Phase 2 study of the Exportin 1 inhibitor selinexor in patients with recurrent gynecological malignancies

BACKGROUND

Selinexor is an oral inhibitor of the nuclear export protein Exportin 1 (XPO1) with demonstrated antitumor activity in solid and hematological malignancies. We evaluated the efficacy and safety of selinexor in heavily pretreated, recurrent gynecological malignancies.

METHODS

In this phase 2 trial, patients received selinexor (35 or 50 mg/m2 twice-weekly [BIW] or 50 mg/m2 once-weekly [QW]) in 4-week cycles. Primary endpoint was disease control rate (DCR) including complete response (CR), partial response (PR) or stable disease (SD) ≥12 weeks. Secondary endpoints were progression-free survival (PFS), overall survival (OS) and safety.

RESULTS

114 patients with ovarian (N = 66), endometrial (N = 23) or cervical (N = 25) cancer were enrolled. Median number of prior regimens for ovarian, endometrial and cervical cancer was 6 (1-11), 2 (1-5), and 3 (1-6) respectively. DCR was 30% (ovarian 30%; endometrial 35%; cervical 24%), which included confirmed PRs in 8%, 9%, and 4% of patients with ovarian, endometrial, and cervical cancer respectively. Median PFS and OS for patients with ovarian, endometrial and cervical cancer were 2.6, 2.8 and 1.4 months, and 7.3, 7.0, and 5.0 months, respectively. Common Grade 3/4 adverse events (AEs) were thrombocytopenia (17%), fatigue (14%), anemia (10%), nausea (9%) and hyponatremia (9%). Patients with ovarian cancer receiving 50 mg/m2 QW had fewer high-grade AEs with similar efficacy as BIW treatment.

CONCLUSIONS

Selinexor demonstrated single-agent activity and disease control in patients with heavily pretreated ovarian and endometrial cancers. Side effects were a function of dose level and treatment frequency, similar to previous reports, reversible and mitigated with supportive care.

Safety, pharmacokinetics and pharmacodynamics of selgantolimod, an oral Toll-like receptor 8 agonist: a Phase Ia study in healthy subjects

BACKGROUND

Selgantolimod is a novel oral, selective Toll-like receptor 8 (TLR8) agonist in development for the treatment of chronic hepatitis B (CHB). TLR8 is an endosomal innate immune receptor and a target for treatment of viral infections. This first-in-human study investigated the safety, tolerability, pharmacokinetics (PK) and pharmacodynamics (PD) of selgantolimod in healthy volunteers.

METHODS

Of 71 subjects enrolled, 59 received a single dose of selgantolimod (0.5, 1.5, 3 or 5 mg) or placebo, and 12 were evaluated for food effect. Safety, PK and PD activity by induction of cytokines, chemokines and acute phase proteins were assessed. PK/PD analyses were conducted.

RESULTS

Single doses of 0.5-5 mg were generally safe. No serious adverse events (AEs) or AEs leading to discontinuation were reported, and most were Grade 1 in severity. Selgantolimod displayed rapid absorption and dose-proportional PK and PD activity. Food had minimal effect on PK but resulted in diminished PD activity. In PK/PD analyses, near-saturation of induction for most evaluated biomarkers occurred at the 5-mg dose.

CONCLUSIONS

Single doses of up to 5 mg selgantolimod were safe and induced dose-dependent PD responses. These data support evaluation of selgantolimod in combination with other agents in future clinical studies of CHB. Australian New Zealand Clinical Trials Registration: ACTRN12616001646437.

Risk of Diabetic Foot in Diabetic Patients with Peripheral Arterial Disease

Background The prevalence of peripheral arterial disease is higher in diabetic patients. And 11.6% of the patients with diabetic foot ulcer have associated peripheral arterial disease. Objective The main objective of the study is to assess the risk of diabetic foot in diabetic patients with peripheral arterial disease. Method This was a case control study conducted in Bir Hospital, National Academy of Medical Sciences (NAMS). The sample size was 173 out of which cases (diabetic foot) and unmatched controls (diabetics without diabetic foot) were divided in the ratio of 1:2. The Odds Ratio (OR) of peripheral arterial disease in diabetic foot was calculated. The study was conducted after taking ethical clearance from Institutional Review Board of National Academy of Medical Sciences. Result There were 173 participants enrolled in the study. Four were excluded, 55 participants were cases of diabetic foot (cases) and 114 participants were diabetics without diabetic foot (controls). The odds of diabetic foot in patients with peripheral arterial disease was 4.12, p < 0.001. Conclusion The risk of diabetic foot in diabetic patients with peripheral arterial disease was higher as compared to diabetic patients without peripheral arterial disease.

