Preclinical and clinical activity of sunitinib in patients with cisplatin-refractory or multiply relapsed germ cell tumors: a Canadian Urologic Oncology Group/German Testicular Cancer Study Group cooperative study

BACKGROUND

The objective of the study was to investigate the activity of sunitinib in a cell line model and subsequently in patients with cisplatin-refractory or multiply relapsed germ cell tumors (GCT).

METHODS

The effect of sunitinib on cell proliferation in cisplatin-sensitive and cisplatin-refractory GCT cell lines was evaluated after 48-h sunitinib exposure by MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] assay, and IC(50) (concentration that causes 50% inhibition of growth) doses were determined. Sunitinib was subsequently administered at a dose of 50 mg/day for 4 weeks followed by a 2-week break to 33 patients using a Simon two-stage design.

RESULTS

Sunitinib demonstrated comparable dose-dependent growth inhibition in cisplatin-sensitive and cisplatin-resistant cell lines, with IC(50) between 3.0 and 3.8 μM. Patient characteristics were as follows: median of 2 (1-6) cisplatin-containing regimens; high-dose chemotherapy 67%; late relapse 33%; and cisplatin refractory or absolute cisplatin refractory 54%. Toxic effects included fatigue (39%), anorexia (21%), diarrhea (27%), mucositis (45%), nausea (33%), hand-foot syndrome (12%), dyspepsia (27%), and skin rash (18%). No unexpected side-effects were observed. Thirty -two of 33 patients were assessable for response. Three confirmed partial responses (PRs) and one unconfirmed PR were seen for a total response rate of 13%. Median progression-free survival (PFS) was 2 months, with a 6-month PFS rate of 11%.

CONCLUSIONS

Sunitinib shows in vitro activity in cisplatin-resistant GCT cell lines. Modest clinical activity in heavily pretreated GCT patients was observed.

Primary anti-VEGF-refractory metastatic renal cell carcinoma (mRCC): Clinical characteristics, risk factors, and subsequent therapy

305

Background: A proportion of patients treated with anti-VEGF therapy first line exhibit progressive disease (PD) as best response (per RECIST). The characteristics and outcome of this population are poorly understood.

Methods: Data from patients with mRCC treated with anti-VEGF therapy were collected through the International mRCC Database Consortium from 12 centers.

Results: One thousand fifty-six evaluable patients were treated with VEGF-inhibitors as their first-line antiangiogenic therapy. Of those, 272 (26%) patients had PD as best response. Their initial treatment was sunitinib (n=203), sorafenib (n=51), or bevacizumab (n=18). Six percent of patients were favorable risk, 55% intermediate risk, and 39% poor risk as per Heng et al JCO 2009 prognostic factors. On multivariable analysis, predictors of PD at first restaging were KPS < 80% (OR 2.3, p < 0.0001), diagnosis to treatment < 1 year (OR 2.1, p < 0.0001), neutrophilia (OR 1.9, p = 0.0021), thrombocytosis (OR 1.7, p = 0.0068), and anemia (OR 1.6, p = 0.0058). The median progression-free survival (PFS) and overall survival (OS) in patients with primary refractory disease vs. patients without (i.e., partial response or stable disease) was 2.4 vs. 11 months (p<0.0001) and 6.8 vs. 29 months (p<0.0001), respectively. Only 108 (40%) VEGF-refractory patients proceeded to receive 2nd line VEGF inhibitors (sunitinib (n=32), sorafenib (n=44), axitinib (n=2), bevacizumab (n=4)), mTOR inhibitors (temsirolimus (n=14), everolimus (n=11)), or interferon (n=1). The response rate, PFS and OS of this second-line therapy was 9%, 2.5 months and 7.4 months, respectively. The response rate, PFS and OS of those receiving second-line VEGF vs. mTOR inhibitors was 10% vs. 6% (p=NS), 2.8 vs. 2.0 months (p=0.069) and 7.9 vs. 4.7 months (p=0.40), respectively.

Conclusions: Primary anti-VEGF-refractory mRCC patients have a dismal prognosis. Second-line anti-mTOR agents may not be better than alternate anti-VEGF agents after primary anti-VEGF failure. Investigation into the mechanism of primary resistance and alternative therapeutic strategies are needed.

[Table: see text]

The neoadjuvant management of bladder cancer in Canada: A survey of genitourinary medical oncologists

285

Background: The uptake of neoadjuvant chemotherapy (NC) for the treatment of stage II/III bladder cancer remains variable despite evidence supporting its use. The aim of this study is to better understand the use of NC in Canada to facilitate standardization of practice and develop a platform for clinical trials.

Methods: The survey was initially tested on a subset of medical oncologists. It was then e-mailed to 30 medical oncologists across Canada who primarily treat bladder cancer.

Results: In total, 25 (83%) surveys were completed. Respondents were 92% academic based, 100% full time, and 52% in practice for >10 years. The majority of referrals for all stages came from urologists with 4 respondents (16%) seeing 5-10 cases/yr, 10 (40%) seeing 11-15/yr, 5 (20%) seeing 16- 20/yr and 6 (24%) seeing >20/yr. Of these 8 reported having only 1-2 referrals for NC; 7 had 3-4 NC referrals; 7 had 5-6 NC referrals; and 2 reported seeing >6 referrals/year. Patients referred for NC tended to be younger (50-65); Performance Status (PS) 0/1; T-stage T3a/T3b; or nodal status N1/N2. 96% indicated they do offer NC to selected patients as both standard of care and to downsize tumors. Key factors cited for not offering NC were: Age >85, PS 3/4; T-stage T2a or T4a; Nodal status: N3; GFR <40ml/min. Main baseline staging modalities included CT chest/abdomen/pelvis, bone scan and cystoscopy. Gemcitabine/cisplatin was most commonly used with 20% using high-dose MVAC. Six (27%) reported doing midway staging with CT abdomen/pelvis and cystoscopy; 36% report staging after completion of chemo. Average time from last chemotherapy to cystectomy was 4-6 wks, with no patients being offered adjuvant chemotherapy postoperatively.

