatment and a better alternative to chemoembolization for unresectable hepatocellular carcinoma (HCC). The authors aim to study the safety and efficacy of this treatment. Methods: Unresectable HCC diagnosed by histology or viral serology + AFP > 500 ug/l + typical imaging; bilirubin ≤ 30 umol/l; hypervascular tumor on CT / angiogram, no vascular invasion or extrahepatic spread. LEM with Lipiodol and ethanol mixed in ratio of 2:1 by volume was infused transarterially into tumor vasculature by superselective catheterization of tumor feeders at a subsegmental level under fluoroscopy until flow stagnation. Adverse events (AE) graded by NCI-CTC V2.0. Tumor response monitored by CT scan q3m. LEM repeated for residual enhancing lesion or intrahepatic progression on CT scan. Primary endpoint was response rate. Secondary endpoints: toxicity and survival. Results: From 7/2001 to 4/2005, 77 pts enrolled. Age 28–85 (median 64). M:F=60:17. ECOG 0=68; 1=9. Cirrhosis 92%. HBV 77%, HCV 14%, alcohol 4%. Child A 88%, B 12%. Okuda A 73%, B 27%. Histology confirmed in 78%. 39% had previous treatment. Median tumor size 4.5cm (range 1.5–15cm); Number of lesions: One (58), Two (14), Three (5). Best tumor response (WHO criteria): CR 0%, PR 43%, MR 36%, SD 17%, PD 4%. Patients received 1 to 8 LEM treatments (mean 2.2). Mean hospital stay 2.7 days (range 2 -15). Significant AEs are shown in the table. Fever in 15% for mean duration of 3.1 days. After a median follow-up of 1.65 yr, 23 pts died. One year survival 77%. 3 pts had tumor resection after downstage by LEM. Conclusions: Transarterial ablation with LEM is a well tolerated and effective local regional treatment of unresectable HCC. The high tumor response and 1-year survival rate warrants further investigation in comparative study. [Table: see text]

No significant financial relationships to disclose.