A randomized phase II trial comparing two doses of lenalidomide for the treatment of stage IV ocular melanoma

e20012

Background: Ocular melanoma is the most common primary intraocular malignancy in adults with an incidence of 4.3 new cases per million. Approximately 50% of patients will develop metastases and the mean survival of those with liver metastases is 8–10 months. There are no effective systemic therapies. Pre-clinical studies of the antiangiogenic and immunomodulatory agent, lenalidomide, have shown promise in animal models of human ocular melanoma. We therefore conducted a phase II trial comparing two doses of oral lenalidomide. Methods: Patients with stage IV ocular melanoma, who met eligibility criteria and demonstrated disease progression, were enrolled on an IRB approved prospective random assignment trial comparing 5 mg and 25 mg of lenalidomide administered once a day orally for 21 days with a 7 day recovery (one cycle). Lesions were measured at baseline and every 3 months and scored for response by RECIST criteria. Patients who completed 3 cycles were eligible for response evaluation. Patients with responding lesions or with stable disease could continue receiving the agent. Toxicity was assessed using the NCI Common Toxicity Criteria. Results: Seventeen patients (13 female, 4 male; mean age 53) met eligibility criteria and were randomized to 5 mg (9 patients) or 25 mg (8 patients) of lenalidomide. The agent was well tolerated at both doses with only three grade 3 toxicities (two decreased ANC and one rash/puritis) requiring dose adjustments. Sixteen patients were eligible for response assessments. Nine patients had progressive disease by RECIST criteria following 3 cycles of therapy. Seven patients (44%) had stable disease for a mean of 7 months (range 6–12 months). There were no RECIST defined responders. There were no differences between the two dose groups with respect to toxicity or disease stabilization. Conclusions: Lenalidomide is well tolerated at doses of 5 mg and 25 mg orally for a 21 day cycle by patients with stage IV ocular melanoma. While no responses were seen, disease stabilization for a mean of 7 months was seen in 44% of patients. This effect was consistent with the pre-clinical animal data. Based on these results, further development of lenalidomide in combination with other agents should be considered for the treatment of metastatic ocular melanoma.

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Results of a completed phase I clinical trial of CYT-6091: A pegylated colloidal gold-TNF nanomedicine

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Background: CYT-6091 is the first tumor-targeted nanomedicine formulation designed to safely deliver an API that itself is not approved for systemic administration due to unacceptable toxicity. CYT-6091, consisting of tumor necrosis factor-α (TNF) covalently linked to pegylated colloidal gold nanoparticles, has been safely administered in preclinical models, demonstrating an increased T1/2 compared to native TNF, a documented trafficking of nanoparticles to tumor, and no hypotension, the known DLT for TNF. Methods: CYT-6091 was tested in a phase I open label trial in solid tumor, advanced stage patients. Patients (n = 3/dose), admitted to the NIH Clinical Center ICU, received two IV injections of CYT-6091 on day 0 and 14. Dosing started at 50 μg/m2 of TNF, up to 600 μg/m2. Vital signs were monitored and blood samples were drawn over 48 h. The primary endpoint of the study was to determine the MTD for CYT-6091. Secondary endpoints included PK, disease response (staged 45 days post treatment by RECIST), and the detection of gold nanoparticles in tumors and in adjacent healthy tissue. Results: Twenty-nine patients were treated. Even at the lowest dose (50 μg/m2), patients exhibited a febrile response, which was mitigated by acetaminophen and indomethacin pretreatment. None of the 29 patients treated with doses of 50–600 μg/m2 showed a DLT hypotensive response, and in fact, no DLT was seen. T1/2 estimates for TNF, administered as CYT-6091, are 120, 131, 127, 146, 112, 113, 266, 371, and 160 minutes for 50, 100, 150, 200, 250, 300, 400, 500, 600 μg/m2, respectively (published T1/2 for native TNF is ∼27 minutes). In the 28 patients eligible for response assessment, there was 1 PR (100 μg/m2 dose, 7 months duration) and 3 SD (2, 2, and 3 months duration). Electron micrographs show gold nanoparticles in tumor biopsies. Conclusions: CYT-6091 is well tolerated at doses up to 600 μg/m2 of TNF, levels 3-times greater than the published MTD for native TNF. CYT-6091 targets tumors in humans. Efficacy studies in combination with chemotherapy are planned.

[Table: see text]

[Automatic detection of perfusion deficits with Bolus Harmonic Imaging]

PURPOSE

The diagnosis of ischemic stroke relies increasingly on the usage of ultrasound-based methods. One of the recent methods is the transcranial, contrast agent-based Bolus Harmonic Imaging (BHI) method. The captured image sequence is manually examined by clinical experts thus resulting in a time-consuming procedure. The purpose of this study is to evaluate three different methods to analyze BHI image sequences automatically for the detection of ischemic brain tissue.

