Cardio-protective effects of statins in patients undergoing anthracycline-based chemotherapy: An updated meta-analysis of randomized controlled trials

INTRODUCTION

Several interventions have been tested for cardio-protection against anthracycline-induced cancer therapy-related cardiovascular dysfunction (CTRCD). The role of statins in this setting remains unclear.

METHODS

We systematically searched PubMed, Embase, Cochrane Library, Clinicaltrials.gov, and Web of Science for randomized controlled trials (RCTs) comparing statins versus control (placebo or no intervention) for preventing anthracycline-induced CTRCD. We applied a random-effects model to pool risk ratios (RR) and mean differences (MD) with 95 % confidence intervals (CI).

RESULTS

We included seven RCTs comprising 887 patients with planned chemotherapy with anthracycline-based regimens, of whom 49.8 % were randomized to statins. Relative to placebo, statins significantly reduced the incidence of cardiotoxicity/CTRCD (RR 0.46; 95 % CI 0.29 to 0.72; p < 0.001). The left ventricular end-systolic volume was also lower in patients treated with statin (MD -3.12 mL; 95 % CI -6.13 to -0.12 mL; p = 0.042). There was no significant difference between groups in post-anthracycline left ventricular ejection fraction (LVEF) overall.

CONCLUSION

In this meta-analysis of RCTs, statins were significantly associated with a lower incidence of anthracycline-induced CTRCD and attenuated changes in the left ventricular end-systolic volume. Thus, our findings suggest that statins should be considered as a cardio-protection strategy for patients with planned anthracycline-based chemotherapy.

Trastuzumab deruxtecan in human epidermal growth factor receptor 2-positive breast cancer brain metastases: a systematic review and meta-analysis

BACKGROUND

Trastuzumab deruxtecan (T-DXd) has shown promising results in patients with breast cancer brain metastases (BCBMs). We conducted a systematic review and meta-analysis to evaluate the effectiveness and safety of T-DXd in the human epidermal growth factor receptor 2 (HER2)-positive BCBM population.

PATIENTS AND METHODS

We searched PubMed, Embase, and Cochrane Library databases as well as American Society of Clinical Oncology (ASCO), European Society for Medical Oncology (ESMO), and San Antonio Breast Cancer Symposium (SABCS) websites for clinical trials (CTs) and observational studies evaluating T-DXd in patients with HER2-positive BCBM. Heterogeneity was assessed with I2 statistics. Random effects models were used for all statistical analyses, which were carried out using R software (version 4.2.2).

RESULTS

Ten studies were included, six CTs (n = 189) and four observational studies (n = 130), with a total of 319 patients. The median progression-free survival was 15 months [95% confidence interval (CI) 13.9-16.1 months]. The objective response rate (ORR) was 61% (95% CI 52% to 70%), and the intracranial (IC)-ORR was 61% (95% CI 54% to 69%). No significant differences in ORR and IC-ORR were observed between CTs and observational studies (P = 0.31 and 0.58, respectively). The clinical benefit rate (CBR) was 80% (95% CI 52% to 94%), and the IC-CBR was 70% (95% CI 54% to 82%). The ORR was 68% (95% CI 57% to 77%) in the subgroup of patients with stable BMs and 60% (95% CI 48%-72%) in patients with active BM, with no significant difference between groups (P = 0.35).

CONCLUSIONS

Our systematic review and meta-analysis supports the IC activity of T-DXd in patients with stable BM and active BM.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) under the protocol number CRD42023422589.

Mesenchymal-Epithelial Transition Kinase Inhibitor Therapy in Patients with Advanced Papillary Renal-Cell Carcinoma: A Systematic Review and Meta-Analysis

Papillary subtypes of renal-cell carcinoma (pRCC) represent 10-15% of the cases and commonly have MET alterations. This systematic review and single-arm meta-analysis evaluated MET inhibitor therapy (METi) efficacy and safety in adults with confirmed advanced pRCC. The search strategy included PubMed, Web-of-science, Cochrane, and Scopus. We used the DerSimonian/Laird random effect model for all analyses; p-value < 5% was considered significant, and heterogeneity was assessed with I2. Three clinical trials and six cohort studies were included with 504 patients; 31% were MET-driven. Our pooled analysis demonstrated an objective response rate (ORR) in MET-driven, MET-independent, and overall patients of: 36% (95%CI: 10-62), 0% (95%CI: 0-3), and 21% (95%CI: 1-41), respectively. One-year disease control and progression-free survival rates were, respectively, 70% (95%CI: 52-88) and 15% (95%CI: 10-20). Twelve- and twenty-four-month survival rates were, respectively, 43% (95%CI: 23-64) and 10% (95%CI: 0-30). The prevalence of adverse events of any grade and grades 3-5 were 96% (95%CI: 91-100) and 44% (95%CI: 37-50), respectively. We suggest METi has anti-tumor activity and is tolerable in patients with advanced pRCC.

