Histological differentiation of skin toxicity between cetuximab, erlotinib and panitumumab (single ErbB1) and lapatinib (dual ErbB1/2) epidermal growth factor receptor inhibitors

e20617

Background: Epidermal growth factor receptor inhibition by monoclonal antibodies and tyrosine kinase inhibitors has demonstrated activity in solid tumors. However, blockade of EGFR in skin results in disabling skin toxicity that may lead to therapeutic dose modification or interruption. This study compares cutaneous histological alterations among four EGFR inhibitors (EGFRIs): cetuximab (C), erlotinib (E), lapatinib (L) and panitumumab (P). Methods: Punch skin biopsies from patients with papulopustular rash were collected from 8 patients per each EGFRI (n=32). Two dermatopathologists performed independent blinded assessment of epidermis, dermis, follicle and inflammatory infiltrates. Histologic features were rated as 0 (absent) or 1 (present), with the exception of dyskeratosis, rated from 0 (absent) to 2 (severe) and infiltrate, rated from 0 (absent) to 3 (most prominent). Where variation occurred, scores were reconciled and combined for analysis. Results: Epidermal atrophy was observed for C, E, L and P (range 0–1, median 1, 1, 0, 0.5, respectively) and neutrophilic follicular infiltrate was observed for C, E, L and P (range 0–3, median 0.5, 3, 0, 3, respectively). Neutrophilic dermal infiltrate (range 0–3) and follicular neutrophilic pustules (range 0–1) were most prevalent in P (median 0.5), whereas the median for C, E and L was 0. A mononuclear dermal infiltrate (range 0–3) was least prevalent with C (median 0) while E, L and P had a median of 0.5. Concretions (range 0–1) were most prevalent for E (median 1), whereas the median for C, L and P was 0. Conclusions: Lapatinib, a dual ErbB1/2 inhibitor, induced the least structural disarray and inflammation in the skin as measured by median scores for epidermal atrophy, neutrophilic dermal and follicular infiltrates, neutrophilic pustules and lack of bacterial concretions. These histological data confirm a more benign pattern of rash with lapatinib compared to single ErbB1 inhibitors.

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The human CD94 gene encodes multiple, expressible transcripts including a new partner of NKG2A/B

CD94/NKG2A is an inhibitory receptor expressed by natural killer (NK) cells and a subset of CD8+ T cells. Ligation of CD94/NKG2A by its ligand HLA-E results in tyrosine phosphorylation of the NKG2A immunoreceptor tyrosine-based inhibitory motifs, and recruitment and activation of the SH2 domain-bearing tyrosine phosphatase-1, which in turn suppresses activation signals. The nkg2a gene encodes two isoforms, NKG2A and NKG2B, with the latter lacking the stem region. We identified three new alternative transcripts of the cd94 gene in addition to the originally described canonical CD94Full. One of the transcripts, termed CD94-T4, lacks the portion that encodes the stem region. CD94-T4 associates with both NKG2A and NKG2B, but preferentially associates with the latter. This is probably due to the absence of a stem region in both CD94-T4 and NKG2B. CD94-T4/NKG2B is capable of binding HLA-E and, when expressed in E6-1 Jurkat T cells, inhibits TCR mediated signals, demonstrating that this heterodimer is functional. Coevolution of stemless isoforms of CD94 and NKG2A that preferentially pair with each other to produce a functional heterodimer indicates that this may be more than a serendipitous event. CD94-T4/NKG2B may contribute to the plasticity of the NK immunological synapse by insuring an adequate inhibitory signal.

Family history of haematopoietic malignancies and non-Hodgkin's lymphoma risk in the California Teachers Study

Family history of haematopoietic malignancies appears to be a risk factor for non-Hodgkin's lymphoma (NHL), but whether risk varies by family member's gender is unclear. Among 121 216 women participating in the prospective California Teachers Study, NHL risk varied by type of haematopoietic malignancy and gender of the relative.

Prognosis in BRCA1, BRCA2 associated breast cancer (BC): a prospective Breast Cancer Family Registry (BCFR) international population-based cohort study