Conclusions: The majority of GU MO in Canada would offer NC. Stage, PS, renal function, and comorbidities were the biggest determinants of offering NC, while age played a lesser role. The number of overall referrals for NC, however, remains relatively low. We plan to survey urologists in Canada to determine if differences in attitudes about NC or barriers to referrals account for the low number of referrals.

No significant financial relationships to disclose.

The effect of low serum sodium on treatment outcome to vascular endothelial growth factor (VEGF)-targeted therapy in metastatic renal cell carcinoma: Results from a large international collaboration

322

Background: Hyponatremia has been associated with poor survival in many solid tumors and more recently found to be of prognostic and predictive value in metastatic renal cell cancer (mRCC) patients (pts) treated with immunotherapy (Jeppesen et al, Br J Cancer. 2010). We sought to investigate the influence of baseline hyponatremia in mRCC pts treated with contemporary vascular endothelial growth factor (VEGF)- targeted therapy in a larger international and multi-institutional database.

Methods: Baseline characteristics and outcomes on 855 pts treated with first-line anti-VEGF therapy for mRCC were available from 8 Cancer Centers to study the impact of hyponatremia (defined as serum Na<135 mmol/L) on clinical outcome as measured by overall survival (OS), time to treatment failure (TTF), best response (CR, PR, SD and PD).

Results: Median OS after treatment initiation was 16.8 months (mos) (95% CI: 14.9, 18.5 mos), with 334 (39%) of patients remaining alive. Median follow-up in pts alive was 18.8 mos. Median baseline serum sodium was 138 mmol/L (range: 122–159), and hyponatremia was found in 16.7% of pts. On univariate analysis, hyponatremia was associated with shorter OS (6.5 vs. 18.8 mos; HR 2.32 [95% CI: 1.86–2.89], p<0.0001), shorter TTF (2.8 vs. 6.9 mos.; HR 2.20 [95% CI: 1.81–2.68], p<0.0001), and lower disease control rate (DCR) as defined by CR+PR+SD (51.2% vs. 74.6%, OR 0.36 [95% CI: 0.2–0.57], p<0.0001). In multivariate analysis adjusted for MSKCC or Heng's risk criteria (JCO 2009), these effects remain significant with p<0.001 for OS and TTF and p=0.01 for DCR. The results were similar (p<0.001) if sodium was analyzed as a continuous variable.

Conclusions: This is the first large multi-institutional report to show that low serum sodium is independently associated with a worse outcome in mRCC pts treated with VEGF-targeted agents.

No significant financial relationships to disclose.

Intermittent androgen-deprivation therapy in the management of castrate-resistant prostate cancer (CRPCa): Results of a multi-institutional randomized prospective clinical trial

131

Background: Patients who develop CRPCa typically continue on androgen deprivation therapy (ADT). Whether these patients need to remain on ADT has not been well studied. We conducted a multicenter randomized trial to compare intermittent versus continuous approach to ADT in CRPCa patients. Overall survival, health related quality of life (QOL) and cost were the main endpoints. We hypothesized that the intermittent approach would be cost-saving while maintaining similar oncologic and QOL outcomes.

Methods: CRPCa patients were randomized 1:2 to continuous or intermittent luteinizing hormone releasing hormone agonists (LHRHa). Patients were followed with clinical assessments, laboratory investigations, and QOL questionnaires (EORTC QLQ-C30 or PROSQOLI) every 2 months. If the serum testosterone rose above castrate levels (1.75nmol/L), LHRHa were re-initiated. The study was designed to close if >50% of patients needed to restart ADT in the intermittent arm.

Results: 31 patients were followed with a median follow-up of 26.8 months; 18 in the intermittent arm and 13 in the continuous. 12/18 patients on the intermittent arm were re-initiated on LHRHa at a median time of 17.9 months. There was no difference in overall or cancer-specific survival between the two arms. There was no statistically significant difference in QOL between the two arms at 0 and 12 months. The total mean costs at 24 months were significantly lower in the intermittent arm (3135 $CAD vs 8253 $CAD, p=0.0167) compared to the continuous arm largely due to the reduced costs of the LHRHa.

Conclusions: We have observed that intermittent ADT in patients with CRPCa, using a testosterone of >1.75 ngmol/L as a trigger to re-initiate LHRHa, results in a substantial cost savings with no negative impact on oncologic and QOL outcomes. These findings need to be corroborated in a study with a larger sample size.

[Table: see text]

Efficacy of targeted drug therapy for metastatic renal cell carcinoma in the elderly patient population

318

Background: Targeted therapy has become the mainstay of treatment for metastatic renal cell carcinoma (mRCC). The efficacy of this therapy on the older population is poorly understood.

Methods: Data from patients with mRCC treated with first-line anti-VEGF therapy were collected through the International mRCC Database Consortium from 14 centers.

Results: One thousand three hundred eighty-one patients were treated with targeted therapy as their first-line treatment. Of those, 144 (10%) were seventy-five years or older (median=78 years, range=75–89). Four percent of these individuals were favorable risk, 69% intermediate risk, and 27% poor risk as per Heng et al. JCO 2009 prognostic factors. There was no statistical difference in these prognostic groups between the older (≥75) and younger populations (<75) (p=0.1779). The initial treatment for those ≥ 75 years was with sunitinib (n=98), sorafenib (n=35), bevacizumab (n=7), and AZD2171 (n=4). The older population had fewer nephrectomies (71% vs. 80%, p=0.0133) and fewer brain metastases (3% vs. 9%, p=0.0128). Only 23% of older patients went on to receive second line therapy in comparison to 39% of the younger population (p<0.0001). The overall response rate, median treatment duration and overall survival for the older vs. younger group were 18% vs. 25% (p=0.0975), 5.5 months vs. 7.5 months (p=0.1388), and 16.8 months vs. 19.7 months (p=0.3321), respectively. When adjusted for known poor prognostic factors, age over 75 years was not found to be associated with poorer overall survival (HR 1.002, 95%CI 0.781–1.285) or shorter treatment duration (HR 1.018, 95%CI 0.827–1.252).

Conclusions: Overall response rates, treatment duration, and overall survival rates are not different between the older and younger populations and age is not a prognostic factor. Thus, the decision to treat with targeted therapy should not depend on age alone.