PD-1/PD-L1 inhibitors plus carboplatin and paclitaxel compared with carboplatin and paclitaxel in primary advanced or recurrent endometrial cancer: a systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Paclitaxel and carboplatin is the standard chemotherapy for the treatment of advanced or recurrent endometrial cancer. However, the benefit of adding programmed cell death 1 (PD-1)/programmed death ligand 1 (PD-L1) inhibitors to chemotherapy is still unclear.

METHOD

We searched PubMed, Scopus, Cochrane, and Web of Science databases for randomized controlled trials that investigated PD-1/PD-L1 inhibitors plus carboplatin and paclitaxel compared with carboplatin and paclitaxel in primary advanced or recurrent endometrial cancer. We computed hazard ratios (HRs) or risk ratios (RRs) for binary endpoints, with 95% confidence intervals (CIs). We used DerSimonian and Laird random-effect models for all endpoints. Heterogeneity was assessed using I2 statistics. R, version 4.2.3, was used for statistical analyses.

RESULTS

A total of three studies and 1,431 patients were included. Compared with carboplatin plus paclitaxel-based chemotherapy, progression-free survival (PFS) rate (HR 0.32; 95% CI 0.23-0.44; p < 0.001) and overall survival (OS) at 30 months (RR 3.13; 95% CI 1.26-7.78; p = 0.01) were significant in favor of the PD-1/PD-L1 inhibitors plus carboplatin and paclitaxel group in the mismatch repair-deficient subgroup. However, there were no significant differences in the mismatch repair-proficient subgroup for PFS (HR 0.74; 95% CI 0.50-1.08; p = 0.117) or OS at 30 months (RR 2.24; 95% CI 0.79-6.39; p = 0.13).

CONCLUSION

Immunotherapy plus carboplatin-paclitaxel increased significantly PFS and OS among patients with advanced or recurrent endometrial cancer, with a significant benefit in the mismatch repair-deficient and high microsatellite instability population.

Identification of characteristics predictive of long-term survival with durvalumab or durvalumab plus tremelimumab in metastatic urothelial carcinoma

BACKGROUND

This retrospective analysis of data from clinical trials in metastatic urothelial carcinoma (mUC) was conducted to determine baseline patient characteristics associated with long-term survival (LTS) following treatment with immune checkpoint inhibitors.

METHODS

Data for this analysis were from patients with platinum-refractory mUC who received durvalumab or durvalumab plus tremelimumab in phase 1/2 studies. The primary outcome measure was LTS. Patients were categorised as overall survival (OS) ≥ 2 years (from first dose) or OS < 2 years. A univariable analysis assessed independent associations with LTS and multivariable logistic regression was employed including each variable with P ≤ 0.05 as covariates.

RESULTS

Among 360 patients, 88 (24.4%) had OS ≥ 2 years and 272 (75.6%) had OS < 2 years. In univariable analysis, several baseline characteristics and laboratory measurements were associated with LTS including sex, ECOG PS, PD-L1 expression, prior surgery, time from initial diagnosis, lymph node-only involvement, visceral disease, haemoglobin level, absolute neutrophil count, neutrophil-lymphocyte ratio and lactate dehydrogenase level. In multivariable analysis, LTS was significantly associated with ECOG PS, PD-L1 expression, haemoglobin level and absolute neutrophil count.

CONCLUSIONS

Several baseline clinical characteristics and laboratory measurements were associated with LTS for patients with platinum-refractory mUC treated with durvalumab or durvalumab plus tremelimumab.

A retrospective review of primary prophylaxis with granulocyte-colony stimulating factor (G-CSF) for patients with genitourinary malignancies receiving chemotherapy during the COVID-19 pandemic and implications for the future

