First pulmonary case reported in Argentina of infection with mycobacterium szulgai, a rare pathogen

Mycobacterium szulgai is a rare pathogen. Nontuberculous mycobacteria usually produce disease in people with some kind of immunosuppression or another predisposing condition. A case of pulmonary Mycobacterium szulgai infection is described.

Recruitment experience in a phase 0 trial of ABT-888, an inhibitor of poly (ADP-ribose) polymerase (PARP), in patients (pts) with advanced malignancies

14111

Background: Phase 0 trials conducted under the FDA Exploratory IND Guidance involve limited exposures to study drug with no expectation of clinical benefit. We present our experience in recruiting pts to a Phase 0 study of ABT-888, the first to be conducted at the NCI. Methods: Objective: To determine the ABT-888 dose that inhibits PARP in PBMCs and tumor after a single oral administration. Tumor biopsies at baseline and 3–6 hrs post drug were planned once PARP activity inhibition in PBMCs or target plasma Cmax was achieved. Protocol was approved by the NCI scientific committee, IRB, and CTEP, and was reviewed by the NIH Ethics Committee. Informed consent included an explicit statement acknowledging the non-therapeutic, non-personal benefit nature of the study. Results: Since 6/06, 17 pts screened; 6 enrolled. Reasons for declining participation: Non-therapeutic study (2); biopsy requirement (2); recommendation by oncologist (2) or family member (2); condition requiring treatment (3). Reasons for participation: Altruism (4); altruism + waiting for another study (2). Of 6 pts enrolled, colon cancer (2), lymphoma (2), carcinoid (1), lung cancer (1). Median age: Participants (P) 57 (49–64) and non-participants (NP): 62 (42–78). Median prior therapies: P 3.6 (0–8) and NP: 3 (0–7). Referral origin for P: Prior participation on NCI studies (2), prior pt-NCI physician relationship (4). Ethnicity of P: White (5) and Hispanic (1). 3 of 6 pts underwent serial biopsies as required by protocol. Conclusion: Phase 0 recruitment is feasible and the accrual can be completed in a timely fashion, but depends on pt altruism and prior physician-pt relationship. These studies can be ethically conducted provided that interventions are of minimal risk, the study experience is commensurate with pt expectations, and that results are invaluable to subsequent pts.

No significant financial relationships to disclose.

Inhibition of poly (ADP-ribose) polymerase (PARP) by ABT-888 in patients with advanced malignancies: Results of a phase 0 trial

3518

Background: Inhibition of PARP activity sensitizes tumor cells to the effects of DNA damaging agents. We conducted a phase 0 pharmacokinetic (PK) and pharmacodynamic (PD) study of ABT-888, an oral inhibitor of PARP. Methods: The objectives were to determine a dose range at which ABT-888 inhibits PARP in tumor tissue and in peripheral blood mononuclear cells (PBMC); and the PK of ABT-888. Patients with advanced solid tumors refractory to at least one line of therapy were eligible; patients with CLL or follicular lymphomas were also eligible if standard therapy was not currently indicated. A single oral dose of ABT-888 was administered per patient, dose escalations were planned in cohorts of 3 patients each (10 mg, 25 mg, 50 mg, 100 mg, and 150 mg). PBMC and tumor sampling were performed before and after drug administration for real time PK and PD analyses. All patients underwent PBMC sampling; tumor biopsies were planned once significant inhibition of PARP activity in PBMCs was seen in 1 of 3 patients in a cohort or plasma Cmax of 210 nM was achieved in at least 1 patient. Tumor biopsies were performed at baseline in the week prior to drug administration and then 3–6 hours post drug administration. Significant inhibition of PARP activity was defined as at least 0.69 reduction on the log scale, which also satisfied statistical significance. Results: A total of 6 patients have been studied so far, 3 each for the 10 mg and 25 mg cohorts. No treatment related adverse events have been observed. Target Cmax was exceeded in the first cohort, all patients in the next cohort underwent tumor biopsies in addition to PBMC sampling. A trend towards inhibition of PARP activity in PBMCs was observed in the first cohort. Significant inhibition of PAR levels was observed in tumor biopsies from all 3 patients in the second cohort (92%, 99%, 100% reductions respectively, as compared to baseline). Greater than 85% reduction of PAR levels was observed in PBMCs from 2 of the 3 patients in the second cohort (one patient was not evaluable). Conclusions: ABT-888 is orally bioavailable and inhibits PARP activity in PBMCs and tumor cells. Target assay feasibility was established in human samples. Funded in part by NCI Contract N01-CO-12400

No significant financial relationships to disclose.

