Toxicokinetics of plasmatic VX in a swine model: comparison of a simple enzymatic titration method with a mass spectrometry method

Recent events have shown that organophosphorus nerve agents (OPNAs) are a serious threat. Cholinesterase inhibition by OPNAs results in acetylcholine accumulation, a cholinergic crisis leading to death if untreated. Efficacy assessment of new medical countermeasures against OPNAs relies on translational animal models. We developed a swine model of percutaneous VX intoxication and a simple plate reader-based enzymatic method to quantify plasmatic VX over time. Juvenile pigs anesthetized with sevoflurane were poisoned with a single supralethal (n = 5; 1200 μg/kg) or sublethal (n = 6; 320 μg/kg) percutaneous dose of VX. These intoxicated animals were compared to 7 control animals. Repeated blood sampling was performed up to 6 h post-intoxication. Blood cholinesterase activities were measured using the Ellman assay. Nanomolar plasma concentrations of VX were measured by exogenous butyrylcholinesterase added to an aliquot of plasma. As expected, we observed a steady increase in plasma concentration of VX over time concomitant to a decrease in blood cholinesterase activities for all intoxicated pigs. Despite the simplicity of the enzymatic method, the results obtained are in good agreement with those of the liquid chromatography-mass spectrometry method. This method is also applicable to other OPNAs such as novichoks with minor adaptations.

Expected and paradoxical effects of obesity on cancer treatment response

Obesity, whose prevalence is pandemic and continuing to increase, is a major preventable and modifiable risk factor for diabetes and cardiovascular diseases, as well as for cancer. Furthermore, epidemiological studies have shown that obesity is a negative independent prognostic factor for several oncological outcomes, including overall and cancer-specific survival, for several site-specific cancers as well as for all cancers combined. Yet, a recently growing body of evidence suggests that sometimes overweight and obesity may associate with better outcomes, and that immunotherapy may show improved response among obese patients compared with patients with a normal weight. The so-called 'obesity paradox' has been reported in several advanced cancer as well as in other diseases, albeit the mechanisms behind this unexpected relationship are still not clear. Aim of this review is to explore the expected as well as the paradoxical relationship between obesity and cancer prognosis, with a particular emphasis on the effects of cancer therapies in obese people.

Sensitivity and specificity of strain rate for the early detection of left ventricular dysfunction in breast cancer patients receiving adjuvant treatment with adriamycin with or without trastuzumab

Background

Medical literature states that a global longitudinal strain rate (GLS) <−19% and further reductions in relation with baseline GLS may predict long term left ventricular dysfunction in breast cancer patients receiving adjuvant treatment with Adriamycin (A) with or without trastuzumab (T). However, there is not strong evidence to support the use of this technique in daily clinical practice.

Purpose

To analyze the sensitivity (S) and specificity (Sp) of GLS <−19% or its relative 10, 15 and 20% reduction form baseline, for the early detection of left ventricular dysfunction in breast cancer patients receiving adjuvant treatment with A with or without T.

Methods

Patients were prospectively assessed with a cardiac echoDoppler + GLS at baseline, every 3 months during the first year and every 4 months thereafter. We assessed the S and Sp of GLS <−19% or its relative >10%, >15% and >20% reduction form baseline after treatment with A with or without T as predictors of cardiotoxicity (defined as a >10 percentage points decrease of left ventricular ejection fraction to a value below the lower normal limit with respect to baseline).

Results

136 out of 884 patients (16%) had GLS measured at each visit: 83 patients (60%) and 53 patients (40%) treated with A or A+T respectively. Patients were followed up to 31±6 months. Mean age was 51±12 years. The table shows the baseline characteristics of both groups. 10 out of 83 patients in group A (12%) and 18 out of 53 P in group A+T (34%) developed cardiotoxicity. Baseline left ventricular ejection fraction and GLS were 61±4,7% and −20,18±2,6% in group A, and 58,7±5,8% and −19,5±2,6 post treatment. In this group, GLS S and Sp were 50 and 80%, respectively. In the group A+T, the best GLS cutoff was −19%, with a 60% sensitivity and 78% specificity.

Conclusions

In our non-selected cohort of patients, nor GLS or its percentage reductions along follow up predicted the reduction of left ventricular ejection fraction and the developing of cardiotoxic ventricular dysfunction in breast cancer patients receiving adjuvant treatment with A with or without T. The systematic use of this tool should be further investigated and validated at each center to help establish its usefulness in daily practice.