[Table: see text]

Proteomics of isolated mitotic chromosomes identifies the kinetochore protein Ska3/Rama1

Despite many decades of study, mitotic chromosomes remain poorly characterized with respect to their structure and composition. Here, we have purified mitotic chromosomes from nocodazole-treated chicken DT40 cells. These chromosomes have a 0.7:1:1 ratio of nonhistone proteins to histones to DNA. They also contain a significant content of RNAs that have yet to be characterized. Overall, the isolated chromosomes contained >4000 polypeptides, >500 of which are either novel or uncharacterized. Elsewhere, we have developed an approach for comparing the results of multiple proteomics experiments. As a validation of this approach, one of 13 novel centromere proteins identified was found to occur in a complex with the previously described proteins Ska1 and Ska2. This novel protein, now known as Ska3/Rama1, occupies a unique domain in the outer kinetochore and was revealed by RNA interference (RNAi) experiments to be essential for cell cycle progression in human cells. The approach presented here offers a powerful way to define the functional proteome of complex organelles and structures whose composition is not simple or fixed.

Pharmacokinetics and tissue distribution of 14C-labeled grape polyphenols in the periphery and the central nervous system following oral administration

Grape polyphenols confer potential health benefits, including prevention of neurodegenerative diseases. To determine the absorption and tissue distribution of the complex grape polyphenol mixture, (14)C-labeled polyphenols were biosynthesized by grape cell suspension cultures, during co-incubation with radioisotopically labeled sucrose, and fractionated into polyphenolic subfractions. The pharmacokinetics and distribution of grape polyphenols into blood, brain, and peripheral interstitial fluid were determined by tracking the (14)C label. The blood peak (14)C concentration of the fractions ranged from 15 minutes to 4 hours. Absorption and tissue distribution varied greatly between fractions. Concentrations in interstitial fluid were lower than in blood. The amount of residual label in the brain at 24 hours ranged from 0.1% to 1.7% of the dose, depending on the fraction. (14)C label found in the brain tissue and brain microdialysate indicated that grape polyphenols or their metabolites are able to cross the blood-brain barrier. Using (14)C-labeled plant polyphenols it is possible to track the compounds or their metabolic products into any tissue and determine distribution patterns in spite of low concentrations. A central question regarding the potential role of dietary polyphenolics in neurodegenerative research is whether they are bioavailable in the brain. Our observations indicate that some grape-derived polyphenolics do reach the brain, which suggests their potential value for applications in neurodegenerative disorders.

A randomized controlled trial of the effect of school food and dining room modifications on classroom behaviour in secondary school children

BACKGROUND/OBJECTIVES

Adequate nutrition is considered important for learning, but there is little robust research on the association between diet and learning in school-aged children in industrialized countries. This study investigated the effect of tailored modifications to the food and dining experience in secondary schools on learning-related behaviours.

SUBJECTS/METHODS

In 2008, 12 co-educational secondary schools in England were recruited. Schools were randomly allocated to receive a tailored action plan and support to modify their food provision and dining environment over a 15-week period (intervention or to control). Learning-related behaviours were systematically observed during post-lunchtime classes at all schools. Observations were made by trained observers using a validated protocol to determine whether pupils were 'on-task' (concentrating and alert) or 'off-task' (disruptive or disengaged).

RESULTS

In total, 156 pupils were observed (control n = 58, intervention n = 98) at baseline (12,210 and 20,560 observations, control and intervention, respectively) and at follow-up (16,846 and 23,462, respectively). On-task and off-task behaviours were similar across treatment groups at baseline. At follow-up, intervention group pupils were 18% more likely to be on-task (odds ratio (OR) 1.18, 95% confidence interval ((95% CI) 1.05-1.33) and 14% less likely to be off-task (OR 0.86, 95% CI 0.75-0.98) compared with control group pupils.

CONCLUSIONS

This study suggests that modifying food provision and the dining environment can improve learning-related behaviours of secondary school pupils in the post-lunch period. This finding supports ongoing investment and interventions by local authorities across the United Kingdom to improve school food and lunchtime dining facilities.

School lunch and learning behaviour in primary schools: an intervention study

BACKGROUND/OBJECTIVES

In addition to the nutritional benefits of healthier school food, anecdotes describe improvements in children's behaviour and educational outcomes when school food or the school dining room environment is improved. This study hypothesized that a school food and dining room intervention would improve pupils' learning-related classroom behaviour.

SUBJECTS/METHODS

A controlled intervention trial involving six primary schools matched in triplets and randomly assigned to a 12-week intervention (promotion of healthier school food at lunchtime and changes in the school dining environment) or 12-week wait-listed control group. Study outcome was learning-related behaviours measured in a random sample of 146 pupils in years 3-5.

RESULTS

On-task and off-task behaviours were observed and used as proxy measures for concentration and disengagement (disruption), respectively. Teacher-pupil on-task engagement was 3.4 times more likely in the intervention schools compared with the control schools (adjusted model odds ratio (OR)=3.40 (95% confidence interval (CI)=1.56, 7.36), P=0.009). However, on-task pupil-pupil behaviour was less likely in the intervention group (adjusted model OR=0.45 (95% CI=0.28, 0.70), P<0.001). Similarly, off-task pupil-pupil behaviour was more likely in the intervention group than in the control group in both the unadjusted model (OR=2.18 (95% CI=1.52, 3.13), P<0.001) and the adjusted model (OR=2.28 (95% CI=1.25, 4.17), P=0.007).

CONCLUSIONS

This study offers some support for the hypothesis that a school food and dining room intervention can have a positive impact on pupils' alertness. However, if raised alertness is not channelled and supervised, it may result in increased off-task behaviour when pupils are working together.

Temsirolimus in VEGF-refractory metastatic renal cell carcinoma

BACKGROUND

Temsirolimus is an i.v. administered inhibitor of mammalian target of rapamycin with activity in the first-line setting in poor-prognosis patients with metastatic renal cell carcinoma (RCC). The efficacy of this agent after failure of prior inhibitors of vascular endothelial growth factor (VEGF) is unknown.

METHODS

a retrospective review of patients with metastatic RCC treated at the Cleveland Clinic Taussig Cancer Institute and three regional cancer centers in Ontario, Canada, through the Torisel (temsirolimus) Compassionate Use Program was conducted. Demographic, toxicity and response data were collected.

