[Interdisciplinary recommendations for the treatment of metastatic renal cell carcinoma]

With the introduction of targeted drug therapies, a paradigm shift for the treatment of metastatic renal cell carcinoma has taken place. New compounds like sunitinib, sorafenib, bevacizumab and temsirolimus have become established as new therapeutic standards to replace the use of cytokines as standard therapy. Recently, these substances have been complemented by everolimus and pazopanib. An interdisciplinary consensus conference was held to discuss which criteria to consider when using these drugs (treatment sequence) and what questions remain unanswered based on the current study situation (open questions). Results from the 2009 conference provided the basis for the 2010 meeting. The results of the 2010 conference are presented as short theses.

[Urogynaecology for urologists]

The field of urogynaecology represents an interdisciplinary subspecialty which is dedicated to qualified diagnostics and effective treatment of functional, static, endocrine and urological pelvic floor disorders. Core areas of the surgical uro-gynaecology are pelvic floor reconstruction for the treatment of urinary and anal incontinence, descensus and prolapse including proctological surgery. Also included are the therapy and correction after trauma of the pelvic floor, as well as reconstruction after oncological interventions. In urogynaecological pelvic floor reconstruction, supporting tapes and mesh implants are usually implanted tension-free. The principle of the tension-free tape and mesh graft implantation is based on the induction of collagen regeneration as well as the development of scar tissue creating a tight, statically effective tissue within the pelvic floor. Surgical goal is the improvement of quality of life and the restitution of an appropriate coenaesthesia with preservation of a regular micturition and continence. Another important aspect is the restitution of a regular sexuality. Conservative urogynaecology represents the medicinal, physiotherapeutic or neuromodulatory treatment of mainly descensus disorders and urinary and anal incontinence. Other foci are urinary infections, chronic pelvic pain as well as postoperative and posttraumatic insufficiency of the pelvic floor.

Antiangiogenic antitumor activity of HPMA copolymer-paclitaxel-alendronate conjugate on breast cancer bone metastasis mouse model

Polymer therapeutics have shown promise as tumor-targeted drug delivery systems in mice. The multivalency of polymers allows the attachment of different functional agents to a polymeric backbone, including chemotherapeutic and antiangiogenic drugs, as well as targeting moieties, such as the bone-targeting agent alendronate (ALN). We previously reported the conjugation of ALN and the chemotherapeutic drug paclitaxel (PTX) with N-(2-hydroxypropyl)methacrylamide (HPMA) copolymer. The in vitro physicochemical properties, cancer cytotoxicity and antiangiogenic activity of HPMA copolymer-PTX-ALN conjugate were extensively characterized. The reported results warranted in vivo evaluations of the conjugate. In this manuscript, we evaluated the in vivo anticancer and antiangiogenic activity of HPMA copolymer-PTX-ALN conjugate. The conjugate exhibited an antiangiogenic effect by decreasing microvessel density (MVD), and inducing apoptotic circulating endothelial cells (CEC) following treatment of the mice. Using intravital imaging system and mCherry-labeled breast cancer cell lines, we were able to monitor noninvasively the progression of orthotopic metastatic tumors injected into the tibia of the mice. HPMA copolymer-PTX-ALN conjugate showed the greatest antitumor efficacy on mCherry-labeled 4T1 mammary adenocarcinoma inoculated into the tibia, as compared with PTX alone or in combination with ALN. Treatment with the bone-targeted polymeric conjugate demonstrated improved efficacy, was better tolerated, and was more easily administered intravenously than the clinically used PTX formulated in Cremophor/ethanol.

External quality control for immunocytochemistry on cytology samples: a review of UK NEQAS ICC (cytology module) results

OBJECTIVE

To date, external quality control for immunocytochemistry on cytology samples is provided only by the United Kingdom national external quality assessment service for immunocytochemistry and in situ hybridisation (UK NEQAS ICC & ISH). For the purpose of this study a retrospective analysis of a comprehensive collection of quality-related data regarding immunocytochemistry on cytology samples collected through this service was analysed.

METHODS

The quality of immunocytochemical reactions, using on-line collected data, was analysed for the last 23 UK NEQAS ICC cytology module external quality assessments carried out on cytology samples completed in the period from 2004 to 2010.

