[Target selectivity of anticancer drugs]

Since the first use of chemotherapy, many efforts were devoted to develop drugs with a specific anticancer activity. Nevertheless, although several approaches to this end were used leading to significant results in cancer treatment, chemotherapy has mainly a palliative effect. The remarkable scientific advances in the knowledge of molecular changes in neoplastic diseases brought to development of new drugs with a specific molecular target. In some cases, this approach against a single molecular target, has been extremely successful, like imatinib in GIST. However, since in most cases tumor growth involves multiple genetic changes, it seems more appropriate to develop multitargeted agents. A successful way to improve target selectivity of anticancer drugs and to better choose patients to treat could be the use phase 0 clinical trials. In the future, the hope is to discover all genetic changes in each cancer patient and to restore the normal function of the cell with the aid of more advanced technologies.

Human bone marrow-derived mesenchymal stem cells

Mesenchymal stem cells (MSCs) have elicited a great clinical interest, particularly in the areas of regenerative medicine and induction of tolerance in allogeneic transplantation. Previous reports demonstrated the feasibility of transplanting MSCs, which generates new prospects in cellular therapy. Recently, injection of MSCs induced remission of steroid-resistant acute graft-versus-host disease (GVHD). This review summarizes the knowledge and possible future clinical uses of MSCs.

Irinotecan, docetaxel and oxaliplatin combination in metastatic gastric or gastroesophageal junction adenocarcinoma

This phase II study was designed to evaluate the activity and safety of a combination of irinotecan, docetaxel and oxaliplatin in metastatic gastric or gastroesophageal junction (GEJ) adenocarcinoma. Forty patients with measurable distant metastasis received irinotecan 150 mg m(-2) and docetaxel 60 mg m(-2) on day 1, and oxaliplatin 85 mg m(-2) on day 2. Cycles were repeated every 3 weeks. The primary end point was to demonstrate a 50% improvement in time-to-progression (TTP) over historical controls. All patients were evaluable. Median TTP was 6.5 months (95% confidence interval (CI) 5.6-7.4), the overall response rate was 50% (95% CI 35-65%) and the median overall survival was 11.5 months (95% CI 8.7-14.3). Grade 3/4 neutropaenia occurred in 47.5% of patients. There were four episodes of febrile neutropaenia in three patients. Other non-haematological grade 3 toxicities included diarrhoea in four patients (10%), vomiting in three patients (7.5%) and mucositis in two patients (5%). The irinotecan, docetaxel and oxaliplatin combination chemotherapy is an active and well-tolerated novel regimen for treating metastatic gastric or GEJ adenocarcinoma and deserves further evaluation in randomised trials and in combination with molecular targeting agents.

[Neoadjuvant endocrine therapy for locally advanced breast cancer]

The use of neoadjuvant chemotherapy in the treatment of locally advanced breast cancer is now well established. However, endocrine therapy can be a valid alternative to primary chemotherapy in the treatment of hormone-sensitive tumors, particularly in post-menopausal women. Tamoxifen (TAM) was initially used in older or frail patients who were not candidates for chemotherapy. Response rate of 49% to 68% were observed. These encouraging results prompted subsequent randomized phase III studies demonstrating the superiority of surgery in comparison to TAM as primary treatment. The successful use of aromatase inhibitors (AI) in the metastatic and adjuvant setting has encouraged studies that compare these agents with tamoxifen in the neoadjuvant setting. In terms of response rates, anastrozole and exemestane did not differ from TAM, while letrozole was superior. Nevertheless, all the AI were found to be superior to TAM as far as breast conserving surgery is concerned. The Americal College of Surgeons Oncology Group (ACOSOG) has recently activated a neoadjuvant randomized trial comparing anastrozole, letrozole and exemestane in postmenopausal patients with estrogen receptor positive tumors. Hopefully, this study will clarify which of these agents is more effective as primary endocrine therapy. In the meantime, neoadjuvant hormonal treatment should be considered in elderly patients with inoperable tumors or tumors not amenable to conservative surgery, with highly expressed estrogen receptors and contraindication to chemotherapy.

[High-dose CEF (cyclophosphamide, epirubicin, fluorouracil) as primary chemotherapy in locally advanced breast cancer: long-term results]

PURPOSE

To determine wether primary CEF is effective in locally advanced breast cancer, as measured by response, local recurrences, disease free survival (DFS) and overall survival (OS).

MATERIAL AND METHODS

From 1990 to 1998, 62 patients with stage III disease were enrolled into a prospective study at Regina Elena Institute for Cancer Research, Rome. Inflammatory breast cancer (IBC) was included. Patients received three 21 days cycles of chemotherapy that consisted in epirubicin 50 mg/m2, cyclophosphamide 400 mg/m2, and fluorouracil 500 mg/m2 i.v. on days 1 and 8. G-CSF (300 microg) was given subcutaneously every other day from day 5 to day 17. After primary chemotherapy, whenever possible, mastectomy or conservative surgery was performed. Subsequently responding patients received the same regimen, while non responders were given a non cross resistant chemotherapy. In case of conservative surgery or initial T4 tumor radiation therapy was performed at the end of adjuvant chemotherapy. ER positive patients received tamoxifen 20 mg/d for five years.

RESULTS

Seven IIIA patients had a median OS of 43 months (C.I. 95%, 31-55) and DFS of 42 months (C.I. 95%, 16-68), while 15 IBC patients had a median OS of 52 months (C.I. 95%, 52-79) and DFS of 27 months (C.I. 95%, 14-39). Forty IIIB non inflammatory breast cancer patients had a median DFS of 87 months (C.I. 95%, 1-175); median OS was not reached. Ten-year OS was 28.6% for stage IIIA, 50.6% for stage IIIB and 36% for IBC.

CONCLUSION

Primary CEF appear to be an effective treatment. In our study we obtained a good local control and interesting long term data of disease free and overall survival.

