A multicenter, randomized trial of flat dosing versus intrapatient dose escalation of single-agent carboplatin as first-line chemotherapy for advanced ovarian cancer: an SGCTG (SCOTROC 4) and ANZGOG study on behalf of GCIG

BACKGROUND

The aim of the study is to demonstrate that intrapatient dose escalation of carboplatin would improve the outcome in ovarian cancer compared with flat dosing.

PATIENTS AND METHODS

Patients with untreated stage IC-IV ovarian cancer received six cycles of carboplatin area under the curve 6 (AUC 6) 3 weekly either with no dose modification except for toxicity (Arm A) or with dose escalations in cycles 2-6 based on nadir neutrophil and platelet counts (Arm B). The primary end-point was progression-free survival (PFS).

RESULTS

Nine hundred and sixty-four patients were recruited from 71 centers. Dose escalation was achieved in 77% of patients who had ≥1 cycle. The median AUCs (cycle 2-6) received were 6.0 (Arm A) and 7.2 (Arm B) (P < 0.001). Grade 3/4 non-hematological toxicity was higher in Arm B (31% versus 22% P = 0.001). The median PFS was 12.1 months in Arm A and B [hazard ratio (HR) 0.99; 95% confidence interval (CI) 0.85-1.15; P = 0.93]. The median overall survival (OS) was 34.1 and 30.7 months in Arms A and B, respectively (HR 0.98; 95% CI 0.81-1.18, P = 0.82). In multivariate analysis, baseline neutrophil (P < 0.001), baseline platelet counts (P < 0.001) and the difference between white blood cell (WBC) and neutrophil count (P = 0.009) had a significant adverse prognostic value.

CONCLUSIONS

Intrapatient dose escalation of carboplatin based on nadir blood counts is feasible and safe. However, it provided no improvement in PFS or OS compared with flat dosing. Baseline neutrophils over-ride nadir counts in prognostic significance. These data may have wider implications particularly in respect of the management of chemotherapy-induced neutropenia.

Micro-RNAs in inflammatory diseases and as a link between inflammation and cancer

OBJECTIVE

The objective of this review is to examine the role of miRNA in various inflammatory diseases and in inflammatory diseases progressing to cancer.

INTRODUCTION

MicroRNAs are small, conserved, non-coding RNA molecules which are present in most of the eukaryotes. miRNA have been reported to play a major role in the physiological control of gene expression and in the pathogenesis of various diseases. They regulate the gene expression mainly at the post-transcriptional level. miRNA expression profile is reported to be altered in various inflammatory diseases and subsequently affects the expression of genes, which is important in disease pathogenesis.

METHODS

A Pubmed database search was performed for studies related to miRNA studies in inflammatory disease, cancer and in inflammatory diseases progressing to cancer.

CONCLUSION

The evidence shows very important role of miRNA in inflammatory diseases. Few miRNAs involved in common inflammatory process and suggest miRNA as a link between inflammation and cancer. Future research should be directed to use miRNA therapeutically to target common inflammatory pathway and to develop miRNA as biomarker to detect development of cancer at early stages.

Osteoporosis drug therapy strategies in the setting of disease-modifying agents for autoimmune disease

The purpose of this systematic review is to evaluate the effects of methotrexate (MTX) and tumor necrosis factor-alpha (TNF-α) inhibitors on bone mineral properties in the clinical literature. A systematic review of the literature identifying relevant case reports, population-based studies, cohort studies, case control studies, and randomized controlled trials in Pubmed and Web of Science databases from inception to December 31, 2011 was conducted. The following keywords were used: "bone turnover," "bone mineral density," "TNF-α inhibitors," "infliximab," "adalimumab," "etanercept," and "MTX." The bibliographies of all retrieved studies were also reviewed to identify additional articles. Based on these results, a rational drug therapy strategy was suggested for treating osteoporosis in patients with inflammatory disease. MTX and TNF-α inhibitors do not appear to have an adverse effect on BMD in patients with inflammatory disease. Their negative effects on BMD and bone turnover in pre-clinical models appear to be outweighed by their anti-disease effects in clinical studies. Treatment with MTX or TNF-α inhibitors has no adverse effect on BMD in patients with inflammatory disease. Future studies will focus on developing optimal drug strategies when combining DMARDs with anti-osteoporotic agents in this patient population.