Brain pseudotumour secondary to Behçet's disease

Neuro-Behçet's disease (NBD) is a serious manifestation of Behçet's disease (BD) and can affect either the central or peripheral nervous systems, or both. It occurs in 10-50% of patients with BD. We report on a patient with an unusual intraparenchymal lesion, initially thought to be a brain tumour. Histological examination revealed vasculitis consistent with BD. Clinicians should include NBD as a differential diagnosis when considering an isolated inflammatory intracranial lesion.

Adaptive Radiotherapy for Carcinoma of the Urinary Bladder: Long-term Outcomes With Dose Escalation

AIMS

To report long-term outcomes with dose-escalated, image-guided adaptive radiotherapy (ART) for bladder preservation in muscle-invasive bladder cancer (MIBC).

MATERIALS AND METHODS

All MIBC patients receiving bladder-preserving ART at our institute from 2009 to 2018 were analysed. For ART, three anisotropic planning target volumes (PTV) were concentrically grown around the simulation bladder volume. A library of intensity-modulated radiotherapy plans was created for each patient. A total dose of 64 Gy in 32 fractions to the entire bladder and 55 Gy to pelvic nodes was planned, with 68 Gy to the tumour bed (2 Gy equivalent dose = 68.7 Gy, α/β = 10) as simultaneous integrated boost for solitary tumours. The most appropriate PTV encompassing the bladder ('plan-of-the-day') was chosen daily using on-board megavoltage imaging. Neoadjuvant and concurrent chemotherapy was prescribed for medically fit patients.

RESULTS

Of a total of 106 patients, most had T2 (68%) or T3 (19%) disease. Ninety-two patients (87%) completed 64 Gy to the whole bladder. Sixty-three patients (59%) received 68 Gy as tumour bed boost. Seventy-six per cent received concurrent weekly chemotherapy. At a median follow-up of 26 months, 3-year locoregional control, disease-free survival and overall survival were 74.3, 62.9 and 67.7%, respectively. Eighty-two per cent of patients retained disease-free bladder. Radiation Therapy Oncology Group grade III/IV acute genitourinary and gastrointestinal toxicities were 7.5% and 0%, respectively, and late genitourinary/gastrointestinal toxicities were 6.5% and 3.8%, respectively. Overall survival, disease-free survival, locoregional control and grade III/IV genitourinary/gastrointestinal toxicities did not differ significantly with dose escalation.

CONCLUSION

Plan-of-the-day ART is clinically safe and effective for bladder preservation and can be implemented in routine clinical practice. A high bladder preservation rate is achievable without compromising on survival or toxicities. Dose escalation does not seem to affect outcomes.

Combined GS-4774 and Tenofovir Therapy Can Improve HBV-Specific T-Cell Responses in Patients With Chronic Hepatitis

BACKGROUND & AIMS

One strategy to treat chronic hepatitis B virus (HBV) infection could be to increase the functions of virus-specific T cells. We performed a multicenter phase 2 study to evaluate the safety and efficacy of GS-4774, a yeast-based therapeutic vaccine engineered to express HBV antigens, given with tenofovir disoproxil fumarate (TDF) to untreated patients with chronic HBV infection.