Abstract #2072

Hereditary BC occurs at a younger age and is associated with more adverse tumor-related features than sporadic breast cancer (BC) (defined here as BC in those with no 1st or 2nd degree family history of breast or ovarian cancer). Using pre-specified criteria, we assembled a population-based cohort of newly diagnosed BC at 3 centers: Ontario, Canada (1996-98), San Francisco Bay area, USA (1995-2000), Melbourne/Sydney, Australia (1991-1998). Medical information was obtained from medical records; women were followed prospectively for recurrence, new cancers and death. Pathology data were obtained from central review or pathology reports. BRCA1 and BRCA2 mutation testing was performed on 77% and 70% of cases, respectively (sporadic BC cases were not tested at 2 centers). Hereditary and sporadic BC cases were compared using Cox proportional hazards (stratified by center). 3215 eligible cases were enrolled in the BCFR, with a mean age at diagnosis of 46.9 years. Median follow-up was 7.61 years; 565 women had distant recurrences and 547 died. There were 92 cases with BRCA1 and 72 with BRCA2 mutations; 1549 (48.2%) had sporadic BC; the remainder had familial BC as defined above. BRCA1 mutations were associated with young age, estrogen and progesterone receptor (ER and PgR) negativity and high grade; BRCA2 mutations were associated with node positivity and high grade. Distant disease-free survival (DDFS) and overall survival (OS) did not differ significantly between BRCA1 carriers and sporadic cases in univariate or multivariate analyses. DDFS and OS were worse in BRCA2 carriers than in sporadic cases (HR 1.6, p=0.04 and HR 1.8, p=0.01, respectively) in univariate analyses but not in multivariate analyses (DDFS HR 1.0, p=0.98; OS HR 1.13, p=0.61). The small group of BRCA2 carriers who did not receive adjuvant chemotherapy had a significantly worse OS (multivariate HR 3.63, p = 0.005). Furthermore, BRCA2 carriers who received adjuvant tamoxifen had significantly worse OS than women with sporadic BC (HR=2.0, p=0.03). We conclude that BRCA1 and BRCA2 mutations do not independently impact DDFS or OS. Significantly worse outcomes were seen in BRCA2 carrier subgroups defined by adjuvant treatment; this requires further investigation and may have implications for clinical practice.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2072.

Reliability and validity of the revised Triple C: Checklist of Communicative Competencies for adults with severe and multiple disabilities

AIMS

Few tools are available to assess the communication skills of adults with severe and multiple disabilities functioning at unintentional to early symbolic levels. An exception is the Triple C: Checklist of Communicative Competencies. In this study, aspects of support worker and clinician agreement, internal consistency and construct validity of a revised version of the Triple C were explored.

METHOD

Triple C checklists were completed for 72 adults with severe intellectual disabilities (ID) by 118 support workers and stages were assigned by the researchers. Two support workers completed checklists for each of 68 adults with ID. Three researchers also conducted direct observations of 20 adults with ID.

RESULTS

The average support worker agreement for items across the five stages of the Triple C ranged from 81% to 87%; agreement for stage assignment based on first and second support worker checklists was moderate to high (k = 0.63). Internal consistency was high (KR20 = 0.97); the stages were found to tap one factor (accounting for approximately 74% of variance), interpreted to be unintentional to early symbolic communication. Agreements between stages based on researcher observations and support worker-completed checklists were 35% and 71% across first and second support workers.

CONCLUSION

The revised Triple C provides a reliable means of gathering data on which to determine the communication skills of adults with severe and multiple disabilities. The results support a collaborative use of the Triple C, such that a speech-language pathologist or other communication specialist works with a support worker to ensure understanding of the skills observed and development of appropriate intervention strategies.

Calculations for displacive ω-phase transformations in Ti-Al alloys with Nb additions at finite temperature

We examine by means of first-principles calculations the bcc-like (bcc: body centered cubic) to ω-like phase transformations in Ti-Al alloys with Nb additions at finite temperature. To simulate the alloy we use different discrete atomic configurations in a six atom unit cell of the stoichiometry Ti(3)Al(2)Nb. Calculated ground state energies show an instability in the ternary Ti(3)Al(2)Nb alloy against the ω structure type atomic displacement. To better understand the role of entropy in the stability/instability of these systems, the first-principles calculations are extended to finite temperature by including various contributions to the free energy. In particular, the vibrational free energy is calculated within a quasiharmonic approximation. It is shown that the bcc structure is stabilized by the contribution of the low energy modes to the lattice entropy against ω type atomic displacements. We find that configurational entropy plays a major role in the ω to B8(2) transformation. Calculated lattice parameters and transition temperatures are found to be in excellent agreement with experiment.