Quantitative immunohistochemical detection of gamma-H2AX in paraffin-embedded human tumor samples at National Clinical Target Validation Laboratory

10565

Background: DNA double-strand breaks (DSBs) caused by exposure to DNA damaging agents initiate phosphorylation of histone H2AX to form gamma-H2AX, which is considered a surrogate marker of DSBs. However, it is a challenge to quantitatively measure gamma-H2AX in clinical samples such as tumor biopsies. The aim of this study was to develop an immunohistochemical detection method for gamma-H2AX and to quantitatively evaluate the levels of gamma-H2AX in paraffin-embedded tumor samples. Methods: Human breast cancer MCF-7 cells were treated with the topoisomerase I inhibitor irinotecan at 1 μM or vehicle for 1 h, and fixed in 10% neutral buffered formalin and embedded in paraffin. Staining with gamma-H2AX antibody was performed on sections of treated MCF-7 cells, tumor specimens, and biopsies at baseline and after doxorubicin-containing chemotherapy from cancer patients. Numbers of foci and level of gamma-H2AX expression per tumor nucleus were determined by manual counting under a light microscope and an Automated Cellular Imaging System. Results: There was a rise in the mean numbers of nuclear foci and intensity of gamma-H2AX in MCF-7 cells treated with irinotecan versus vehicle (19.9 ± 2.7 vs. 9.95 ± 3.6; P < 0.0001 and 61.2 ± 8.5 vs. 16.2 ± 13.6; P < 0.0001 by Wilcoxon rank sum test). The level of gamma-H2AX foci in human tumor samples was 18.8 ± 13.1, 44.8 ± 14.5, 51.2 ± 20.8, or 69.7 ± 21.2 in carcinomas of the breast, colon, ovary, or prostate. In a patient with stable disease, levels of gamma-H2AX foci were 62.7 ± 26.9 at baseline and 67.2 ± 25.3 after doxorubicin-containing regimen chemotherapy. Conclusions: Our data suggest that the quantitative immunohistochemical detection of gamma-H2AX levels is facilitated by a digital imaging system, and is a reliable method to measure the effects of DNA damaging agents in cells and paraffin-embedded human tumor samples. Its application may help evaluate tumor response to various DNA damaging agents currently in the clinic and those presently undergoing clinical development.

No significant financial relationships to disclose.

Statistical considerations for a phase 0 trial

14038

Background: Phase ‘0’ clinical trials are small first in man studies to determine a dose or dose range which results in a desired biologic effect. Novel statistical designs are needed due to the limited number of patients and the complexities of analyzing primary pharmacodynamic endpoints. Methods: In general, the effect of the agent will be evaluated, based on a biologic endpoint(s), at two levels, the individual participant level (for a given dose amount), and the agent dose amount level (across individual participants). At the participant level, the effect is preferably defined as a dichotomous outcome. The statistical criteria should be such that the threshold is not surpassed with more than .10 probability, for a given participant, at a given dose amount, for the null hypothesis case of no true biologic effect. At the dose amount level, the effect rate is defined as the probability that a randomly chosen participant will satisfy the participant level threshold. The statistical criteria for declaring an observed effect rate to be significant should be such that the over-all probability of declaring the agent effective (summed across all dose amounts) should not exceed .10 for the null hypothesis case of no true biologic effect. A target effect rate, measured across participants, should be given, and the power to detect it, for a given dose amount, should be estimated. Ideally, there will be multiple pre-agent administration endpoint measurements, per participant, to define variability. Examples: 1. If 10 participants are accrued to a single dose amount, an observed effect rate for that dose amount could be defined to be significant if at least 2 of the 10 participants satisfy the participant threshold, yielding 85–90% power to detect a 35% effect rate. 2. If 5 participants are accrued to each of 2 dose amounts, an observed effect rate for a particular dose amount could be defined to be significant if at least 2 of the 5 participants satisfy the participant threshold, yielding approximately 90% power to detect a 60% effect rate. 3. If 3 participants are accrued to each of 4 dose amounts, an observed effect rate for a particular dose amount could be defined to be significant if at least 2 of the 3 participants satisfy the participant threshold, yielding approximately 90% power to detect an 80% effect rate.

No significant financial relationships to disclose.