Multiplexed genotyping using a novel digitally inscribed bead-based system

21089

Background: Genotyping of clinical samples has been limited to low levels of multiplexing, ranging from one to a few dozen single nucleotide polymorphisms (SNPs) per sample. By increasing multiplexing levels, a clinical lab can increase information content per sample, decreasing costs and sample material requirements. Methods: We have adapted the GoldenGate® Assay for simultaneously genotyping 96 to 1,536 SNPs to the BeadXpress™ System, a new high-throughput platform that utilizes digitally inscribed VeraCode™ beads in a compact fluidic instrument. Genotyping on this platform ranges from 96 to 384 multiplexing, using the same GoldenGate Assay that has proven highly robust for millions of genotypes. In preliminary tests, we have observed greater than 99% call rates, and greater than 99.5% rates for reproducibility and heritability. In a test of 96 SNP genotypes chosen for a study of colorectal cancer, a point mutation in the MSH2 gene, previously implicated in predisposition to several cancers, was correctly genotyped when compared to qPCR analysis of the same samples. Conclusion: Together with genotyping data from reference samples, the GoldenGate Assay on the BeadXpress System has yielded highly reproducible and accurate genotypes, suggesting that this approach will prove useful for rapid refinement of SNPs for development of clinical genotyping tests.

No significant financial relationships to disclose.

A proposal of pathological classification (pTNM) of patients with head and neck cancer according to capsular rupture (pN- RC)

16525

Background: Lymph node metastasis remains one of the most significant prognostic factors of head and neck squamous cell carcinoma survival. Several studies have demonstrated that capsular rupture (CR) significantly decreases survival in patients with a positive neck dissection. We proposed to investigate whether inclusion of CR in the pTNM improves the prognostic capacity of the classification. Methods: We reviewed 841 patients (p) who underwent neck dissection and had a minimum follow-up of two years. The Kaplan-Meier method was used to analyce survival according to presence of neck nodes with CR and number of nodes with CR. Results: We analyzed 841p (151 oral cavity, 97 oropharynx, 136 hypopharynx, 258 supraglotis, 151 glotis and 48 only node; T1, 208 T2, 336 T3, 164 T4; 349 N0, 174 N1, 242 T2 and 78 N3). Treatment was surgery in 220 p and surgery plus radiotherapy in 621p. We treated 465 p with induction chemotherapy. Five-year survival was: 87% for pN0 (n=34), 67.2% for pN1RC-negative (n=118), 74.6% for pN1RC-positive (n=24), 51.7% for pN2RC-negative (n=127), 39.8% for pN2RC-positive only one node (n=58), 17.4% for pN2RC-positive more than one node (n=93) and 21.7% for pN3 (n=72). Conclusions: These results indicate that including CR information in the pTNM improves prognostic capacity of the classification. We propose four pTNM categories: Category 0: pN0; category 1: pN1RC-negative or -positive; category 2: pN2RC-negative or pN2RC-positive only one node; category 3: pN2RC-positive more than one node or pN3.

No significant financial relationships to disclose.

[Thrombin induced tumour growth - pharmacological control]

The central enzyme of blood coagulation, the serine proteinase thrombin, is capable to modify the growth of tumour cells by interaction with protease activated receptors 1 and 4 of the tumour cells. Thrombin is permanently available in tumour micro environment; meizothrombin is generated from prothrombin at a tumour specific activation complex and can influence tumour cell growth via PAR-1 and 7-transdomain protein receptor signalling pathway, too. PEG-coupled direct thrombin inhibitors that possess special pharmacokinetic characteristics and that have been designed for long lasting efficacy in extracellular space, control serine proteinase activity in tumour micro environment and therefore they own a high potential anti-tumour efficacy. In xenographic tumour models this new substance class has shown a significant carcinostatic effect.

Post-appendectomy intra-abdominal abscesses--can they successfully be managed with the sole use of antibiotic therapy?

PURPOSE

Controversy persists concerning the management of post-appendectomy intra-abdominal abscesses. We hypothesised that most of these abscesses can be successfully managed by antibiotic treatment alone, avoiding the complications of surgical treatment.

METHODS

Hospital records of children treated in our unit for intra-abdominal post-appendectomy abscesses over a 6-year period were reviewed retrospectively.

RESULTS

This study investigates a series of 26 children from 2 to 15 years of age presenting with one or more post-appendectomy intra-abdominal abscesses. After an average delay of 7 days after initial surgery, 23 children had developed an isolated abscess, while 3 children had multiple abscesses. Twenty-two patients (84.8 %) were treated conservatively by intravenous triple antibiotic therapy alone. Complete clinical, radiological and biological resolution of the abscesses was obtained in all of these children after a mean hospitalisation of 8 days. Four children (15.2 %) were treated surgically: three children with a stable patient status and one child with septic shock requiring urgent surgery.

CONCLUSION

The results suggest that intravenous triple antibiotic therapy alone is an efficacious first-line treatment in children developing intra-abdominal abscesses following appendectomy. Surgical intervention is rarely necessary except in patients with an alarming patient status or with signs of septic shock.

Innate immunity and new adjuvants

Vaccination remains the most cost-effective biomedical approach to the control of infectious diseases in livestock. Vaccines based on killed pathogens or subunit antigens are safer but are often ineffective and require coadministration with adjuvants to achieve efficacy. Unfortunately, most conventional adjuvants are poorly defined, complex substances that fail to meet the stringent criteria for safety and efficacy desired in new generation vaccines. A new generation of adjuvants that work by activating innate immunity presents exciting opportunities to develop safer, more potent vaccines. In this review the authors highlight the role of innate immunity in protection against infectious disease and provide some examples of promising new adjuvants that activate innate immunity. They do not review the conventional adjuvants present in many vaccines since they have been reviewed extensively previously.

Whole-brain and regional brain atrophy in amyotrophic lateral sclerosis

BACKGROUND AND PURPOSE

Recent evidence from neuropsychologic and neuroimaging studies suggests that central nervous system involvement in amyotrophic lateral sclerosis (ALS) extends beyond motor neurons. Our purpose was to obtain measures of global and regional atrophy in nondemented patients with ALS to assess subtle structural brain changes.