115

Background: To mitigate the risks of chemotherapy associated neutropenia, during the COVID-19 pandemic, all genitourinary (GU) cancer patients treated with chemotherapy at the Princess Margaret Cancer Centre (PMCC) were offered primary prophylaxis with GCSF. We hypothesize that this reduced rates of febrile neutropenia, hospitalizations, healthcare costs and improved overall outcomes, compared to GU cancer patients treated with chemotherapy without GCSF in the 2 years prior to the pandemic. Methods: We performed a retrospective review of GU cancer patients, receiving curative or palliative intent chemotherapy, with or without primary GCSF prophylaxis between January 2018 and June 2022. GCSF was given either as a single dose or as consecutive doses post chemotherapy. Main outcomes were incidence of febrile neutropenia, hospitalization, health care expenditures as well as disease specific outcomes. Results: Overall, 248 patients with prostate cancer (44%), urothelial cancers (33%) germ cell (21%), and rare GU cancers (4%) were identified. Median age was 70 (range 19-91), 92% were male, 65% were ECOG 0/1. Treatment intent was neoadjuvant (13%), adjuvant (20%), or palliative (67%). Main regimens used were docetaxel, cabazitaxel, carboplatin, cisplatin/etoposide, gemcitabine/cisplatin and BEP. Median follow-up was 10.5 months (0.23-52.3 months). A total of 206/248 received primary GCSF prophylaxis. During chemotherapy, the median white blood cell levels were higher in the GCSF group compared to the non-GCSF group (14.1*10*9/L vs 2.90*10*9/L, p<0.0001); and neutropenia rates were markedly lower (2% vs. 93%, P=<0.0001). Hospital admission rates were significantly lower in G-CSF users compared to non-users (19% vs. 69%, P<0.0001). Symptomatic disease progression 13% was the leading cause of admission in the G-CSF group. Infectious causes such as UTI, pneumonia, COVID-19, and sepsis were seen in only 12% of the G-CSF group compared to 31% in the non-users. G-CSF was generally well tolerated with just 0.97% discontinuing G-CSF. Conclusions: During the COVID-19 pandemic, primary prophylactic G-CSF use in GU cancer patients, undergoing chemotherapy significantly lowered rates of both febrile neutropenia and hospitalizations and could be a cost-effective strategy in this patient population that warrants further study.

The Role of Neoadjuvant Chemotherapy in Bladder Preservation Approaches in Muscle-Invasive Bladder Cancer

Neoadjuvant chemotherapy (NAC), which aims to eliminate micrometastatic disease, has been established as the standard of care for patients with muscle-invasive bladder cancer (MIBC) undergoing radical cystectomy (RC). This is based on randomized controlled trials showing a survival benefit of NAC prior to RC compared to RC alone. It was anticipated that a similar survival benefit would also be seen when NAC was given prior to bladder preserving approaches, but the e phase III RTOG 8903 study which explored this concept was reported to be a negative study. However, there are a number of important caveats to be considered. First, the profile of patients opting for bladder preservation has changed from the older, frailer non-surgical candidates, to now also include younger, fitter patients opting for bladder preservation and who are also more likely to tolerate NAC. In recent years, there have also been important advances in systemic chemotherapy, immunotherapy, radiation techniques, and supportive care. As such revisitng the role of NAC prior to bladder preserving approaches in MIBC appears warranted.

Prognostic impact of bone metastasis in patients with metastatic urothelial carcinoma (mUC) treated with durvalumab (D) with or without tremelimumab (T) in the DANUBE study

4564

Background: In mUC, bone metastases (BM) are associated with significant morbidity and mortality, but their independent impact on outcomes is not well established, especially in the current era of immune checkpoint inhibitors (ICIs). This post-hoc analysis assessed the impact of BM, as well as PD-L1 status (within the same BM category) on outcomes of patients with mUC treated with ICIs. Data was derived from the Phase 3 DANUBE study, which compared D, D+T, and standard chemotherapy (SoC). Methods: Patient characteristics, disease characteristics, treatments, and outcomes were collected. Patients were categorized as having BM or no BM. Outcomes included median overall survival (OS) and median progression-free survival (PFS) (in months [mo]), estimated by the Kaplan-Meier method. PD-L1 expression was assessed using the VENTANA PD-L1 (SP263) Assay. Results: Overall, 1032 patients were included; 266 had BM (D, 80; D+T, 97; SoC, 89), and 766 had no BM (D, 262; D+T, 249; SoC, 255). Among all patients, those with BM had a lower OS than those with no BM (HR, 1.67; 95% CI, 1.43-1.92; nominal P< 0.0001) when controlling for cisplatin eligibility, PD-L1 expression, presence of visceral metastases, and treatment. Similarly, patients with BM had lower PFS compared to those without BM (HR, 1.52; 95% CI, 1.30-1.75; nominal P< 0.0001) Within each treatment arm, median OS was lower for patients with BM compared to patients with no BM for all patients, regardless of PD-L1 status (Table). Patients with BM and PD-L1–high expression, treated with either D or D+T, had numerically higher median OS compared to those with PD-L1 low; this difference was also seen in patients with no BM. In contrast, there was no difference in median OS, for BM or no BM, based on PD-L1 expression for patients treated with SoC (Table). Conclusions: In this post-hoc analysis, presence of BM was significantly and consistently associated with worse outcomes in patients with mUC across all treatment arms of the DANUBE study. PD-L1–high expression was associated with higher median OS in patients treated with D or D+T, regardless of presence of BM. These data reinforce the negative prognostic impact of BM in mUC and the role for PD-L1 expression in predicting benefit for patients treated with ICIs. Funding: AstraZeneca. Clinical trial information: NCT02516241. [Table: see text]