Continuously tunable optical multidimensional Fourier-transform spectrometer

A multidimensional optical nonlinear spectrometer (MONSTR) is a robust, ultrastable platform consisting of nested and folded Michelson interferometers that can be actively phase stabilized. The MONSTR provides output pulses for nonlinear excitation of materials and phase-stabilized reference pulses for heterodyne detection of the induced signal. This platform generates a square of identical laser pulses that can be adjusted to have arbitrary time delays between them while maintaining phase stability. This arrangement is ideal for performing coherent optical experiments, such as multidimensional Fourier-transform spectroscopy. The present work reports on overcoming some important limitations on the original design of the MONSTR apparatus. One important advantage of the MONSTR is the fact that it is a closed platform, which provides the high stability. Once the optical alignment is performed, it is desirable to maintain the alignment over long periods of time. The previous design of the MONSTR was limited to a narrow spectral range defined by the optical coating of the beam splitters. In order to achieve tunability over a broad spectral range the internal optics needed to be changed. By using broadband coated and wedged beam splitters and compensator plates, combined with modifications of the beam paths, continuous tunability can be achieved from 520 nm to 1100 nm without changing any optics or performing alignment of the internal components of the MONSTR. Furthermore, in order to achieve continuous tunability in the spectral region between 520 nm and 720 nm, crucially important for studies on numerous biological molecules, a single longitudinal mode laser at 488.5 nm was identified and used as a metrology laser. The shorter wavelength of the metrology laser as compared to the usual HeNe laser has also increased the phase stability of the system. Finally, in order to perform experiments in the reflection geometry, a simple method to achieve active phase stabilization between the signal and the reference beams has been developed.

A novel apparatus for in situ compression of submicron structures and particles in a high resolution SEM

We report on the development and characterization of a novel in situ manipulation device to perform stressing experiments on the submicron scale inside a high resolution field emission scanning electron microscope. The instrument comprises two main assembly groups: an upper part for positioning and moving a mounted probe and a force sensor as well as a specimen support as lower part. The upper part consists of a closed loop tripod piezoelectric scanner mounted on a self-locking coarse positioning stage. Two interlocked steel springs and a linear variable differential transformer measuring the springs' deflections compose the lower part of the instrument. This arrangement acts as force-sensor and sample support. In comparison to already well-established concepts a wide measuring range is covered by adjusting the spring constant between 30 N/m and 50000 N/m. Moreover, the new device offers striking advantages with respect to force calibration and sample deformation measurements. Force calibration is performed using the eigenfrequency of the force detection system directly inside the SEM. Deformation data are obtained with high accuracy by simultaneously recording displacements above and below the specimen. The detrimental apparatus compliance is determined, and the influence on measured data subsequently minimized: an easy to validate two-springs-in-series model is used for data correction. A force resolution in normal direction of 100 nN accompanied by a sample deformation resolution of 5 nm can be achieved with the instrument using an appropriate load cell stiffness. The capabilities and versatility of this instrument are exemplified by compression experiments performed on submicron amorphous silica particles.

Ongoing outbreak of Shigella flexneri serotype 3a in men who have sex with men in England and Wales, data from 2009–2011

Diagnoses of Shigella flexneri in the United Kingdom (UK) are usually travel-related. However, since 2009, there has been an overall increase in UK-acquired cases. The Health Protection Agency has been investigating a national outbreak of S. flexneri detected in 2011 and which is still ongoing. Cases occurred mostly in men who have sex with men and were of serotype 3a. The investigation aimed at obtaining epidemiological data to inform targeted outbreak management and control.

Ongoing outbreak of Shigella flexneri serotype 3a in men who have sex with men in England and Wales, data from 2009-2011

Diagnoses of Shigella flexneri in the United Kingdom (UK) are usually travel-related. However, since 2009, there has been an overall increase in UK-acquired cases. The Health Protection Agency has been investigating a national outbreak of S. flexneri detected in 2011 and which is still ongoing. Cases occurred mostly in men who have sex with men and were of serotype 3a. The investigation aimed at obtaining epidemiological data to inform targeted outbreak management and control.

Can plasma HHV8 viral load be used to differentiate multicentric Castleman disease from Kaposi sarcoma?