Funding Acknowledgement

Type of funding sources: None. Baseline characteristics

Lenvatinib as a salvage therapy for advanced metastatic medullary thyroid cancer

PURPOSE

Patients with advanced progressive metastatic medullary thyroid cancer (MTC), show poor prognosis and few available systemic therapeutic options. After the loss of clinical benefit with other tyrosine kinase inhibitors (TKI), we evaluated the use of lenvatinib as salvage therapy.

METHODS

Ten patients who experienced the loss of clinical benefit after treatment with at least one previous TKI, were treated with lenvatinib. We assessed patient's response immediately before, at the first (first-EV) and last (last-EV) evaluation, after the beginning of treatment.

RESULTS

At first-EV, one patient died, while all the remaining 9 showed a stable disease (SD) in the target lesions. At last-EV, SD was still observed in seven patients, while partial response (PR) and progressive disease (PD), in one patient each. Conversely, analyzing all target and non-target lesions, at first-EV, we observed PR in one patient and SD in eight patients. At last-EV, PR was shown in two patients and SD was shown in seven. Bone metastases showed stable disease control at both first-EV and last-EV in only approximately 60% of cases. Tumor markers (CTN and CEA) decreased at first-EV, while they increased at last-EV. Seven patients experienced at least one dose reduction during treatment with lenvatinib.

CONCLUSIONS

In this real-life clinical experience, lenvatinib showed interesting results as salvage therapy in patients with advanced progressive metastatic MTC patients. Its usefulness could be effective in patients without any other available treatment, because previously used or unsuitable, especially with negative RET status with no access to the new highly selective targeted therapies.

Bone metastases from differentiated thyroid carcinoma: current knowledge and open issues

Bone represents the second most common site of distant metastases in differentiated thyroid cancer (DTC). The clinical course of DTC patients with bone metastases (BM) is quite heterogeneous, but generally associated with low survival rates. Skeletal-related events might be a serious complication of BM, resulting in high morbidity and impaired quality of life. To achieve disease control and symptoms relief, multimodal treatment is generally required: radioiodine therapy, local procedures-including surgery, radiotherapy and percutaneous techniques-and systemic therapies, such as kinase inhibitors and antiresorptive drugs. The management of DTC with BM is challenging: a careful evaluation and a personalized approach are essential to improve patients' outcomes. To date, prospective studies focusing on the main clinical aspects of DTC with BM are scarce; available analyses mainly include cohorts assembled over multiple decades, small samples sizes and data about BM not always separated from those regarding other distant metastases. The aim of this review is to summarize the most recent evidences and the unsolved questions regarding BM in DTC, analyzing several key issues: pathophysiology, prognostic factors, role of anatomic and functional imaging, and clinical management.

Real-world efficacy and safety of lenvatinib: data from a compassionate use in the treatment of radioactive iodine-refractory differentiated thyroid cancer patients in Italy

BACKGROUND

Lenvatinib is a multi-kinase inhibitor approved for patients with radioactive iodine (RAI)-resistant differentiated thyroid cancer (DTC). Before the drug approval from the Italian National Regulatory Agency, a compassionate use programme has been run in Italy. This retrospective study aimed to analyse data from the first series of patients treated with lenvatinib in Italy.

METHODS

The primary aim was to assess the response rate (RR) and progression-free survival (PFS). Secondary end-points include overall survival (OS) and toxicity data.

RESULTS

From November 2014 to September 2016, 94 patients were treated in 16 Italian sites. Seventeen percent of patients had one or more comorbidities, hypertension being the most common (60%). Ninety-eight percent of patients were treated by surgery, followed by RAI in 98% of cases. Sixty-four percent of patients received a previous systemic treatment. Lenvatinib was started at 24 mg in 64 subjects. Partial response and stable disease were observed in 36% and in 41% of subjects, respectively; progression was recorded in 14% of patients. Drug-related side-effects were common; the most common were fatigue (13.6%) and hypertension (11.6%). Overall, median PFS and OS were 10.8 months (95% confidence interval [CI], 7.7-12.6) and 23.8 months (95% CI, 19.7-25.0) respectively.

CONCLUSION

Lenvatinib is active and safe in unselected, RAI-refractory, progressive DTC patients in real-life setting. RR and PFS seem to be less favourable than those observed in the SELECT trial, likely due to a negative selection that included heavily pretreated patients or with poor performance status.

Thyroid nodule recurrence following lobo-isthmectomy: incidence, patient's characteristics, and risk factors

PURPOSE

This study was aimed at assessing the incidence and timing of thyroid nodules recurrence, defined as appearance of new benign or malignant nodules in contralateral lobe in patients with benign thyroid nodules or thyroid microcarcinoma treated with lobo-isthmectomy. Patient's characteristics and risk factors associated with this phenomenon were also investigated.