The prognostic impact of bone metastasis in patients with metastatic urothelial carcinoma treated with first-line platinum-based chemotherapy

Background:

In metastatic urothelial cancer (mUC), bone metastasis (BM) are associated with significant morbidity and mortality, yet their role as an independent prognostic variable remains unclear. We aimed to determine the impact of BM on overall survival (OS) in patients with mUC treated with first-line platinum-based chemotherapy (PBC).

Methods:

mUC patients receiving PBC at the Princess Margaret Cancer Center, Tom Baker Cancer Center, or Cross Cancer Institute from January 2005 to January 2018 were identified retrospectively using central pharmacy database records. Patient disease, treatment, and response characteristics were collected. Progression-free survival (PFS) and OS were estimated using the Kaplan–Meier method. Variables reaching significance (p < 0.05) in univariable analysis (UVA) of survival (OS) were included in multivariable analysis (MVA) (Cox).

Results:

Overall, 376 patients with a median follow-up of 16.8 (range: 2.2–218.3) months were included. Median age was 67 (range: 28–91) years, 76% were male, 63% had an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0–1, and 41% had BM. All patients received first-line PBC. Patients with BM had inferior median PFS (4.9 months (95% CI 3.6–6.2) versus 6.5 months (95% CI 5.4–7.6), p = 0.03) and median OS (8.8 months (95% CI 7.8–9.7) versus 10.8 months (95% CI 9.1–12.5), p = 0.002). In UVA, ECOG PS 2–3 (p < 0.001), presence of BM (p = 0.002), and WBC count ⩾ 11,000 cells/mm³ (p = 0.001) were associated with inferior survival. Prior cystectomy (p < 0.001) and lack of progression (stable disease, partial or complete response) on treatment was associated with improved OS (p < 0.001). These variables maintained significance in MVA.

Conclusion:

In this retrospective study, mUC patients with BM had worse OS suggesting that BM may be an independent negative prognostic factor and including BM as a stratification factor in future mUC clinical trial designs may be warranted. A greater focus must be placed on novel therapeutic strategies to better manage BM to reduce both morbidity and mortality.

Genomic characterization and identification of actionable variants in patients with locally advanced or metastatic urothelial carcinoma (mUC)

562

Background: Next generation sequencing (NGS)-based molecular profiling has been widely used across various tumor types including genitourinary malignancies to better understand and potentially predict tumor behavior. The goal of this study was to determine the feasibility of using NGS to characterize mUC and to identify potentially actionable variants. Methods: Patients with locally advanced or metastatic urothelial carcinoma (mUC) treated at the Princess Margaret Cancer Center were prospectively recruited for the OCTANE study, which collects archival tumor samples to provide genomic characterization through NGS with a custom hybridization capture DNA-based panel (555 genes) or a targeted DNA/RNA amplicon panel (Oncomine Comprehensive Assay v3, 161 driver gene panel). Variants were annotated using a somatic variant scheme [PMID: 25880439] or the oncoKB database. Comprehensive clinical information including patient, disease and treatment characteristics was collected using electronic patient records. Kaplan-Meier and cox regression were used for survival analysis. Results: Of the 73 patients, median age was 65 (23-83), majority were men (69%), most had lower tract disease (80%) and 41% had de novo metastatic disease. NGS was deemed feasible, based on availability of tumor samples, and performed in 67 (92%) patients. Overall, 61 (91%) had at least one oncogenic variant, including 34 (56%) with a potentially "druggable" target. The most frequent genomic alterations found were TP53 (44%), FGFR (18%), TERT (18%), ARID1A (18%) and PIK3CA (16%), all classified as "pathogenic/likely pathogenic". Only 2 patients received targeted treatment, one as part of clinical trial and one as standard of care. mOS was numerically longer among patients with genomic mutations compared to the ones without: 55 vs 31 months (HR: 0.87, CI 95% 0.3-2.4; p:0.7). No specific mutation was shown to significantly impact survival (table). Conclusions: Use of NGS technology in characterizing the genomic profile of patients with locally advanced or metastatic UC was feasible in most cases. Oncogenic variants were detected in the majority of patients, and more than half of them harbored a potentially "druggable" target, which may lead to future therapeutic advances.[Table: see text]

Metastatic Urothelial Cancer: a rapidly changing treatment landscape

Despite significant progress, metastatic urothelial cancer remains an incurable condition with a limited life expectancy. Platinum-based chemotherapy is still the mainstay of treatment for metastatic disease, but immunotherapy, antibody drug conjugates, and targeted agents have shown encouraging results in several recent practice changing trials. In this review, we discuss the standard of care, recent therapeutic advances, ongoing clinical trials, and future perspectives in metastatic urothelial carcinoma.