MATERIALS AND METHOD

BHI captures an image sequence that provides information on the dynamic behavior of the ultrasound contrast agents. This image sequence is analyzed using three different procedures. First a system relying on expert knowledge is used to determine perfusion defects. This procedure requires parametric images, which are previously extracted from the image sequence. The parameter images are then categorized by an unsupervised classification method in well-perfused and ischemic tissue by regarding the parametric images as features describing the perfusion. Thirdly, the whole image sequence can be interpreted as a pixel-by-pixel behavior out of contrast agents. The dynamic curve of each pixel can be automatically classified as perfused and ischemic tissue by the K-Means method without extracting parametric images. In all three cases a closing step is necessary for the accurate interpretation of the results. Transcranial ultrasound imaging produces typical stripe artifacts that have to be detected and eliminated. A result image is then created and provides a conclusion about perfusion reduction in brain tissue.

RESULTS

All three methods have been validated on the basis of 26 patients by clinical experts. The segmentation on the contrast agent kinetics has proven to be most effective. According to our patient database, it provides the highest detection accuracy, resulting in a sensitivity of 100% and a specificity of 100%.

CONCLUSION

The presented methods seem to be adequate for detecting ischemic brain tissue. The classification of contrast agent kinetics provides the best results and has further advantages. It is robust with respect to noise and the calculation is fast because the extraction of parametric images is omitted. The very high sensitivity and specificity must be validated in a larger patient population. Reliable and automated detection of perfusion defects at the bedside seems to be possible.

Reliability of modeling evoked flow responses

PURPOSE

Visually evoked flow characterises the relative changes of blood flow velocity in the posterior cerebral artery in response to visual stimulation. The present study is the first to address the reliability of model fitting to evoked flow responses, rigorously defined by Cronbach's alpha.

MATERIALS AND METHODS

We fitted two models to the evoked flow responses recorded from 19 subjects on two different days. Model 1 characterises a harmonic oscillator with frequency omega and damping coefficient xi which (after a delay DeltaT) is driven from zero towards a new equilibrium K by an impulse with magnitude T. Model 2 is the sum of a first order system subjected to a step and a transient smoothed pulse, both again delayed by DeltaT.

RESULTS

Model 1 exhibited slightly smaller fit errors and convergence was less dependent on starting values for the parameters. As judged from the residual noise in the evoked flow response, there was no clear indication of sustained oscillations characterising model 1 exclusively. Both models showed considerable retest errors. Nonetheless, Cronbach's alpha was significant for K and omega, and highest for K.

CONCLUSION

Retest errors were considerable, particularly so for the damping coefficient xi and impulse magnitude T. A physiological interpretation of these parameters is limited by our findings.

Transcranial sonography findings in a large family with homozygous and heterozygous PINK1 mutations

OBJECTIVE

To investigate substantia nigra (SN) echogenicity in members of a family with homozygous and heterozygous PTEN induced kinase (PINK1) mutations with or without signs of Parkinson's disease (PD).

METHODS

Transcranial sonography (TCS) was used to investigate 20 members of a family with PINK1 mutations, including four homozygous and 11 heterozygous mutation carriers and five individuals with no mutation. For comparison, a healthy control group of 18 subjects without a positive family history of PD (control group) and a healthy control group of 15 subjects with a positive family history of sporadic PD (relative group) were investigated. For statistical analysis, the larger area of the two SNs echogenicity (aSNmax) of each individual was selected.

RESULTS

A significantly increased aSNmax was found for all subgroups compared with the control group. The group of homozygous carriers of a PINK1 mutation had a significantly increased aSNmax compared with all of the other subgroups, except the group of heterozygous mutation carriers.

CONCLUSIONS

These findings in carriers of a PINK1 mutation are comparable with those in carriers of Parkin mutations and non-genetic PD. The increased aSNmax in family members without a mutation suggests an additional contributing factor independent of the PINK1 mutation that may also play a role in relatives of patients with sporadic PD.

[Does the service of the federal government commissioner for patient issues appeal to the elderly?]

BACKGROUND

For the first time, this study investigates to which extent elderly persons write to the federal government commissioner for patient issues in Germany.

METHODS

A 33% sampling (n=850) of the written inquiries (correspondence and emails) addressed to the commissioner in the first six months of the year 2005 (n=2580) was investigated. Socio-demographic data were extracted from the material; furthermore, it was registered which diseases the citizens described.

RESULTS

Older persons outweigh the younger (69% over 60 years, mean age 63 years). Within the group of the elderly, approximately as many persons belong to the age group 60-69 years and to the age group 70 years and older. Most frequently, the citizens describe chronic diseases of the musculoskeletal system.