METHODS

A retrospective study was performed by evaluating 413 patients undergoing lobo-isthmectomy with a minimum follow-up of 1 year. Clinical characteristics, surgical interventions and complications, histological diagnosis, and thyroid function at last follow-up were collected.

RESULTS

Single or multiple thyroid nodule recurrence equally occurred in 80 patients (23%) with a median time to relapse of ~ 5 years (range 0.3-34.5 years) after lobo-isthmectomy. Recurrence was significantly associated with younger age (< 46 years) and number of pregnancies in women. Development of hypothyroidism was not rare either (~ 10%) and appeared in 3-19 months; a preoperative TSH level > 2.43 mIU/L was associated with the need of l-thyroxin replacement therapy after surgery. The most frequent surgical complication was transient hypoparathyroidism (4.6%), while the rate of permanent hypoparathyroidism significantly increased in patients submitted to completion thyroidectomy (5.3%).

CONCLUSIONS

Thyroid nodules recurrence following lobo-isthmectomy is not a rare event and occurs within 5 years after surgery, more frequently in younger patients with family history of nodular goiter and in women with multiple pregnancies. Pre-surgical TSH levels may predict the development of post-surgical hypothyroidism, possibly improving the management of patients addressed to surgery.

Abstract P6-09-09: Meta-analysis of ESR1 mutation prevalence in metastatic breast cancer

Introduction: ESR1 mutations were described for the first time in 1996 when different tyrosine 537 mutations were found to confer constitutive activation of the receptor, describing this region as a key factor in the ligand regulation of ER transcriptional activity. However, due to the low prevalence of this mutation in primary breast tumors its clinical significance maintained unknown. With the advent of large scale genomic analysis, a new understanding of breast cancer molecular characteristics has gained relevance. The low prevalence of ESR1 mutations in primary breast cancer has been confirmed but mutations in metastatic ER-positive breast cancers has been proved to be a completely different scenario. Nevertheless, information regarding real prevalence of ESR1 mutation in metastatic breast cancer is not known as selection of patients and molecular technique used are heterogeneous.

Sources: Search was carried by corresponding clinical oncologists of the Breast Cancer Unit of Alexander Fleming Institute. In March 2017, key words “ESR1 mutations”, “Estrogen receptor mutations” and “Breast cancer” were used as search strategy for the present meta-analysis in PubMed. Furthermore, abstracts from congress presentations were analyzed and hand searching from reference list of obtained articles was executed. Online search retrieved 60 articles published, 3 abstracts related were found and 3 further studies were detected by hand search. Articles were excluded if they only included primary tumors and not metastatic cases and if they were undertaken before 2000 due to important technical differences of mutation detection, including finally 23 cohorts.

Study Selection: Studies considered were prospective or retrospective cohorts of metastatic breast cancer patients with mutation analysis of tissue or circulating DNA. A data form was used by the primary reviewer to extract equivalent information from each article. Information extracted included population sampled, prevalence estimates, clinical characteristics of cohort, sample analyzed and technical procedure for mutation detection. A second reviewer blinded to the primary reviewer's decisions checked the article selection and data extraction. Any differences of opinion were discussed, and a third reviewer was available to arbitrate any issues.

Meta-analysis was undertaken using a random-effects model conducted using the metaprop function in Meta package of R studio Version 1.0.136 (© 2009-2016 RStudio, Inc.). PRISMA guidelines were followed in conducting and reporting the results.

Results and Discussion: Results show a prevalence of ESR1 mutation of 24% (CI95% 19-30%) in the 3607 patients included. Nevertheless, important heterogeneity (I2 =90%) is observed due to great differences in the articles published of this topic. This heterogeneity is attributed to the type of cohorts presented, the selection of patients, the technique used and type of sample studied, but another source of heterogeneity must be present as it still persists after grouping studies according to this variables. The importance of this analysis resides in the fact that it is the most complete information of the prevalence of this mutation that may have future importance in therapeutic decisions in metastatic breast cancer.

Citation Format: Mandó P, Rizzo MM, Perez de la Puente C, Costanzo MV, Nervo A, Nadal J, Colo F, Loza CM, Loza J, Fabiano V, Ponce C, Chacon R. Meta-analysis of ESR1 mutation prevalence in metastatic breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-09-09.