Phase I trial of fenretinide (4-HPR) intravenous emulsion for hematologic malignancies

13007

Background: 4-HPR is a retinoid cytotoxic for cancer cell lines. In clinical trials, oral capsule 4-HPR had limited bioavailability and activity. An intravenous intralipid emulsion formulation of 4-HPR (ILE 4-HPR) was developed to increase bioavailability. The objectives of this phase I trial were to determine a maximally tolerated dose (MTD) of ILE 4-HPR, and to assess toxicities, pharmacokinetics (PK), and preliminary response data. Methods: We used an accelerated titration Simon design 2 dose escalation schema with 100% increase in ILE 4-HPR per dose level tested until moderate toxicity was observed in 2 patients or DLT in one. Ten dose levels were planned with a starting dose of 80 mg/m2/day (continuous i.v. x 5 days q 3 weekly), increasing until Dose level 10 at 1,810 mg/m2. A De-escalation to 1,240 mg/m2/day Dose level 9 was added when DLT was observed in 2 patients at 1,810 mg/m2 dose level 10. Results: To date, 11 patients have been enrolled. At dose level 10 (1,810 mg/m2/day), 2 pts experienced a DLT of grade IV hypertriglyceridemia with grade 2 pancreatitis. A de-escalation to dose level 9 (1,280 mg/m2/day) has enrolled 4 pts, 1 had grade IV hypertriglyceridemia; enrollment is ongoing. We observed a transient response in a patient with NHL at 320 mg/m2 and a continued partial response in one patient with NHL on dose level 10 (1,810 mg/m2). PK showed a linear relationship of dose to plasma level, with steady-state levels of 54 μM (1,280 mg/m2)and 62 μM (1,810 mg/m2). Conclusions: ILE 4-HPR was given via continuous infusion to a dose of 1,810 mg/m2/day x 5 days. 1 patient with NHL had a transient partial response and a second patient with chemotherapy-refractory NHL had a partial response sustained on treatment for > 6 months. The DLT of hypertriglyceridemia is likely related to the intralipids delivered. Enrollment continues at a dose of 1,280 mg/m2/day. ILE 4- HPR can be safely administered and obtained plasma levels 6 to 7 times higher than previously obtained by oral capsule 4-HPR, with clinical activity in hematologic malignancies.

No significant financial relationships to disclose.

A pilot trial of topotecan administered orally in patients with advanced solid tumors expressing hypoxia inducible factor (HIF)- 1α

14103

Background: HIF-1 is a transcription factor frequently over-expressed in common human cancers that mediates a transcriptional program leading to tumor angiogenesis, survival and metastases. Previous studies have demonstrated that daily administration of topotecan (TPT), a topoisomerase I poison, inhibits HIF-1a expression, angiogenesis and tumor growth in human xenograft models. The primary aim of this study is to investigate whether TPT inhibits HIF-1a expression in human cancers. Methods: TPT was administered orally at 1.6 mg/m2 daily x 5 for 2 weeks, on a 28-day cycle, to adult patients with advanced solid tumors expressing HIF-1a in at least 10% of tumor cells, as assessed by IHC. Tumor biopsies are obtained before and at the end of treatment in cycle 2 and tested for HIF-1a protein expression by IHC and mRNA expression of HIF-1 target genes by real-time PCR. 18FDG-PET, to assess tumor metabolism, and DCE-MRI, to assess blood flow and permeability, were obtained at baseline, at the end of 2 weeks of therapy and then at the end of treatment on cycle 2. CT scans were performed before and after 2 cycles of therapy. Serial blood samples are obtained for PK analysis. Results: Seven patients, median age 54 (range 35–70), have been treated so far, with 6 patients being evaluable for the primary endpoint with paired tumor biopsies for analyses: melanoma (1), colorectal cancer (2), bladder (1), breast (1), ovarian (1). First two patients received the planned dose of 1.6 mg/m2; patient # 2 developed grade 3 neutropenia and grade 4 thrombocytopenia. As the objective was to develop a regimen for chronic dosing that was well tolerated and not directly cytotoxic, the protocol was amended to reduce the dose. Four patients have received a median of 2 cycles at 1.2 mg/m2, which has been well tolerated. A decrease of VEGF mRNA expression by more than 70% was observed in the 2 patients treated at 1.6 mg/m2 after 2 cycles of treatment. However, no consistent decrease of HIF-1a protein levels was detected in the corresponding tumor tissue. Enrollment continues. Conclusion: This is the first study aimed to validate inhibition of the HIF-1 signaling pathway in cancer patients. Funded in part by NCI Contract N01- CO-12400.

No significant financial relationships to disclose.

Validity and reliability of the Italian version of the ECOS-16 questionnaire in postmenopausal women with prevalent vertebral fractures due to osteoporosis

OBJECTIVE

To investigate the reliability and validity of the Italian version of ECOS-16 (Assessment of health related quality of life in osteoporosis) in comparison to other questionnaires in postmenopausal women with osteoporosis.