RESULTS

Our study showed that the majority of participants in the cytology module (66%) sent formalin-fixed paraffin-embedded (FFPE) tissue sections for assessment as in-house control slides and only 34% sent cytology slides of various types. The highest UK NEQAS ICC score for the quality of immunocytochemical staining among in-house control slides was achieved on cell block sections, followed by cytospins, FFPE tissue sections, liquid-based cytology slides and smears. With regard to fixation, acetone-fixed slides achieved significantly lower scores than other reported fixatives. The strength of agreement in perception of immunocytochemical staining quality was good between in-house assessors (Kappa=0.64) but only fair between in-house and UK NEQAS ICC assessors (Kappa=0.22).

CONCLUSIONS

Good quality of immunocytochemical staining can be achieved on cytology slides prepared and fixed in different ways as well as on cell blocks. Unified criteria for high-quality immunocytochemical staining and proper internal and external quality assurance could facilitate further improvement and standardization of immunocytochemistry on cytology samples.

Integrin-assisted drug delivery of nano-scaled polymer therapeutics bearing paclitaxel

Angiogenesis plays a prominent role in cancer progression. Anti-angiogenic therapy therefore, either alone or in combination with conventional cytotoxic therapy, offers a promising therapeutic approach. Paclitaxel (PTX) is a widely-used potent cytotoxic drug that also exhibits anti-angiogenic effects at low doses. However, its use, at its full potential, is limited by severe side effects. Here we designed and synthesized a targeted conjugate of PTX, a polymer and an integrin-targeted moiety resulting in a polyglutamic acid (PGA)-PTX-E-[c(RGDfK)(2)] nano-scaled conjugate. Polymer conjugation converted PTX to a macromolecule, which passively targets the tumor tissue exploiting the enhanced permeability and retention effect, while extravasating via the leaky tumor neovasculature. The cyclic RGD peptidomimetic enhanced the effects previously seen for PGA-PTX alone, utilizing the additional active targeting to the α(v)β(3) integrin overexpressed on tumor endothelial and epithelial cells. This strategy is particularly valuable when tumors are well-vascularized, but they present poor vascular permeability. We show that PGA is enzymatically-degradable leading to PTX release under lysosomal acidic pH. PGA-PTX-E-[c(RGDfK)(2)] inhibited the growth of proliferating α(v)β(3)-expressing endothelial cells and several cancer cells. We also showed that PGA-PTX-E-[c(RGDfK)(2)] blocked endothelial cells migration towards vascular endothelial growth factor; blocked capillary-like tube formation; and inhibited endothelial cells attachment to fibrinogen. Orthotopic studies in mice demonstrated preferential tumor accumulation of the RGD-bearing conjugate, leading to enhanced anti-tumor efficacy and a marked decrease in toxicity as compared with free PTX-treated mice.

[Castration resistant prostate cancer 2011]

Our understanding of - as well as our approach to - castration resistant prostate cancer is currently undergoing major changes. New drugs like the CYP-17 inhibitor abiraterone have shown that even in the "hormone refractory" stage the progression of prostate cancer is still driven by signaling of the androgen receptor. Changing the term to castration resistant prostate cancer is one consequence of these new insights. Here we give an overview on the current situation of drug development, therapeutic consequences and future trends.

Phase III study of the efficacy and safety of zibotentan (ZD4054) in patients with bone metastatic castration-resistant prostate cancer (CRPC)

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Background: Endothelin-1 and the endothelin A (ETA) receptor have been implicated in prostate cancer progression in bone. Zibotentan, a specific ETA receptor antagonist, had a promising signal for prolonged overall survival (OS) in a phase II study of patients with CRPC and bone metastases who were pain free or mildly symptomatic for pain. The aim of this phase III study was to confirm the efficacy and safety of zibotentan in a similar but larger population.

Methods: Patients with CRPC and bone metastases were randomized 1:1 to zibotentan 10 mg/day po or placebo, plus standard of care including chemotherapy. The primary endpoint was OS. Secondary endpoints included times to pain progression, chemotherapy use, new bone metastases, and safety. Efficacy endpoints were analyzed using a log-rank test. At least 263 deaths were required for formal analysis. If the true hazard ratio (HR) for zibotentan versus placebo was 0.67, the analysis would have 90% power to demonstrate a statistically significant effect in OS at the 5% level.