METHODS

MR images, acquired from 16 patients and 9 healthy subjects (HS), were processed by using the Structural Imaging Evaluation of Normalized Atrophy (SIENA) software to estimate whole-brain atrophy measures and the voxel-based morphometry (VBM) method to highlight the selective volumetric decrease of single cerebral areas. In addition, each subject underwent a neuropsychologic examination.

RESULTS

In patients with ALS, brain parenchymal fraction was slightly lower compared with HS (P = .012), and seemed to be related to the presence of cognitive impairment. Patients showed a gray matter volume decrease in several frontal and temporal areas bilaterally (P < .001 uncorrected) compared with HS, with a slight prevalence in the right hemisphere. No volume reduction in primary motor cortices of patients was detected. Performances on Symbol Digit Modalities Test were significantly worse in patients compared with HS (P = .025).

CONCLUSIONS

The presence of mild whole-brain volume loss and regional frontotemporal atrophy in patients with ALS could explain the presence of cognitive impairment and confirms the idea of ALS as a degenerative brain disease not confined to motor system.

Edelfosine protects precultured heart fragments against the invasion of malignant cells through altered sialylation

1-O-octadecyl-2-O-methylglycero-3-phosphocholine (ET-18-OMe)-treated precultured heart fragments (PHF) are resistant to the invasion of malignant cells. Previous studies have demonstrated that this effect is due to the alterations of the N-linked glycoproteins in PHF after 48-h ET-18-OMe treatment. Moreover, the observed effect was still present seven days after ET-18-OMe was omitted. The present study reveals that approximately 13.4% of the administered ET-18-OMe was taken up by PHF and about 75% of the initial uptake was still present after ET-18-OMe was removed. In addition, we found significant changes in the sialic acid content and sialyltransferase activities in both conditions. Overall, these results clearly demonstrate that the uptake and retention of ET-18-OMe are responsible for the resistance to the invasion of malignant cells due to the altered sialylation of the cell surface glycoproteins in PHF.

Fertility assessment in non-infertile HIV-infected women and their partners

The objective of the study was to assess the fertility of non-infertile couples seeking pregnancy in whom the woman was HIV infected. Therefore, a cross-sectional study was conducted between January 1998 and March 2005. A standardized fertility assessment was performed in all the included couples. A total of 130 women and 121 men were evaluated. Their median age was 34 years (range 22-43). Only 7.2% of the women were severely immunocompromised. The majority of women had regular cycles. Only one woman had an active sexually transmitted disease at the time of evaluation. A tubal occlusion on hysterosalpingogram was present in 27.8% of the women with no proven fertility. In 50.5% of the women, hepatitis C virus co-infection was present. One-third of the male partners (38/121) was infected with HIV. Abnormal semen parameters were observed in 83.4% of HIV-infected and 41.7% of HIV-uninfected partners (OR = 7; 95% CI = 2.1-23). It is concluded that the great majority of the HIV-infected women seeking pregnancy had a good infection status. Because in many of the couples, the women presented unexplained tubal occlusions and the men presented semen alterations, a hysterosalpingography and semen analysis should be part of the preconceptional investigations.

[New combination chemotherapy regimens in the primary treatment of operable breast cancer]

Primary (neoadjuvant) systemic chemotherapy is the standard treatment for locally advanced breast cancer and a standard option for primary operable disease. Although survival results are similar, primary chemotherapy has the following advantages in comparison to adjuvant chemotherapy: it represents a chemosensitivity test in vivo and can be of value in determining the prognosis of the patient since pathologic complete responses are related to improved survival. Among a variety of primary chemotherapy regimens currently available, the most effective seem to be those containing both anthracyclines and taxanes, expecially when these agents are administered sequentially. There are also several ongoing studies evaluating primary hormonal therapy and the combination of cytotoxic chemotherapy and targeted agents. It is conceivable that in the future primary chemotherapy of breast cancer will be increasingly used. In fact, besides its clinical effectiveness, primary chemotherapy is extremely important to evaluate new agents and to find useful prognostic and predictive factors.

Olive oil mill wastewaters pollution abatement by physical treatments and biodegradation with Phanerochaetae chrysosporium

This paper discusses decolorization and chemical oxygen demand (COD) abatement in olive mill wastewaters (OMW) by Phanerochaetae chrysosporium grown in static, suspended and immobilised cultures. When P chrysosporium is used in cultures, no decolorization of crude OMW is observed. Decolorization occurs only after removal of polyphenols by adsorption on wood sawdust, which allows for removal of 39% of polyphenols. The use of High lignin peroxides (Lip) producing medium, yields the highest OMW decolorization and COD removal efficiencies. The use of P. chrysosporium immobilized on polyurethane foam leads to significant abatements of OMW polluting characteristics. In fact, chemical oxygen demand (COD), Biological oxygen demand (BOD5) and polyphenols contents are significantly reduced. In addition, a significant effluent decolorization is obvious.

[Merkel cell carcinoma]

Merkel cell carcinoma is a rare form of skin cancer of likely neuroendocrine origin wich affects mainly white population in sun-exposed areas. It is an aggressive tumor and survival is dependent on stage at the time of diagnosis. The staging evaluation include CT imaging and recently PET scan. Surgical excision with or without lymph node dissection, followed by postoperative radiotherapy in stage II disease, is the standard treatment of non metastatic disease. The role of adjuvant chemotherapy is still controversial. In patients with metastatic disease, chemotherapy regimens active in small cell lung cancer are generally used. The combination of cyclophosphamide, doxorubicin and vincristine (CAV) has an overall response rate of 75%, whereas the response rate of etoposide in combination with cisplatin or carboplatin is 60%. Experience with other therapeutic agents, such as tumor necrosis factor, interferon and octreotide is scanty. Recently, encouraging preliminary results with targeted agents have been reported. Our experience in 14 patients, four of whom treated with chemotherapy for advanced disease, is in agreement with literature