DISCUSSION

The new service of the federal government commissioner for patient issues appeals to the elderly in Germany. The high proportion of people with chronic illness among the inquirers emphasizes the need for information, advice and support for this target group. Further research is needed on the answers to the inquirers, and on the question how helpful the contact to the government commissioner's office is from the viewpoint of the citizens; furthermore, possible barrieres (e.g. social state) should be analyzed.

Influence of sward height, daily timing of concentrate supplementation, and restricted time for grazing on forage utilization by lactating beef cows

To establish the effect of sward height, concentrate feeding time, and restricted time for grazing on forage utilization by grazing cattle, 32 crossbred beef (24 Angus and eight Hereford) cows (632 kg BW) and calves (104 kg BW) were grouped by weight and calving date. They were assigned randomly to two sward height treatments (4 to 8 or 8 to 12 cm), replicated four times. The herbage comprised mainly Kentucky bluegrass, orchardgrass, some forbs, and white clover. The cows were restricted to 12 h/d grazing (0700 to 1900) or unrestricted to 24 h/d grazing and fed a concentrate supplement (4.1 kg DM.cow(-1).d(-1), approximately 0.65% of BW or 33% of total DMI) either at 0700 or 1800. The experiment was repeated over three 15-d periods in May, June/July, and August 2000. The herbage on high sward height pasture was higher (P = 0.06) in NDF and ADF and lower (P < 0.01) in CP than low sward height herbage. For cows restricted to 12 h/d grazing, supplementing at 0700 as opposed 1800 resulted in greater (P = 0.04) forage DMI (8.6 vs. 8.1 kg/d), whereas cows that were unrestricted showed little change (8.2 kg/d at 0700 vs. 8.4 kg/d at 1800). Supplementing at 1800 as opposed to 0700 resulted in greater (P = 0.03) herbage DM digestibility (67.7 vs. 64.5%) for cows on high sward height, whereas cows on low sward height exhibited minimal differences (65.4% at 1800 vs. 66.3% at 0700). Cows restricted to 12 h/d grazing and supplemented at 0700 as opposed to 1800 resulted in greater (P = 0.06) digestible DMI (5.0 vs. 4.7 kg/d), whereas unrestricted cows exhibited the opposite response (4.6 kg/d digestible DMI at 0700 vs. 4.9 kg/d at 1800). Supplementing at 1800 as opposed to 0700 increased the time spent grazing to a greater (P = 0.09) extent for restricted than for unrestricted cows. When forage availability or grazing time was limiting (due to a low forage allowance and restricted access to forage, respectively) supplementing concentrates at 0700 resulted in greater forage utilization and intake rate because of increased forage DMI, DM digestibility, and digestible DMI. However, when forage or grazing time was not limiting, supplementing concentrates at 1800 resulted in greater forage utilization because of increased forage DM digestibility.

Association of Fertility with Numbers of Antral Follicles within a Follicular Wave During the Oestrous Cycle in Beef Cattle

The association between conception rate at first service and numbers of follicles developed during a follicular wave was examined in 102 suckled beef cows and 14 heifers. Follicular development was monitored using ultrasonography for either two (trial 1) or three (trial 2) consecutive oestrous cycles (pre-breeding, breeding and post-breeding equivalent). Animals were examined on alternate days from day 6 after first oestrus (day 0) until ovulation and from day 6 after insemination until next ovulation or day 24 of pregnancy and were observed for oestrus twice daily and inseminated artificially at either the second (trial 1) or third oestrus (trial 2). Cows were classified as having two or three waves of follicular development for each oestrous cycle. Numbers of follicles >or=4 mm per wave were determined, and based on the maximum diameter they attained, were classified as small (4-6 mm), medium (7-10 mm) or large (>or=11 mm) follicles. Total numbers of follicles, and primarily numbers of small and medium follicles, were affected by trial and within trial by cow, oestrous cycle and follicular wave. Heifers had more small and total numbers of follicles, but fewer large follicles than cows in trial 1 (p < 0.05). The average number of antral follicles per wave in the breeding cycle or post-breeding period did not affect conception rates, which averaged 84%. Repeatability of the total numbers of antral follicles between and among oestrous cycles and follicular waves ranged from 0.01 to 0.97. In conclusion, fertility was not affected by the numbers of antral follicles >or=4 mm in diameter in a single follicular wave.

