Abstract OT3-01-04: An open-label, single-arm, phase II study of pertuzumab with high-dose trastuzumab for the treatment of central nervous system progression post-radiotherapy in patients with HER2-positive metastatic breast cancer (PATRICIA)

Background: Central nervous system (CNS) metastases are observed in up to half of patients with HER2-positive metastatic breast cancer (MBC), with incidence likely to continue to rise due to longer survival through improved systemic treatments. While radiotherapy-based approaches can be effective, there are potential short- and long-term toxicities, and patients frequently progress. CNS response to existing systemic therapies has been generally poor, and there is a high unmet need with no approved treatment for CNS metastases in HER2-positive MBC. Combination of the HER2-targeted monoclonal antibodies trastuzumab and pertuzumab provides a more comprehensive blockade of HER2 than either antibody alone, and data from the phase III CLEOPATRA trial suggest that adding pertuzumab to trastuzumab and docetaxel may delay onset of CNS disease. Trastuzumab concentrations in the CNS are increased under conditions of an impaired blood–brain barrier (BBB) and subtherapeutic levels in the CNS may be related to insufficient dosing rather than inability to cross the BBB. The PATRICIA trial is evaluating the addition of pertuzumab with high-dose trastuzumab to a patient's current systemic treatment for HER2-positive MBC patients with CNS progression post-radiotherapy and stable systemic disease.

Study design: In this US-based, phase II, open-label, single-arm study, patients will receive intravenous pertuzumab (840 mg loading dose followed by 420 mg every 3 weeks) in combination with intravenous high-dose trastuzumab (6 mg/kg weekly) in addition to their current systemic therapy (except for ado-trastuzumab emtansine or lapatinib) until disease progression or unacceptable toxicity.

Eligibility criteria: Patients aged ≥18 years with confirmed HER2-positive MBC with new and/or progressive CNS lesions >60 days after whole-brain radiotherapy or stereotactic radiosurgery for CNS metastases, performance status 0–1, and stable systemic disease will be eligible. Patients must have a baseline left ventricular ejection fraction (LVEF) ≥50%, no significant history of cardiac disease or current use of anthracyclines, life expectancy >12 weeks, and not be pregnant or lactating.

Aims: The primary efficacy endpoint will be objective response rate (ORR) in the CNS, assessed by the investigator using RANO–BM criteria. Secondary endpoints will include duration of CNS response, progression-free survival (CNS and/or non-CNS), overall survival, and safety. Pharmacokinetic and patient-reported outcomes will also be evaluated. LVEF will be assessed throughout treatment and follow-up. An interim analysis will be performed when 15 patients have completed 2 cycles, and the study will be stopped if no clinical benefit (complete response, partial response, or stable disease in the CNS) is seen or if two or more patients have congestive heart failure events related to trastuzumab or pertuzumab.

Statistical methods: The recruitment target is 40 patients; with 35 evaluable, the 95% confidence interval around an estimated ORR of 20% will be 8.4–36.9%. The trial opens for accrual in Q3 2015.

Citation Format: Lin NU, Pegram MD, Lai C, Lacasia A, Stein A, Yoo B, Perez EA. An open-label, single-arm, phase II study of pertuzumab with high-dose trastuzumab for the treatment of central nervous system progression post-radiotherapy in patients with HER2-positive metastatic breast cancer (PATRICIA). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT3-01-04.

Abdominal fat radiodensity, quantity and cardiometabolic risk: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND AND AIMS

Fat radiodensity, as measured by fat attenuation on computed tomography (CT), has emerged as a potential biomarker of "fat quality." We sought to characterize the relationship between fat radiodensity and quantity in subcutaneous, visceral, and intermuscular fat depots, and its role in inflammation, insulin resistance, and metabolic syndrome (MetS).

METHODS AND RESULTS

We studied 1511 individuals from the Multi-Ethnic Study of Atherosclerosis who underwent CT for measurement of regional fat distribution and radiodensity, along with biomarker assessments and adjudication of incident metabolic syndrome (MetS). Linear, logistic and Cox regression analyses were used to measure association between fat radiodensity and (1) fat quantity, (2) biomarkers of cardiometabolic dysfunction, and (3) both prevalent and incident MetS. In each fat depot, radiodensity was strongly and inversely associated with quantity (e.g., visceral fat radiodensity vs. quantity: ρ = -0.82, P < 0.01). After adjustment for age, sex and race, lower visceral fat radiodensity was associated with greater C-reactive protein, leptin and insulin, but lower adiponectin (P < 0.01 for all). After full adjustment for cardiovascular disease risk factors, visceral (but not subcutaneous or intermuscular) fat radiodensity was associated with prevalent MetS (OR = 0.96, 95% CI = 0.93-0.99, P = 0.01). Moreover, lower visceral fat radiodensity was associated with incident MetS after the same adjustment (HR = 0.95, 95% CI 0.93-0.98, P < 0.01). However, this association became non-significant after further adjustment for visceral fat quantity.

CONCLUSION

Fat radiodensity is strongly correlated with fat quantity and relevant inflammatory biomarkers. Fat radiodensity (especially for visceral fat) may be a complementary, easily assessed marker of cardiometabolic risk.