METHODS

A cross-sectional multicentre study was carried out among postmenopausal women with osteoporosis who were attending primary care centres and hospital outpatient clinics. The patient group included 234 females (mean age 69 years, range 48-89) who presented vertebral fractures due to osteoporosis. The control group consisted of 244 asymptomatic osteoporotic subjects matched for age with the patient group. The psychometric properties of the questionnaires were evaluated in terms of feasibility, validity (construct validity and discriminant validity) and internal consistency. Test-retest reliability was analysed for 196 outpatients who reported that their general health status due to osteoporosis had not changed after one week. In all patients the ECOS-16, the SF-36 (Medical Outcomes Study Short Form-36), EUROQoL (EQ-5D), mini-OQLQ (mini-Osteoporosis Quality of Life Questionnaire), and RMDQ (Roland-Morris Disability Questionnaire) were administered, and all clinical variables and sociodemographic variables were taken into account. Construct and discriminant validity were assessed by Spearman's correlations, the Wilcoxon rank sum test, the Kruskal Wallis test and by receiver operating characteristic (ROC) curves. Internal consistency was evaluated using Cronbach's alpha and the test-retest reliability was evaluated by intra-class correlation coefficients (ICCs).

RESULTS

96.9% of the patients answered all items of the ECOS-16 questionnaires. The mean administration time was 10 minutes. Factor analysis yielded two factors that accounted for 88.4% of the explained variance in the ECOS-16 questionnaire. The first factor was the ECOS-16 Physical Component Score (PCS) (45.9% of the explained variance) and the second factor was the ECOS-16 Mental Component Score (MCS) (42.4% of the explained variance). The inter-item correlation between the two factors was 0.48. Significant correlations were found between the scores of similar domains or subscales of the ECOS-16 and SF-36, EQ-5D and mini-OQLQ, supporting the concept of convergent construct validity. The total ECOS-16 score progressively increased with the number of prevelant vertebral fractures (p<0.001) and the effect of the first fracture was already statistically significant (p<0.01). On ROC curve analysis the total ECOS-16 score showed the highest performance among the different questionnaires in discriminating between patients with vertebral fractures and controls with no fractures. In the reliability study, internal consistency within the domain of ECOS-16 was generally good, with Chronbach's alpha values ranging from 0.81 to 0.89. Test-retest reliability was 0.87 for the total ECOS-16 score.

CONCLUSION

The Italian version of the ECOS-16 questionnaire was demonstrated to have good psychometric properties and could offer a useful tool in research and routine clinical practice to evaluate HRQoL in post-menopausal women with osteoporosis. A full validation of the psychometric properties will require data on its sensitivity to change.

Tumour necrosis factor (TNF)alpha -308 G/G promoter polymorphism and TNFalpha levels correlate with a better response to adalimumab in patients with rheumatoid arthritis

OBJECTIVE

To investigate the influence of -308 tumour necrosis factor-alpha (TNFalpha) promoter polymorphism and circulating TNFalpha levels in the clinical response to adalimumab treatment in patients with rheumatoid arthritis (RA).

METHODS

Eighty-one patients with active RA were genotyped for the -308 TNFalpha polymorphism by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis and subdivided into two groups for each polymorphism (G/A and G/G genotype). All received 40 mg of adalimumab subcutaneously every other week. We compared the groups' clinical responses to adalimumab at 8, 16, and 24 weeks using the Disease Activity Score in 28 joints (DAS28).

RESULTS

Both groups showed a significant improvement from baseline. A significant difference between groups was found at week 24. We found that 88.2% of G/G versus 68.4% of G/A for the -308 polymorphism were DAS28 responders (p = 0.05). The score improvement at week 24 was 2.5 +/- 1.3 in the G/G group and 1.8 +/- 1.3 in the G/A group for the -308 polymorphism (p = 0.04). The median of serum TNFalpha levels of the G/A group were lower than those of the G/G group, and statistically different at weeks 8 and 24 (p < 0.039 and p < 0.043). When comparing baseline levels to those achieved at 8, 16, and 24 weeks for the whole group, only responder patients showed a statistically significant overall increase in TNFalpha over time (p < 0.000001).

CONCLUSION

A relationship between DAS28 improvement, the -308 G/G polymorphism, and increased circulating TNFalpha levels was found in Chilean RA patients treated with adalimumab.

DAPK1 promoter hypermethylaiton in brain metastases and peripheral blood

The DAPK1 gene works as a regulator of apoptosis and is frequently inactivated in cancer by aberrant promoter hypermethylation. Loss of DAPK1 expression is associated with a selective advantage for tumor cells to resist apoptotic stimuli, allowing them to separate from the original tumor; from this point of view, DAPK1 could be considered a tumor metastases inhibitor gene. To verify the participation of DAPK1 silencing in cerebral invasion, we analyzed its promoter methylation status in a series of 28 samples from cerebral metastases using MSP and sequencing of the MSP-product. We have found hypermethylation in 53.6% (15/28) metastatic tumor samples as well as in 27.8% (5/18) of its peripheral blood samples. Our data suggest an important role of DAPK1 for silencing through promoter CpG island hypermethylation in the development of brain metastases from solid tumors. The detection of aberrant hypermethylation on DAPK1 promoter from peripheral blood samples has potential clinical implications as a tumor prognosis marker.