RESULTS

a total of 87 patients with metastatic RCC were identified who had previously been treated with inhibitors of VEGF subsequently treated with temsirolimus. The majority of patients had either intermediate or poor-prognosis disease at baseline. Expected toxic effects including hyperglycemia and noninfectious pneumonitis were observed. The RECIST-defined objective response rate was 5% and the stable disease rate was 65%. The median time to progression (TTP) was 3.9 months (95% confidence interval 2.8-4.8 months), and median overall survival was 11.2 months.

CONCLUSIONS

in a cohort of pre-treated intermediate to poor-prognosis patients with metastatic RCC, weekly i.v. temsirolimus is associated with predictable, but manageable toxicity, and a TTP approaching 4 months.

Clinical experience with an antimicrobial hydrogel dressing on recalcitrant wounds

OBJECTIVE

To assess the performance of a newly-introduced, iodine-based antimicrobial wound dressing (Iodozyme) within normal clinical practice.

METHOD

51 case records were collected from 30 wound care locations in England. Reporting clinicians used Iodozyme on one or more difficult wounds of their own choice (of various aetiologies) from their current case loads. Basic patient-specific data were collected, relating to both their own and their patients' experience with the product over a 6-week period of treatment (or less, if healing was achieved earlier). In every case, the wound continued to be treated in accordance with local 'best practice', in accordance with the manufacturer's instructions and by the same clinician. Each wound was assessed in terms of size, condition (margins and wound bed), exudate (type and amount), comfort/pain, overall satisfaction (by patient and clinician) and healing status (in terms of healed, improved, static or deteriorated). In addition, clinicians were asked to use their own local criteria and parameters where possible, with general guidance as and when it was needed.

RESULTS

The mean duration of all wounds was 25.8 months (median 13 and range 1-312). Nine patients had a wound of less than six months' duration, and 17 had one of two years' or more duration. Within the 6-week study period, 6 wounds healed fully, 37 were judged to have improved, 7 remained static and 1 deteriorated. Overall, the majority of clinicians and patients were 'satisfied' or 'very satisfied' with product performance and 77% of clinicians concluded that the dressing was 'better' or 'much better' than other dressings they had previously used on similar wounds.

CONCLUSION

While we cannot generalise from this study, the encouraging clinical results and positive patient and clinician feedback lead us to believe that Iodozyme is a dressing worthy of consideration when treating chronic wounds. These encouraging preliminary findings are now to be followed up with a randomised control trial.

Method for evaluating the potential of C labeled plant polyphenols to cross the blood-brain barrier using accelerator mass spectrometry

Bioactive compounds in botanicals may be beneficial in preventing age-related neurodegenerative diseases, but for many compounds conventional methods may be inadequate to detect if these compounds cross the blood brain barrier or to track the pharmacokinetics in the brain. By combining a number of unique technologies it has been possible to utilize the power of AMS to study the pharmacokinetics of bioactive compounds in the brain at very low concentrations. (14)C-labeled compounds can be biosynthesized by plant cell suspension cultures co-incubated with radioisotopically-labeled sucrose and isolated and separated into a series of bioactive fractions.To study the pharmacokinetics and tissue distribution of (14)C labeled plant polyphenols, rats were implanted with jugular catheters, subcutaneous ultrafiltration probes and brain microdialysis probes. Labeled fractions were dosed orally. Interstitial fluid (ISF) and brain microdialysate samples were taken in tandem with blood samples. It was often possible to determine (14)C in blood and ISF with a β-counter. However, brain microdialysate samples (14)C levels on the order of 10(7) atoms/sample required AMS technology. The Brain Microdialysate(AUC)/Serum(AUC) ranged from .021- to .029, with the higher values for the glycoside fractions. By using AMS in combination with traditional methods, it is possible to study uptake by blood, distribution to ISF and determine the amount of a dose which can reach the brain and follow the pharmacokinetics in the brain.

Sunitinib and sorafenib in metastatic renal cell carcinoma patients with renal insufficiency

BACKGROUND

Although clinical trials with sunitinib and sorafenib in metastatic renal cell carcinoma (mRCC) have included patients with moderate renal insufficiency (RI), the incidence of renal toxicity induced by their administration as well as the safety of these agents in patients with more severe renal insufficiency has not been extensively reported.

PATIENTS AND METHODS

Patients with mRCC treated with vascular endothelial growth factor-targeted therapy with either RI at time of treatment initiation or who developed RI during therapy were identified. RI was defined as serum creatinine (Cr) > or = 1.9 mg/dl or a creatinine clearance (CrCl) < 60 ml/min/1.73 m(2) for >3 months before treatment. Objective outcomes and toxic effects of treatment were also measured.

RESULTS

A total of 39 patients were identified: 21 patients who initiated therapy with preexisting RI and 18 patients who developed RI during treatment. In patients with RI at the start of therapy, Cr increased in 57%, and 48% of patients required dose reduction. The median time to maximum RI was 6.6 months (range 0.4-19.6 months). In patients who developed RI while receiving therapy, median serum Cr and CrCl at the start of therapy were 1.5 mg/dl (range 1.1-1.8) and 61 ml/min (range 43-105), respectively. Patients experienced a median increase in serum Cr of 0.8 mg/dl (range 0.3-2.8) and a median decrease in CrCl of 25 ml/min (range 8.54-64.76). Overall, 5 patients (24%) achieved a partial response (PR), 13 (62%) had stable disease (SD) and 3 (14%) had progressive disease (PD). Estimated progression-free survival (PFS) was 8.4 months. The most common toxic effects (all grades) were fatigue (81%), hand-foot syndrome (HFS) (52%) and diarrhea (48%). Six patients experienced grade III toxicity (29%), primarily HFS.

CONCLUSIONS

Sunitinib and sorafenib can be safely given to patients with renal insufficiency, provided adequate monitoring of renal function. For those patients developing an increase in Cr, dose modifications may be required to allow continuation of therapy. The clinical outcome of patients with baseline renal dysfunction and patients who develop renal dysfunction does not appear to be compromised.

