Abstract P3-14-11: Comparative effectiveness of antiemetic regimens for highly emetogenic chemotherapy-induced nausea and vomiting: A systematic review and network meta-analysis

Background

The optimal choice of antiemetic therapy for chemotherapy-induced nausea and vomiting (CINV) needs to be clarified. This study assessed the efficacy and safety of antiemetic regimens for highly emetogenic chemotherapy (HEC).

Methods

Randomized trials that compared different antiemetic regimens were included from MEDLINE. Quality was assessed using the Cochrane risk-of-bias tool. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Data were pooled using random-effects models. We conducted indirect comparisons using network meta-analysis of a Bayesian model. The main outcomes were the odds ratio (OR) for overall complete response (CR [i.e., no emesis and no rescue]). Safety was assessed from the trial description. All statistical tests were two-sided.

Findings

We systematically reviewed 24 randomized control trials (12,104 participants), which compared 12 different antiemetic regimens. Palonosetron (PAL) 0·75 mg (PAL0·75) + dexamethasone (Dex); aprepitant (APR) + a serotonin-3 receptor antagonist (5HT3) + Dex; and APR + PAL (0·25 mg or 0·50 mg) + Dex were more favorable than the reference regimen (OR, 1·51; 95% credibility interval [95%CrI], 1·18-1·91; OR, 1·78; 95%CrI, 1·58-2·05; and OR, 2·28; 95%CrI, 1·66-3·18, respectively). The oral combination of netupitant and palonosetron (NEPA) was more effective than conventional regimens (OR, 2·39; CrI, 1·73-3·30). Olanzapine (OLZ)-containing regimens were apparently the most effective: the ORs of OLZ + 5HT3 + Dex, OLZ + PAL + Dex, and OLZ + APR + 5HT3 + Dex were 2·78, 2·58, and 4·98, respectively.

Interpretation

The regimens of PAL0·75 + Dex, APR + 5HT3 + Dex, and APR + PAL + Dex were more favorable in conventional regimens (i.e., regimens without NEPA or OLZ), which support the NCCN guideline strategy. NEPA could be a better choice than conventional regimens. OLZ-containing regimens could be an optimal choice; thus, more trials need to be accumulated.

Citation Format: Yokoe T, Hayashida T, Nagayama A, Seki T, Takahashi M, Takano T, Abe T, Kitagawa Y. Comparative effectiveness of antiemetic regimens for highly emetogenic chemotherapy-induced nausea and vomiting: A systematic review and network meta-analysis [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-14-11.

Abstract P5-20-11: Comparative effectiveness of neoadjuvant therapy for HER2-Positive breast cancer: Addition of new clinical evidence to network meta-analysis and data update after 5 years

Background: It is becoming more popular to perform neoadjuvant chemotherapy including anti-HER2 agents to operable HER2-positive breast cancer patients. Increasing HER2-targeted treatment options urge us to define the best neoadjuvant therapy. In 2014, we reported the systematical assessment of the efficacy and safety of neoadjuvant therapy for HER2-positive breast cancer, using network meta-analysis based on Bayesian model (Nagayama et al., JNCI 2014). Network meta-analysis synthesizes information from a network of trials, which helps interpret the randomized evidence and can rank treatments from different trials. After five years from our first literature search, we decided to update our analysis due to accumulation of new clinical evidence.

Methods: We assessed odds ratio for pathological complete response (pCR), completion, and safety in seven treatment arms utilizing pooling effect sizes. The treatment arms included the combinations of chemotherapy (CT), trastzumab (tzmb), lapatinib (lpnb) and pertzumab (pzmb). All statistical tests were two-sided, and we followed Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) guidelines.

Results: A database search identified 993 articles with 13 studies meeting the eligibility criteria, adding three studies (a trial of CT + tzmb vs CT + lpnb, and two trials of CT + tzmb vs CT + lpnb vs CT + tzmb + lpnb) to previous analysis. In direct comparison, CT + tzmb significantly achieved more pCR than CT + lpnb (OR=0.68, 95% CI = 0.52 to 0.89, p=.005) despite no statistical difference was found previously. In indirect comparison, treatment arms of dual anti-HER2 agents with CT achieved more pCR than other arms, reducing their credibility intervals against all other arms. This trend was stronger in CT + tzmb + lpnb arm (CT + tzmb + lpnb vs CT + tzmb, OR = 1.62, 95% CrI = 1.19 to 2.22, p = .003), which we added sufficient clinical evidence. Moreover, it exposed the need for additional clinical data for pzmb relative arms. Values of surface under the cumulative ranking (SUCRA) suggested that CT + tzmb + pzmb had the highest probability of being the best treatment arm for pCR (SUCRA = 0.95), followed by CT + tzmb + lpnb (SUCRA = 0.87), and CT + tzmb (SUCRA = 0.62), widening the gap and differentiating the top two dual blockade arms which were close in our previous report. All outcomes from our present analysis were consistent with our previous report and strengthened data solidity by reducing confidence or credibility intervals.

