ECOG 4599 phase III trial of carboplatin and paclitaxel ±bevacizumab: Subset analysis of survival by gender

7036

Background: E4599 compared carboplatin and paclitaxel (PC) versus carboplatin, paclitaxel, and bevacizumab (PCB) in patients with advanced stage non-small cell lung cancer. Survival was superior with PCB. However, an unplanned subset analysis did not show a survival benefit for women in the PCB arm. Methods: Patients (pts) in the E4599 database were divided into male (M) and female (F) cohorts by assigned treatment. Survival was calculated separately for each cohort. Known prognostic factors and toxicities were compared by gender. Proportional hazards models (PHM) of survival with multiple factor combinations were fit to adjust for treatment effect for sex, performance status, stage, liver, bone and adrenal involvement, measurable disease, prior radiation therapy, weight loss ≤ 5% and to examine the difference in treatment effect by sex. Results: The analysis includes 850 patients. The median survival for M is 8.7 months (mo) (PC) versus (vs) 11.7 mo (PCB) (p=0.001). The median survival for F is 13.1 mo (PC) vs 13.3 mo (PCB) (p=0.87). On PCB, progression free survival (PFS) for M and F is 6.3 mo and 6.2 mo respectively. Response rate (RR) is 23.6% for M and 38.5% for F. Duration of response is 6.8 mo for both. No demographic differences exist between the two arms for M. A higher proportion of F on the PCB arm have liver metastasis (PCB 23.2% vs PC 11.7%, p=0.003). On the PC arm, the febrile neutropenia rate is higher for M (M 3.1% vs F 0%, p=0.02). On the PCB arm, the adverse events with a gender difference are severe hypertension (M 4.2%, F 9.9%, p=0.02), constipation (M 1.4%, F 4.7%, p=0.05), and abdominal pain (M 0.9%, F 5.2%, p=0.01). The test for a treatment by sex interaction in a PHM for survival has p = 0.04. In the PHM adjusting for the other factors, the estimated treatment hazard ratios are 0.73 for M and 0.97 for F and the test for a sex by treatment interaction has p=0.09. Conclusions: Women on the PCB arm vs the PC arm appear not to have a survival advantage. Reasons for this remain unclear. However, the addition of bevacizumab does result in significant improvements in RR and PFS, arguing in favor of an overall treatment benefit. Further analysis of other demographic information (tumor type and second-line therapy) is ongoing.

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Efficacy and safety of patupilone in non-small cell lung cancer (NSCLC): A phase I/II trial

7104

Background: Based on its activity in a wide range of tumors including those that are taxane resistant, the novel microtubule stabilizer patupilone (EPO906; epothilone B) has the potential to treat NSCLC. Fifty patients were enrolled in phase I to evaluate safety, efficacy, and optimal dose. The phase II part of this study is investigating the antitumor activity of patupilone in 53 patients with stage IIIB/IV NSCLC. Methods: Patients with histologically or cytologically confirmed unresectable, locally advanced, or metastatic NSCLC documented before 1st-line therapy without symptomatic or uncontrolled brain metastases received patupilone at a starting dose of 10.0 mg/m2 q3wk by 20-minute IV infusion. Additional inclusion criteria: age ≥18 years; WHO performance status 0–1; prior treatment with a platinum-containing regimen. Primary objective of the phase II, single-arm, 2-stage, multicenter trial: to determine activity of patupilone q3wk (overall response using modified RECIST) in NSCLC. An additional cohort with recurrent brain metastases from NSCLC is being accrued to evaluate safety, pharmacokinetics, and activity. Results: In phase I, all patients received prior treatment with platinum therapy; 28% had received taxanes and 78% nontaxanes. Patupilone dose was escalated from 6.5 to 13.0 mg/m2 q3wk. Dose-limiting toxicities occurred in 4 patients: 1 with grade 3 asthenia and 3 with grade 3 diarrhea at various dose levels. The most frequent adverse events (AEs) were diarrhea (66%), nausea (40%), vomiting (34%), paraesthesia (32%), abdominal pain (30%), and fatigue (30%). The most frequent grade 3 AE was diarrhea (14%); a grade 4 AE (asthenia) occurred in 1 patient. Overall phase I response: 5 PR, 16 SD, and 26 PD. Based on risk-benefit analyses, 10.0 mg/m2 q3wk was recommended as the phase II dose. Phase II is ongoing: 25 of 53 patients (15 men and 6 women with NSCLC; 2 men and 2 women with brain metastases) have been enrolled. Conclusions: In phase I, patupilone q3wk was safe and well tolerated, with antitumor activity in patients with advanced pretreated NSCLC. Data from phase II will be available at time of presentation.