First-line therapy with sunitinib in advanced renal cell carcinoma: interpretation of the overall survival data from ASCO 2008

Sunitinib is now a standard first-line therapy for metastatic clear-cell kidney cancer. This paper focuses on interpretation of the overall survival data presented at the 2008 annual meeting of the American Society of Clinical Oncology from the pivotal phase iii trial comparing sunitinib with interferon in the first-line setting. The previously published progression-free survival and response rate data from that study are also summarized.

Does isolated patellofemoral osteoarthritis matter?

OBJECTIVES

To describe the structure-pain and structure-function associations in isolated patellofemoral osteoarthritis (PF OA).

DESIGN

Population-based study of 819 adults aged > or =50 years with knee pain. The severity of knee pain, stiffness and disability were measured using the Western Ontario and McMaster Osteoarthritis Index (WOMAC). Three radiographic views of the knee were obtained.

RESULTS

Isolated PF OA was mild in 142 participants and moderate/severe in 44. Mean WOMAC scores for pain, stiffness and function were associated with radiographic severity of PF OA (F(2,389)=4.7, P=0.01; F(2,392)=4.5, P=0.012 and F(2,392)=6.1, P=0.002, respectively, adjusted for age, gender, and body mass index (BMI)). Post-hoc tests demonstrated statistically significant differences for mean pain, stiffness and function score between those with mild PF OA and those with normal X-rays. In task-specific items there was evidence of a stepped response, the proportion of participants with moderate/severe/extreme pain or difficulty in performing everyday tasks increasing with the severity of PF OA. The strongest association was observed for pain going up and down stairs (age-gender-BMI adjusted odds ratio (OR) 3.0; 95% confidence interval (CI) 1.4,6.6. Functional tasks most strongly related to radiographic severity were: descending stairs (OR 3.2; (CI 1.5,6.5)), getting in/out of the bath (3.2; 1.5,6.6), getting in/out of a car (3.0; 1.4,6.1).

CONCLUSIONS

Mild isolated PF OA is significantly associated with symptoms of pain, stiffness and functional limitation. Further research on its recognition in clinical practice and the development of targeted treatments to prevent or slow progression are warranted.

The impact of head injury neurobehavioural sequelae on personal relationships: Preliminary findings

BACKGROUND

Existing evidence suggests that neurobehavioural disability is a frequent legacy of serious head trauma and has a major impact on the psychological well-being of relatives and friends of people with brain injuries.

OBJECTIVE

To explore which neurobehavioural legacies of serious head trauma have the greatest impact on personal relationships and increase the risk of relationship breakdown.

METHOD

Forty-eight partners of people who had suffered serious head trauma were asked to complete a 12-item measure to rate how different neurobehavioural characteristics had adversely affected their relationship with the brain injured person. Twenty-three couples who had divorced or separated from their injured partner in the years following injury comprised the 'separated' group, 25 still in the relationship at the time data were collected comprised the 'together' group.

RESULTS

Even though many neurobehavioural characteristics of brain injury were reported by partners of both the separated and the together group as placing a strain on the relationship only mood swings accounted for a significant between groups difference [t(40.13) = 3.33, p = 0.002]. The magnitude of the difference in the means was large (712 = 0.19).

CONCLUSIONS

Unpredictable patterns of behaviour, as perceived by partners of brain injured individuals, impose the greatest burden on personal relationships and may contribute to relationship breakdown.

Engaging parliamentarians as advocates for women's health: findings from Kenya and Namibia

Members of parliament (MPs) are well placed to promote national health policies that improve women's access to quality health care, including HIV services. To catalyse political will and leadership, the International Centre for Research on Women, Centre for the Study of AIDS at the University of Pretoria, International Community of Women Living with HIV/AIDS and Realising Rights: The Ethical Globalization Initiative, conducted the Parliamentarians for Women's Health project in select African countries. This paper focus on participatory community assessments - a methodology used by the project to improve MPs' understanding of women's health issues, particularly HIV/AIDS, and to increase their engagement with civil society in order to better represent women's health needs and concerns. In-depth interviews with eight MPs from Kenya and Namibia highlight the value of the assessments in identifying women's health problems and service gaps. The MPs reported that they undertook various activities after the assessments, including gathering more information about women's health from local communities, pushing for new parliamentary committees to be a platform for health issues, using the information from the assessments to inform policy, more carefully reviewing budget allocations and establishing relationships with civil society. Participatory methods can be used to meet political leaders' needs for information and communities' needs to influence policymaking that affects their lives.

A phase I pharmacokinetic (PK) study of MBP-426, a novel liposome encapsulated oxaliplatin

2535

Background: MBP-426 is a novel liposome encapsulated oxaliplatin (L-OHP) formulation bound to human transferrin, developed to improve the safety and efficacy of L -OHP through the prolongation of circulation time and by targeting transferrin receptors on tumor cells. In vitro, MBP-426 is effective against various human cancer cell lines. This study assessed the toxicity and safety of intravenously (IV) administered MBP-426, including defining the maximally tolerated dose (MTD), dose-limiting toxicities (DLTs), and pharmacokinetics (PKs). Methods: Patients (pts) with advanced/ metastatic solid tumors refractory to conventional therapy received MBP-426 as 2–4 hrs IV infusion every 3 weeks in cohorts of 3 to 6 pts. Enrollment required age > 18 yrs, ECOG Performance Status 0–2 and adequate organ functions. Tumor response was assessed by RECIST. Plasma was sampled for PK. Results: 39 pts were dosed, median age 59 (range 27–79), 25 (64%) male. The common tumor types were colorectal 23 (60%), pancreas 3 (8%), and neuroendocrine 3 (8%). Most pts were heavily pretreated with chemotherapy or chemoradiation. 77% pts had received oxaliplatin or cisplatin. Eleven dose levels ranging from 6 to 400 mg/m2 were evaluated. At 400 mg/m2, 2/3 pts had DLT as grade 4 thrombocytopenia and prolonged thrombocytopenia (1 pt each). The recommended phase II dose is 226 mg/m2 where 1/6 pts had grade 4 thrombocytopenia. Grade 3–4 toxicities included fatigue (3 pts), hypercholesterolemia (3 pts), anemia (2 pts) and constipation (1 pt). Common grade 1–2 toxicities were nausea and/or vomiting (59%), fatigue (43%), infusion reaction (15%), thrombocytopenia (15%), anemia (13%) and peripheral neuropathy (13%). 15 pts had stable disease after 2 cycles. 3 pts with colon carcinoma refractory to conventional oxaliplatin had stable disease for 4, 5 and 6 cycles respectively, one of them had 25% decrease in target lesions. PKs of MBP-426 were dose-proportional. Main PK parameters at 226 mg/m2 were AUC 2141+419 μg.hr/ml, and t½ 89+92 hr, comparing favorably with intact L-OHP. Conclusions: MBP-426 has a favorable safety profile with thrombocytopenia as main DLT. The PK target concentration of L-OHP was exceeded at higher doses. Based on PK and toxicity profiles, the recommended dose is 226 mg/m2.