Impact of the COVID-19 pandemic on the wellbeing of international fellows training in hematology/oncology at the Princess Margaret Cancer Centre (PMCC)

11038

Background: The COVID-19 pandemic has led to significant disruptions across all levels of medical training. International fellows in subspecialty training programs are essential members of the frontline physician workforce, who may be facing additional and unique challenges being far away from their home country. We aimed to understand the impact of the pandemic on the wellbeing of current international fellows in the Hematology/Oncology training program. Methods: We conducted an online survey of 52 international fellows at the PMCC from July 6-August 10, 2020. There were 60 questions divided into 4 sections: demographics, wellbeing assessment using the validated Short Warwick Edinburgh Mental Wellbeing Scale (SWEMWBS), fellowship specific questions (personal and professional) and coping strategies using the validated brief COPE scale. Results: Response rate was 46% (n = 24). Relevant demographics include: married (65%), male (54%), age between 31-35 years (48%), have children (48%), and home country from Asia (48%). Mean SWEMWBS score was 21, indicating lower overall wellbeing than the general population (23.6). Compared to pre-COVID-19, many reported a decline in their wellbeing (63%), sense of guilt for not being with their family (45%) or helping their country (41%), stress in personal relationships (26%), fatigue (50%), sleep disorders (38%) and loss of interest in daily activities (38%). Personal events were altered by almost 80% and 20% plans to extend their fellowship. According to the Brief-COPE scale, most fellows used more adaptive coping mechanisms (mean score 39.2) as opposed to maladaptive ones (mean score 21.8). Conclusions: The ongoing COVID-19 pandemic has negatively affected the overall wellbeing of international fellows. Understanding the specific challenges and coping mechanisms of international fellows may help Institutions develop better targeted strategies to promote their overall wellbeing, professional development and high-quality patient care during these unprecedented times.

Identification of characteristics associated with long-term survival in patients with metastatic urothelial carcinoma (mUC) who received durvalumab (D) with or without tremelimumab (T) in clinical studies

441

Background: Immune checkpoint inhibitors (ICI) have changed the landscape of mUC, yet outcomes are variable as some patients (pts) do not respond to treatment while others have a durable response. To optimally select pts who may derive benefit from ICIs, predictive factors are required. This retrospective, post-hoc analysis evaluated pt characteristics to determine differences between short and long-term survivors among pts with mUC who received D (anti–PD-L1) with or without T (anti–CTLA-4) in two clinical studies. Methods: Pts with platinum-refractory mUC who received D monotherapy in the phase I/II study 1108 (10 mg/kg Q2W, up to 12 mo) or D+T in the phase I study 10 (D at 20 mg/kg + T at 1 mg/kg Q4W for 4 mo, then D at 10 mg/kg Q2W for 12 mo) were included. Pt characteristics, tumor characteristics, radiological assessments, and biological assessments were collected. The primary outcome measure was long-term overall survival (OS). Pts were categorized as OS ≥2 yrs (from 1st dose of study drug) or OS <2 yrs. A univariate analysis was conducted on each baseline characteristic to assess independent associations with long-term OS; a multivariate logistic regression model was employed including each variable with a p-value ≤0.1 as factors or covariates. Results: A total of 367 pts with mUC were included in the analysis: 88 (24.0%) had OS ≥2 yrs (range: 2.09–4.99) and 279 (76.0%) had OS <2 yrs (range: 0.03–1.98). Pts with OS ≥2 yrs had a significantly higher objective response rates than those with OS <2 yrs (71.6% vs 5.7%; p<0.0001) and a significantly longer duration of response (median 2.3 yrs vs 0.39 yrs; p<0.0001). The characteristics included in the multivariate logistic regression model are listed in the Table. Long-term OS was significantly associated with ECOG PS, PD-L1 status, baseline hemoglobin level, and baseline absolute neutrophils count. Conclusions: Our analyses show that several characteristics, including tumor response to treatment, are associated with long-term OS for pts with mUC treated with D or D+T. Further investigation into these and other characteristics may provide additional insights into long-term survival outcomes with ICIs. [Table: see text]

The prognostic impact of bone metastasis in urothelial carcinoma treated with first-line platinum-based chemotherapy