Possible alternative to European Pharmacopoeia's method of analysis Test for Fc Function of Immunoglobulin (2.7.9) by using tetanus toxoid as antigen

Preparations of intravenous immunoglobulins must keep functional integrity throughout the purification process. In order to assess Fc fragment functionality, the European Pharmacopoeia proposes the Test for Fc function of immunoglobulin (2.7.9), which is based on a rubella antigen of high titre. Sometimes, such antigen is difficult to obtain. In the present study, we develop the same assay using tetanus toxoid instead of rubella antigen, adapting the procedure for the use of tetanus toxoid. The comparison between rubella-based and tetanus-based assays showed that the slopes of the haemolysis curves were higher if red blood cells had been sensitised with the rubella antigen than with tetanus toxoid. Nonetheless, the tetanus-based assay gave satisfactory results and it could be a good alternative antigen target.

Correlated break at PARK2/FRA6E and loss of AF-6/Afadin protein expression are associated with poor outcome in breast cancer

Common fragile sites (CFSs) are regions of chromosomal break that may play a role in oncogenesis. The most frequent alteration occurs at FRA3B, within the FHIT gene, at chromosomal region 3p14. We studied a series of breast carcinomas for break of a CFS at 6q26, FRA6E, and its associated gene PARK2, using fluorescence in situ hybridization on tissue microarrays (TMA). We found break of PARK2 in 6% of cases. We studied the PARK2-encoded protein Parkin by using immunohistochemistry on the same TMA. Loss of Parkin was found in 13% of samples but was not correlated with PARK2 break. PARK2 break but not Parkin expression was correlated with prognosis. Alteration of PARK2/FRA6E may cause haplo-insufficiency of one or several telomeric potential tumor suppressor genes (TSG). The AF-6/MLLT4 gene, telomeric of PARK2, encodes the Afadin scaffold protein, which is essential for epithelial integrity. Loss of Afadin was found in 14.5% of cases, and 36% of these cases showed PARK2 break. Loss of Afadin had prognostic impact, suggesting that AF-6 may be a TSG. Loss of Afadin was correlated with loss of FHIT expression, suggesting fragility of FRA6E and FRA3B in a certain proportion of breast tumors.

[Skin adnexal tumors]

Adnexal skin tumors are rare neoplasms that develop from hair follicles, sebaceous glands and sweat glands. In the majority of cases these tumors are benign, although metastases have been reported in rare occasion. The diagnosis in always histologic and often it is sufficient to report the lesion simply as benign or malignant. Radical surgery is the treatment of choice. When the tumor is large, the Mohs technique can be used. Local recurrence is frequent in case of incomplete surgical removal. Etastatic disease, although rare, has a poor prognosis. Chemotherapy and radiotherapy experience is very limited. Overall, combination chemotherapy seems to be superior to single agent treatment.

FOLFOX-4 + cetuximab in untreated patients with advanced colorectal cancer. A phase II study of the Gruppo Oncologico dell’Italia Meridionale (prot. GOIM 2402)

3559

Background: Cetuximab is an IgG monoclonal antibody targeting the EGFR showing to be effective both as single agent or in combination with Irinotecan (CPT-11) or Irinotecan/FU/FA in patients (pts) with EGFR-expressing metastatic colorectal cancer (CRC) in the first and second/subsequent-line setting. The current trial was designed to evaluate the efficacy and the safety of Cetuximab plus Folfox-4 as first -line treatment. The main objective was the percentage of confirmed objective response rate. Methods: Chemonaivepts with non-resectable metastatic CRC and expressing EGFR were treated with Cetuximab (400 mg/m2 week 1 and 250 mg/m2 weekly thereafter) plus Folfox-4 (every 2 weeks: Oxaliplatin 85 mg/m2, day 1; FA 100 mg/m2 2h, simultaneously with OH-P, and FU 400 mg/m2 iv bolus followed by 600 mg/m2 iv for 22h on days 1 and 2). The first evaluation of disease status (Recist criteria) was performed after the first 4 cycles and confirmed after one month. The treatment was continued until a maximum of 12 cycles of chemotherapy; the maintenaice with Cetuximab was permitted. Preliminary results: On the 65 screened pts, 47 (72%) had EGFR-expressing metastatic disease and were enrolled. Their main characteristics were: median Ecog PS 0; median age 66 yrs (range 43–74); main sites of disease: liver 31, lung 12, lymph-nodes 3, others 8. To date twenty-two pts are evaluable for activity and 27 for toxicity; 2 pts are not evaluable and 25 are too early. We observed 16 PR (72.7%), 5 NC (22.7%) and 1 PD (4.6%) for an ORR of 72.7% and a TGCR of 95.4%; the confirmed PR were 15 (68%). To date 2 pts undergone surgery of their metastases both for lung. The main adverse events grade 3/4 (NCI criteria) were: acne-like rush 18.5%, diarrea 7%, nausea/vomiting 4% and anemia 4%. Conclusions: Our preliminary results confirm that the combination of Cetuximab plus Folfox-4 has an high activity and a good safety profile in advanced CRC pts. The study is ongoing.

No significant financial relationships to disclose.