Sudden deterioration in nonclassical infantile-onset Pompe disease responding to alglucosidase alfa infusion therapy: a case report

A patient with atypical infantile Pompe disease suffered acute respiratory insufficiency at the age of 8 years which resulted in complete immobilization and dependence on assisted ventilation. Shortly after initiation of enzyme replacement therapy, she regained her mobility and, after 20 months of treatment, she now leads an almost normal life with limited restrictions.

Manufacturing of gene-modified cytotoxic T lymphocytes for autologous cellular therapy for lymphoma

BACKGROUND

The production of therapeutic T-cell populations for adoptive immunotherapy of cancer requires extensive ex vivo cell processing, including the isolation or creation of Ag-specific T cells and their subsequent propagation to clinically relevant numbers. These procedures must be performed according to the principles of current good manufacturing practices (cGMP) for phase I clinical trials to ensure the identity, purity potency and safety of the cellular product. In this report we describe our approach to manufacturing and characterizing bulk populations of gene-modified autologous T cells for use in treating follicular lymphoma.

METHODS

PBMC from healthy donors, obtained after informed consent, were stimulated in vitro with Ab to CD3epsilon (OKT3) and recombinant human IL-2 and then electroporated with plasmid DNA containing a human CD19-specific chimeric Ag receptor (CAR) gene and HSV-1 thymidine kinase (TK) gene. Stably transfected cells were selected in cytocidal concentrations of hygromycin B over multiple 14-day stimulation culture cycles and then cryopreserved. Vials of cryopreserved/selected T cells were used to initiate T-cell expansion cultures to produce cell products for clinical infusion. These cultures were characterized for phenotype, function and suitability for use in adoptive immunotherapy studies.

RESULTS

Our results demonstrate that bulk populations of gene-modified T cells derived from peripheral blood of healthy donors express CD19+ chimeric Ag receptor at low levels and can specifically lyse CD19+ target cells in vitro. These cells display a differentiated T-effector phenotype, are sensitive to ganciclovir-mediated killing and display a non-transformed phenotype. TCR Vbeta usage indicated that all populations tested were polyclonal. Ex vivo cell expansion from cryopreserved cell banks is sufficient to produce doses of between 5 x 10(9) and 1 x 10(10) cells/run. One of three transductions resulted in a population of cells that was not suitable for infusion but was identified during release testing. No populations displayed any evidence of bacterial, fungal or mycoplasma contamination.

DISCUSSION

We have established a manufacturing strategy that is being used to produce T cells for a phase I clinical trial for follicular lymphoma. Genetically modified T cells have been characterized by cell-surface marker phenotype, functional activity against CD19+ targets and requisite safety testing. These pre-clinical data confirm the feasibility of this approach to manufacturing T-cell products.

Phase I trial of the oral histone deacetylase inhibitor MS-275 administered with food

13036

Background: The histone deacetylase (HDAC) inhibitor MS-275, a synthetic benzamide derivative, has demonstrated antitumor activity in vitro & in vivo. After determining maximum tolerable dose (MTD = 2 mg/m2) & dose limiting toxicity (DLT) for MS-275 given to fasting patients (pts) weekly ×4 q6 weeks, we explored toxicity profile, MTD, & pharmacokinetics (PK) of MS-275 when given po on the same schedule with food. Methods: MS-275 at 2, 4, or 6 mg/m2 was administered to pts with advanced malignancy & PS ≤2, LFTs ≤2.5 × normal, adequate hematopoietic & renal function, & normal resting MUGA. PK samples were analyzed by LC-MS. Data for pts in the fed state were compared to data obtained in previous cohorts of pts treated in the fasting state. Protein acetylation assessed by a novel flow cytometric assay & HDAC enzymatic activity were measured in peripheral blood mononuclear cells (PBMC). Results: 16 pts received a median of 2 cycles (1–5) of MS-275 2–6 mg/m2 with food. No DLT occurred on 2 or 6 mg/m2 (n = 3 each), while 1 pt on 4 mg/m2 (n = 10) had a DLT: grade 3 hypophosphatemia. For 2–6 mg/m2 other grade 3 toxicities were neutropenia & lymphopenia. Grade 1–2 toxicities in >1 pt were leucopenia, anemia, thrombocytopenia, fatigue, nausea, vomiting, headache, hypoalbuminemia, hypophosphatemia, hyponatremia, & hypocalcemia. MTD has not been reached; current dose level is 8 mg/m2. Comparing PK for fasting & fed pts on 2–4 mg/m2, there was no difference in Tmax (0.5h); average Cmax & AUC were 35% & 25% lower, respectively, in fed pts; this difference is not statistically significant. Interindividual variability in exposure to MS-275 increased from 52% in fasting pts to 100% in fed pts. PBMC protein acetylation & HDAC inhibition were seen at all dose levels (2–6 mg/m2) in fed pts. Of 9 pts evaluable for response (2–4 mg/m2), 2 of 6 pts on 4 mg/m2 had stable disease. Conclusions: MTD has not yet been established for MS-275 given with food on this schedule but is ≥4 mg/m2 weekly x4 q6 weeks. Interindividual variability in exposure increases with food. Whether intestinal absorption is decreased when MS-275 is given with food requires further evaluation with additional patients. Drug-related protein hyperacetylation & HDAC inhibition were observed.