Conclusion: Consistent results in not only in pCR but also in completion rates and adverse events indicate that we are looking at the results which are close to the truth. Additional trials of lpnb relative regimens are not probable to change the results, but pzmb relative trials are required to improve evidence solidity. New clinical data established stronger evidence in network meta-analysis that combining two anti-HER2 agents with CT is most effective in the neoadjuvant setting for HER2-positive breast cancer.

Citation Format: Nakashoji A, Hayashida T, Yokoe T, Maeda H, Watanuki R, Kikuchi M, Seki T, Takahashi M, Abe T, Kitagawa Y. Comparative effectiveness of neoadjuvant therapy for HER2-Positive breast cancer: Addition of new clinical evidence to network meta-analysis and data update after 5 years [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-20-11.

The utility of FDG-PET for detecting multiple primary cancers in hypopharyngeal cancer patients

Aim: To examine the utility of 2'-[18F]-fluoro-2'-deoxy-D-glucose positron emission tomography (FDG-PET) for detecting multiple primary cancers (MPC) in patients with hypopharyngeal cancer (HPC). Patients, methods: Seventy patients with HPC underwent FDGPET to determine the staging. Routine clinical examinations were carried out, including computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (US), and oesophagealgastroduodenoscopy (EGDS). The detection rate of synchronous and metachronous cancer was calculated based on FDG-PET alone or FDG-PET combined with clinical routine examination. Sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV), and accuracy were used to diagnose oesophageal cancer using FDG-PET. Results: Of the 70 patients, 12 (17.1%) had 15 synchronous tumours, and 2 of the 58 remaining patients (3.4%) had metachronous tumours. Oesophageal cancer was discovered most frequently: superficial type (n = 6), advanced type (n = 4). On a per-patient basis, 11 of 12 patients (91.6%) were diagnosed with synchronous tumours, and on a per-lesion basis, 12 of 15 lesions (80.0%) were detected by FDG-PET. The sensitivity, specificity, accuracy, PPV, and NPV of FDG-PET regarding oesophageal cancer were 70%, 100%, 95.7%, 100%, and 95.2% respectively. Three of the six superficial types were positive on FDG-PET. Both of the metachronous tumour lesions were detected by FDG-PET. Conclusion: FDG-PET is useful for estimating the MPC in HPC patients. Since 3 of 10 synchronous oesophageal cancer were missed with PET alone, a combination with EGDS should be considered to exclude synchronous oesophageal cancer.

Versatility of HDA19-deficiency in increasing the tolerance of Arabidopsis to different environmental stresses

Histone acetylation is controlled by HATs and HDACs, which are essential epigenetic elements that regulate plant response to environmental stresses. A previous study revealed that a deficiency in an HDAC isoform (HDA19) increases tolerance to high salinity stress in the Arabidopsis wild-type Col-0 background. Here, the increased tolerance of hda19 to drought and heat stresses is demonstrated. Results indicate that hda19 plants have greater tolerance than wild-type plants to stress conditions. The data indicate that the stress response pathway coordinated by HDA19 plays a pivotal role in increasing tolerance to a variety of different abiotic stresses in Arabidopsis, including salinity, drought, and heat. The greater level of tolerance of hda19 plants to several different environmental stresses suggests that HDA19 represents a promising target for pharmacological manipulation in order to enhance abiotic stress tolerance in plants.

ABBREVIATIONS

HAT, histone acetyltransferase; HDAC, histone deacetylase; HSF, heat shock transcription factor; RPD3, reduced potassium dependency 3; SIRT, Silent Information Regulator 2.

Single-particle states vs. collective modes: friends or enemies ?

The quantum self-organization is introduced as one of the major underlying mechanisms of the quantum many-body systems. In the case of atomic nuclei as an example, two types of the motion of nucleons, single-particle states and collective modes, dominate the structure of the nucleus. The collective mode arises as the balance between the effect of the mode-driving force (e.g., quadrupole force for the ellipsoidal deformation) and the resistance power against it. The single-particle energies are one of the sources to produce such resistance power: a coherent collective motion is more hindered by larger spacings between relevant single particle states. Thus, the single-particle state and the collective mode are “enemies” against each other. However, the nuclear forces are rich enough so as to enhance relevant collective mode by reducing the resistance power by changing single-particle energies for each eigenstate through monopole interactions. This will be verified with the concrete example taken from Zr isotopes. Thus, the quantum self-organization occurs: single-particle energies can be self-organized by (i) two quantum liquids, e.g., protons and neutrons, (ii) monopole interaction (to control resistance). In other words, atomic nuclei are not necessarily like simple rigid vases containing almost free nucleons, in contrast to the naïve Fermi liquid picture. Type II shell evolution is considered to be a simple visible case involving excitations across a (sub)magic gap. The quantum self-organization becomes more important in heavier nuclei where the number of active orbits and the number of active nucleons are larger.