415

Background: Metastatic urothelial carcinoma (mUC) is an aggressive disease with a median overall survival (OS) of ≈ 15 months. In the first-line setting, key prognostic factors include ECOG performance status, white blood cell count, and response to treatment per the Galsky nomogram. Bone metastases (BM) in mUC are associated with morbidity and mortality but are grouped with visceral disease; hence, their impact on prognosis is not well established. We aimed to assess the survival impact of BM in mUC patients treated with first-line platinum-based chemotherapy (PBC). Methods: A retrospective collection of patient and tumor characteristics, with clinical response to treatment (complete response [CR], partial response [PR]; stable disease [SD] or progressive disease [PD]) for patients treated at Princess Margaret Cancer Centre, Tom Baker Cancer Centre, and Cross Cancer Institute from 2005-2018 was performed. Progression-free survival (PFS) and OS were estimated using the Kaplan-Meier method. Univariate (UVA) followed by multivariate analysis (MVA) of patient variables [Cox] using PFS and OS was performed. Results: Overall 376 mUC patients were included; 222 (59%) had soft-tissue metastases (STM) only, 70 (19%) had bone-only metastases, and 84 (22%) had both STM and BM. Overall, 35% had PR or CR, 19% had SD, and 39% had PD (7%: unknown response). The median PFS and OS for the whole cohort were 5.6 months (95%CI: 4.8-6.4) and 9.7 months (95% CI: 8.8-10.8) respectively. Select UVA by metastatic site showed inferior PFS for bone-only (p=0.03) and combination STM and BM (p=0.017). Only combination STM and BM were significant on UVA for OS (p=0.002). MVA showed that bone-only metastases (p=0.03) and ECOG 3-4 (p<0.0001) were associated with worse PFS (Table). Predictors of worse OS were the combination of STM and BM (p=0.02), ECOG 3-4 (p=0.001), and WBCs ≥ULN (p=0.02), (Table). Conclusions: BM are a significant predictor of worse outcomes for mUC patients treated with first-line PBC. Consideration as a treatment stratification factor for future studies is suggested. Strategies for the treatment of mUC patients with BM (ie: bone targeted agents) in the first-line setting should be addressed in future trials. [Table: see text]

Trends over time in survival in patients with urothelial carcinoma in the real-world: A multicenter analysis

412

Background: Patients with muscle-invasive bladder cancer (MIBC) historically have poor long-term outcomes, with nearly 50% developing metastatic disease. Similarly, patients with metastatic urothelial carcinoma (mUC) have had median overall survivals of less than 2 years. Novel therapies have been implemented over time in attempts to improve outcomes. This study evaluates trends in survival over time in patients with MIBC and mUC treated in the real-world setting. Methods: Retrospective data was collected from two major cancer centres in Alberta and the Princess Margaret Cancer Centre in Ontario, Canada. Consecutive patients treated with platinum-based chemotherapy between 01/2005 and 01/2018 who had confirmed MIBC or mUC were evaluated. Patients were excluded if they had been treated as part of a clinical trial in the first-line setting. Patients were categorized based on year of diagnosis at presentation: time period 1 (T1) diagnosed between 01/2005 and 12/2011, and time period 2 (T2) diagnosed between 01/2012 and 12/2018. The co-primary endpoints were disease-free survival (DFS) for MIBC, progression-free survival (PFS) for mUC, and overall survival (OS) for both. Results: 572 patients were included, 196 (78% male; median age 63.8 years) had MIBC and 376 (76% male; median age 68.4 years) were treated for mUC. Amongst patients with MIBC, 33% (65) were treated in T1 and 67% (131) in T2. Median DFS and OS were significantly improved in T2 compared to T1 for patients with MIBC (Table). On multivariate analysis, earlier year of diagnosis and ECOG status ≥2 was independently associated with poor outcomes (p=0.016 and p=0.008, respectively). Amongst patients with mUC, 205 (55%) were treated in T1 and 171 (45%) in T2. Median PFS and OS did not significantly improve over time in patients with mUC from T1 to T2 (Table). Conclusions: In this real-world analysis, outcomes for patients with MIBC have significantly improved over time. This is likely attributed to standardization of perioperative chemotherapy protocols and improvements in surgical techniques. Similar improvements have not yet been demonstrated for patients with mUC during the two time periods. However, novel therapies (eg. immunotherapy) were only approved in 2017. Future analysis may explore the reasons for improvement in patients with MIBC and will evaluate outcomes in mUC patients treated from 2017 onwards. CI= confidence interval, HR= hazard ratio. [Table: see text]