[Table: see text]

A phase II study of BAY 43–9006 (Sorafenib) in patients with relapsed non-small cell lung cancer (NSCLC)

17119

Background: Sorafenib is an inhibitor of multiple kinases including Raf-1 (C-Raf), b-Raf and pro-angiogenic tyrosine kinases (VEGFR-2/3 and PDGFR-β) and showed preclinical activity against NSCLC cell lines. Its anti-tumor activity may be attributable to inhibition of proliferative signaling through the RAS/Raf/MEK/ERK pathway and its anti-angiogenic effects. In NSCLC, the proliferation signaling of the Ras/Raf/MEK/ERK pathway is increased due to the increase in K-ras mutations. We initiated a single agent sorafenib trial in patients (pts) with relapsed NSCLC to assess clinical response and translational endpoints in tumor biopsies. Methods: This phase 2 trial uses a two-stage design targeting an objective response rate (RR) which can rule out 5% in favor of a more desirable 20% RR. Eligibility criteria: Pts with recurrent NSCLC with measurable disease who have received only one prior chemotherapy regimen, ECOG 0–1. Pts receive Sorafenib 400 mg bid continuously on 28-day cycle. Responses were evaluated every 8 weeks (wks) according to RECIST criteria. Dynamic contrast enhanced MRI (DCE-MRI) and tumor biopsy are performed before cycle 1 and at C1D15 to study early changes in tumor vascularity and translational endpoints. Results: 6 pts are evaluable for toxicity and 5 pts are evaluable for response. Best Response: 1PR (41% tumor reduction at wk 8, remained in PR until wk 28), 1 PR (unconfirmed) at wk 3, 2SD (16 and 19 wks respectively) and 1PD after 8 wks of treatment. Skin toxicity: Acne like drug-related rash (5 pts), hand-foot syndrome (6 pts), keratoacanthoma (1pt) and vasculitis (1pt). All skin toxicities are G1 or G2 and have responded to temporary withdrawal of Sorafenib and supportive care. Hypertension occurred in 1 pt (G2). No G4 toxicities have been observed. G3 toxicities include: anemia (1 pt), hyponatremia (2 pts), and nausea (1 pt). DCE-MRI results: 1 pt on C1D15 showed decrease in permibility parameters (ktrans and kep) and tumor size. DCE-MRI from the other 2 pts (1 PD, 1 SD for 16 weeks) showed no decrease in the permeability parameters. Conclusions: Sorafenib appears to be well-tolerated and active against relapsed NSCLC. Preliminary evidence of objective response warranting second stage accrual.

No significant financial relationships to disclose.

Molecular analysis of the EGFR gene in astrocytic gliomas: mRNA expression, quantitative-PCR analysis of non-homogeneous gene amplification and DNA sequence alterations

The epidermal growth factor receptor (EGFR) is a transmembrane glycoprotein with tyrosine kinase activity. This report investigates the presence of mutations, amplification and/or over-expression of the EGFR gene in 86 glial tumours including 44 glioblastomas, 21 anaplastic astrocytomas, and 21 WHO grade II astrocytomas, using polymerase chain reaction/single-strand conformation polymorphism, semiquantitative reverse-transcription-polymerase chain reaction (RT-PCR) and Southern Blot techniques. Gene amplification values were found in 34 tumours. Amplification levels were not uniform, as the transmembrane region presented lower amplification rates than extra- and intracellular domains. For the 19 samples with sufficient available tumour tissue we found over-expression in 11, and no EGFR mRNA expression in three. Ten cases showed deletion transcripts, and EGFR VIII was identified in all of these cases. One of the cases with EGFR vIII also presented a truncated form, C-958, while another showed an in frame tandem duplication of exons 18--25. We found 14 cases with sequence/structure gene alterations, including seven on which genomic novel DNA changes were identified: a missense mutation (1052C > T/Ala265Val), an insertion (InsCCC2498/Ins Pro748), three intronic changes (E6+72delG, E22--14C>G and E18--109T>C), a new polymorphic variant E12+ 22A > T, and one case that presented a 190 bp insertion, that was produced by the intron-7-exon-8 duplication and generated a truncated EGFR with intact exons 1--8 followed by an additional amino acidic sequence: Val-Ile-Met-Trp. These findings corroborate that EGFR is non-randomly involved in malignant glioma development and that different mutant forms participate in aberrant activation of tyrosine kinase pathways.