Islet transplantation for brittle type 1 diabetes: the UIC protocol

This prospective phase 1/2 trial investigated the safety and reproducibility of allogeneic islet transplantation (Tx) in type I diabetic (T1DM) patients and tested a strategy to achieve insulin-independence with lower islet mass. Ten C-peptide negative T1DM subjects with hypoglycemic unawareness received 1-3 intraportal allogeneic islet Tx and were followed for 15 months. Four subjects (Group 1) received the Edmonton immunosuppression regimen (daclizumab, sirolimus, tacrolimus). Six subjects (Group 2) received the University of Illinois protocol (etanercept, exenatide and the Edmonton regimen). All subjects became insulin- independent. Group 1 received a mean total number of islets (EIN) of 1460 080 +/- 418 330 in 2 (n = 2) or 3 (n = 2) Tx, whereas Group 2 became insulin- independent after 1 Tx (537 495 +/- 190 968 EIN, p = 0.028). All Group 1 subjects remained insulin free through the follow-up. Two Group 2 subjects resumed insulin: one after immunosuppression reduction during an infectious complication, the other with exenatide intolerance. HbA1c reached normal range in both groups (6.5 +/- 0.6 at baseline to 5.6 +/- 0.5 after 2-3 Tx in Group 1 vs. 7.8 +/- 1.1 to 5.8 +/- 0.3 after 1 Tx in Group 2). HYPO scores markedly decreased in both groups. Combined treatment of etanercept and exenatide improves islet graft function and facilitates achievement of insulin-independence with less islets.

New IRB guidelines: Will cancer patient safety improve?

6520

Background: Beginning in the 1990s, drug companies increasingly sent reports of all serious adverse events (AEs) to any Institutional Review Board (IRB) overseeing a trial using the agent involved, whether or not the same study was underway at that IRB site and regardless of the likelihood of a causal link between the event and agent. This led to a flood of AE reports and a small signal-to-noise ratio. Recent federal draft guidance emphasizes that regulations require investigators to notify IRBs only when there are “unanticipated problems involving risks to subjects or others. Consequently, many IRBs relaxed their reporting requirements, focusing only on unanticipated events. The objective of this study is to estimate how adoption of the new guidance affects IRB workload and patient safety. Methods: We reviewed AEs reported since 2004 to the IRB at Oregon Health & Science University for eight oncology drugs: bevacizumab, gefitinib, imatinib mesylate, oxaliplatin, bortezomib, sorafenib, sunitinib, and cetuximab. We defined unanticipated AE as any AE not included in the patient consent forms. Results: Forty-seven studies were reviewed with 885 unique AEs reported for the eight drugs. Of these, 494 were unanticipated, meaning the event was not described in the consent form. Thus, the IRB workload would decrease by 44% under the new guidance. Twenty-six AEs led to actual consent form changes, suggesting these signal events represented serious, related, but previously unknown toxicities of the study drug. This led to a signal-to-noise ratio improvement from 3% to 5.3%. For imatinib mesylate, the signal-to-noise ratio improved from 4.1% (14 signals out of 339 reports) to 7.8% (14 signals out of 179 reports), the largest improvement of the drugs studied. Conclusions: These results suggest that adoption of the new guidance may improve signal detection capabilities of local IRBs while decreasing workload. More empirical evidence is needed to ensure patient safety. Enhanced pharmacovigilance practices at the IRB level should lead to improved detection of serious AEs during clinical trials - before the drug is approved and widely available to veterans. In addition, improving the signal-to-noise ratio should allow IRBs to improve the welfare of cancer research subjects.

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The European Working Time Directive and training in cardiothoracic surgery in the United Kingdom

The European Working Time Directive (EWTD) limited average working hours for junior doctors to 58 per week in 2004. The Cardiothoracic Specialty Advisory Board conducted postal and email surveys of cardiothoracic trainees' work patterns and attitudes in 2003 and 2005-6. The results reveal an increase in shift-based working from 15% to 58% of respondents. One hundred per cent of respondents felt that the EWTD had had a negative impact on training, and only 30% were satisfied with their training to date. Satisfied trainees were more likely to work in larger units as assessed by ITU beds (20.6 vs. 8.9, p < 0.001) and cardiac cases/year (1586.2 vs. 828.4, p < 0.001). They had performed more cardiac cases than their peers (72.7 vs. 26.7, p = 0.005). Fifty-two per cent thought that their quality of life improved after EWTD implementation. The EWTD is unpopular amongst cardiothoracic trainees, who perceive it as harming training. Overall trainee satisfaction is low. Larger units and increased personal operative experience are associated with trainee satisfaction. Training programmes must act vigorously to safeguard training quality before implementation of the 48-hour limit in 2009.

Population-based estimates of breast cancer risks associated with ATM gene variants c.7271T>G and c.1066-6T>G (IVS10-6T>G) from the Breast Cancer Family Registry