Results: A total of 594 patients were randomized (299 to zibotentan; 295 to placebo). Baseline group demographics were similar. Mean age was ∼71 yrs, and 64% were Caucasian. Although median OS was longer in zibotentan-treated patients than those receiving placebo (median 24.5 vs 22.5 months), the difference did not reach significance (HR [95.2% confidence interval]; 0.87 [0.69–1.10]: P=0.240). No significant differences were observed for any secondary endpoints. The most commonly reported AEs in the zibotentan group, peripheral edema and headache, were consistent with the pharmacologic action of zibotentan as a vasodilator. Cardiac failure events, actively solicited following a phase II signal, were higher in the zibotentan group (any grade, 5.7%; Common Terminology Criteria for Adverse Events [CTCAE] grade ≥3, 3.0%) than placebo (any grade, 1.7%; CTCAE grade ≥3, 1.0%), but were manageable and reversible.

Conclusions: In this placebo-controlled phase III trial treatment with zibotentan 10 mg/day did not lead to a significant improvement in OS in patients with CRPC and bone metastases. Zibotentan had an acceptable safety profile.

[Table: see text]

Everolimus in patients with metastatic renal cell carcinoma (mRCC) who are intolerant of or have progressed after prior vascular endothelial growth factor receptor–tyrosine kinase inhibitor (VEGFr-TKI) therapy: An international expanded access program (EAP)

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Background: The mammalian target of rapamycin (mTOR) inhibitor everolimus is the first agent to show efficacy in a randomized, controlled phase III trial in patients with mRCC after progression on VEGFr-TKIs (RECORD-1). Progression-free survival (PFS) was significantly improved (4.9 vs 1.9 months) and the risk of disease progression was reduced by 67% with everolimus compared with placebo. To fulfill an unmet medical need, everolimus was offered globally in this EAP. Presented here are preliminary results on 605 patients.

Methods: The program began in July 2008 (ClinicalTrials.gov: NCT00655252 ; EudraCT: 2007-005460-28), and since then over 1,000 patients in 34 countries have been enrolled. Patients with clear cell and non–clear cell mRCC who failed or became intolerant of VEGFr-TKIs received daily oral doses of everolimus with investigator assessment every 3 months.

Results: Data were collected for 605 patients who had discontinued treatment as of January 15, 2010. Evaluable patients had a mean age of 63 years, and most (94%) had progressed after prior VEGFr-TKI therapy. The adverse event (AE) profile did not differ significantly from that reported in the RECORD-1 trial. Most frequently reported grade 3–4 AEs were anemia (6.1%), stomatitis (4.6%), fatigue (4.6%), hyperglycemia (4.0%), and infection (3.6%). Grade 3–4 noninfectious pneumonitis was reported in 2.8%. Best overall response was stable disease, which was evident in 42% of patients.

Conclusions: The EAP has allowed patients with mRCC access to everolimus before marketing approval. The rapid enrollment rate of this EAP confirms the unmet medical need after failure of VEGFr-TKIs. Everolimus has shown good tolerability, and no new safety issues have been identified. The investigator-assessed response rate is consistent with that reported in the RECORD-1 trial. The EAP provides an efficient framework for the development of other programs for innovative anticancer agents in patients without satisfactory therapeutic options.

[Table: see text]

Using community pharmacies to evaluate the safety of a prescription only medicine in an OTC environment: a unique method in Europe

Focal points

Abstract P3-10-21: Audit of the Accuracy of Immunohistochemical (IHC) Testing of HER2 Status of Breast Cancer in the United Kingdom: An Interim Analysis

