A phase II, multicenter, randomized clinical trial to evaluate the efficacy and safety of bevacizumab in combination with either chemotherapy (docetaxel or pemetrexed) or erlotinib hydrochloride compared with chemotherapy alone for treatment of recurrent or refractory non-small cell lung cancer

7062

Background: Bevacizumab is a recombinant, humanized anti-VEGF MAb. Erlotinib is a potent, reversible, highly selective and orally available EGFR tyrosine-kinase inhibitor. Both compounds have demonstrated a survival benefit in the treatment of NSCLC: bevacizumab when added to chemotherapy in the first line setting, and erlotinib when given alone in the 2nd/3rd line. In addition, a single arm phase I/II study of the combination of bevacizumab and erlotinib has shown encouraging survival and response rate data, with a favorable safety profile (Sandler et al, PASCO 2004). Methods: A multicenter, randomized phase II trial was conducted to evaluate the safety of combining bevacizumab with chemotherapy (docetaxel or pemetrexed), or with erlotinib; and to make a preliminary assessment of the efficacy of combining bevacizumab with chemotherapy or erlotinib relative to chemotherapy alone, as measured by progression-free survival. All patients had histologically confirmed non-squamous NSCLC and had experienced disease progression (clinical or radiological) during or following one platinum-based regimen for advanced stage disease. Randomization was on a 1:1:1 basis to docetaxel or pemetrexed plus placebo (arm 1) v docetaxel or pemetrexed plus bevacizumab (arm 2) v bevacizumab plus erlotinib (arm 3). Patients remained in the treatment phase of the study until documented radiographic or clinical disease progression or through 52 weeks of study treatment. Results: Between August 2004 and November 2005, 120 patients were randomized and treated. To date, there have been 68/85 required PFS events; arms 1 and 2 therefore remain blinded. Demographics from the first 85 patients for arms 1 & 2 v 3 are as follows: median age 65 v 68;% male/female 64/36 v 44/56; ethnicity % white/black/asian/other 83/12/2/3 v 74/15/4/7; % ECOG PS 0/1/2 46/52/2 v 50/50/0; % adenocarcinoma/BAC&BAC-like/Other 67/7/26 v 69/8/23; % current/previous/never-smoker 15/71/14 v 11/74/15. Conclusions: Efficacy and safety results will be presented at the meeting.

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Final results of a phase II trial of bexarotene capsules as 3rd or subsequent line therapy in patients with advanced non-small cell lung cancer (NSCLC)

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Background: Bexarotene, a rexinoid that binds to RXR nuclear receptors, has antiproliferative, differentiating, and apoptotic effects. Phase II studies of bexarotene plus chemotherapy in previously untreated NSCLC suggested improved patient survival. This study evaluated bexarotene for relapsed advanced NSCLC. Methods: Patients were eligible if they had NSCLC Stage IIIB wet/IV, had failed ≥ 2 prior systemic therapies, had previously received a taxane and platinum, had ECOG performance status (PS) 0–2, and had adequate organ function. Bexarotene 400 mg/m2 daily plus prophylactic levothyroxine and a lipid-lowering agent were given until disease progression or unacceptable toxicities occurred. The primary efficacy endpoint was survival. To detect a 50% increase in median survival from 4 months, as shown with 3rd line chemotherapy, to 6 months, 125 evaluable patients were required for a 90% power at a 1-sided 5% significance. Results: A total of 146 patients were enrolled at 32 sites. Median age = 66 (range, 34–87), male = 51%, PS 2 = 23%, adenocarcinoma = 54%, and median prior therapies = 3 (range 1–7) with 55% having failed gefitinib. Bexarotene was usually well tolerated and there were no therapy-related deaths. For the 124 patients who were treated for at least 14 days and were considered evaluable for efficacy, median and 1-year survival were 6 months and 25%, respectively. Baseline albumin < 3 g/dL and PS = 2 were significantly associated with shorter survival. For 26 patients who developed hypertriglyceridemia plus skin rash by Day 21, median and 1-year survival were 12 months and 44%, respectively, vs. 2 months and 12% in 36 patients with neither (p = 0.0003). Partial response was reported in 1 patient. When assessed by FACT-G, quality of life was improved or stabilized in 65% of patients. Conclusions: Survival of patients with heavily pretreated NSCLC may be extended with oral bexarotene therapy. Confirmation of these results with a randomized trial is warranted. Ongoing investigations attempt to explain the notable outcome reported in this and other bexarotene trials in the subset of patients who developed hypertriglyceridemia with or without skin rash.

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Wound infection prophylaxis in pediatric acute appendicitis: a 26-year prospective study

PURPOSE

The purpose of this study was to determine the best wound infection prophylaxis in pediatric acute appendicitis.

METHODS

From 1969 to 1995 inclusive, 453 consecutive pediatric patients at the same children's hospital had an appendix with acute inflammation (acute appendicitis) removed by the same staff surgeon and his resident. The stump was not inverted, and chromic catgut was used throughout. No intraperitoneal antibiotics, irrigation, or drains were used, and the skin closure was with silk sutures initially and then with staples since 1986. The infants and children were divided into 6 consecutive groups of 52 to 96 patients, with each group lasting 2 to 5 years. The wound treatment groups were as follows: no treatment, drain or pack, drain or pack plus antibiotic powder, antibiotic powder, preoperative intravenous antibiotic plus antibiotic powder, and preoperative intravenous antibiotic. The wound Penrose drain, one half-inch gauze pack, and/or antibiotic powder (ampicillin, 1977-1981; cefoxitin, 1982-1995) were all placed in the subcutaneous space.

