Phase 1 trial of temsirolimus in combination with irinotecan and temozolomide in children, adolescents and young adults with relapsed or refractory solid tumors: a Children's Oncology Group Study

BACKGROUND

mTOR inhibitors have activity in pediatric tumor models. A phase I trial of the mTOR inhibitor temsirolimus (TEM) with irinotecan (IRN) and temozolomide (TMZ) was conducted in children with recurrent/refractory solid tumors, including central nervous system (CNS) tumors.

METHODS

Escalating doses of intravenous (IV) TEM were administered on days 1 and 8 of 21-day cycles. IRN (50 mg/m(2)/dose escalated to a maximum of 90 mg/m(2)/dose) and TMZ (100 mg/m(2)/dose escalated to a maximum of 150 mg/m(2)/dose) were administered orally (PO) on days 1-5. When maximum tolerated doses (MTD) were identified, TEM frequency was increased to weekly.

RESULTS

Seventy-one eligible pts (median age 10.9 years, range 1.0-21.5) with neuroblastoma (16), osteosarcoma (7), Ewing sarcoma (7), rhabdomyosarcoma (4), CNS (22) or other (15) tumors were enrolled. Dose-limiting hyperlipidemia occurred in two patients receiving oral corticosteroids. The protocol was subsequently amended to preclude chronic steroid use. The MTD was identified as TEM 35 mg/m(2) IV weekly, with IRN 90 mg/m(2) and TMZ 125 mg/m(2) PO on days 1-5. At higher dose levels, elevated serum alanine aminotransferase and triglycerides, anorexia, and thrombocytopenia were dose limiting. Additional ≥ grade 3 regimen-related toxicities included leukopenia, neutropenia, lymphopenia, anemia, and nausea/vomiting. Six patients had objective responses confirmed by central review; three of these had sustained responses through ≥ 14 cycles of therapy.

CONCLUSION

The combination of TEM (35 mg/m(2)/dose IV weekly), IRN (90 mg/m(2)/dose days 1-5) and TMZ (125 mg/m(2)/dose days 1-5) administered PO every 21 days is well tolerated in children. Phase 2 trials of this combination are ongoing.

The influence of social comparison on cognitive bias modification and emotional vulnerability

The Cognitive Bias Modification (CBM) paradigm was devised to test predictions that cognitive biases have a causal influence on emotional status. Increasingly, however, researchers are testing the potential clinical applications of CBM. Although generally successful in reducing emotional vulnerability in clinical populations, the impact of CBM interventions has been somewhat variable. The aim of the current experiment was to investigate whether social comparison processing might be an important moderator of CBM. Healthy participants were presented with 80 valenced scenarios devised to induce a positive or negative interpretative bias. Critically, participants answered a series of questions designed to establish whether they assimilated or contrasted themselves with the valenced descriptions. The induction of an interpretation bias that was congruent with the valence of the training scenarios was successful only for participants who tended to assimilate the valenced scenarios, and not for those participants who tended to evaluate themselves against the scenarios. Furthermore, the predicted influence of CBM on emotional outcomes occurred only for those who had an assimilative rather than evaluative orientation toward CBM training material. Of key importance, results indicated that "evaluators" showed increased emotional vulnerability following positive CBM training. This result has both theoretical and clinical implications in suggesting that the success of CBM is dependent upon the way in which participants socially compare themselves with CBM training material.

Trait anxiety and perceptual load as determinants of emotion processing in a fear conditioning paradigm

The impact of trait anxiety and perceptual load on selective attention was examined in a fear conditioning paradigm. A fear-conditioned angry face (CS+), an unconditioned angry face (CS-), or an unconditioned face with a neutral or happy expression were used in distractor interference and attentional probe tasks. In Experiments 1 and 2, participants classified centrally presented letters under two conditions of perceptual load. When perceptual load was high, distractors had no effect on selective attention, even with aversive conditioning. However, when perceptual load was low, strong response interference effects for CS+ face distractors were found for low trait-anxious participants. Across both experiments, this enhanced distractor interference reversed to strong facilitation effects for those reporting high trait anxiety. Thus, high trait-anxious participants were faster, rather than slower, when ignoring CS+ distractors. Using an attentional probe task in Experiment 3, it was found that fear conditioning resulted in strong attentional avoidance in a high trait-anxious group, which contrasted with enhanced vigilance in a low trait-anxious group. These results demonstrate that the impact of fear conditioning on attention is modulated by individual variation in trait anxiety when perceptual load is low. Fear conditioning elicits an avoidance of threat-relevant stimuli in high trait-anxious participants.

