Abstract OT2-07-09: A phase Ib study of neratinib, pertuzumab, and trastuzumab with paclitaxel in patients with metastatic and locally advanced breast cancer

Background: Neratinib, a potent irreversible pan-ErbB tyrosine kinase inhibitor that blocks signal transduction through HER1, HER2, and HER4, has demonstrated activity against metastatic HER2-positive breast cancer (HER2+ BC) in patients pretreated with trastuzumab. The FDA recently approved neratinib as an adjuvant treatment for HER2+ BC patients who have received trastuzumab for at least 1 year. Preclinical data demonstrate that trastuzumab-resistant BC cells remain sensitive to neratinib. Also, neratinib enhances responses to trastuzumab possibly by increasing trastuzumab's internalization, immune-mediated action, and other mechanisms. Taken together, these findings provide the rationale for adding neratinib to the standard of care combination of trastuzumab and pertuzumab with paclitaxel to enhance anti-HER2 efficacy in advanced HER2+ BC. Here, we report on the phase Ib portion of an ongoing phase Ib/II trial of this drug combination.

Trial Design: Patients with metastatic or locally advanced HER2+ BC will be enrolled in the phase Ib portion of the trial. Neratinib is given orally in 3-week cycles. The initial neratinib dose of 80 mg daily is increased to 120, 160, and 200 mg daily after safety assessments of each dose level. Other agents are administered as per the standard of care. Patients continue therapy with per-protocol dose escalation and de-escalation according to toxicity until the maximum tolerated dose (MTD) of neratinib is reached. The target maximum dose-limiting toxicity rate is 20%. All patients receive 4 cycles of the combination therapy. If patients do not have disease progression or excessive toxicity, they may receive 2-4 additional cycles at the treating physician's discretion. During therapy, patients undergo blood tests every week and have clinical visits and restaging scans every 3 weeks. Because gastrointestinal toxicity, mainly diarrhea, is anticipated, patients receive prophylactic antidiarrheal medication (e.g., loperamide, budesonide) beginning with the first dose of neratinib.

Eligibility Criteria: Eligible patients must have histologically confirmed metastatic or locally advanced HER2+ BC (BC may be inflammatory or non-inflammatory and have any hormone receptor status); an ECOG performance status score of 0 or 1; and adequate hematologic and organ function, including adequate cardiac function (as indicated by a left ventricle ejection fraction of ≥50%).

Specific Aims:

1- To determine the MTD of neratinib in combination with paclitaxel, pertuzumab, and trastuzumab.

2- Pharmacodynamic markers will be measured on biologic specimens. Neratinib-induced changes in pEGFR and/or HER2 expression will be analyzed and compared between dose levels.

Statistical Methods: The Bayesian modified toxicity probability interval is used to determine dose adjustment.

Accrual: The target enrollment for the phase Ib cohort is 20 patients. The trial has enrolled 3 patients since its activation in January 2018. This trial is supported by Puma Biotechnology, Aggressive Breast Cancer Research Program Grant.

Citation Format: Al-Awadhi A, Kono M, Marx A, Moseley T, Willey J, Sun H, Fu M, Whitman GJ, Valero V, Ueno NT, Lim B. A phase Ib study of neratinib, pertuzumab, and trastuzumab with paclitaxel in patients with metastatic and locally advanced breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-07-09.

Rehmanniae Radix Preparata suppresses bone loss and increases bone strength through interfering with canonical Wnt/β-catenin signaling pathway in OVX rats

Rehmanniae Radix Preparata (RRP) improves bone quality in OVX rats through the regulation of bone homeostasis via increasing osteoblastogenesis and decreasing osteoclastogenesis, suggesting it has a potential for the development of new anti-osteoporotic drugs.

INTRODUCTION

Determine the anti-osteoporotic effect of RRP in ovariectomized (OVX) rats and identify the signaling pathway involved in this process.

METHODS

OVX rats were treated with RRP aqueous extract for 14 weeks. The serum levels of tartrate-resistant acid phosphatase (TRAP), receptor activator of nuclear factor kappa-Β ligand (RANKL), alkaline phosphatase (ALP), and osteoprotegerin (OPG) were determined by ELISA. Bone histopathological alterations were evaluated by H&E, Alizarin red S, and Safranin O staining. Bone mineral density (BMD) and bone microstructure in rat femurs and lumbar bones were determined by dual-energy X-ray absorptiometry and micro-computed tomography. Femoral bone strength was detected by a three-point bending assay. The expression of Phospho-glycogen synthase kinase 3 beta (p-GSK-3β), GSK-3β, Dickkopf-related protein 1 (DKK1), cathepsin K, OPG, RANKL, IGF-1, Runx2, β-catenin, and p-β-catenin was determined by western blot and/or immunohistochemical staining.