We measured plasma human herpesvirus 8 (HHV8) DNA load in consecutive patients presenting with HIV-associated multicentric Castleman disease (MCD) and in contemporaneous patients who had Kaposi sarcoma (KS), lymphoma or other diagnoses. All 11 patients with MCD had detectable plasma HHV8 DNA compared with 18 (72%) of 25 patients with KS, none with lymphoma and one of 38 patients with other diagnoses. Detectable plasma HHV8 DNA levels were higher among MCD patients, median (interquartile range [IQR]) = 43,500 (5200–150,000) copies/mL, when compared with those with KS, median (IQR) = 320 (167–822) copies/mL and those with lymphoma and other diagnoses (one-way analysis of variance; P = 0.0303). Using receiver operating characteristic analysis, a cut-off of >1000 copies HHV8 DNA/mL of plasma helped to discriminate between MCD and other diagnoses, with a specificity of 94.7% and a negative predictive value of 97.3%. The level of HHV8 viraemia, while not diagnostic, may aid discrimination between patients with MCD and those with KS and other systemic illnesses.

Efficacy and safety of conversion from twice-daily to once-daily tacrolimus in a large cohort of stable kidney transplant recipients

Prolonged-release tacrolimus was developed to provide a more convenient once-daily dosing that could improve patient adherence. We conducted a multicenter, prospective, observational, 12-month study to describe the efficacy, safety and patient preference of conversion from tacrolimus twice-daily to once-daily formulation in stable kidney transplant recipients in routine clinical practice. Conversion was made on a 1 mg: 1 mg basis (1 mg: 1.1 mg in patients with trough levels <6 ng/mL). The study included 1832 patients (mean age (± SD): 50.0 ± 13.4 years; 62.7% male). After conversion, a modest reduction in tacrolimus trough levels, necessitating an increase in daily dose, was observed (mean changes at 12 months of -9.1% and +1.24%, respectively; p < 0.0001). Mean glomerular filtration rate did not change significantly (56.5 ± 19.7 mL/min at conversion vs. 55.7 ± 20.6 mL/min at 12 months). Proteinuria, blood pressure, lipid, hepatic and glucose parameters remained stable. Eight patients (0.4%) had acute rejection and 34 patients (1.85%) discontinued treatment. Almost all patients (99.4%) preferred the once-daily formulation, because of less frequent dosing (66%) and improved adherence (34%). In conclusion, at similar doses to twice-daily tacrolimus, once-daily formulation provided stable renal function, a low acute rejection rate, and good tolerability in stable kidney transplant recipients in the routine clinical practice setting.

SCOTCERV: a phase II trial of docetaxel and gemcitabine as second line chemotherapy in cervical cancer

OBJECTIVE

The aim of the study was to determine the response rate and response duration of cervical cancer previously treated by cisplatin (with or without radiation) to a combination of docetaxel and gemcitabine. Secondary endpoints were assessment of toxicity and quality of life (QoL) of patients receiving the treatment.

METHODS

This was a multicentre phase II trial of 3 weekly docetaxel 75 mg/m(2) day 1 (reduced to 60 mg/m(2) after 32 cycles had been administered) and gemcitabine 1000 mg/m(2) (days 1 and 8). A two stage Gehan design was used initially. Twenty-nine patients recruited had disease outside the irradiated pelvis (Group 1), and 21 had disease confined to the irradiated pelvis (Group 2). The target response for the Gehan 2 design was 25% (Group 1) and 10% (Group 2).

RESULTS

The overall response rate for Group 1 was 21.4% (95% CI 8.3-41.0%). Amongst those who had at least 3 cycles of chemotherapy the response rate was 27.3% (95% CI 10.7-50.2%). The median survival was 7.3 months (95% CI 5.4 to 9.2 months) with 39.3% (95% CI 21.7-56.5%) alive at 1 year. In Group 2 the overall response rate was 9.5% (95% CI 1.2%-30.4%). The response rate for those who had at least 3 cycles of chemotherapy was 12.5% (95% CI 1.6-38.4%). The median survival was 7.9 months (95% CI 2.2-13.6 months). Toxicity was mainly haematological with 51% developing grade 3 or 4 neutropenia after at least 1 cycle of chemotherapy. QoL showed a significant deterioration from baseline for physical and role function but there was an improvement in emotional function during treatment.