Toxicity of epirubicin and cyclophosphamide (EC) vs. docetaxel (D) followed by EC in the adjuvant (adj) treatment of node positive breast cancer. A multicenter randomized phase III study (GOIM9902)

10526

Background: Due to high activity of taxanes (T) and anthracyclines (A) in advanced breast cancer (BC) and to the lack of cross-resistance between them, several adjuvant (adj) trials have been performed to test the efficacy of combination or sequential schedules of T and A adjuvant. In most of the sequential trials A followed T. The sequence T->A was proven active in metastatic BC, but no data are available in the adj setting. This multicenter randomized phase III study was designed to evaluate the efficacy of the sequence T->A vs an A containing regimen Methods: Pts with pT1–3 pN1 M0 (UICC1997) BC, age 18–70, PS(ECOG) 0–1, normal cardiac function, adequate bone marrow, hepatic and renal function were eligible for the study. Pts were stratified according to institution, age (≤ 50 vs > 50), hormonal receptor status and number of involved nodes (≤ 3, 4–9, ≥ 10) and were randomized to receive either 4 cycles of EC (Epirubicin 120 mg/m2 + Cyclophosphamide 600 mg/m2 on day 1 q21) in arm A or 4 cycles of D (100 mg/m2 on day 1 q21) followed by 4 cycles of EC in arm B. Primary endpoint was DFS. Secondary endpoints OS and toxicity. Results: Between april 1999 and october 2005, 750 pts were enrolled (374 in arm A and 376 in arm B) in 25 Italian institutions. Pts characteristics are as follows: Arm A: age ≤ 50 yrs 185/374; ≤ 3 nodes 182/374, 4–9 nodes 129/374, ≥ 10 nodes 63/374; positive HR 287/374 Arm B: age ≤ 50 yrs 197/376; ≤ 3 nodes 184/376, 4–9 nodes 131/376, ≥ 10 nodes 61/376; positive HR 289/376 Toxicity data (Arm A vs Arm B) of the first 495(241/254) pts are the following: Neutropenia G3 (29% vs 21.3%), neutropenia G4 (32.7% vs 48.8%), febrile neutropenia G3–4 (3.7% vs 9.5%), thrombocytopenia G3–4 (3.3% vs 1.6%), anemia G3 (0% vs 2.4%), N/V G3–4 (6.2% vs 3.1%), mucositis G3–4 (3.7% vs 3.9%), diarrhea G3–4 (0.4% vs 2.8%), peripheral neuropathy G1–3 (0% vs 9.9%), hypersensitivity reactions G3–4 (0% vs 4.3%), cardiac toxicity G3 (0.4% vs 0%) Conclusions: Treatment was generally well tollerated in both arms with a higher incidence of neutropenia, usually short lasting, in arm B. The use of prophylactic G-CSF in those patients experiencing neutropenia G3–4 may be advisable. There were no significant differences in cardiac toxicity.

No significant financial relationships to disclose.

FOLFIRI with or without celecoxib in advanced colorectal cancer: a randomized phase II study of the Gruppo Oncologico dell'Italia Meridionale (GOIM)

BACKGROUND

The aim of the study was to verify the efficacy and safety of the addition of celecoxib to FOLFIRI combination therapy in patients affected by advanced colorectal cancer.

PATIENTS AND METHODS

Eighty-one chemotherapy-naïve patients entered in this randomized phase II trial of the GOIM (protocol no. 2301). Patients were randomized to receive FOLFIRI regimen (arm A): irinotecan 180 mg/m(2) on day 1 with LV5FU2 regimen (LV at 100 mg/m(2) administered as a 2-h infusion before FU at 400 mg/m(2) as an intravenous bolus injection, and FU at 600 mg/m(2) as a 22-h infusion immediately after 5-FU bolus injection on day 1 and 2); or FOLFIRI plus celecoxib 400 mg twice daily for 14 days (arm B). Both treatments were repeated every 2 weeks.

RESULTS

Seventy-seven patients (38 in arm A and 39 in arm B) were evaluable for response. The overall response rate was 41% in arm A (95% CI 27% to 57%) and 35% in arm B (95% CI 20% to 50%). When only assessable patients were analyzed, overall response rate was 45% in arm A (95% CI 29% to 61%) and 36% in arm B (95% CI 21% to 51%). Median time to progression, median duration of response and survival were, respectively, 8 months, 9 months and 16 months in arm A, and 7 months, 9 months and 19 months in arm B. All patients were evaluable for toxicity, which was globally mild in both arms; grade 3-4 toxicity was uncommon, and gastrointestinal disturbances were the most common.

CONCLUSIONS

FOLFIRI regimen is effective and well-tolerated as a first-line treatment in patients with advanced colorectal cancer. The addition of celecoxib to FOLFIRI regimen does not improve results.

[Clinical guidelines for the management of gastrointestinal stromal tumors]

Treatment of gastrointestinal stromal tumors (GIST) has been revolutioned by the recently discovered molecular mechanism responsible for the oncogenesis of this disease. In addition, due to the rapid progress at molecular and clinical level observed in the last few years, there is a need to review the current state of the art in order to delineate appropriate guidelines for the optimal management of these tumors. A panel of experts from several specialities, including medical oncology, surgery, pathology, molecular biology and imaging, were invited to participate in a meeting to present and discuss a number of pre-selected questions, and to achieve a consensus according to the categories of the National Comprehensive Cancer Network (NCCN) and the Standard Options Recommandations (SOR) of the French Federation of Cancer Centers. Generally, consensus points were from categories 2A of the NCCN and B2 of the SOR. Conventional histologic examination with immunohistochemistry for CD117, CD34, SMA, S-100 and desmin is considered standard. Molecular analysis for the identification of KIT and PDGFRA mutation may be indicated in CD117-negative GIST. Complete tumor resection with negative margins is the optimal surgical treatment. Adjuvant imatinib should be considered an experimental approach. Neoadjuvant imatinib is also experimental, although its use may be justified in unresectable or marginally resectable GIST. Imatinib should be started in metastatic or recurrent disease, and should be continued until progressive disease or drug intolerance. In these cases, sunitinib can be used. The optimal criteria for the assessment and monitoring of GIST undergoing imatinib therapy are not well known, but they should include reduction in tumor size and disease stabilization, as well as reduction of tumor density on CT scan and metabolic activity on PET scan.