Alemtuzumab more effective than interferon β-1a at 5-year follow-up of CAMMS223 clinical trial

OBJECTIVE

To report the long-term safety and efficacy results from CAMMS223 comparing alemtuzumab with interferon β-1a in early, active relapsing-remitting multiple sclerosis (RRMS). What are the long-term effects of alemtuzumab treatment, received 36 to 48 months previously, on relapse and disability in early, active RRMS? This study provides evidence of the effectiveness of alemtuzumab in reducing the relapse rate and accumulation of disability compared with interferon β-1a (IFNβ-1a) through extended follow-up (up to 60 months from baseline).

METHODS

Of 334 patients originally randomized, 198 participated in the extension phase (151 [68%] alemtuzumab and 47 [42%] IFNβ-1a). Disability, relapses, and safety were assessed as in the original study period. Efficacy outcomes were analyzed from baseline of the original trial period to 60 months. Safety data extended beyond 60 months.

RESULTS

Over 5 years, alemtuzumab lowered the risk of sustained accumulation of disability by 72% and the rate of relapse by 69% compared with IFNβ-1a (both p < 0.0001). The annualized relapse rate from baseline to month 60 was 0.11 for alemtuzumab and 0.35 for IFNβ-1a. Complete safety follow-up reflected 988 and 376 person-years for alemtuzumab and IFNβ-1a patients, respectively. Serious infections were seen in 7% of alemtuzumab patients and 3% of IFNβ-1a patients, and thyroid disorders were seen in 30% of alemtuzumab patients vs 4% of IFNβ-1a patients. Immune thrombocytopenia occurred in 3% of alemtuzumab patients and 0.9% of IFNβ-1a patients during the initial study period; no additional events were reported during the extension phase. One alemtuzumab patient developed Goodpasture disease 39 months after the second annual cycle of alemtuzumab.

CONCLUSIONS

Through extended follow-up, alemtuzumab remained significantly more efficacious than IFNβ-1a, with a safety profile consistent with previous reports.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that alemtuzumab is more effective than interferon β-1a in reducing relapses and disability in patients with RRMS in a long-term follow-up of a rater-blinded, randomized clinical trial with 59.5% of patients participating in the extended follow-up period.

Enhanced anger superiority effect in generalized anxiety disorder and panic disorder

People are typically faster and more accurate to detect angry compared to happy faces, which is known as the anger superiority effect. Many cognitive models of anxiety suggest anxiety disorders involve attentional biases towards threat, although the nature of these biases remains unclear. The present study used a Face-in-the-Crowd task to investigate the anger superiority effect in a control group and patients diagnosed with either generalized anxiety disorder (GAD) or panic disorder (PD). The main finding was that both anxiety groups showed an enhanced anger superiority effect compared to controls, which is consistent with key theories of anxiety. Furthermore, both anxiety groups showed a differential pattern of enhanced bias towards threat depending on the crowd in the displays. The different attentional bias patterns between the GAD and PD groups may be related to the diverse symptoms in these disorders. These findings have implications for the diagnosis and treatment of anxiety.

The serotonin transporter gene alters sensitivity to attention bias modification: evidence for a plasticity gene

BACKGROUND

Attention bias modification (ABM) procedures have been shown to modify biased attention with important implications for emotional vulnerability and resilience. The use of ABM to reduce potentially toxic biases, for instance, is a newly emerging therapy for anxiety disorders. A separate line of gene-by-environment interaction research proposes that many so-called vulnerability genes or risk alleles are better seen as plasticity genes, as they seem to make individuals more susceptible to environmental influences for better and for worse.

METHODS

A standard ABM procedure was used with a sample of 116 healthy adults. Participants were randomly assigned to one of two training groups. One received an ABM procedure designed to induce a bias in attention toward negative material, while the other was trained toward positive pictures. Individuals with low- and high-expressing forms of the serotonin transporter gene (5-HTTLPR) were compared.

RESULTS

Those with a low-expression form (S/S, S/Lg, or Lg/Lg) of the 5-HTTLPR gene developed stronger biases for both negative and positive affective pictures relative to those with the high-expression (La/La) form of the gene.