CONCLUSION

Response rates and survival duration were similar to those reported following treatment with platinum based doublets. In view of the relatively poor response rates (no more than 36%) to conventional chemotherapy future developments should be a combination of chemotherapy and biological agents such as VEGFR inhibitors.

A randomised double-blind placebo-controlled trial to determine the effect of cranberry juice on decreasing the incidence of urinary symptoms and urinary tract infections in patients undergoing radiotherapy for cancer of the bladder or cervix

AIMS

Radical pelvic radiotherapy is one of the main treatment modalities for cancers of the bladder and cervix. The side-effects of pelvic radiotherapy include urinary symptoms, such as urinary frequency and cystitis. The therapeutic effects of cranberry juice in the prevention and treatment of urinary tract infections in general are well documented. The purpose of this study was to evaluate the effectiveness of cranberry juice on the incidence of urinary tract infections and urinary symptoms in patients undergoing pelvic radiotherapy for cancer of the bladder or cervix.

MATERIALS AND METHODS

The study was a placebo-controlled, double-blind design. Participants were randomised to receive cranberry juice, twice a day (morning and night) for the duration of their radiotherapy treatment and for 2 weeks after treatment (6 weeks in total) or a placebo beverage, for the same duration.

RESULTS

The incidence of increased urinary symptoms or urinary tract infections was 82.5% on cranberry and 89.3% on placebo (P=0.240, adjusted odds ratio [cranberry/placebo] 0.48, 95% confidence interval 0.14-1.63).

CONCLUSIONS

The power of the study to detect differences was limited by the below target sample size and poor compliance. Further research is recommended, taking cognisance of the factors contributing to the limitations of this study.

Chemoradiation in Advanced Head and Neck Cancers: A Comparison of two Radiosensitizers, Paclitaxel and Cisplatin

To compare the locoregional control rates, survival outcome and toxicity profiles between two groups of patients of squamous cell carcinoma (SCC) of Head and Neck (Stage III & IV) receiving concomitant chemo-radiotherapy with Paclitaxel and Cisplatin. A prospective study was done on 94 previously untreated patients of histopathologically proved squamous cell carcinoma of head and neck region-AJCC stage III & IV (T3 & T4 with N0 -N3, M0) treated with concomitant chemoradiation. The patients were divided into two groups. Group A (44 patients) received concomitant chemotherapy (C.T.) with Paclitaxel 40 mgm/m2 while Group B (50 patients) received concomitant chemotherapy with Cisplatin 40 mgm/m2. All the patients in both the groups responded. In Group A (Paclitaxel + R.T.), complete response was seen in 72.7% and partial response in 27.3%. In Group B (Cisplatin +R.T.) complete response was seen in 52% and partial in 48%. At one year follow up, the locoregional control rate (LRC) in Group A was significantly higher as compared to that in Group B (65.9 vs. 46%, P<0.05) while there was no difference in the disease free survival (DFS) and the overall survival (OS). A 3 year estimate of the LRC, DFS and OS using Kaplan Meier Estimator revealed no difference in the LRC, DFS and OS between the 2 groups. There was a higher incidence of skin and mucosal toxicity with Paclitaxel while the gastro-intestinal and hematological toxicity was more with Cisplatin. No significant chronic toxicity except xerostomia was observed in either group. Paclitaxel has better complete response and locoregional control rates at 1 year as compared to cisplatin. However, there is no difference in the estimated 3 year rates of locoregional control, disease free survival and overall survival between the 2 groups.

Abstract P4-11-12: Neurocognitive Function and Quality of Life of Patients Treated within a Prospective Randomised Clinical Trial Testing the Role of Prophylactic Cranial Radiotherapy (PCI) in Patients Treated with Trastuzumab (Herceptin®) for Metastatic Breast Cancer. The Anglo Celtic VII Trial

Background. Various authors have reported a relatively high incidence of CNS metastases in patients with HER2 positive tumours receiving Trastuzumab based therapy for metastatic breast cancer. There has been concern with regard to the possible neuropsychological sequelae of PCI, although data from two prospective randomised trials assessing toxicity and quality of life after PCI for small cell lung cancer (UK02 and PCI 85) have failed to confirm this.