Abstract P6-09-40: Her2 and hormonal receptor analysis in breast cancer synchronic node metastases could add therapeutic information

Introduction: Breast cancer is the tumor with highest incidence and mortality in women in Argentina. Hormonal receptors (HR) and HER2 are the most important prognostic and predictive factors. It is suggested that estrogen receptors (ER), progesterone receptors (PR) and HER2 expression can vary during tumor progression and metastases development. Published evidence has reported discordance between primary tumors and its metastases ranging from 15-54% for HR and HER2 overexpression. A similar discordance situation may exist among primary tumor (PT) and its axillary nodal metastases (NM)

Objective: To describe the expression and discordance of ER, PR and HER2 in PT and its synchronic NM

Material and methods: Prospective analysis of surgical breast cancer patients (pts) at Instituto Alexander Fleming (Sept 2013 to Feb 2016). HR were analyzed by immunohistochemistry (IHC) according to CAP protocols; values ≥ 10% were considered positive. HER2 overexpression was defined by 3+ IHC or positive FISH. Paired t test was used to compare mean using Prims 5 software.

Results: In 587 breast cancer surgeries, 190 pts presented NM. HR and HER2 analysis was performed in 101 paired samples. Median age was 51 years (r 25-83). Mean tumor size was 3,3 ± 0,2 cm. 0,99% (1) were stage I, 68,3% (69) stage II and 30,7% (31) stage III. Most frequent histologic subtype was ductal carcinoma (66.3%). 78.2% presented lymphovascular invasion. Median positive nodes were 2 (r 1-21). Paired samples allowed ER analysis in 99 cases, PR in 98 and HER2 in 96; 8 NM were Her2++; FISH analysis was inconclusive in 4 of them due to insufficient tissue. No differences were observed on ER between PT and NM (72% vs 71.1%, OR: 0,91, IC95 -3.2-5.1; p&gt;0,05), nor PR expression (52.1% vs 54,5%, OR: -2.1, IC95 -7.1-3.01; p&gt;0,05). PT were ER+ in 86.1% of the cases; NM were ER+ in 82.2%. Regarding PR, PT were 74.3% PR+ and NM were 76.2% PR+. 28 of the 101 pts (27.7%) were discordant. 5 pts with ER+ PT had ER- NM, and 3 pts had PT ER- but ER+ NM, representing a 7.9% of discordance. 4 of 75 pts with PR+ in PT were PR- in NM, while 8 of 26 pts were PR- in PT but PR+ in NM. Of the 13 HER2+ pts, 2 (15%) did not present overexpression in NM. On the other hand, 6 (7%) of the 83 HER2- PT were HER2+ in NM. 4 of 9 pts had PT RH and Her2- (TN), but NM RH and/or Her2+.

Discussion: Tumor heterogeneity is an important issue that may affect clinical decisions. Axillary nodes are the first metastatic site for breast cancer and different studies have shown discrepancy between PT and NM. We described a discordant expression in ER, PR and HER2 of 8%, 12% and 9% respectively. These differences could be due to technical reasons, intratumor heterogeneity and/or a different cellular phenotype. Although the clinical importance of these changes are not completely understood, NM status could bring important prognostic and therapeutic information defining a particular group of patients in which a specific therapeutic strategy could influence long term results. In fact, in our series 44% of TN tumors presented NM with a therapeutic target, either HR or HER2. We therefore confirm that pathological analysis of NM may bring up additional information that could be useful in a prognostic or therapeutic point of view.

Citation Format: Rizzo MM, Mando P, Perez de la Puente C, Maino M, Ponce C, Fabiano V, Pombo MT, Loza CM, Costanzo MV, Nervo A, Nadal J, Colo F, Chacon RD. Her2 and hormonal receptor analysis in breast cancer synchronic node metastases could add therapeutic information [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-09-40.

Abstract P3-01-07: Second axillary sentinel lymph node biopsy for breast tumor recurrence: Instituto Alexander Fleming experience in Buenos Aires, Argentina

Sentinel Lymph Node Biopsy (SLNB) is the standard technique for axillary staging of patients with operable breast cancer and a clinically negative axilla because it avoids unwarranted axillary dissection and consequently reduces postoperative morbidity.

Purpose: The aim of this study is to determinate the feasibility and accuracy of the second SLNB for patients with ipsilateral breast cancer recurrences with clinically negative axilla, who were treated previously with breast surgery and study of the axilla.

Methods: Retrospective review of the database of the Instituto Alexander Fleming. Between October 2009 and October 2014, 1029 patients with diagnosis of breast cancer required surgery. The study included 26 patients with the diagnosis of operable local breast cancer recurrence, who had previously undergone axillary surgery either as SLNB, sampling or axillary lymph node dissection (ALND). They subsequently underwent additional breast surgery and a second SLNB.