Enfortumab Vedotin in urothelial cancer

The treatment landscape for metastatic urothelial cancer (mUC) beyond first-line platinum-based chemotherapy has changed significantly over the last 5 years with the recent approvals of the immune checkpoint inhibitors (ICIs), fibroblast growth factor receptor (FGFR) inhibitors and most recently Enfortumab Vedotin (EV). EV is a novel antibody–drug conjugate (ADC), that delivers monomethyl auristatin E (MMAE), a microtubule-disrupting agent, inside cells harboring the cell surface nectin-4 receptor. In mUC, EV has shown encouraging response rates and received accelerated approval from the Food and Drug Administration (FDA) in December 2019 in the post-platinum and ICI setting. EV is generally well tolerated, with the main toxicities being neuropathy, skin rash, alopecia and fatigue. Notably EV can also be administered to patients with renal dysfunction, which is commonly a concern in this patient population. EV is now being tested in combination strategies and in earlier disease settings in urothelial cancers. In this review, we will discuss its mechanism of action, clinical trials leading to FDA approval as well as ongoing trials and future directions.

PTEN and cetuximab resistance in head and neck squamous cell carcinoma (HNSCC)

6061

Background: Platinum-based chemotherapy in association to cetuximab is the standart first-line treatment for metastatic HNSCC. There is no established biomarker for cetuximab efficacy in HNSCC. We have previously shown that PTEN loss of expression is a bad prognostic factor for patients treated with platinum-based chemotherapy and cetuximab. The aim of the present study was evaluate the prognostic impact of PTEN loss of expression in patients treated with or without cetuximab and to evaluate its predictive value to cetuximab benefit. Methods: One hundred and nineteen patients with metastatic or locally recurrent HNSCC were included. Clinical data on treatment and outcomes was retroespectively colected from medical charts. Tissue micro-array was constructed to evaluate PTEN protein expression through immunohistochemistry. Citoplasmatic staining was evaluated using H-score. Tumors with H-score < 10 were considered to present PTEN loss of expression. Results: From the 119 patients 72 were treated with chemotherapy plus cetuximab while 47 were treated with chemotherapy alone. Median overall survival (mOS) was 9.2 months and median progression free survival (PFS) was 4.6 months. Patients treated with cetuximab compared to those who were not treated with cetuximab had a mOS of 11.4 vs 7.0 months (p = 0.770) and a median PFS of 6.2 vs 3.0 months (p = 0.249). Patients with PTEN loss of expression had a worse OS and PFS with mOS of 5.8 vs 10.5 months (p = 0.002) months and mPFS of 3.2 vs 5.2 (p = 0.015). On multivariate analysis including PTEN loss of expression and ECOG performance status both remained independently associated to survival with HR 2.25 (CI95% 1.28-3.97, p = 0.005) for PTEN loss of expression and a HR 1.63 (CI95% 1.07-2.50, p = 0.023) for ECOG. Negative prognostic impact of PTEN loss of expression was seen only in the cetuximab treated patients (mOS 7.3 vs 13.0 months; p = 0.002) but not in the chemotherapy only group (mOS 3.2 vs 7.5 months; p = 0.051). Interaction test for treatment group and PTEN loss of expression showed a p = 0.418. Conclusions: The present study confirms PTEN as a prognostic factor for metastatic HNSCC and suggests PTEN expression should be studied in larger cohorts to evaluate its predictive value to cetuximab response.

Homologous recombination deficiency and platinum rechallenge in platinum-resistant ovarian cancer patients

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Background: Ovarian carcinomas show homologous recombination deficiency (HRD) in up to 50% of cases and in 15 to 20% of cases occur due to germline BRCA1 or BRCA2 mutations. BRCA mutated tumors are more sensitive to PARP inhibitors and platinum based chemotherapy. The objective of this study was to characterize a cohort of ovarian cancer patients regarding HRD and to evaluate the impact of these scores in prolonged platinum sensitivity. Methods: Thirty one ovarian cancer patients with platinum resistant recurrence reexposed to platinum based chemotherapy were selected. Paraffin embedded tumor samples from 14 patients were analyzed using ONCOSCAN assay (Affymetrix) to evaluate HRD scores. The association of the scores with response rate to platinum rechallenge, overall survival and clinical pathologic factors was evaluated. Results: From the cohort of 31 patients, 15 samples from 14 patients were analyzed for genomic alterations. Median scores were 19.5 for TAI, 12.5 for cnLOH+L, 26.0 for LST and 6.3 for HRD. High scores were found in 10 out of 14 (for cnLOH+L score) and 9 out of 14 (for LST score) patients. Seven of the 14 patients analyzed analyzed for genomic alterations had response, which suggested homologous recombination deficiency. No significant differences were observed between response rates for high versus low scores. Numerically, cnLOH+L, LST and HDR scores were higher in patients with response to treatment compared to those without response. Median overall survival was 13.4 months from the beginning of platinum rechallenge and no difference in survival according to scores was observed. Among the clinical pathologic factors, family history of breast or ovarian cancer or personal history of breast cancer was associated to higher response rate to platinum rechallenge. Conclusions: In conclusion,HRD scores showed to be potential markers of response to platinum rechallenge in the platinum resistant setting. Further studies are necessary to clarify the best cutoffs for each score, the impact of tumor heterogeneity and the analysis of tumor samples in the moment of treatment. Positive family history of cancer is a clinical factor predictvie of platinum rechallenge response.