Methods. The HER-PCI trial was a prospective randomised trial of PCI in patients with HER2 positive breast cancer who had progressive systemic disease and had Trastuzumab therapy + chemotherapy as planned treatment. Patients had a screening MRI or CT of the brain after randomisation with a view to excluding those with sub-clinical CNS disease. Neurocognitive function was assessed at baseline, 3,6 and 9 months from randomisation using EORTC QLQC30, EORTC neurological sub-scale BN20, Hospital anxiety and depression score (HADS) and the Addenbrookes Cognitive Examination (ACE-R). Patients were randomised 1:1 to no PCI or PCI delivered at around 6 weeks after the start of their systemic treatment for metastatic disease. The PCI dose was 30Gy in 10 fractions, a fraction deferred if due on a day of planned chemotherapy.

Results. 51 patients entered the randomisation between March 2007 and March 2010. 25 received PCI and 26 did not. 46 (90%) of patients received Trastuzumab + chemotherapy and 5 patients single agent Trastuzumab. The mean age was 54 years. Results of the neurcognitive testing and QOL will be presented

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-11-12.

Chondrosarcoma of the arytenoid cartilage

Chondrosarcoma is the most frequently encountered nonepithelial tumor of the larynx. Still, laryngeal chondrosarcoma is a rare disease, accounting for less than 1% of all laryngeal neoplasms; only about 600 cases have been reported in the world literature. The two most common sites of origin are the cricoid cartilage (69% of cases) and the thyroid cartilage (9%); arytenoid cartilage origin has been seen in less than 3% of cases. The diagnosis of laryngeal chondrosarcoma is easy to miss because of its infrequent occurrence, its indolent pattern of growth, and the difficulty in differentiating it histopathologically from chondroma. However, suspicion of arytenoid chondrosarcoma may be raised by a finding of its characteristic appearance as a smooth, hard, mucosa-covered supraglottic mass that is fairly recognizable on indirect laryngoscopy. We report a new case of chondrosarcoma of the arytenoid cartilage in a 47-year-old man, and we discuss the clinical features, diagnosis, and management of this uncommon tumor.

Donor-site morbidity after osteochondral autologous transplantation for lesions of the talus

BACKGROUND

Autologous osteochondral transplantation is accepted as one of the major treatment options for cartilage defects of the talus. One disadvantage of this technique is the need to harvest a donor graft from a normal knee. The potentially detrimental effect of graft harvest on knee function remains unclear.

METHODS

Two hundred patients who had transplantation of an autologous osteochondral graft obtained from an asymptomatic knee for the treatment of an osteochondral defect of the talus were evaluated. Of the 200 patients, 112 were followed for a minimum of two years (mean duration of follow-up, fifty-five months). The WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) and the Lysholm score were used to assess functional outcome. Variables that were examined included the number of grafts, total size of the harvested cylinders, patient age, body mass index, and overall satisfaction of the patient with the result of the procedure at the knee. A multiple linear regression analysis was utilized to determine the influence of each parameter on the WOMAC and Lysholm scores. In addition, the Lysholm scores for the entire patient group were reviewed to determine how long after the index surgery clinical improvement ceased.

RESULTS

The mean postoperative WOMAC score (and standard deviation) for the 112 patients who had been followed for a minimum of two years was 5.5% +/- 0.1%, and the mean postoperative Lysholm score was 89 +/- 17 points. The number of grafts, the size of the transplanted cylinders, and patient age did not influence either the Lysholm or the WOMAC score. A higher body mass index and lower general satisfaction ratings did negatively influence the Lysholm and WOMAC scores. Gradual clinical improvement, as measured with the Lysholm score for all 200 study subjects, continued throughout the postoperative period.

CONCLUSIONS

Donor-site morbidity of a knee from which a graft has been harvested can potentially lead to functional impairment. In our study, the functional outcome of the knee was not affected by the number of donor grafts, the size of the donor grafts, or the age of the patient. Surgeons performing osteochondral transplantations and harvesting autografts from the knee should be aware of the potentially negative effect of a higher body mass index on clinical outcomes after surgery.