Preliminary results of a phase I clinical trial of CYT-6091: A pegylated colloidal gold-TNF nanomedicine

3603

Background: CYT-6091, a nanotherapeutic manufactured by covalently linking tumor necrosis factor-a (TNF) onto the surface of 30 nm particles of pegylated colloidal gold, avoids uptake by the reticuloendothelial system (RES) and distributes primarily to solid tumors. In tumor bearing mice, CYT-6091 shows little to no uptake by the RES and increases intra-tumor TNF levels 10-fold. Electron micrographs show the accumulation of gold nanoparticles in tumors, with few particles in healthy tissue. In dogs with naturally occurring cancers and healthy rabbits, CYT-6091 caused fever but no hypotension, the known DLT for TNF. Methods: CYT-6091 is being tested in a phase I open label trial in solid tumor, advanced stage disease patients. Patients (n=3/dose), admitted to the NIH Clinical Center ICU, receive two IV injections of CYT-6091 on day 0 and 14. Doses start at 50 μg/m2 of TNF and increase by 50 μg/m2 increments to 300 μg/m2. Vital signs are monitored and blood samples are drawn over 48 hours. The primary endpoint of the study is to determine the MTD for CYT-6091. Secondary endpoints include PK, disease response (staged 45 days post treatment), and the detection of gold nanoparticles in tumors and in adjacent healthy tissue. Results: Seven patients have been treated to date. The three treated with the lowest dose (50 μg/m2) exhibited a febrile response, which was mitigated by acetaminophen and indomethacin pretreatment. None of the seven patients treated with 50, 100 or 150 μg/m2 showed a DLT hypotensive response, and blood chemistries and urinalysis were not significantly different following treatment. PK estimates for the TNF T1/2, administered as CYT-6091, are 117, 145 and 127 minutes for 50, 100 and 150 μg/m2, respectively. Electron micrographs of tumor biopsies and adjacent healthy tissue show as much as a 10-fold increase in the number of gold nanoparticles in tumors from 5 of 6 patients compared to adjacent healthy tissue. Conclusion: These observations are the first definitive demonstration in man of the tumor targeting of a systemically administered, colloidal gold-based nanomedicine.

No significant financial relationships to disclose.

A pilot study of local injection of TNFerade biologic in addition to neo-adjuvant chemoradiation for the treatment of primary and recurrent rectal cancer

14585

Background: Rectal cancer presents unique therapeutic considerations due to competing concerns regarding sphincter preservation and local recurrence. Treatments using pre-operative chemoradiation are employed to decrease local recurrence and improve the probability of sphincter preservation. Agents, which improve the pathologic response rate may be of further benefit. Methods: TNFerade biologic is a replication deficient adenovirus expressing human TNF-alpha driven by a radiation inducible promoter. TNFerade biologic (4X10e10 pfu) is injected locally into rectal tumors once a week for 5 weeks. Patients receive concurrent chemoradiation utilizing oral capecitabene (937.50 mg/m2 BID, Monday-Friday) and external beam radiotherapy (1.8 Gy/day, 5 days per week to a total dose of 45 Gy). A boost dose of 5.4–9 Gy is delivered to sites of gross disease. After treatment, patients recover for 6–9 weeks before surgery. Patients are scored prior to the start of neo-adjuvant therapy for the feasibility of a sphincter preserving operation versus an abdominal perineal resection (APR). Following surgery the specimen (entire area submitted for processing) is examined for the percent of viable tumor remaining. The goal of the study is to show a target pathologic response rate of <10% viable tumor in more than 30% of patients treated. Results: Six patients have been treated (4M, 2F). There has been no toxicity attributable to the TNFerade biologic, and the chemoradiation has been well tolerated with only mild, expected toxicities. Five of the six patients have undergone surgery (one is awaiting surgery). Three of these five patients were thought to require an APR prior to treatment due to the size and location of their tumor. All five patients have successfully undergone sphincter- preserving operations. On examination of the five specimens, 3 had less than 5% viable tumor while 2 had greater than 50% viable tumor. All resections were margin negative. The target pathologic response rate of <10% viable tumor was achieved in 60% of the patients evaluated. Conclusion: The addition of TNFerade biologic to pre-operative chemoradiation was well tolerated and a prospective randomized trial comparing the addition of this agent to chemoradiation is warranted.

No significant financial relationships to disclose.

CcpA mutants with differential activities in Bacillus subtilis

CcpA is the master regulator for carbon catabolite regulation in Bacillus subtilis and regulates more than 300 genes by repression or activation. To revealthe effects of different functional domains of CcpA on various regulatory modes, we compared the activities of CcpA point mutants in activation (alsS, ackA) and repression (xynP, gntR). CcpA variants mutated at residues in the HPrSerP-binding region without allosteric functions are inactive. On the other hand, CcpA variants mutated at residues that change their conformation upon HPrSerP or CrhP binding regulate only ackA. Another set of mutants with alterations in the corepressor-binding region show glucose-independent regulation of xynP. The data presented here demonstrate the involvement of HPrSerP and/or CrhP in activation of ackA and alsS by CcpA. Furthermore, these data also indicate that activation and repression mediated by CcpA may utilize different conformational changes of the protein.