Comparison of systemic exposure to nemifitide following two methods of subcutaneous administration to healthy volunteers

The purpose of this study was to evaluate the safety and pharmacokinetics of nemifitide, a synthetic antidepressant pentapeptide, following its subcutaneous (s.c.) administration by standard needle injection or by a needle-free (Biojecttrade mark) injection and to compare these two routes of administration for systemic exposure. This small-scale, randomized, single-dose, parallel design, open-label pilot study consisted of three treatment groups of four subjects each dosed as follows: group 1: 40 mg of nemifitide administered by standard needle/syringe and groups 2 and 3: 40 and 80 mg nemifitide, respectively, administered by using a needle-free (Bioject injection delivery system. Plasma concentrations of nemifitide were determined by LC/MS/MS in blood samples collected at 10 min and 0.5, 1, 2, 4, 6 and 24 h after dosing. PK parameters, including observed C(max), T(max) and AUC(0-24), were calculated and statistical analysis of the data was conducted. Safety assessments (dosing site evaluations) were done at 0.5, 1, 5 and 24 h after dosing. Vital signs and clinical laboratory tests were taken on day 1 prior to dosing and at 24 h post-dose. Adverse experiences in all subjects were observed only as drug-related local reactions at the injection sites. All were considered mild in severity and transient (resolved by 24 h after dosing). T(max) was observed at 10 min after dose and was the same in all subjects. In the three dosing groups, 1 (40 mg), 2 (40 mg) and 3 (80 mg), observed C(max) values were 226, 245 and 440 ng/ml, respectively, and AUC(0-24) values were 108, 106 and 205 ng.h/ml, respectively. Ratios of AUC(0-24) and observed C(max) for nemifitide in plasma between groups 1 and 2 were within the 80%-125% range, indicating that the two modes of drug administration resulted in similar systemic exposure to nemifitide. Pharmacokinetic parameters (AUC(0-24) and C(max)) indicate dose-proportionality between the doses of 40 and 80 mg.

First clinical trial of a novel caspase inhibitor: anti-apoptotic caspase inhibitor, IDN-6556, improves liver enzymes

OBJECTIVE

To evaluate the safety of IDN-6556, a novel anti-apoptotic pan-caspase inhibitor, administered in single and multiple ascending doses in normal volunteers and patients with hepatic dysfunction.

MATERIALS AND METHODS

IDN-6556 was administered as a 30-minute intravenous infusion in rising doses to 3 groups: Group A, normal volunteers, given as a single infusion, Group B, normal volunteers, given q.i.d. for 7 days, Group C, patients with hepatic impairment (elevated transaminases, alanine transaminase, ALT and aspartate transaminase, AST), given q.i.d. for 7 days.

RESULTS

The drug was well tolerated up to 10 mg/kg/infusion for a single dose, and 1.5 mg/kg/infusion q.i.d. for 7 days, with the dose-limiting adverse event of phlebitis or inflammation at the site of the infusion. This toxicity was predicted from animal studies. Clinically and statistically meaningful dose-related falls in transaminases were seen in all but 1 of the hepatic impaired patients. Two-way ANOVA analyses of the changes for all the IDN-6556 groups combined versus placebo were: ALT absolute change: p < 0.0001 and % change: p = 0.012, AST absolute and % changes: p < 0.0001. After discontinuation of the drug (after 7 days of dosing), the transaminases rapidly returned to the pre-treatment levels.

CONCLUSIONS

Following intravenous administration of a novel anti-apoptotic caspase inhibitor, adverse events were mild-to-moderate in severity, resolved in a few days and did not result in any subject terminating treatment prematurely. The effects in hepatic impaired patients appear to be consistent with both the administration and subsequent abrupt withdrawal of an effective hepatoprotective drug that delays cell death in hepatocytes.

Psychoeducation and cognitive-behavioral therapy in bipolar disorder: an update

OBJECTIVE

To review the available literature on psychoeducation and cognitive-behavioral therapy (CBT) in bipolar disorder (BD) and to give an integral view of these therapies.

METHOD

Studies were identified through Medline searches in English language publications between 1971 and 2003. This was supplemented by a hand search and the inclusion of selected descriptive articles on good clinical practice.

RESULTS

A number of studies demonstrate that psychoeducation enhances adherence to treatment, and one finds that it improves outcome in BD. Other studies find that CBT diminishes depressive symptoms and improves quality of life in BD. Occasionally some adverse effects may occur with psychotherapy and, although they are sporadic, should not be overlooked.