The ATM gene variants segregating in ataxia-telangiectasia families are associated with increased breast cancer risk, but the contribution of specific variants has been difficult to estimate. Previous small studies suggested two functional variants, c.7271T>G and c.1066-6T>G (IVS10-6T>G), are associated with increased risk. Using population-based blood samples we found that 7 out of 3,743 breast cancer cases (0.2%) and 0 out of 1,268 controls were heterozygous for the c.7271T>G allele (P=0.1). In cases, this allele was more prevalent in women with an affected mother (odds ratio [OR]=5.5, 95% confidence interval [CI]=1.2-25.5; P=0.04) and delayed child-bearing (OR=5.1; 95% CI=1.0-25.6; P=0.05). The estimated cumulative breast cancer risk to age 70 years (penetrance) was 52% (95% CI=28-80%; hazard ratio [HR]=8.6; 95% CI=3.9-18.9; P<0.0001). In contrast, 13 of 3,757 breast cancer cases (0.3%) and 10 of 1,268 controls (0.8%) were heterozygous for the c.1066-6T>G allele (OR=0.4; 95% CI=0.2-1.0; P=0.05), and the penetrance was not increased (P=0.5). These findings suggest that although the more common c.1066-6T>G variant is not associated with breast cancer, the rare ATM c.7271T>G variant is associated with a substantially elevated risk. Since c.7271T>G is only one of many rare ATM variants predicted to have deleterious consequences on protein function, an effective means of identifying and grouping these variants is essential to assess the contribution of ATM variants to individual risk and to the incidence of breast cancer in the population.

Isotope dependence of the lifetime of the vibration of oxygen in silicon

By simply changing the isotopes of the Si atoms that neighbor an oxygen Oi atom in crystalline silicon, the measured decay rate tau of the asymmetric-stretch vibration (nu3=1136 cm-1) of oxygen (Oi) in silicon changes by a factor of approximately 2.5. These data establish that nu3 decays by creating one nu1 symmetric-stretch, local-vibrational mode of the Si-Oi-Si structure. If the residual energy (nu3-nu1) is less than the maximum frequency num of the host lattice, as for 28Si-16O-28Si in natural silicon, then it is emitted as one lattice mode, and tau depends on the density of one-phonon states at nu3-nu1. If (nu3-nu1)>num, as for 16O in single-isotope 30Si silicon, two lattice modes are created in addition to nu1, increasing tau. Prediction of tau for a particular defect clearly requires a detailed knowledge of that defect.

First-principles calculations of vibrational lifetimes and decay channels: hydrogen-related modes in Si

The vibrational lifetimes and decay channels of local vibrational modes are calculated from first principles at various temperatures. Our method can be used to predict the temperature dependence of the lifetime of any normal mode in any crystal. We focus here on the stretch modes of H2*, H+(BC), and VH x HV in Si. The frequencies are almost identical, but the lifetimes vary from 4 to 295 ps. The calculations correctly predict the lifetimes for T > 50 K and illustrate the critical importance of pseudolocal modes in the decay processes of high-frequency local vibrational modes.

Practical experiences of moving molecular diagnostics into routine use at the Veterinary Laboratories Agency

The practical bench application of molecular tests (here defined as nucleic acid-based tests) in a routine testing situation is not without its challenges. This paper outlines the approaches we take at the Veterinary Laboratories Agency (VLA) and highlights some of the practical issues which we have found to be important for the successful introduction and use of molecular tests in a routine testing environment. The potential advantages of molecular tests, and factors which dictate which tests are adopted for routine testing, are discussed before giving some examples of molecular tests in routine use at the VLA. The instrumentation, reagents and assays we use are outlined, followed by sections of how we approach validation and how we manage and resource the transfer of molecular tests into routine use.

Patient valuation of pharmacist services for self care with OTC medications

BACKGROUND AND OBJECTIVES

The objectives of this study were to determine whether patients would be willing to pay for pharmacist self-care services on proper use of over-the-counter medications. In addition, we examined whether patients' willingness to pay was associated with community pharmacy setting and patients' socio-economic factors.

METHODS

A self-administered questionnaire was handed out to patrons of community pharmacies in Arkansas, USA. The questionnaire contained question items related to patients' willingness to pay, community pharmacy setting, prescription drug insurance and socio-economic information. Patients' willingness to pay was measured using the checklist method.

RESULTS AND DISCUSSION

A total of 262 questionnaires were completed. More than twice as many patients (51%) are now willing to pay for pharmacist services for patient self care than a decade ago. They were willing to pay about US5 dollars for a 5-min consultation. Willingness to pay was significantly associated with community pharmacy setting (chi-square, P = 0.030). Grocery/chain pharmacy patrons were more willing to pay than independent pharmacy patrons.

CONCLUSION

This increased patient willingness to pay, along with growing self-care markets, provides pharmacists with opportunities to develop self-care clinics or services.

First-principles calculations of pseudolocal vibrational modes: the case of Cu and Cu pairs in Si

Pseudolocal vibrational modes (pLVMs) are defect-related vibrational modes which are localized despite being below the phonon maximum. Such modes are sometimes seen as phonon replicas in photoluminescence spectra. The pLVMs associated with two copper-related defects are calculated from first-principles density-functional theory in periodic supercells. The localization of the pLVMs is quantified using the magnitude of the eigenvectors of the dynamical matrix.