METHODS

We performed an open-label study at 34 sites in Canada, Italy, New Zealand, Romania, South Korea, and United States from July 2014 to August 2016. Adults who were positive for HB surface antigen (HBsAg) > 6 months and levels of HBV DNA ≥2000 IU/mL who had not received antiviral treatment for HBV within 3 months of screening were randomly assigned (1:2:2:2) to groups given oral TDF 300 mg daily alone (n = 27; controls) or with 2, 10, or 40 yeast units GS-4774 (n = 168), administered subcutaneously every 4 weeks until week 20 for a total of 6 doses. Blood samples were collected and analyzed and patients received regular physical examinations. Efficacy was measured by decrease in HBsAg from baseline to week 24. Specific responses to HBV (production of interferon gamma [IFNG], tumor necrosis factor [TNF], interleukin 2 [IL2], and degranulation) were measured in T cells derived from 12 HBeAg-negative patients with genotype D infections, after overnight or 10 days of stimulation of peripheral blood mononuclear cells with peptides from the entire HBV proteome. T-regulatory cells were analyzed for frequency and phenotype. Data from studies of immune cells were compared with data on reductions in HBsAg, HBV DNA, and alanine aminotransferase in blood samples from patients.

RESULTS

GS-4774 was safe and well tolerated but did not produce significant decreases in levels of HBsAg. Production of IFNG, TNF, and IL2 increased significantly at weeks 24 and 48, compared with baseline, in HBV-specific CD8+ T cells from patients given GS-4774 but not from controls. GS-4774 had greater effects on CD8+ than CD4+ T cells, which were not affected at all or very weakly by TDF with or without GS-4774. GS-4774 did not affect responses of T cells to other viruses tested. HBV core peptides induced the greatest production of IFNG by T cells following overnight stimulation, whereas HBV envelope antigens did not induce a response. Following 10 days of stimulation, production of IFNG and TNF increased with time of exposure to GS-4774; the greatest levels of responses were to HBV envelope antigens followed by core and polymerase peptides. We observed a correlation in patients given GS-4774 between increased T-cell functions and reductions in numbers of T-regulatory cells.

CONCLUSIONS

In a phase 2 study of patients with chronic HBV infection given TDF with or without GS-4774, we found that vaccination can increase production of IFNG, TNF, and IL2 by CD8+ T cells exposed to antigenic peptides, with little effect on CD4+ T cells. Although GS-4774 did not reduce levels of HBsAg in patients, its strong immune stimulatory effect on CD8+ T cells might be used in combination with other antiviral agents to boost the antivirus immune response. Clinicaltrials.gov no: NCT02174276.

Indications of Fetal Echocardiography and Detection of Congenital Heart Disease Prenatally in Tertiary Care Hospital

Background Congenital Heart Diseases are common childhood congenital anomalies encountered in developed and developing countries. Due to the improved prenatal diagnostic modalities, the diagnosis of cardiac disease is increasing in newborns. Fetal echocardiography is considered a good and accurate diagnostic method for congenital heart disease. Objective To study the common indications of fetal echocardiography and the detection of congenital heart disease in Dhulikhel Hospital, Kathmandu University Hospital. Method In this hospital-based, retrospective study, we reviewed medical records of 324 fetuses who were indicated for fetal echocardiography at Dhulikhel Hospital over 24 months period of time (September 1, 2017 to August 31, 2019). Result The mean age of pregnant women at presentation for fetal echocardiography was 30.7 ± 4.7 years. The mean gestational age at diagnosis was 28.9 ± 4.9 weeks. Among all the pregnant women, 208 (65%) presented during the second trimester and 112 (35%) presented during the third trimester. Maternal indications for fetal echocardiography were seen in48.12% cases, whereas fetal indications were seen in 42.81% cases. The most common indication was for maternal gestational diabetes (30.31%). Among the 324fetal echocardiography results, 65.43% cases had normal findings, echogenic intra-cardiac foci were seen in 18.82% and significant abnormal findings were seen in 15.74% of cases. Among all women having maternal indication for echocardiography, 34 (22.07%) fetus had some form of abnormal findings, whereas only 17 (12.40%) fetus with fetal indication showed abnormal findings (p < 0.05). Conclusion Indication of fetal echocardiography is increasing and can be a good diagnostic tool to improve prognosis and outcome of a newborn. It has become widely used in pediatric cardiology. Raising awareness is necessary regarding the importance of fetal echocardiography in the management and outcome of a newborn with cardiac anomalies.