Minimum alveolar concentration threshold of sevoflurane for postoperative dream recall

BACKGROUND

Many factors affect postoperative dream recall, including patient characteristics, type of anesthesia, timing of postoperative interview and stress hormone secretion. Aims of the study were to determine whether Bispectral Index (BIS)-guided anesthesia might decrease sevoflurane minimum alveolar concentration (MAC) when compared with hemodynamically-guided anesthesia, and to search for a MAC threshold useful for preventing arousal, dream recall and implicit memory.

METHODS

One hundred thirty patients undergoing elective thyroidectomy were enrolled. Anesthesia was induced with propofol 2 mg kg(-1), fentanyl 3 mcg kg(-1) and cis-atracurium 0.15 mg kg(-1). For anesthesia maintenance, patients were randomly assigned to one of two groups: a BIS-guided group in which sevoflurane MAC was adjusted on the basis of BIS values, and a hemodynamic parameters (HP)-guided group in which MAC was adjusted based on HP. An auditory recording was presented to patients during anesthesia maintenance. Dream recall and explicit/implicit memory were investigated upon awakening and approximately after 24 h.

RESULTS

Mean sevoflurane MAC during auditory presentation was similar in the two groups (0.85 ± 0.16 and 0.87 ± 0.17 [P = 0.53] in BIS-guided and HP-guided groups, respectively). Frequency of dream recall was similar in the two groups: 27% (N. = 17) in BIS-guided group, 18% (N. = 12) in HP-guided group, P = 0.37. In both groups, dream recall was less probable in patients anesthetized with MAC values ≥ 0.9 (area under ROC curve = 0.83, sensitivity = 90%, and specificity = 49%).

CONCLUSION

BIS-guided anesthesia was not able to generate different MAC values compared to HP-guided anesthesia. Independent of the guide used for anesthesia, a sevoflurane MAC over 0.9 was required to prevent postoperative dream recall.

Predicting hepatic steatosis and liver fat content in obese children based on biochemical parameters and anthropometry

BACKGROUND

Predictors of quantitative evaluation of hepatic steatosis and liver fat content (LFC) using clinical and laboratory variables available in the general practice in the obese children are poorly identified.

OBJECTIVE

To build predictive models of hepatic steatosis and LFC in obese children based on biochemical parameters and anthropometry.

METHODS

Hepatic steatosis and LFC were determined using proton magnetic resonance spectroscopy in 171 obese children aged 5.5-18.0 years. Routine clinical and laboratory parameters were also measured in all subjects. Group analysis, univariable correlation analysis, and multivariate logistic and linear regression analysis were used to develop a liver fat score to identify hepatic steatosis and a liver fat equation to predict LFC in each subject.

RESULTS

The predictive model of hepatic steatosis in our participants based on waist circumference and alanine aminotransferase had an area under the receiver operating characteristic curve of 0.959 (95% confidence interval: 0.927-0.990). The optimal cut-off value of 0.525 for determining hepatic steatosis had sensitivity of 93% and specificity of 90%. A liver fat equation was also developed based on the same parameters of hepatic steatosis liver fat score, which would be used to calculate the LFC in each individual.

CONCLUSIONS

The liver fat score and liver fat equation, consisting of routinely available variables, may help paediatricians to accurately determine hepatic steatosis and LFC in clinical practice, but external validation is needed before it can be employed for this purpose.

The relationship between microstructure and in vivo degradation of modified bacterial cellulose sponges

The interaction between the nanofibers of bacterial cellulose and hydroxyapatite has an extensive influence on the microstructure and the macroscopic properties of this type of composite, but the structural anisotropy and the speed of granulation ingrowth are strongly interdependent.

Cholesterol efflux capacity, carotid atherosclerosis, and cerebrovascular symptomatology

OBJECTIVE

To investigate the association of cholesterol efflux capacity with carotid atherosclerosis and cerebrovascular disease.

APPROACH AND RESULTS

Patients with high-grade carotid stenosis (n=154) were recruited from Vascular Surgery clinics and 9 healthy controls from the McGill University Health Network, Montreal, Canada. Cerebrovascular symptomatology history was obtained. Stenosis was assessed by carotid ultrasound. Fasting blood samples were collected and depleted of apolipoprotein B particles by polyethylene glycol precipitation from serum. Cholesterol efflux was determined by incubating apolipoprotein B-depleted serum in cAMP-stimulated J774 cells for 6 hours. Carotid specimens were classified by 2 vascular pathologists using the American Heart Association atheromatous plaque classification. Differences in efflux were assessed according to (1) stenosis, (2) American Heart Association classification, and (3) cerebrovascular symptomatology. Normalized efflux was significantly lower in patients with carotid atherosclerosis compared with controls (0.97±0.16 versus 1.5±0.46; P<0.0001). Efflux was inversely associated with stenosis; the odds ratio for 80% to 99% versus 50% to 79% stenosis of tertile 1 (lowest) versus tertile 3 (highest) of efflux was 3.78 (95% confidence interval, 1.18-12.06) after adjusting for age, sex, low-density lipoprotein, and high-density lipoprotein. There were significant differences in cholesterol efflux between American Heart Association fibroatheroma (Va, 0.91±0.13), mainly calcific (Vb, 0.97±0.15), and mainly fibrotic (Vc, 1.03±0.21; P=0.05). There were no significant differences in efflux according to symptomatology.