DXA-Rectified Appendicular Lean Mass: Development of Ultrasound Prediction Models in Older Adults

OBJECTIVE

Dual-energy X-ray absorptiometry (DXA)-derived appendicular lean soft tissue mass (aLM) is used to diagnose sarcopenia. However, DXA-derived aLM includes non-skeletal muscle components, such as fat-free component of adipose tissue fat cell. These components, if not accounted for, could falsely inflate the aLM in individuals with a high amount of adipose tissue mass. B-mode ultrasound accurately measures muscle size in older adults. We sought to develop regression-based prediction equations for estimating DXA-rectified appendicular lean tissue mass (i.e. DXA-derived aLM minus appendicular fat-free adipose tissue (aFFAT); abbreviated as aLM minus aFFAT) using B-mode ultrasound.

DESIGN

Cross-sectional study.

MEASUREMENTS

Three hundred and eighty-nine Japanese older adults (aged 60 to 79 years) volunteered in the study. aLM was measured using a DXA, and muscle thickness (MT) was measured using ultrasound at nine sites. An ordinary least-squares multiple linear regression model was used to predict aLM minus aFFAT from sex, age and varying muscle thicknesses multiplied by height. Based on previous studies, we chose to use 4 MT sites at the upper and lower extremities (4-site MT model) and a single site (1-site MT model) at the upper extremity to develop prediction models.

RESULTS

The linear prediction models (4 site MT model; R2 = 0.902, adjusted R2 = 0.899, and 1-site MT model; R2 = 0.868, adjusted R2 = 0.866) were found to be stable and accurate for estimating aLM minus aFFAT. Bootstrapping (n=1000) resulted in optimism values of 0.0062 (4-site MT model) and 0.0036 (1-site MT model).

CONCLUSION

The results indicated that ultrasound MT combined with height, age and sex can be used to accurately estimate aLM minus aFFAT in older Japanese adults. Newly developed ultrasound prediction equations to estimate aLM minus aFFAT may be a valuable tool in population-based studies to assess age-related rectified lean tissue mass loss.

Randomized clinical trial of duct-to-mucosa versus invagination pancreaticojejunostomy after pancreatoduodenectomy

BACKGROUND

The postoperative pancreatic fistula (POPF) rate for duct-to-mucosa and invagination anastomosis after pancreatoduodenectomy is still debated. The aim of this RCT was to investigate the POPF rate for duct-to-mucosa versus invagination pancreaticojejunostomy.

METHODS

Patients were stratified by pancreatic texture and diameter of the main pancreatic duct and randomized to the duct-to-mucosa or invagination group. The primary endpoint was the rate of clinically relevant POPF (defined as grade B or C). Secondary endpoints were suture material cost for pancreaticojejunostomy, drain insertion duration and duration of postoperative hospital stay.

RESULTS

Some 120 patients undergoing pancreatoduodenectomy were included following consent. Clinically relevant POPF developed in six of 59 patients (10 per cent) in the invagination group and in 14 of 61 patients (23 per cent) in the duct-to-mucosa group (P = 0·077). Duration of drain insertion (6 versus 7 days respectively; P = 0·027) and postoperative hospital stay (19 versus 24 days; P = 0·015) were shorter in the invagination group. Subgroup analysis for 61 patients with a soft pancreas revealed a lower rate of clinically relevant POPF in the invagination group (10 per cent versus 42 per cent in the duct-to-mucosa group; P = 0·010). Among 20 patients with a clinically relevant POPF, the six patients in the invagination group had a shorter duration of drain insertion (38·5 days versus 49 days for 14 patients in the duct-to-mucosa group; P = 0·028) and postoperative hospital stay (42 versus 54·5 days respectively; P = 0·028).

CONCLUSION

This study did not demonstrate a superiority of invagination over duct-to-mucosa pancreaticojejunostomy in the risk of POPF. However, in high-risk patients with a soft pancreas, invagination may reduce the risk of clinically relevant POPF compared with duct-to-mucosa. Registration number: UMIN000005890 (http://www.umin.ac.jp).