CONCLUSION

When combined with pharmacological treatment, psychoeducation helps to improve adherence. Training in the identification of early manic symptoms helps to improve outcomes and decreases the number of manic relapses in BD.

Principal components of mania

OBJECTIVE

An alternative to the categorical classification of psychiatric diseases is the dimensional study of the signs and symptoms of psychiatric syndromes. To date, there have been few reports about the dimensions of mania, and the existence of a depressive dimension in mania remains controversial. The aim of this study was to investigate the dimensions of manic disorder by using classical scales to study the signs and symptoms of affective disorders.

METHODS

One-hundred and three consecutively admitted inpatients who met DSM IV criteria for bipolar disorder, manic or mixed were rated with the Young Mania Rating Scale (YMRS) and the Hamilton Depression Rating Scale (HDRS-21). A principal components factor analysis of the HDRS-21 and the YMRS was carried out.

RESULTS

Factor analysis showed five independent and clinically interpretable factors corresponding to depression, dysphoria, hedonism, psychosis and activation. The distribution of factor scores on the depressive factor was bimodal, whereas it was unimodal on the dysphoric, hedonism and activation factors. Finally, the psychosis factor was not normally distributed.

LIMITATIONS

Patients of the sample were all medicated inpatients.

CONCLUSIONS

Mania seems to be composed of three core dimensions, i.e. hedonism, dysphoria and activation, and is frequently accompanied by a psychotic and a depressive factor. The existence of a depressive factor suggests that it is essential to evaluate depression during mania, and the distribution of the depressive factor supports the existence of two different states in mania.

Aberrant methylation of multiple genes in neuroblastic tumours. relationship with MYCN amplification and allelic status at 1p

Aberrant hypermethylation occurs in tumour cell CpG islands and is an important pathway for the repression of gene transcription in cancers. We investigated aberrant hypermethylation of 11 genes by methylation-specific polymerase chain reaction (PCR), after treatment of the DNA with bisulphite, and correlated the findings with MYCN amplification and allelic status at 1p in a series of 44 neuroblastic tumours. This tumour series includes five ganglioneuromas (G), one ganglioneuroblastoma (GN) and 38 neuroblastomas (six stage 1 tumours; five stage 2 tumours; six stage 3 cases; 19 stage 4 tumours, and two stage 4S cases). Aberrant methylation of at least one of the 11 genes studied was detected in 95% (42 of 44) of the cases. The frequencies of aberrant methylation were: 64% for thrombospondin-1 (THBS1); 30% for tissue inhibitor of metalloproteinase 3 (TIMP-3); 27% for O6-methylguanine-DNA methyltransferase (MGMT); 25% for p73; 18% for RB1; 14% for death-associated protein kinase (DAPK), p14ARF, p16INK4a and caspase 8, and 0% for TP53 and glutathione S-transferase P1 (GSTP1). No aberrant methylation was observed in four control normal tissue samples (brain and adrenal medulla). MYCN amplification was found in 11 cases (all stage 4 neuroblastomas), whereas allelic loss at 1p was identified in 16 samples (13 stage 4 and two stage 3 neuroblastomas, and one ganglioneuroma). All but one case with caspase 8 methylation also displayed MYCN amplification. Our results suggest that promoter hypermethylation is a frequent epigenetic event in the tumorigenesis of neuroblastic tumours, but no specific pattern of hypermethylated genes could be demonstrated.

Treatment of bipolar I rapid cycling patients during dysphoric mania with olanzapine

The simultaneous presentation of manic and depressive symptoms in the same patient is fairly common. The terms and have been used as equivalents to mixed states. Pharmacotherapy is less effective in this group of patients. The aim of this study is to determine the effectiveness and safety of olanzapine as an add-on therapy in patients with bipolar disorder with a rapid cycling course during a dysphoric mania episode. Thirteen patients treated with mood stabilizers for at least 1 year and diagnosed with a mixed episode were included in an open trial. All had at least 4 episodes in the last year. Patients with organic diseases, including altered thyroid function, were excluded from the research. Patients were evaluated at inclusion and at day 28. Response was defined as a decrease of 50% in the Young Mania Rating Scale and the Hamilton Rating Scale for Depression concomitant with a Clinical Global Impression improvement of 1 or 2. All patients completed the study. The doses of olanzapine were 16.15 +/- 5.82 mg/day. There was a reduction in the manic and depressive symptoms in all patients. Ten of the 13 patients were considered to have responded to the treatment according to the response definition. Adverse effects included somnolence (23.08%) and weight gain (0.81 +/- 1.96 kg in women, 2.20 +/- 2.28 kg in men). Our results suggest that olanzapine combined with mood stabilizers is safe and effective in the treatment of the manic and the depressive symptoms of dysphoric mania with a rapid cycling course.