Background: The analysis of the level and distribution of HER2 protein expressed by cancer cells (HER2 status) is of great clinical value in the management of breast cancer patients both for the determination of the prognosis of disease and for identification of those patients who are eligible for anti-HER2 therapy. Accurate assessment of the HER2 status is essential for identifying patients which will benefit from HER2 targeted therapy. HER2 status in the UK is established using a two tier strategy with IHC as the initial test and subsequent reflex of equivocal results to in situ hybridization (ISH). IHC staining of the HER2 protein is graded as 0- 3+ dependent upon the intensity of staining, cellular localisation and the percentage of cells positive in accordance with CAP/ASCO and UK guidelines. HER2 3+ cases are considered as positive, with HER2 2+ cases (equivocal) retested by ISH to ascertain the gene amplification status. Cases that are scored as 0 and 1+ by IHC have no additional testing and are classed as negative. The literature indicates that a subset of these IHC negative cases show HER2 gene amplification by FISH (range 1.1-10.7%). The aim of this audit is to evaluate the discordance rate of HER2 IHC negative, FISH positive breast cancer in the UK, with a secondary objective to resolve if this is related to the choice of antibody used. Materials and methods: This audit selected a total of 1000 sequential cases reported as HER2 negative on IHC, from three UK reference centres receiving cases from 29 different hospitals. The cases were given a unique identifying number and annonymised. Each of the three centres used a different IHC method for frontline HER2 testing with centre one using HercepTest™ (DAKO), centre two Pathway 4B5 (Roche), and centre three, Oracle (Leica Microsystems). HER2 gene amplification status was determined using dual colour FISH analysis, PathVysion (ABBOTT) fluorescence ISH (FISH) in a single centre to provide standardised methodology and assessment. HER2 was classed as amplified when the HER2/cep 17 ratio was two or greater in accordance with UK guidelines. All cases which showed discordance between IHC and FISH were retested with each of the HER2 IHC platforms to discover whether these are truly discordant results or if the discrepancy is a consequence of the choice of antibody.

Results: An interim analysis of 170 cases shows an overall IHC negative/FISH positive discordance rate of 2.37%. The discordance rate per antibody was 1.7% for HercepTest, 3.3% with 4B5 and 2.5% with Oracle. Of the FISH positive cases the HER2/cep 17 ratios ranged from 2.2 - 6.17. The overall discordance rate between IHC negative and FISH positive is in keeping with the literature and is comparable between the three IHC platforms.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-10-21.

Abstract P3-10-13: Prognostic Value of Genomic Analysis after Neoadjuvant Chemotherapy for Breast Cancer

Background

Oncotype DX® Recurrence Score® (RS) provides both predictive and prognostic information for estrogen receptor positive (ER+) breast cancer. Whether RS evolves after exposure to chemotherapy (C), or if RS post-neoadjuvant C has prognostic capacity for outcomes after bevacizumab, is not known. Methods

DFCI 05-055 treated patients (pts) with residual invasive disease following neoadjuvant C with sequential bevacizumab-containing regimens. Archival FFPE tissue was obtained from participants at 3 potential timepoints: pre-C core biopsy, post-C surgical residual disease, and core biopsy at time of systemic recurrence. Standard RS testing was performed on all samples.

Results

A total of 162 pts were enrolled on the parent study; of that, 118 samples from 80 pts were available for testing, including 48 pre-C core biopsies, 68 post-C surgical samples, and 34 paired samples before and after C. Comparison of ER/PR/HER2 testing by local IHC vs RT-PCR for the pre-C core biopsies showed excellent concordance. For the entire cohort of 80, 20 pts (25%) experienced distant recurrence (9 ER+, 11 ER-by IHC). RS risk distribution in this group included 14 high, 3 intermediate (int), and 3 low. High RS was positively associated with distant recurrence for the entire cohort (t-test p=0.04); this association remained consistent whether RS was tested pre-C (t-test p=0.07) or post-C (t-test p=0.02). Specimen characteristics of the 34 paired pre-C/post-C samples are described below. Of the 34 paired samples, RS was highly correlated before and after exposure to neoadjuvant C, (r=0.85, 95% CI 0.72-0.92), suggesting little, if any, change in RS from C exposure. Specific changes over time included 24 without change in RS group, 3 high to int, 1 high to low, 1 int to low, and 5 low to int. Testing by RT-PCR remained consistent for ER (r=0.91, 95% CI 0.82-0.95), PR (r=0.79, 95% CI 0.62-0.89) and HER2 (r=0.88, 95% CI 0.76-0.94) before and after neoadjuvant C. Two pts had biopsy samples from systemic recurrence; testing showed RS, ER, PR, HER remained in similar range from core biopsy to surgery to disease recurrence.