Randomized trial of intrapatient dose escalation of single agent carboplatin as first-line treatment for advanced ovarian cancer: An SGCTG study (SCOTROC 4)

5537

Background: In the absence of toxicity, carboplatin (the most widely used drug in ovarian cancer) is generally given at the same (flat) dose with each treatment cycle. However, retrospective data suggest a correlation between extent of myelosuppression and outcome, as has been observed in other diseases. Our hypothesis was therefore that intrapatient dose escalation, according to nadir blood counts, could lead to an improved outcome compared to conventional flat dosing. Methods: Patients with previously untreated stage IC to IV ovarian cancer were randomized to receive 6 cycles of carboplatin AUC 6 q3 w either with no dose modification except for toxicity (Arm A) or with dose escalations in cycles 2–6 based on nadir FBC (Arm B). The primary outcome measure was progression-free survival (PFS), and a target accrual of 1300 pts was envisaged, aimed at detecting a 20% increase in PFS with 80% power (5% 2-sided level of statistical significance). Results: From March 2004 to November 2008, 937 pts were recruited from 70 centres. Dose escalation occurred in 82% pts on Arm B. The median AUCs actually received were 6.0 (Arm A) and 6.84 (Arm B). As expected, more myelosuppression was seen in Arm B (p < 0.001 for all parameters). More grade 3/4 non-haematological toxicity was also seen in Arm B (31%, vs 22% in Arm A, p < 0.001) but there was no significant difference in global quality of life. To date, 477 PFS events have been observed out of a planned total of 950. The median PFS was 13.9m in Arm A, and 13.5m in Arm B, and the observed hazard ratio (Arm B/Arm A) is 1.04, with 95% C.I. of 0.87 to 1.24. This excludes the clinically relevant benefit of 0.83 used to design the study. A futility analysis also indicated that the probability of a statistically significant result in favour of Arm B at the planned study end was 0.12 at best. Conclusions: Following the Data Monitoring Committee recommendation, the trial has therefore been closed to recruitment, with no evidence of benefit for intra-patient dose escalation of carboplatin. A separate analysis of tissue samples, aimed at elucidating mechanisms of (single agent) carboplatin resistance is ongoing.

No significant financial relationships to disclose.

Randomized phase II study of decitabine in combination with carboplatin compared with carboplatin alone in patients with recurrent advanced ovarian cancer

5562

Background: Experimental and clinical data (Gifford et al, Clin Cancer Res. 2004) indicate the potential importance of methylation in mediating resistance to carboplatin in ovarian cancer. A previous phase I trial (Appleton et al, J Clin Oncol. 2007) established the feasibility of combining carboplatin with the demethylating agent decitabine on a day 1 + 8 q4 weekly (w) schedule and PD data provided evidence of target cell demethylation. Methods: Patients (pt) with ovarian cancer relapsing 6–12 months following first line treatment were randomised to receive either 6 cycles of carboplatin AUC 6 q4 w (Arm A), or 90 mg/m2 decitabine as a 6 hour infusion on day 1 and carboplatin AUC 6 on day 8 q4 w (Arm B). The primary endpoint was response rate. An interim analysis was planned after 11 patients were enrolled into Arm B. Results: 29 pt were enrolled. After the first 4 pt had been treated (at 90 mg/m2 decitabine) the frequency of dose delays due to neutropenia was considered unacceptable, and therefore the starting dose of decitabine was reduced to 45 mg/m2 for the subsequent 11 pt. 7 out of 14 pt in Arm A completed 6 cycles compared with 0 of 11 in Arm B (at 45 mg/m2 decitabine). Grade 2/3 hypersensitivity reactions were more common in Arm B than Arm A (64% vs. 21%), as were prolonged treatment delays due to neutropenia (36% vs. 10%). At the interim analysis, in the 11 pt treated with 45mg/m2 (Arm B), there were no RECIST responses, while 2 pt had short-lived CA125 responses (59 and 63 days). In contrast 6 of 14 patients in Arm A had RECIST responses consistent with the expected efficacy of carboplatin in this population. Conclusions: The lack of efficacy, as well as the difficulties in treatment delivery in Arm B, led the project team to conclude that the study should be closed. With this dose and schedule, decitabine is ineffective in reversing carboplatin resistance. Further investigations are ongoing to understand (a) the apparent increased incidence of hypersensitivity and (b) the trend towards reduced efficacy in Arm B.

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