[Anthracyclines in the adjuvant treatment of breast carcinoma: thirty years later]

In the last decades, the use of adjuvant systemic treatment for early breast cancer has increased progressively, and has contributed to the decrease in breast cancer mortality in the U.S. and in some European countries, although a raising in the disease incidence has been observed. Traditionally, the most extensively used chemotherapy regimens have been those containing an anthracycline, namely doxorubicin or epirubicin. Due to its more favorable toxic profile, epirubicin is preferable to doxorubicin and, in fact, it has been used in the majority of adjuvant studies carried out in Europe. The use of epirubicin in the U.S. is increasing since 1999, when it was approved by the Food and Drug Administration. Anthracycline-based regimens are superior to CMF-like combinations. The recent development of anthracycline-taxane regimens has shown further benefit in disease-free survival and, in some trials, in overall survival. In patients with HER2-positive tumors, trastuzumab has dramatically improved therapeutic results when added to standard adjuvant treatment. It is likely that new technologies (i.e. genomics and proteomics), as well as the appropriate use of translational research along with the development of new molecularly targeted agents, will lead to even greater achievements in the management of early breast cancer. Nevertheless, it should be considered that at present time chemotherapy is generally needed either alone or in combination with hormonal or biologic agents. In particular, the role of anthracyclines remains unchanged because they have contributed significantly to the improvement of survival of patients with breast carcinoma.

Liver-specific deletion of insulin receptor substrate 2 does not impair hepatic glucose and lipid metabolism in mice

AIMS/HYPOTHESIS

Hepatic insulin resistance is thought to be a critical component in the pathogenesis of type 2 diabetes but the role of intrinsic insulin signalling pathways in the regulation of hepatic metabolism remains controversial. Global gene targeting in mice and in vitro studies have suggested that IRS2 mediates the physiological effects of insulin in the liver. Reduced hepatic production of IRS2 is found in many cases of insulin resistance. To investigate the role of IRS2 in regulating liver function in vivo, we generated mice that specifically lack Irs2 in the liver (LivIrs2KO).

MATERIALS AND METHODS

Hepatic insulin signalling events were examined in LivIrs2KO mice by western blotting. Glucose homeostasis and insulin sensitivity were assessed by glucose tolerance tests and hyperinsulinaemic-euglycaemic clamp studies. The effects of high-fat feeding upon glucose homeostasis were also determined. Liver function tests were performed and expression of key metabolic genes in the liver was determined by RT-PCR.

RESULTS

Proximal insulin signalling events and forkhead box O1 and A2 function were normal in the liver of LivIrs2KO mice, which displayed minimal abnormalities in glucose and lipid homeostasis, hepatic gene expression and liver function. In addition, hepatic lipid homeostasis and the metabolic response to a high-fat diet did not differ between LivIrs2KO and control mice.

CONCLUSIONS/INTERPRETATION

Our findings suggest that liver IRS2 signalling, surprisingly, is not required for the long-term maintenance of glucose and lipid homeostasis, and that extra-hepatic IRS2-dependent mechanisms are involved in the regulation of these processes.

High activity of salvage treatment with biweekly paclitaxel-gemcitabine combination in heavily pretreated breast cancer patients

The treatment of refractory metastatic breast cancer is primarily palliative, without a significant impact on overall survival. Among the innovative combinations in this unfavourable setting, paclitaxel and gemcitabine showed a possible synergistic action and an encouraging activity in some clinical trials. This phase II study was carried out to evaluate paclitaxel-gemcitabine combination in very heavily pretreated advanced breast cancer on a bi-weekly schedule.Thirty-nine women with advanced breast cancer were treated with paclitaxel 150 mg/m2 as 3 hrs infusion, and gemcitabine 1,500 mg/m2 as 30 mins infusion, both drugs administered on days 1, 15, with cycles repeated every 28 days. All but two patients received granulocyte colony stimulating factor (G-CSF) on days 7 to 9 and 20 to 22 of every cycle. More than two third (71%) of the patients had previously received two or more chemotherapy regimens for advanced disease, including almost all active agents in this disease. Objective responses were observed in 18 out of 34 evaluable patients (53%; 95% CI, 36% to 70%). Disease remained stable in 7 patients (21%). Responses by sites were 67% in soft tissue and in bone, and 48% in visceral disease. Median time to progression and overall survival were 9 and 20 months, respectively. Treatment was well tolerated, with G3-4 neutropenia in 8%, and G 1-2 thrombocytopenia in 13% of the patients; non-hematological toxicities were mild, with G3 hepatotoxicity in 5% of the patients, and G3 peripheral neurotoxicity in 10% of the patients. Biweekly paclitaxel/gemcitabine combination with G-CSF support appears to be very active as salvage therapy in heavily pretreated breast cancer patients, with a very favourable safety profile.

205 DERIVATION OF CAT EMBRYONIC STEM-LIKE CELLS FROM IN VITRO-PRODUCED BLASTOCYSTS AND THEIR SUPPORT BY INTRASPECIFIC VS. INTERSPECIFIC FEEDER CELLS