RESULTS

Treatment of OVX rats with RRP aqueous extract rebuilt bone homeostasis demonstrated by increasing the levels of OPG as well as decreasing the levels of TRAP, RANKL, and ALP in serum. Furthermore, RRP treatment preserved BMD and mechanical strength by increasing cortical bone thickness and epiphyseal thickness as well as improving trabecular distribution in the femurs of OVX rats. In addition, RRP downregulated the expression of DKK1, sclerostin, RANKL, cathepsin K, and the ratio of p-β-catenin to β-catenin, along with upregulating the expression of IGF-1, β-catenin, and Runx2 and the ratio of p-GSK-3β to GSK-3β in the tibias and femurs of OVX rats. Echinacoside, jionoside A1/A2, acetoside, isoacetoside, jionoside B1, and jionoside B2 were identified in the RRP aqueous extract.

CONCLUSION

RRP attenuates bone loss and improves bone quality in OVX rats partly through its regulation of the canonical Wnt/β-catenin signaling pathway, suggesting that RRP has the potential to provide a new source of anti-osteoporotic drugs.

[Therapeutic effects of postauricularinjection of lidocaine in tinnitus]

Objective:To observe clinical efficacy of postauricular injection of lidocaine for subjective tinnitus and explore the clinical effective method in the treatment of tinnitus.

METHOD

Eighty patients with tinnitus as their first complaint were included in our study. They were randomly divided into four groups, each with 20 cases.They were treated with oral ginaton and mecobalamin tablets,and at the same time with postauricular injection of lidocaine at different doses (Group A, 2% lidocaine 3 ml; Group B, 2% lidocaine 2 ml+physiological saline 1 ml;Group C, 2% lidocaine 1 ml+physiological saline 2 ml; Group D, physiological saline 3 ml). TEQ scores were evaluated and compared before treatment, at the end of treatment, and one month after treatment.Result:At the end of treatment, the clinical effiCIency rates of four groups were 80%,70%,65% and 25% respectively. One month after treatment, the clinical effiCIency rates of four groups were 80%, 55%, 45% and 0% respectively. There were significant differences among four groups by chi square test (P<0.05).Patients' TEQ scores of the four groups after treatment were analyzed and compared by one-way ANOVA. TEQ scores of Group A,B and C were lower than Group D(P<0.05). TEQ scores of Group A were lower than Group C(P<0.05).TEQ scores at the end of treatment and one month after treatment were analyzed by paired t-test. Group B and C had higher TEQ scores one month after treatment(P<0.05).The total effective rate at the end of treatment for acute, subacute and chronic tinnitus patients was 79.31%, 70.83% and 42.86% respectively. The total effective rate of one month after treatment was 75.86%, 45.83% and 42.86%, respectively. The results of chi square test showed that the total effective rate of acute tinnitus patients was significantly higher than that of subacute and chronic tinnitus in one month after treatment (P<0.05).

CONCLUSION

Postauricular injection of lidocaine is effective for simple subjective tinnitus, and the dose and concentration of lidocaine affect the efficacy and durability. Postauricular injection of lidocaine for the treatment of subjective tinnitus is a therapeutic method worthy of further research and popularization.

[Diagnosis and treatment of canal conversion during canalith repositioning procedure for benign paroxysmal positional vertigo]

Objective:To investigate the diagnosis and treatment of canal conversion during canalith repositioning procedure for benign paroxysmal positional vertigo.Method:The clinic features, nystagmus characteristics, diagnosis and treatment of the patients with benign paroxysmal positional vertigo who suffered from canal conversion during canalith repositioning procedure were analyzed retrospectively.All patients'positioning test and canalith repositioning procedure were done with the aid of videonystagmography.Result:A total of 186 patients with benign paroxysmal positional vertigo were diagnosed and performed canalith repositioning procedure.Eight patients (4.3%) developed canal conversion after canalith repositioning procedure.Of these 8 patients,5 cases with posterior canal canalolithiasis converted to lateral canal canalolithiasis,2 cases with lateral canal canalolithiasis converted to posterior canal canalolithiasis,and 1 case with posterior canal canalolithiasis converted to anterior canal canalolithiasis. All cases recovered well under the corresponding repositioning procedure.Conclusion:The change of the characteristics of positioning nystagmus is the major diagnostic feature of canal conversion. Accurate diagnosis and targeted repositioning procedure are the key to the success of canal conversion treatment.