[Table: see text]

Sunitinib in patients (pts) with unresectable primary renal cell carcinoma (RCC)

5096

Background: Sunitinib inhibits VEGF and related receptors, with high tumor shrinkage rates in metastatic (met) RCC. Shrinkage of primary tumors has been observed, although prospective investigation is lacking. The ability of sunitinib to convert primary RCC tumors from unresectable to resectable is of high clinical interest. Methods: Pts with histologically-confirmed RCC with an unresectable primary tumor with or without met disease were enrolled on a single-arm phase II trial. Primary tumors were unresectable due to ≥ 1 of the following: large tumor size, bulky lymphadenopathy, encasement of renal vessels, IVC thrombosis or proximity to vital structures. Pts received 50 mg sunitinib continuous dosing in repeated 6-week cycles. Staging by CT scans or MRI was done at baseline and every 2 cycles. A Simon 2-stage design was employed to test the alternative hypothesis of a conversion to resectability rate of 20% versus the null hypothesis of 5%; β = 0.8, α = 0.05 (n = 31). Results: 18 pts have been enrolled; 1 excluded due to a non-RCC diagnosis. Pts were unresectable due to bulky lymphadenopathy (6), IVC thrombosis (4), proximity to vital structures (4) or tumor size (3), although most pts had multiple factors. Median age among 14 evaluable pts was 61 years (range, 37–80), 59% male, 76% ECOG PS 0; 79% had distant met disease. The 14 evaluable pts have received a median of 3 cycles of therapy (range, 1–10+). Three pts (21%) have undergone primary tumor resection; viable RCC was identified in all specimens with no unexpected surgical morbidity. Nine pts (53%) had primary tumor reduction (median 19%; range, -64% to -1%). Overall, median best % change in tumor burden was 4.9% reduction for primary tumors (range, -43.1% to +8.5%) and 10.7% reduction for met sites (range, -89.5% to +28.6%). Median PFS is 4.9 months. Eleven pts (79%) discontinued therapy; 8 for PD, 1 for adverse events and 2 following surgery which removed all visible disease. Eight pts (57%) experienced grade 3 toxicity including thrombocytopenia, fatigue, hypertension, anemia, hemoptysis, and hand-foot syndrome; 1 pt had grade 4 neutropenia. Conclusions: Sunitinib has activity in unresectable primary RCC tumors, permitting resection in some pts. Continued prospective investigation is required to optimize patient selection and timing of surgery.

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Effects of repeated ankle plantar-flexions on H-reflex and body sway during standing

The study investigated relations between effects of repeated ankle plantar-flexion movements exercise on the soleus Hoffmann (H) reflex and on postural body sway when maintaining upright stance. Ten young volunteers performed five sets of ankle plantar-flexions of both lower limbs. Assessment of the feet centre-of-pressure (COP) displacement and H-reflex tests were carried out in quiet stance before, during and after the exercise. H-max and M-max responses were obtained in 8 subjects and reported as the peak-to-peak amplitudes of the right soleus muscle electromyographic waves. Mean dispersion of COP along the antero-posterior direction increased significantly during the exercise; whilst the overall H-reflex response indicated a reduction without a concomitant modification in the M-max response. H-reflex responses, however, varied between participants during the first sets of exercise, showing two main trends of modulation: either depression or early facilitation followed by reduction of the H-reflex amplitude. The extent of reflex modulation in standing position was correlated to the concentric work performed during the exercise (r=0.85; p<0.01), but not to the antero-posterior COP dispersion. These results suggest that during a repeated ankle plantar-flexions exercise, modulation of the H-reflex measured in upright stance differs across individuals and is not related to changes of postural sway.

Predicting the course of functional limitation among older adults with knee pain: do local signs, symptoms and radiographs add anything to general indicators?

OBJECTIVE

To determine the additional prognostic value of clinical history, physical examination and x-ray findings to a previously derived simple generic model (age, body mass index, anxiety and pain severity) in a cohort of older adults with knee pain.

METHODS

Prospective cohort study in community-dwelling adults in North Staffordshire. 621 participants (aged >or=50 years) reporting knee pain who attended a research clinic at recruitment and were followed up by postal questionnaire at 18 months. Poor functional outcome was measured by the Physical Functioning Scale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 18-month follow-up defined in 60% of participants.

RESULTS

Three clinical history variables (bilateral knee pain, duration of morning stiffness and inactivity gelling) were independently associated with poor outcome. The addition of the "clinical history" model to the "generic" model led to a statistical improvement in model fit (likelihood ratio (LR) = 24.84, p = 0.001). Two physical examination variables (knee tender point count and single-leg balance) were independently associated with poor outcome but did not lead to a significant improvement when added to the "clinical history and generic" model (LR = 6.34, p = 0.50). Functional outcome was significantly associated with severity of knee radiographic osteoarthritis (OA), but did not lead to any improvement in fit when added to the "generic, clinical history and physical examination" model (LR = 1.86, p = 0.39).

CONCLUSIONS

Clinical history, physical examination and severity of radiographic knee OA are of limited value over generic factors when trying to predict which older adults with knee pain will experience progressive or persistent functional difficulties.