Interspecific nuclear transfer has been successfully demonstrated in nondomestic cats (Gomez et al. 2004 Cloning Stem Cells 6, 247); however, the efficiency remains low and may be attributable to nuclear reprogramming errors. Embryonic stem cells (ESC) may complete nuclear reprogramming more efficiently than somatic cells and, therefore, are potentially useful for increasing cloning success (Jaenisch et al. 2002 Cloning Stem Cells 4, 389). The objectives of this study were to: (1) compare efficiency of immunosurgery vs. mechanical separation for isolating the inner cell mass (ICM) of in vitro-derived cat blastocysts; and (2) determine the influence of mouse (MEF: CF-1) and cat (CEF) embryonic fibroblast feeder layers on ICM attachment and growth of ES-like cells. After ICMs were isolated from in vitro-derived blastocysts (n = 142) by immunosurgery or mechanically, they were plated either on mitotically inactivated CEF (40 �L/mL Mitomycin-C; 5 h) or MEF (30 �L/mL Mitomycin-C; 2.5 h). Cells were cultured in DMEM-F12, 1 mM L-Glutamine, 0.1 mM 2-mercaptoethanol, 1.25% nonessential amino acids, 15% knock-out replacement serum, 5% fetal bovine serum, 40 ng/mL leukemia inhibitory factor, 5 ng/mL basic fibroblast growth factor, 100 IU penicillin, 100 �g/mL streptomycin, and 25 �L/mL amphotericin-B in a humidified atmosphere of 5% CO2 in air at 38�C. Our results indicated that ICM isolation and attachment were not affected by either the method of isolation (immunosurgery: 75.8 � 6.9% vs. mechanical: 89.5 � 6.4%) or the feeders (MEF: 74.6 � 6.7% vs. CEF: 90.7 � 6.6%). However, the incidence of ES-like cell colony formation was significantly affected by the feeder layer (CEF: 55.4 � 7.2% vs. MEF: 12.7 � 7.2%; P < 0.001). A total of 32 ES-like cell lines were derived on CEF (n = 26) and MEF (n = 6), of which 50% were alkaline phosphatase (AP)-positive. One ES-like cell line derived on MEF spontaneously differentiated into myocardiocytes after 14 days in culture. Three ES-like cell lines derived on CEF were immunostained for ESC-markers Oct-4, SSEA-1, and SSEA-4, and for AP. Positive results for all markers were observed in a few colonies of each line, with colonies from one cell line appearing on Day 23 and remaining in culture for 102 days (12 passages). Colonies from the other two cell lines appeared on Day 17 and remained in culture for 78 days (9 passages). Colonies derived on MEF appeared on average at 17.9 days and remained in culture an additional 15 to 61 days without further characterization. The present results describe the first isolation of cat ES-like cells. We have demonstrated an important species-specific relationship between feeder layers and the derivation of cat ESCs. Further studies are in progress to improve culture conditions for the derivation and expansion of stable cat ESC lines.

Benefits of the Thoracoscopic Approach for Short- or Long-Gap Esophageal Atresia

OBJECTIVE

To evaluate the feasibility and results of thoracoscopy in various types of esophageal atresia (EA).

MATERIALS AND METHODS

From April 2001 to August 2002, 5 patients with EA were treated by thoracoscopy. Their mean gestational age was 38 weeks and mean birth weight was 2700 g. Two patients had short-gap atresia with tracheo-esophageal fistula (type III according to Ladd's classification). Three had long-gap atresia: 2 with low fistula to the carina (type IV) and 1 without fistula (type I). Patients were placed in a prone position with the right side elevated at 80 degrees . Four intrapleural ports were necessary. The fistula when present was dissected and sutured with intrathoracic knots and esophageal anastomosis performed in the same manner.

RESULTS

Positive airway pressure increased in all patients after insufflation but was kept in a safe range to prevent lung injury. An esophageal anastomosis was performed in 3 cases (2 short gaps and 1 long gap). Oral feeding started on day 6, and their mean length of hospital stay was 14 days. For one child with type IV EA, the anastomosis was impossible because of a long gap confirmed by an immediate thoracotomy. The ends were just approximated. A "spontaneous" fistula developed, and normal feeding was possible 2.5 months later. For the child with type I EA, the pouches could be only approximated at 2 months of age. A spontaneous fistula developed with a stenosis. A redo anastomosis by open surgery allowed for normal feeding.

CONCLUSION

The thoracoscopic repair of an esophageal atresia is a reasonable choice for experienced surgeons treating patients, including those with long gaps.

[Metastatic breast cancer: new chemotherapy regimens with taxanes]

Patients with breast cancer are frequently treated with anthracyclines and/or taxanes, which are among the most useful agents in this disease. Therefore, it is increasingly difficult to find active regimens in heavily pretreated patients. Gemcitabine is a cytosine arabinoside prodrug analog which shows significant activity, as single agent, in metastatic breast cancer. The combination of gemcitabine and taxanes is particularly valuable because of the different mechanisms of action of each drug and their non-everlapping toxicities. During the last years, we have carried out several trials with gemcitabine in combination with either docetaxel or paclitaxel. The combination of gemcitabine and docetaxel in 53 previously treated patients resulted in 53% response rate (RR) with a median time to progression of 7.5 months, and an overall survival of 16.5 months. When gemcitabine was combined with paclitaxel in a biweekly schedule in 34 evaluable patients with prior exposure to several chemotherapy regimens, RR was 53%. It was 50% in patients previously treated with docetaxel. Toxicity was generally mild to moderate. Paclitaxel plus gemcitabine given as an every 2-weeks schedule is a practical, well tolerated and active regimen in advanced breast carcinoma, which deserves further evaluation in less heavily pretreated patients.

Modulation of 5-fluorouracil as adjuvant systemic chemotherapy in colorectal cancer: the IGCS-COL multicentre, randomised, phase III study

The aims of this multicentre, randomised phase III trial were to evaluate: (1) the role of levamisol (LEV); and (2) the role of folinic acid (FA), added to 5-fluorouracil (5FU) in the adjuvant treatment of colorectal cancer. Patients with histologically proven, radically resected stage II or III colon or rectal cancer were eligible. The study had a 2x2 factorial design with four treatment arms: (a) 5FU alone, (b) 5FU+LEV, (c) 5FU+FA, (d) 5FU+LEV+FA, and two planned comparisons, testing the role of LEV and of FA, respectively. From March 1991, to September 1998, 1327 patients were randomised. None of the two comparisons resulted in a significant disease-free (DFS) or overall (OAS) survival advantage. The hazard ratio (HR) of relapse was 0.89 (95% confidence intervals (CI): 0.73-1.09) for patients receiving FA and 0.99 (95% CI 0.80-1.21) for those receiving LEV; corresponding HRs of death were 1.02 (95% CI: 0.80-1.30) and 0.94 (95% CI 0.73-1.20). Nonhaematological toxicity (all grade vomiting, diarrhoea, mucositis, congiuntivitis, skin, fever and fatigue) was significantly worse with FA, while all other toxicities were similar. In the present trial, there was no evidence that the addition of FA or LEV significantly prolongs DFS and OAS of radically resected colorectal cancer patients.