RESULTS

There were a total of 50 (11%) wound infections (pus) that occurred between 4 and 40 days when no antibiotic powder was used and 2 to 14 days with antibiotic powder. In all 6 groups of patients, no organism was grown in most (80%) infections and Escherichia coli was the second commonest (12%). The serous ooze, which occurred only with the use of antibiotic powder (8%), was seen between 6 and 18 days, and no organism was ever cultured.

CONCLUSIONS

The patients with preoperative (or intraoperative) intravenous antibiotics (cefoxitin) plus wound antibiotic powder (cefoxitin) had the lowest infection rate (2.5%). When this group was compared with the baseline group 1 (no treatment), it was the only group in which wound treatment made a significant difference (P = .003).

Inhibition of the NF-κB pathway enhances TRAIL-mediated apoptosis in neuroblastoma cells

Neuroblastoma is the most common solid extracranial neoplasm in children and causes many deaths. Despite treatment advances, prognosis for neuroblastoma remains poor, and a critical need exists for the development of new treatment regimens. TNF-related apoptosis-inducing-ligand (TRAIL) induces cell death in a variety of tumors, but not in normal tissues. Moreover, TRAIL is nontoxic, making it a strong antitumor therapeutic candidate. We demonstrate that introduction of the TRAIL gene into neuroblastoma cell lines using an adenoviral vector leads to apoptotic cell death. RT-PCR and flow-cytometric analyses demonstrated that TRAIL's effect is mediated primarily via the TRAIL R2 receptor. As TRAIL can activate the nuclear factor-kappaB (NF-kappaB) signaling pathway, which can exert an antiapoptotic effect, we hypothesized that inhibition of NF-kappaB signaling may augment TRAIL's killing effects. TRAIL-mediated cell death was enhanced when neuroblastoma cells were simultaneously infected with a dominant-negative mutant of IkappaB kinase, a kinase essential for NF-kappaB activation. The combination of blockade of NF-kappaB signaling and expression of TRAIL induced apoptotic death in a greater proportion of SKNSH cells than did either treatment alone. Thus, concurrent inhibition of the NF-kappaB pathway and the induction of TRAIL-mediated apoptosis may become a useful approach for the treatment of neuroblastoma.

A "plastic" sutureless abdominal wall closure in gastroschisis

BACKGROUND/PURPOSE

Several techniques are described for closure of the gastroschisis abdominal wall defect. The authors describe a technique that allows for spontaneous closure that is simple, cosmetically appealing, and minimizes intraabdominal pressure after bowel reduction.

METHODS

Under either general anesthetic or analgesia with sedation, the gastroschisis bowel is decompressed, and the bowel is primarily reduced. The gastroschisis defect is covered with the umbilical cord tailored to fit the opening, and 2 Tegaderm (3M Healthcare, MN) dressings reinforce the defect ("plastic closure"). Intragastric pressure is monitored during and after the procedure. If primary reduction is not possible, the bowel is reduced daily via a spring-loaded silo (Bentec Medical, CA). After reduction of the bowel, the defect is allowed to close spontaneously using the "plastic closure" technique. The authors prospectively treated a cohort of patients with gastroschisis that included simple to complex cases using this technique.

RESULTS

Ten children with gastroschisis were treated; 6 of these children had a primary reduction and simple closure of their defect using the "plastic closure." In the remaining 4 children, the plastic closure was used either primarily or secondarily to silo placement, despite the need for repair of complex intestinal anomalies. The average times to first feeding and discharge were 12.5 and 28.3 days, respectively. Six of the 10 children (60%) had small umbilical hernias, and only 1 underwent operative repair at 13 months of age.

CONCLUSIONS

The plastic closure of gastroschisis is simple, safe, and cosmetically appealing. Intraabdominal pressures are well controlled, and the umbilical position remains centrally located in this sutureless technique. Umbilical defects can occur but are observed for spontaneous closure like most primary umbilical hernias.

Practice Parameter: Diagnostic assessment of the child with cerebral palsy: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society

OBJECTIVE

The Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society develop practice parameters as strategies for patient management based on analysis of evidence. For this parameter the authors reviewed available evidence on the assessment of a child suspected of having cerebral palsy (CP), a nonprogressive disorder of posture or movement due to a lesion of the developing brain.

METHODS

Relevant literature was reviewed, abstracted, and classified. Recommendations were based on a four-tiered scheme of evidence classification.

RESULTS

CP is a common problem, occurring in about 2 to 2.5 per 1,000 live births. In order to establish that a brain abnormality exists in children with CP that may, in turn, suggest an etiology and prognosis, neuroimaging is recommended with MRI preferred to CT (Level A). Metabolic and genetic studies should not be routinely obtained in the evaluation of the child with CP (Level B). If the clinical history or findings on neuroimaging do not determine a specific structural abnormality or if there are additional and atypical features in the history or clinical examination, metabolic and genetic testing should be considered (Level C). Detection of a brain malformation in a child with CP warrants consideration of an underlying genetic or metabolic etiology. Because the incidence of cerebral infarction is high in children with hemiplegic CP, diagnostic testing for coagulation disorders should be considered (Level B). However, there is insufficient evidence at present to be precise as to what studies should be ordered. An EEG is not recommended unless there are features suggestive of epilepsy or a specific epileptic syndrome (Level A). Because children with CP may have associated deficits of mental retardation, ophthalmologic and hearing impairments, speech and language disorders, and oral-motor dysfunction, screening for these conditions should be part of the initial assessment (Level A).

CONCLUSIONS

Neuroimaging results in children with CP are commonly abnormal and may help determine the etiology. Screening for associated conditions is warranted as part of the initial evaluation.