Conclusions

In this evaluation of samples pre-and post-neoadjuvant C, high RS determined either before or after neoadjuvant C predicted for disease recurrence after adjuvant bevacizumab treatment. RT-PCR and IHC values for ER/PR/HER2 were concordant. Paired RS and RT-PCR ER/PR/HER2 remained correlated despite interval exposure to neoadjuvant C. Post neoadjuvant C RS may provide valid prognostic information for breast cancer disease recurrence and warrants further study.

Specimen Characteristics for Paired Samples (n=34)

Toward development of targeted nonsteroidal antiandrogen-1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid-gadolinium complex for prostate cancer diagnostics

Androgen receptors are present in most advanced prostate cancer specimens, having a critical role in development of this type of cancer. For correct prognosis of patient conditions and treatment monitoring, noninvasive imaging techniques have great advantages over surgical procedures. We developed synthetic methodologies for preparation of novel androgen receptor-targeting agents in an attempt to build a versatile platform for prostate cancer imaging and treatment. The structure of these compounds comprises of a lanthanoid metal ion, gadolinium-1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (Gd-DOTA)-based binding fragment and, connected to it by a flexible linker, bicalutamide-derived nonsteroidal antiandrogen moiety. A representative gadolinium complex 15 was evaluated as a magnetic resonance imaging (MRI) agent in C57/bl6 male mouse bearing orthotopic TRAMP C2 prostate tumor.

Outcome of treatment discontinuation in patients with metastatic renal cell carcinoma and no evidence of disease following targeted therapy with or without metastasectomy

BACKGROUND

It is unknown if discontinuation of targeted therapy (TT) and readministration in case of recurrence is feasible in patients with metastatic renal cell carcinoma (mRCC) in which complete response (CR) is achieved by TT alone or no evidence of disease (NED) with additional resection of residual metastases.

PATIENTS AND METHODS

Patients in whom TT was discontinued after CR to TT alone or NED after additional metastasectomy were included in this retrospective analysis. Outcome criteria evaluated were time off TT, recurrence of metastases and response to re-exposure to TT. Univariate and multivariate analyses were carried out to identify variables potentially predictive of outcome.

RESULTS

In 36 patients with CR or NED under TT with sunitinib (22), sorafenib (11), bevacizumab/interferon (2) and temsirolimus (1), TT was discontinued. Recurrence was observed in 24 patients (66.7%). Re-exposure to TT was effective in 86.9% of these cases. Twelve patients (33.3%) remained recurrence free at a median follow-up of 12 months (range 3-31). Median time off TT was 7 months (range 1-31). Factors that correlate with outcome could not be identified.

CONCLUSIONS

In the majority of patients with mRCC and CR or NED, discontinuation of TT was followed by recurrence, but re-exposure to TT was effective.

Aberrant hepatic TRIB3 gene expression in insulin-resistant obese humans

AIMS/HYPOTHESIS

The pseudokinase tribbles homologue 3 (Drosophila) (TRIB3) negatively interferes with insulin-mediated phosphorylation and activation of v-akt murine thymoma viral oncogene homologue 1 (AKT1, also known as protein kinase B). Animal studies have shown that Trib3 expression was higher in the fasting state and in animal models of diabetes, promoting hyperglycaemia presumably by increasing glucose production in the liver. Less is known about the role of TRIB3 in insulin resistance in humans, although a gain-of-function mutation associated with abnormalities related to insulin resistance has been described in TRIB3.

METHODS

We determined hepatic mRNA expression of TRIB3 and selected genes encoding enzymes, transcription factors and coactivators involved in glucose homeostasis. We also determined biochemical variables of intermediary metabolism in obese patients with varying degrees of insulin resistance.