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Audit of intrapartum group B streptococcus prophylaxis

Group B streptococcus is the most frequent cause of severe early onset neonatal infection. For over 3 years our department has employed a risk-factor-based protocol of intra-partum antibiotic prophylaxis. Prophylaxis has been considered adequate if women receive antibiotics more than 4 hours before delivery. This study aims (1) to establish the adequacy of intrapartum prophylaxis in routine clinical practice and (2) to determine whether changing the time interval (from commencement of prophylaxis to delivery) for adequacy from 4 to 2 hours (based on RCOG guidelines) improves the percentage of women receiving adequate prophylaxis. This was an audit against established protocol. Case notes of consecutive deliveries over a 4-week period were reviewed retrospectively. A total of 396 deliveries occurred during the study period. Some 44 women (11%) were eligible for antibiotic prophylaxis. Adequate prophylaxis was achieved in 21 cases (49%). If the time for prophylaxis to be considered adequate was reduced from 4 to 2 h, the number of women receiving adequate prophylaxis increased to 33 (76%). In conclusion, despite the protocol being well established, only half of the eligible women receive adequate intra-partum prophylaxis. Reducing the time interval from 4 to 2 h appreciably increases the number of women receiving adequate prophylaxis, which reduces the necessity of providing neonatal prophylaxis.

Once-Weekly Dalbavancin versus Standard-of-Care Antimicrobial Regimens for Treatment of Skin and Soft-Tissue Infections

Dalbavancin, a novel glycopeptide with a long elimination half-life ( approximately 9-12 days), was compared to standard antimicrobial therapy for skin and soft-tissue infections (SSTIs). In a randomized, controlled, open-label, phase 2 proof-of-concept trial, adults received 1100 mg of dalbavancin (as a single intravenous infusion), 1000 mg of dalbavancin intravenously and then 500 mg intravenously 1 week later, or a prospectively defined standard-of-care regimen. A gram-positive pathogen was isolated from samples obtained from 41 (66%) of 62 patients at baseline; Staphylococcus aureus was the most prevalent species (83% of pathogens). Clinical success rates at a follow-up visit (test of cure) were 94.1% among patients treated with 2 doses of dalbavancin, 61.5% among patients treated with 1 dose of dalbavancin, and 76.2% among patients treated with a standard-of-care regimen. All treatment regimens were well tolerated; drug-related adverse reaction rates were similar across the 3 groups. These findings suggest that a regimen of 2 doses of dalbavancin administered 1 week apart is effective in the treatment of complicated, gram-positive bacterial SSTIs and warrants further study.

CDP840. A prototype of a novel class of orally active anti-inflammatory phosphodiesterase 4 inhibitors

The discovery, synthesis and biological activity of a series of triarylethane phosphodiesterase 4 inhibitors is described. Structure-activity relationship studies are presented for CDP840 (29), a potent, chiral, selective inhibitor of PDE 4 (IC(50) 4nM). CDP840 is non-emetic in the ferret at 30mgkg(-1) (po), active in models of inflammation and reverses ozone-induced bronchial hyperreactivity in the guinea pig.

Osteoprotegerin inhibits the development of osteolytic bone disease in multiple myeloma

Multiple myeloma is a B-cell malignancy characterized by the accumulation of plasma cells in the bone marrow and the development of osteolytic bone disease. The present study demonstrates that myeloma cells express the critical osteoclastogenic factor RANKL (the ligand for receptor activator of NF-kappa B). Injection of 5T2MM myeloma cells into C57BL/KaLwRij mice resulted in the development of bone disease characterized by a significant decrease in cancellous bone volume in the tibial and femoral metaphyses, an increase in osteoclast formation, and radiologic evidence of osteolytic bone lesions. Dual-energy x-ray absorptiometry demonstrated a decrease in bone mineral density (BMD) at each of these sites. Treatment of mice with established myeloma with recombinant osteoprotegerin (OPG) protein, the soluble decoy receptor for RANKL, prevented the development of lytic bone lesions. OPG treatment was associated with preservation of cancellous bone volume and inhibition of osteoclast formation. OPG also promoted an increase in femoral, tibial, and vertebral BMD. These data suggest that the RANKL/RANK/OPG system may play a critical role in the development of osteolytic bone disease in multiple myeloma and that targeting this system may have therapeutic potential.