A comparison of the biomechanical stability of pedicle-lengthening screws and traditional pedicle screws: an in vitro instant and fatigue-resistant pull-out test

Aims

The aim of this study was to compare the peak pull-out force (PPF) of pedicle-lengthening screws (PLS) and traditional pedicle screws (TPS) using instant and cyclic fatigue testing.

Materials and Methods

A total of 60 lumbar vertebrae were divided into six groups: PLS submitted to instant pull-out and fatigue-resistance testing (groups A1 and A2, respectively), TPS submitted to instant pull-out and fatigue-resistance testing (groups B1 and B2, respectively) and PLS augmented with 2 ml polymethylmethacrylate, submitted to instant pull-out and fatigue-resistance testing (groups C1 and C2, respectively). The PPF and normalized PPF (PPFn) for bone mineral density (BMD) were compared within and between all groups.

Results

In all groups, BMD was significantly correlated with PPF (r = 0.83, p < 0.001). The PPFn in A1 was significantly less than in B1 (p = 0.006) and C1 (p = 0.002). The PPFn of A2 was significantly less than in B2 (p < 0.001) and C2 (p < 0.001). The PPFn in A1, B1, and C1 was significantly greater than in A2 (p = 0.002), B2 (p = 0.027), and C2 (p = 0.003). There were no significant differences in PPFn between B1 and C1, or between B2 and C2.

Conclusion

Pedicle lengthening screws with cement augmentation can provide the same fixation stability as traditional pedicle screws and may be a viable clinical option. Cite this article: Bone Joint J 2018;100-B:516-21.

Factors associated with implementation of the 5A's smoking cessation model

Background

Several health organizations have adopted the 5A’s brief intervention model (Ask, Advise, Assess, Assist, Arrange), based on evidence-based guidelines for smoking cessation. We examine individual, cognitive, behavioral, and organizational factors associated with the 5A’s performance among clinical healthcare workers in Catalonia. We also investigate how these factors interact and potentially predict the implementation of each component of the 5A’s.

Methods

A cross-sectional survey was conducted among clinical health workers enrolled in an online smoking cessation training course (n = 580). The survey included questions about individual characteristics as well as cognitive, behavioral, and organizational factors previously identified in research. We assessed self-reported performance of the 5A’s, assessed on a scale from 0 to 10, and used Multivariate regression to examine factors associated with its performance.

Results

The performance means (standard deviation) were moderate for the first 3A’s [Ask: 6.4 (3.1); Advise: 7.1 (2.7); Assess: 6.3 (2.8)] and low for the last 2A’s [Assist: 4.4 (2.9); Arrange: 3.2 (3.3)]. We observed a high correlation between Assist and Arrange (r = 0.704, p < 0.001). Having positive experiences and feeling competent were positively associated with performing the 5A’s model and having organizational support with Assist and Arrange. Personal tobacco use among healthcare workers was negatively associated with Advice and Arrange.

Conclusions

Our study found that clinical healthcare workers do not perform the 5A’s completely. The main barriers identified suggest the need of training and making available practical guidelines in healthcare services. Organizational support is essential for moving towards the implementation of Assist and Arrange.

Electronic supplementary material

The online version of this article (10.1186/s12971-017-0146-7) contains supplementary material, which is available to authorized users.

Hypothalamus Specific Re-Introduction of SNORD116 into Otherwise Snord116 Deficient Mice Increased Energy Expenditure

The Snord116 gene cluster has been recognised as a critical contributor to the Prader-Willi syndrome (PWS), with mice lacking Snord116 displaying many classical PWS phenotypes, including low postnatal body weight, reduced bone mass and increased food intake. However, these mice do not develop obesity as a result of increased energy expenditure. To understand the physiological function of SNORD116 better and potentially rescue the altered metabolism of Snord116^-/- mice, we used an adeno-associated viral (AAV) approach to reintroduce the product of the Snord116 gene into the hypothalamus in Snord116^-/- mice at different ages. The results obtained show that mid-hypothalamic re-introduction of SNORD116 in 6-week-old Snord116^-/- mice leads to significantly reduced body weight and weight gain, which is associated with elevated energy expenditure. Importantly, when the intervention targets other areas such as the anterior region of the hypothalamus or the reintroduction occurs in older mice, the positive effects on energy expenditure are diminished. These data indicate that the metabolic symptoms of PWS develop gradually and the Snord116 gene plays a critical role during this process. Furthermore, when we investigated the consequences of SNORD116 re-introduction under conditions of thermoneutrality where the mild cold stress influences are avoided, we also observed a significant increase in energy expenditure. In conclusion, the rescue of mid-hypothalamic Snord116 deficiency in young Snord116 germline deletion mice increases energy expenditure, providing fundamental information contributing to potential virus-mediated genetic therapy in PWS.