CONCLUSIONS

Here, we report the first evidence that allelic variation in the promotor region of the 5-HTTLPR gene predicts different degrees of sensitivity to ABM. These results suggest a potential cognitive mechanism for the gene-by-environment interactions that have been found in relation to the serotonin transporter gene. Variation on this genotype may therefore determine who will benefit most (and least) from therapeutic interventions, adversity, and supportive environments.

Social climate along the pathway of care in women's secure mental health service: variation with level of security, patient motivation, therapeutic alliance and level of disturbance

BACKGROUND

Social climate has been measured in a variety of therapeutic settings, but there is little information about it in secure mental health services, or how it may vary along a gender specific care pathway.

AIM

To assess social climate in women's secure wards and its variation by level of security and ward type, therapeutic alliance, patient motivation, treatment engagement and disturbed behaviour.

METHOD

Three-quarters (80, 76%) of staff and nearly all (65, 92%) of patients in the two medium-security wards and two low-security wards that comprised the unit completed the Essen Climate Evaluation Schema (EssenCES) and the California Psychotherapy Alliance Scale (CALPAS); patients also completed the Patient Motivation Inventory (PMI). Pre-assessment levels of disturbed behaviour and treatment engagement were recorded.

RESULTS

Social climate varied according to ward type and level of security. EssenCES ratings indicative of positive social climate were associated with lower levels of security; such ratings were also associated with lower behavioural disturbance and with higher levels of motivation, treatment engagement and therapeutic alliance.

CONCLUSION

This serial cross-sectional survey indicated that use of the EssenCES alone might be a good practical measure of treatment progress/responsivity. A longitudinal study would be an important next step in establishing the extent to which it would be useful in this regard.

Pharmacokinetically guided phase 1 trial of the IGF-1 receptor antagonist RG1507 in children with recurrent or refractory solid tumors

PURPOSE

This pediatric phase I study was designed to identify the doses of RG1507, a monoclonal antibody against the Type 1 Insulin-like Growth Factor Receptor (IGF1R), that achieves exposures equivalent to those achieved in adults at recommended doses.

EXPERIMENTAL DESIGN

Children with relapsed or refractory solid tumors were treated using the same doses and administration schedules of RG1507 (3 and 9 mg/kg/wk, and 16 mg/kg every 3 weeks [q3W]) as those studied in adults. Detailed pharmacokinetic (PK) sampling was performed after the first dose; selected peak and trough levels were subsequently obtained. Target exposures were ≥85% of mean areas under concentration x time curves (AUCs) in adults at doses of 9 mg/kg/wk and 16 mg/kg q3W. A maximum tolerated dose could be identified if dose-limiting toxicities (DLT) occurred.

RESULTS

Thirty-one evaluable patients aged 3-17 years were enrolled at 3 mg/kg/wk (n = 3), 9 mg/kg/wk (n = 18), or 16 mg/kg q3W (n = 10). There were no DLTs. At 9 mg/kg/wk the mean AUC(0-7d) (21,000 μg h/mL) exceeded the target (16,000 μg h/mL). At 16 mg/kg q3W, the mean AUC(021d) (70,000 μg h/mL) exceeded the target (59,400 μg h/mL). Clearance normalized to body weight was age dependent. There were no objective responses. Seven patients had stable disease for >12 weeks, including two patients with osteosarcoma with stable disease for 52+ and 78+ weeks.

CONCLUSIONS

The recommended doses of RG1507 in children with solid tumors are 9 mg/kg/wk and 16 mg/kg q3W. This flexible design is well suited for trials of agents associated with limited toxicity.

Does emotion processing require attention? The effects of fear conditioning and perceptual load

This study examined the impact of perceptual load on the processing of unattended threat-relevant faces. Participants performed a central letter-classification task while ignoring irrelevant face distractors, which appeared above or below the central task. The face distractors were graded for affective salience by means of aversive fear conditioning, with a conditioned angry face (CS+), an unconditioned angry face (CS-), and a neutral control face. The letter-classification task was presented under conditions of both low and high perceptual load. Results showed that fear conditioned (i.e., CS+) angry face distractors interfered with task performance more than CS- angry or neutral face distractors but that this interference was completely eliminated by high perceptual load. These findings demonstrate that aversively conditioned face distractors capture attention only under conditions of low perceptual load.