The genome of the natural genetic engineer Agrobacterium tumefaciens C58

The 5.67-megabase genome of the plant pathogen Agrobacterium tumefaciens C58 consists of a circular chromosome, a linear chromosome, and two plasmids. Extensive orthology and nucleotide colinearity between the genomes of A. tumefaciens and the plant symbiont Sinorhizobium meliloti suggest a recent evolutionary divergence. Their similarities include metabolic, transport, and regulatory systems that promote survival in the highly competitive rhizosphere; differences are apparent in their genome structure and virulence gene complement. Availability of the A. tumefaciens sequence will facilitate investigations into the molecular basis of pathogenesis and the evolutionary divergence of pathogenic and symbiotic lifestyles.

The effects of lamotrigine on sleep in patients with epilepsy

PURPOSE

The older antiepileptic drugs (AEDs) have a variety of effects on sleep, including marked reduction in REM, slow-wave sleep (SWS) and sleep latency, and increased percentage of light sleep. The effects of the newer AEDs on sleep are unknown. Our purpose was to study the effect of lamotrigine (LTG) on sleep.

METHODS

Ten adults with focal epilepsy, in whom the decision was made to add LTG to either phenytoin (PHT) or carbamazepine (CBZ) for control of seizures, were the subjects of this study. Patients underwent pre- and posttreatment polysomnography (PSG) and completed sleep questionnaires. Polygraphic variables and Epworth Sleepiness Scale (ESS) scores, a subjective measure of sleep propensity, were compared by using the Wilcoxon sign rank test.

RESULTS

Seven patients were taking CBZ, and three were treated with PHT. All subjects were titrated to an LTG dose of 400 mg/day. Treatment with LTG produced a significant decrease in SWS and an increase in stage 2 sleep percentage. No significant difference in ESS or any of the other polygraphic variables was observed. However, LTG treatment was associated with a reduction in arousals and stage shifts and an increase in REM periods. No subjects reported insomnia with treatment.

CONCLUSIONS

LTG appears to be less disruptive to sleep than some of the older AEDs.

Early detection of type 2 diabetes: the role of the community nurse

Recent changes to the diagnostic criteria for type 2 diabetes have raised concerns that if steps are not taken to address relevant issues, the number of diagnosed sufferers will escalate in future years, with a similar increase in the prevalence of associated complications. Research suggests that for many patients, complications are evident at the time of diagnosis, and may have been present for several years before a diagnosis was made. Late presentation is the cause of considerable morbidity and mortality among these patients, largely because undiagnosed complications are often irreversible by the time the underlying diabetes is discovered. The current emphasis on public health augments the need for community nurses to recognize warning signs, particularly in patients who are at an increased risk of developing diabetes. This article aims to raise awareness of early signs and symptoms, and gives a brief insight into some of the associated health problems. If community nurses are to play a significant role in reducing the potentially devastating effects of this disease, they will need to be involved tin educating patients and implementing screening and intervention programmes.

HPA-1a-mediated platelet interaction with monocytes in vitro: involvement of Fcgamma receptor (FcgammaR) classes and inhibition by humanised monoclonal anti-FcgammaRI H22

To gain insight into mechanisms of platelet destruction and its possible inhibition during fetal/neonatal alloimmune thrombocytopenia (FAIT/NAIT) the binding to monocytes (Mo) of anti-HPA-1a-sensitised platelets, the initial step in IgG-mediated destruction by effector cells, was evaluated in an in vitro assay. Neonatal Mo were compared with adult Mo as effectors in the assay. Moreover, the potential involvement of Fcgamma receptor (FcgammaR) classes during platelet destruction in the disease was tested by using FcgammaR class-specific reagents as inhibitors of the binding reaction. Neonatal Mo were 37% less active than adult Mo in their interaction with anti-HPA-1a-sensitised platelets (p < 0.05). The FcgammaRI-specific reagents human monomeric IgG and humanised anti-FcgammaRI monoclonal H22 caused virtually complete inhibition of platelet binding to Mo. When compared to an intravenous immunoglobulin preparation the inhibitory activity of H22 was 10-100 x greater than that of the latter compound. Monoclonal anti-FcgammaRII IV.3 and anti-FcgammaRIII 3G8 decreased platelet binding by 70% and 64%, respectively, but only the anti-FcgammaRII inhibition was statistically significant (p < 0.001). Finally, anti-HPA-1a-sensitised platelets bound to 131H- but not to 131R- FcgammaRIIa transfected 3T6 mouse fibroblasts (p < 0.01), in an anti-HPA-1a-concentration-dependent manner. The results suggest that FcgammaRI and FcgammaRIIa may be involved in anti-HPA-1a-mediated platelet destruction by mononuclear phagocytes during FAIT/NAIT. Moreover, the much greater potency ofmonoclonal H22 than of intravenous immunoglobulin as an inhibitor of anti-HPA-1a-mediated Mo-platelet interaction, might render it superior to the latter agent in the maternal therapy of the disorder.