RESULTS

In our study population hepatic TRIB3 mRNA expression was associated with surrogate markers of insulin resistance. TRIB3 expression was significantly increased in a subgroup with high HOMA of insulin resistance (HOMA-IR) compared with a low HOMA-IR group (p = 0.0033). TRIB3 transcript levels were correlated with PEPCK (also known as PCK2) mRNA expression (p = 0.0014) and mRNA expression of PPARGC1A (p = 0.0020), PPARGC1B (p < 0.0001), USF1 (p = 0.0017), FOXO1 (p = 0.0003) and SREBP-1c (also known as SREBF1; p = 0.0360). Furthermore ligands of peroxisome proliferator-activated receptor alpha/retinoid X receptor and overexpression of its coactivator PPARGC1A as well as overexpression of SREBP-1c and its coactivator PPARGC1B increased TRIB3 promoter activity in HepG2 cells.

CONCLUSIONS/INTERPRETATION

We have found evidence for a role of aberrant hepatic TRIB3 transcript levels in insulin resistance in obese humans and identified potential transcriptional pathways involved in regulation of TRIB3 gene expression in the liver.

Cardiovascular disease risk factors, depression symptoms and antidepressant medicine use in the Look AHEAD (Action for Health in Diabetes) clinical trial of weight loss in diabetes

AIMS/HYPOTHESIS

To determine the associations of baseline depression symptoms and use of antidepressant medicines (ADMs) with baseline cardiovascular disease (CVD) risk factors in Look AHEAD (Action for Health in Diabetes) trial participants.

METHODS

Look AHEAD participants (n = 5,145; age 58.7 +/- 6.8 years; BMI 35.8 +/- 5.8 kg/m(2)) were assessed for CVD risk factors (elevated HbA(1c) or insulin use, elevated BP or antihypertensive use, elevated lipid levels or lipid-lowering medication, current smoking, BMI > or = 30 kg/m(2), lower peak exercise capacity assessed as metabolic equivalents [METs], and ankle-brachial index <0.9 or >1.3). Participants also completed the Beck Depression Inventory (BDI) and reported their use of ADMs.

RESULTS

Of the participants, 14.7% had BDI scores > or = 11, consistent with mild-moderate depression, and 16.5% took ADMs; 4.4% had both depression markers (i.e. elevated symptom scores and took ADMs). In logistic regression analyses of CVD risk (elevated risk factor or use of medication to control the risk factor), controlled for demographic factors, continuous BDI scores and ADM use were each independently associated with elevated BP (or medication), current smoking, BMI > or = 30 kg/m(2) and lower MET values. ADM use was also associated with elevated serum lipids or use of lipid-lowering medication.

CONCLUSIONS/INTERPRETATION

Among Look AHEAD participants, depression symptoms or ADM use on entry to the study were each independently associated with a wide range of CVD risk factors. Future research should assess the temporal dynamics of the relationships of depression symptoms and ADM use with CVD risk factors.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00017953

FUNDING

This study is funded by the National Institutes of Health with additional support from the Centers for Disease Control and Prevention.

[Incarcerated hernia after laparoscopic drainage of a lymphocele]

Laparoscopic lymphocele drainage is considered the gold standard for the treatment of lymphoceles after kidney transplantation. We report on a female patient who developed a symptomatic posttransplant lymphocele. After laparoscopic lymphocele drainage the patient presented with acute pain in the left lower abdomen. A CT scan showed a hernia into the peritoneal window. This is a rare but potentially severe complication after intraperitoneal lymphocele drainage. CT imaging and swift reoperation with enlargement of the peritoneal window are critical to avoid serious complications. To avoid bowel incarceration, the peritoneal window should be as large as possible.

[Interdisciplinary recommendations for the treatment of metastatic renal cell carcinoma]

With the introduction of targeted therapies, a -paradigm shift for the treatment of metastatic renal cell carcinoma has taken place. The use of cytokines as the long-standing standard therapy has declined. New compounds like sunitinib, -sorafenib, bevacizumab and temsirolimus have become established as new therapeutic standards. Since mid-2009, these substances have been complemented by everolimus. An interdisciplinary consensus conference was held to discuss what criteria to consider when using these drugs (treatment sequence) and what questions remain unanswered based on the current study situation (open questions). Results from the 2008 conference provided the basis for the 2009 meeting. The results of the 2009 conference are presented as short theses.