Results: The mean age of the ipsilateral breast cancer recurrences was 59.23 years (range: 32-87) and the most common histologic subtype was invasive ductal carcinoma in 22 patients (84.6%) and 4 patients (15.4%) with invasive lobular carcinoma. 4 patients (15.4%) had previously ALND or sampling and 22 patients (84.6%) SLNB. The identification rate of the second SLNB was 92.31%. Only 2 patients were not identify, one patient with a previous axillary sampling and another one with previous SLNB. In those patients the ALND was performed and the axilla was negative. Lymphoscintigraphy failed to identify any SLN in 6 patients (23%), 2 patients which were not identify and 4 patients only detected with patent blue. The average number of nodes removed at second SLNB was 1.8 (range: 1-5). Second SLNBs were negative in 21 patients (80.8%), and macrometastasis disease was identified in 2 patients and complete ALND was performed.

In 1 patients additional extra-axillary aberrant drainages was observed in the contralateral axilla and interpectoral, and other 3 patients had aberrant drainage in the contralateral axilla (1 patient), internal mammary regions (1 patient), and interpectoral (1 patient). Aberrant drainage pathways were not routinely dissected. Only those accessible during surgery were removed.

The median time between first surgery and ipsilateral breast tumor recurrence was 7.19 years (range: 1-22). The disease free survival (DFS) was 9.16 years (range: 2.25-24).

Conclusion: In the present serie we show a high identification rate of 92.31% in the second SLNB, comparable with other international series published in the literature (range: 51-97%). A second SLNB should be considered for patients with ipsilateral breast tumor recurrence who underwent conservative surgery and have clinically negative axilla. The procedure is technically feasible and accurate for selected patients, and avoids unnecessary ALND. Extra-axillary sentinel lymph node localization rates are higher than for primary SLNB but the clinical significance and management of extra-axillary nodes needs to be clarified.

Citation Format: Maino M, Fabiano V, Ponce C, Loza M, Costanzo V, Nervo A, Nadal J, Mysler D, Amat M, Coló F, Loza J, Chacón R. Second axillary sentinel lymph node biopsy for breast tumor recurrence: Instituto Alexander Fleming experience in Buenos Aires, Argentina. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-01-07.

Non-scheduled consultation in oncologic patients. How many of them are true emergencies? An observational prospective study

Oncologic emergencies have been extensively described and clearly defined. In oncology daily practice, cancer patients seek non-scheduled medical care in situations they perceive as a medical emergency, but which may not be a true emergency. The aim of the study was to identify the main symptoms leading to a non-scheduled consultation (NSC) and their relationship to the type of cancer, and to evaluate whether the diagnosis at discharge of patients admitted as result of a NSC correlates with a true oncologic emergency. This was a prospective observational study. Between July 2002 and April 2003, 365 NSCs were recorded. The most frequent baseline diseases were breast cancer (70), lung cancer (67), gastrointestinal cancer (52), lymphoma (42) and ovarian cancer (22). The most common symptoms for consultation were: fever (84), pain (81), cutaneous manifestations (26), dyspnea (23), bleeding (16) and abdominal distention (16). Overall, 114 of 365 NSCs (31%) resulted in admission. The most frequent symptoms resulting in admission were fever (42), pain (16), dyspnea (11), vomiting (9), neurologic manifestations (7), abdominal distention (6) and anuria (6). At discharge, only 30 patients (26%) admitted after a NSC were diagnosed with a defined oncologic emergency: febrile neutropenia (13), intestinal occlusion (12), obstructive uropathy (4) and abdominal perforation (1). True emergencies were not the most frequent causes of NSC at our institution.

[Phaeohyphomicosis by Wangiella dermatitidis in Republic Argentine.]

We are presenting the case of a 54 year-old woman, who had a kidney transplant. She came to our laboratory to consult for two cutaneous lesions: a cystic one at the back of her right leg and one localized on dorsum of left forearm. Biopsies of both lesions were performed for a histopathologic study as well as microbiological (both bacteriologic and mycologic) cultures. The histopathologic study showed a lesion compatible with a B type cutaneous lymphoma in the lesion in her leg, while in the mycologic study of the cystic lesion elements compatible with phaeohyphomycosis were observed. Development of Wangiella dermatitidis was obtained in the cultures. The cystic lesion localized on forearm was completely removed by surgery, while the lesion in the leg received oncological treatment. The aim of this paper is to describe the first published case of phaeohyphomycosis, by W. dermatitidis, in the Argentine Republic.