[Breast cancer: HER2 changes one's cards on the table]

Recently, preliminary results of several randomized studies using trastuzumab in the adjuvant or neoadjuvant treatment of HER2-positive breast cancer have been reported. In the neoadjuvant setting, patients have been randomized to receive either chemotherapy alone (Group I), 4 cycles of paclitaxel followed by FEC (fluorouracil, epirubicin, cyclophosphamide) fo 4 cycles, or the same chemotherapy with concomitant weekly trastuzumab for 24 weeks (Group II). Pathologic complete responses were 25% in Group I and 66.7% in Group II, showing a significant superiority of treatment including trastuzumab. Among several ongoing studies of adjuvant therapy with trastuzumab, NSABP B-31 trial and NCCTG N9831 trial compared a standard treatment of sequential AC (doxorubicin, cyclophosphamide) followed by paclitaxel to the same chemotherapy regimen in combination with weekly trastuzumab for 1 year. In a third study (HERA trial), patients were randomized to 3 arms following adjuvant chemotherapy: observation, triweekly trastuzumab for 1 year or for 2 years. Joint analysis of B-31 and N9831 trials and interim analysis of patients randomized to receive 1 year trastuzumab in the HERA trial, show a significant improvement in disease-free survival with chemotherapy combined with trastuzumab. Treatment has been generally well tolerated with acceptable cardiotoxic effects (< 4%). However, the short follow-up precludes any information about long-term side-effects. Overall, although the risk/benefit ratio is in favor of trastuzumab including regimens, the use of this monoclonal antibody in the neoadjuvant or adjuvant treatment of HER2-positive breast cancer, should be carefully discussed with the patient.

Epirubicin, cisplatin and docetaxel combination therapy for metastatic gastric cancer

BACKGROUND

Docetaxel is a new agent with activity in metastatic gastric cancer. This phase II study was designed to evaluate the activity and safety of an epirubicin, cisplatin and docetaxel combination in patients with this disease.

PATIENTS AND METHODS

Forty-six patients with gastric adenocarcinoma with measurable distant metastasis were eligible for the study. Patients received epirubicin 50 mg/m(2) and docetaxel 60 mg/m(2), on day 1, and cisplatin 60 mg/m(2) on day 2. Granulocyte colony-stimulating factor 300 mug/day subcutaneously was given on days 5 and 6. Cycles were repeated every 3 weeks for a maximum of eight courses.

RESULTS

All patients were evaluable for response and toxicity. Two complete and 21 partial responses were observed, with an overall response rate of 50% [95% confidence interval (CI) 36% to 64%]. Stable disease was observed in 13 patients (28%) and progressive disease in 10 patients (22%). The median time to progression was 6 months (95% CI 5-7) and the median overall survival was 11.2 months (95% CI 8.5-13.9). Grade 3/4 neutropenia, thrombocytopenia and anemia occurred in 46%, 7% and 13% of patients, respectively. There were five episodes of febrile neutropenia in four patients. Other grade 3 toxicities included mucositis in three patients (6.5%), vomiting in four patients (8.7%) and diarrhea in one patient (2%). There were no cardiac toxicity, severe neurotoxicity or treatment-related deaths.

CONCLUSIONS

The epirubicin, cisplatin and docetaxel combination is an active and well tolerated novel chemotherapy regimen for treating metastatic gastric cancer and deserves further evaluation in randomized studies.

Chromogenic substrates as fundamental tool to design new thrombin inhibitors. Determination of inhibition equilibrium constants

The structure-activity relationship of dipetalogastin II, the strongest thrombin inhibitor isolated and cloned from the bug Dipetalogaster maximus, was examined by introducing gradual changes into the molecule by means of molecular biological methods. The effect upon its inhibition equilibrium constant was determined after each change by a chromogenic assay. This structural information was fundamental to design new dipetalogastin II-derived inhibitors. Our results suggested that the acidic sequence DEHDHDFEDT corresponding to amino acid residues 49 to 58 of dipetalogastin II reacts with the anion binding exosite (ABE) 1 of thrombin. Based on this finding, we constructed a chimeric molecule consisting of the active site blocking segment of dipetalogastin II (amino acid residues 1 to 48) and the ABE 1 blocking segment of hirudin. This construct showed better thrombin inhibitory activity than both separated segments only after the introduction of a glycine linker between both blocking segments. We thus obtained a thrombin inhibitor called dipetarudin with an inhibition equilibrium constant comparable to that of dipetalogastin II and a molecular mass below that of dipetalogastin.

FOLFIRI regimen in advanced colorectal cancer: the experience of the Gruppo Oncologico dell'Italia Meridionale (GOIM)

PURPOSE

To verify the experience of the GOIM in the treatment of advanced colorectal cancer patients with the FOLFIRI combination therapy.

PATIENTS AND METHODS

Patients entered in three consecutive trials of the GOIM (protocols no. 9706, 9901, and 2301) were reported in this analysis. A total of 287 chemotherapy-naive patients were treated with FOLFIRI regimen: Irinotecan 180 mg/m(2) on day 1 with LV5FU2 regimen (LV at 100 mg/m(2) administered as a 2-hour infusion before FU at 400 mg/m(2) as an intravenous bolus injection, and FU at 600 mg/m(2) as a 22-hour infusion immediately after 5FU bolus injection on day 1 and 2); the treatment was repeated every 2 weeks.

RESULTS

287 patients entered in these three trials, and 264 (92%) were evaluable for response. The overall response rate was 34.5% (95% confidence interval [CI]: 29% to 40%). When only assessable patients were analyzed, overall response rate was 37% (95% CI: 31% to 43%). Median time to progression, median duration of response and survival were 7 months, 10.5 months and 14 months, respectively. All but three patients were evaluable for toxicity which was globally mild; grade 3-4 toxicity was uncommon, and gastrointestinal disturbances were the most common.

CONCLUSIONS

FOLFIRI regimen is effective and well-tolerated as first-line treatment in patients with advanced colorectal cancer. Further studies needed to evaluate the improvement in results with the addition of new drugs to this combination therapy.