CONCLUSIONS

Cholesterol efflux capacity is inversely associated with increasing carotid stenosis and is associated with more advanced carotid plaque morphology, suggesting that cholesterol efflux capacity may be a biomarker for severity of carotid atherosclerotic burden. Whether therapies targeting high-density lipoprotein quality could be useful for stabilizing carotid atherosclerosis needs to be assessed.

Behavioural, psychological, and temperamental predictors of risk suicide trend after brief psychodynamic psychotherapy

BACKGROUND

Evidence has shown that psychotherapy is effective for depression, whereas the outcome for suicide risk is unclear.

AIM

It was to investigate whether possible pre-treatment predictors of suicide risk (SR) decrease after a brief psychodynamic psychotherapy treatment and at follow-up.

PATIENTS AND METHODS

Forty-one patients were assessed at: baseline (T0) for clinical history, clinical family history, physical diseases, type of suffered abuse; after the treatment (T1); and, at six-month follow-up (T2) for mood ratings, temperamental features, and SR levels.

RESULTS

The levels of depression and cyclothymia decreased at T1 and T2 compared to T0; however, the distribution of the patients with high SR level was similar between T0 and T1, and at T2 it increased. T1-T0 SR (Δ1SR) was correlated with suicidality in the last month and with depression levels at T0; T2-T0 SR (Δ2SR) was correlated with many historical, clinical, and temperamental variables; T2-T1 SR (Δ3SR) was correlated with the presence of previous psychotherapy, abuse, and anxiety. Linear regression models revealed that Δ1SR was predicted by the suicidality in the last month; Δ2SR was not significantly predicted by any variable; and, Δ3SR was predicted by anxiety.

CONCLUSIONS

The treatment was able to decrease the depression but not the SR. Findings confirm the difficulty of affecting SR and the importance of carefully considering the anxiety and the previous experiences of abuse in order to manage the interruption of the psychotherapy.

Uricemia and homocysteinemia: nontraditional risk factors in the early stages of chronic kidney disease--preliminary data

BACKGROUND

Patients with chronic kidney disease (CKD) show a risk of cardiovascular death, which is 10-100 times higher than that in the general population. This increase is not completely explained by the traditional cardiovascular risk factors. Hyperuricemia and hyperhomocysteinemia are highly prevalent in CKD. Patients suffering from these complications present accelerated atherosclerosis, determined mainly from the endothelial dysfunction that carries out a central role in the pathogenesis of cardiovascular diseases.

AIM

The hypothesis was that brachial artery flow mediated dilation (FMD) and carotid intima-media thickness (cIMT) evaluation can be considered as early and systemic markers of atherosclerosis and that nontraditional risk factors, such as hyperhomocysteinemia and hyperuricemia, are associated with early endothelial dysfunction and vascular damage in patients suffering from first- and second-stage CKD.

PATIENTS AND METHODS

The study comprised 50 patients, 10 for each CKD stage, and 15 age- and sex-matched healthy controls. We compared the traditional and nontraditional factors for cardiovascular diseases with alterations of vascular reactivity, such as cIMT, and brachial artery FMD, in patients affected by CKD with those in the control group.

RESULTS

In our study, hyperuricemia was significantly and independently associated with brachial artery FMD reduction (p = 0.007), while hyperhomocysteinemia was significantly and independently associated with carotid intima-media thickening (p = 0.021) in patients at Stage I and II KDOQI (Kidney Disease Outcomes Quality Initiative).

CONCLUSIONS

In our study, we found a progressive increase in the inflammatory indices and endothelial dysfunction at the early stages of CKD. Hyperuricemia and hyperhomocysteinemia were associated with IMT and FMD at Stage I-III KDOQI, and can be used as markers of subclinical atherosclerosis, especially in nephropathic patients with high cardiovascular risk.

Stress-related biomarkers of dream recall and implicit memory under anaesthesia

The aim of this study was to investigate whether auditory presentation of a story during general anaesthesia might influence stress hormone changes and thus affecting dream recall and/or implicit memory. One hundred and ten patients were randomly assigned either to hear a recording of a story through headphones or to have routine care with no auditory recording while undergoing laparoscopic cholecystectomy. Anaesthesia was standardised. Blood samples for cortisol and prolactin assays were collected 20 min before anaesthesia and 5 min after pneumoperitoneum. Dream recall and explicit/implicit memory were investigated upon awakening from anaesthesia and approximately 24 h after the end of the operation. Auditory presentation was associated with lower intra-operative serum prolactin concentration compared with control (p = 0.0006). Twenty-seven patients with recall of dreaming showed higher intra-operative prolactin (p = 0.004) and lower cortisol (p = 0.03) concentrations compared with those without dream recall. The knowledge of this interaction might be useful in the quest to ensure postoperative amnesia.