WBC changes as a pharmacodynamic marker of outcome in metastatic renal cell carcinoma (mRCC) patients (Pts) receiving sunitinib

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Background: Sunitinib is a VEGF, PDGF, c-Kit and FLT-3 inhibitor with significant anti-tumor activity in mRCC. Myelosuppression is a common side effect observed in mRCC pts treated with sunitinib. Thus, the association of myelosuppression with clinical outcome was investigated. Methods: All mRCC pts receiving sunitinib at The Cleveland Clinic Taussig Cancer Center with available data were investigated. White blood cell (WBC) and differential counts at baseline and day 28 of cycle 1 were collected. Peripheral blood mononuclear cell (PBMC) T helper 1 (Th1), T helper 2 (Th2) and T regulatory cell (Treg) numbers at baseline and day 28 of C1 were determined using flow cytometry. Hematologic parameters were analyzed as continuous variables and also dichotomized using a recursive partitioning algorithm. Fisher’s exact test was used to analyze categorical data, the log rank test was used to assess time to progression (TTP) and Spearman’s rank correlation was used to summarize associations between hematologic and immune parameters. Results: Sixty-seven pts were studied (75% male, median age 59 yrs). Objective responses (OR) included 2 complete and 35 partial responses (overall response rate 55%), with a median (m) TTP of 12.4 months. There was a significant reduction (end of C1 vs. baseline) in the absolute neutrophil count (ANC) (m decrease of 46.4%; p <0.001) and absolute monocyte count (m decrease of 41.3%; p<0.001), but not absolute lymphocyte count (m 6.6% decrease; p=0.5). A decrease in the ANC of =2.5K/uL compared to <2.5 K/uL was associated with improved OR (64% vs. 36%; p= .07) and TTP (m 20.6 months vs. 8 months; p=.003). Patients demonstrating a maximum lymphocyte count =1.2 K/uL at anytime during treatment compared to patients with a maximum lymphocyte count <1.2 K/uL also had a greater OR (64% vs. 25%, p=.02) and TTP (m 17.6 months vs. 4.2 months, p=.03). Changes in Treg number and Th1 and Th2 response bias of PBMC did not correlate with ANC/ lymphocyte changes or clinical outcome. Conclusions: Treatment with sunitinib produces significant neutropenia with minimal effects on total lymphocyte numbers. Changes in ANC and maximum lymphocyte count could represent a pharmacodynamic marker of clinical outcome for mRCC patients treated with sunitinib.

No significant financial relationships to disclose.

Thyroid function test (TFT) abnormalities in patients (pts) with metastatic renal cell carcinoma (RCC) treated with sorafenib

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Background: Sorafenib is an orally bioavailable VEGF receptor inhibitor with anti-tumor activity in metastatic RCC. Sunitinib, another VEGF receptor inhibitor, induces biochemical hypothyroidism in 85% of metastatic RCC pts, the majority of whom have signs or symptoms of hypothyroidism (Rini BI et al. JNCI 2007 99(1):81–83). Thus, the incidence of TFT abnormalities in pts with metastatic RCC receiving sorafenib was investigated. Methods: The medical records of pts with metastatic RCC receiving sorafenib in one of five clinical trials at the Cleveland Clinic Taussig Cancer Center were reviewed. TFTs (TSH, T4, FTI and T3), patient demographics and clinical outcomes were recorded. Results: Between February 2004 and November 2006, 71 pts (49 males, 22 females) were treated with sorafenib. Baseline pt characteristics included a median age of 62 years (range, 35–87), 87% of pts had clear cell histology and 97% had prior nephrectomy. Forty-two pts had TFTs measured while receiving sorafenib and 19/42 pts (45%; 95% CI: 30–61%) had abnormal TFTs. The TFT abnormalities were consistent with hypothyroidism (13 pts), euthyroid sick syndrome (2 pts) or hyperthyroidism (4 pts). The median values in pts with abnormal TFTs were: TSH-7 μU/ml, T3–79 ng/dl, T4–12.7 μg/dl, FTI- 5.4; these values are just outside the normal laboratory ranges. The majority of pts did not have clinical signs or symptoms that could be attributed solely to thyroid dysfunction; only one pt (2%) received thyroid hormone replacement. The estimated progression free survival for pts with normal TFTs is 7.5 months vs. 6.1 months for pts with abnormal TFTs (p=0.79). Conclusion: Mild biochemical TFTs abnormalities are common in pts with metastatic RCC treated with sorafenib. However, severe TFT abnormalities and/or clinical signs/symptoms of thyroid dysfunction are not seen, and thyroid replacement therapy is not often indicated. In contrast to sunitinib, where the high incidence and clinical relevance of thyroid dysfunction requires routine monitoring, pts with metastatic RCC receiving sorafenib should have TFTs monitored only if clinically indicated.

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Relapse patterns and outcomes in a population-based study of Nova Scotia patients with germ cell tumors (GCT)

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Objectives: To examine the frequency and pattern of relapse in a population-based cohort of Nova Scotia patients with germ cell tumors (GCT). Presentation and outcome of these patients will be described with an emphasis on late relapsers. Methods: A retrospective chart review of all patients diagnosed with GCT in Nova Scotia between 1984 and 2004 was completed. Data regarding initial diagnosis and treatment as well as data at time of relapse was collected. Relapse was defined as any recurrence of tumor after initial definitive therapy. Late relapse (LR) was defined as a relapse >2 years from initial definitive therapy or previous relapse. Results: Of the 383 patients diagnosed with GCT during the 20 year period, 135 received chemotherapy. 15/135 (3.7%) patients initially treated with chemotherapy relapsed; 10 early and 5 late. 1/10 early relapsers was alive and NED at 2 years from relapse compared to 4/ 5 late relapsers at 4 years. 3 of the 245 patients whose treatment did not include chemotherapy experienced a LR for a total of 8/383 (2.1%) of all patients. Median time to all LR was 6.6 years. Pathology for 6/8 (75%) patients with LR was nonseminomatous GCT. 50% of patients with LR died. Common to all LR survivors was complete surgical resection ± chemotherapy. All patients with LR who died had either no surgical resection or incomplete surgical resection of disease. Conclusions: The incidence of all GCT patients with LR was 2.1% and the incidence of LR post chemotherapy was 3.7% in this population. The only other population based report of incidence of LR in all GCT patients was 1.3%. A mixture of stages, pathology, and sites of metastases was observed with no obvious baseline or treatment differences between early and late relapsers. Interestingly, in this population, patients with LR had better outcomes than early relapsers. The success to curing patients with LR appears to be complete surgical resection of disease.

No significant financial relationships to disclose.

Macrocytosis in patients with metastatic renal cell carcinoma (mRCC) treated with tyrosine kinase inhibitors (TKI's)

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Background: Sunitinib and sorafenib are TKIs with inhibitory activity against a variety of kinases including VEGFR, PDGFR, and cKIT, as well as significant clinical activity in mRCC. Off target toxicity is frequently seen, and in pts treated with these TKIs the development of anemia ± macrocytosis was noted. Further studies were conducted to clarify the frequency and etiology of these findings. Methods: A retrospective review of mRCC patients treated with sunitinib or sorafenib for = 3 months was undertaken. Complete blood count data including RBC indices was recorded at baseline, 3 months, and at the end of treatment. Thyroid function tests (TFTs) were collected, and in selected patients, bone marrow examination was undertaken. Results: Ninety eight pts were evaluated (61 sunitinib-treated, 37 sorafenib-treated). In sunitinib-treated mRCC patients, median MCV levels increased significantly at 3 months compared to baseline (97.1 fL vs. 90.2 fL; p<0.001) and median Hgb levels decreased from 13.4 to 12.8 (p =0.31). In patients receiving sunitinib >12 months, MCV continued to increase throughout treatment. There was no association between increasing MCV and the development of hypothyroidism. In 10 patients discontinuing sunitinib, MCV returned to baseline within 2 to 4 months. The number of patient receiving sunitinib with an MCV > 100 at the beginning, 3 months, and end of treatment were 2, 14 and 40 respectively. Bone marrow examinations performed during sunitinib therapy (n=3) demonstrated hypocellularity (5–10%) with normal trilineage hematopoiesis and no evidence of dysplastic changes. In contrast, sorafenib- treated mRCC patients showed no effects at 3 months on MCV levels (90.7 fL vs. 90.6 fL) but an increase in hemoglobin level (14.0 g/dL vs. 13.2 g/dL p=0.02) . At the beginning of treatment 2 patients had MCV values more than 100, but at 3 months and 12 months none of the patients had MCV values more than 100. Conclusions: Macrocytosis commonly develops in sunitinib-treated, but not sorafenib- treated mRCC pts. The etiology of this finding is unclear, but studies suggest direct effects on bone marrow precursors. Sunitinib-induced macrocytosis appears reversible with drug discontinuation.

[Table: see text]

Clinical factors associated with outcome in metastatic renal cell carcinoma patients treated with VEGF-targeted therapy

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Background: Therapy targeted against the vascular endothelial growth factor (VEGF) pathway is a standard of care in metastatic renal cell carcinoma (RCC). Identification of clinical features of patients more likely to benefit from these agents would aid in patient selection and interpretation of clinical trial results. Methods: We reviewed 120 metastatic RCC patients receiving bevacizumab, sorafenib, sunitinib or axitinib on one of eight prospective clinical trials at the Cleveland Clinic Taussig Cancer Center. Clinical features associated with outcome were identified by univariate analysis, and then a stepwise modeling approach based on Cox proportional hazards regression was used to identify independent prognostic factors and form a model for progression-free survival (PFS). A bootstrap algorithm was used to provide internal validation. Results: Forty-one patients (34%) achieved an objective response by RECIST criteria (95% C.I. 27–44%). The median PFS for the entire group was 13.8 months (m) (95% C.I. 10.7–19.0 m). Multivariate analysis identified the following independent adverse prognostic factors (PF) for PFS: time from diagnosis to current treatment <2 years, baseline platelet count >300 K/μL, baseline neutrophil count >4.5 K/μL, baseline corrected serum calcium <8.5 or >10.0 mg/dL and initial ECOG performance status >0. Using these factors three prognostic subgroups were formed based on the number of adverse PF present . Median PFS in patients with 0 or 1 adverse PF was 20.1 m (95% C.I. 19.0–22.3 m) compared to 13 m (95% C.I. 8.6–17.6 m) in patients with 2 adverse PF and 3.9 m (95% C.I. 1.8–7.2 m) in patients with >2 adverse PF. Conclusions: Five independent prognostic factors for predicting PFS were identified and used to categorize patients with metastatic RCC receiving VEGF-targeted therapies into three risk groups. These factors can be readily incorporated to clinical patient care, stratification schema for clinical trials utilizing these novel agents and for interpretation of clinical trial results using VEGF-targeted agents therapy.

No significant financial relationships to disclose.

Durable complete responses and near complete responses to sunitinib in metastatic renal cell carcinoma

15514

Introduction: Sunitinib is a tyrosine kinase inhibitor with activity against VEGFR and PDGFR recently approved by the FDA for the treatment of advanced renal cell carcinoma (RCC). There is no existing literature that details complete responses (CRs) in patients taking sunitinib for metastatic RCC. Methods: Seventy-four patients with metastatic RCC receiving sunitinib at the Cleveland Clinic Taussig Cancer Center on clinical trials were reviewed to determine the number of patients with RECIST-defined CRs. Additionally, patients who achieved near-CRs defined as a greater than 90% reduction in composite tumor volume or residual disease of less than or equal to 1 cm were reviewed. Results: Two patients (2.7%) achieved a RECIST-defined CR lasting >15 months. The patients who obtained CRs had non-bulky pulmonary metastases, favorable or intermediate MSKCC risk profiles, were treated with sunitinib in the first-line setting and had a significant reduction in composite tumor measurements within the first two cycles. An additional 2 patients achieved near-CRs, including one patient that previously progressed on bevacizumab. These 2 near-CR patients remain progression-free for more than 19 months. Finally, 1 patient achieved sufficient downstaging and reduction of tumor volume such that the remaining lesion could be excised, resulting in a surgical CR. This patient is currently off sunitinib and remains progression-free 4 months after surgery. Conclusion: Sunitinib is capable of producing durable CRs in cytokine-naïve metastatic RCC patients with non-bulky pulmonary metastases. Additionally, near-CRs can be seen despite non-pulmonary metastatic sites and prior VEGF-targeted therapy.

No significant financial relationships to disclose.