Palmitoylethanolamide controls reactive gliosis and exerts neuroprotective functions in a rat model of Alzheimer's disease

Given the complex heterogeneity of pathological changes occurring in Alzheimer's disease (AD), any therapeutic effort absolutely requires a multi-targeted approach, because attempts addressing only a single event may result ineffective. Palmitoylethanolamide (PEA), a naturally occurring lipid amide between palmitic acid and ethanolamine, seems to be a compound able to fulfill the criteria of a multi-factorial therapeutic approach. Here, we describe the anti-inflammatory and neuroprotective activities of systemic administration of PEA in adult male rats given intrahippocampal injection of beta amyloid 1-42 (Aβ 1-42). Moreover, to investigate the molecular mechanisms responsible for the effects induced by PEA, we co-administered PEA with the GW6471, an antagonist of peroxisome proliferator-activated receptor-α (PPAR-α). We found that Aβ 1-42 infusion results in severe changes of biochemical markers related to reactive gliosis, amyloidogenesis, and tau protein hyperphosphorylation. Interestingly, PEA was able to restore the Aβ 1-42-induced alterations through PPAR-α involvement. In addition, results from the Morris water maze task highlighted a mild cognitive deficit during the reversal learning phase of the behavioral study. Similarly to the biochemical data, also mnestic deficits were reduced by PEA treatment. These data disclose novel findings about the therapeutic potential of PEA, and suggest novel strategies that hopefully could have the potential not just to alleviate the symptoms but also to modify disease progression.

Postoperative infections following total knee replacement: an epidemiological study

From January 1991 to June 1997 217 patients undergoing monolateral or bilateral total knee replacement (TKR) were consecutively enrolled in a prospective study on the incidence of postoperative infections and related risk factors. Regional antimicrobial prophylaxis (teicoplanin 400 mg) was used in 263 (95%) prostheses implanted; in the remaining 14 implants (5%) perioperative antibiotic prophylaxis (teicoplanin 800 mg) was administered as usual by systemic route. None of the patients experienced local or systemic adverse effects. Over the 2-year follow-up period, 8 (2.9%) primary site infectious complications were recorded, i.e. 4 superficial infections, which were cured without involvement of the prostheses, and 4 deep infections, which required prosthesis removal. Six infections occurred in patients who had undergone previous surgery of the same knee joint, and 2 in patients undergoing primary TKR (p= 0.0005); diabetic patients had infections (13%) more frequently than non-diabetic patients (1.9%, p=0.01). Staphylococci were the leading organisms isolated from infections; however 3 strains of Escherichia coli were isolated from patients who had undergone a previous prosthesis implantation at the same knee joint. Regional administration of teicoplanin appears to be a safe and valuable prophylactic technique; however, in patients at risk of infection a prophylactic regimen which is also active against gram-negative bacteria should probably be considered.

Fibrogenesis serum markers in patients with chronic hepatitis C treated with alpha-IFN

The correlation between therapeutic response and liver fibrogenesis was studied in serum and liver specimens taken from 31 patients treated with alpha-interferon (IFN) (14 sustained responders and 17 non-responders) for chronic hepatitis C. Serum samples, collected before therapy, and at further 6-month intervals over 2 years, were tested for markers of liver neofibrogenesis. Serum N-terminal procollagen III peptide (PIIINP) displayed a significant and persistent decrease (P < 0.05) in sustained responders but not in non-responders; significantly lowered (P < 0.05) mean levels of C-terminal procollagen I peptide (PICP) were transiently observed in both patient groups, apparently as a result of IFN administration. Serum laminin (Lam) levels remained unchanged. One year after the cessation of treatment, liver biopsy re-testing showed an improvement in necro-inflammatory scores only in sustained responders, with the histological fibrosis scores remaining unaltered in both groups. IFN treatment seemed to exert an influence on serum levels of markers of hepatic connective tissue turnover even in patients that did not respond to therapy, while no effect was observed on preexistent liver fibrosis.

Mutagenicity, carcinogenicity, and teratogenicity of acrylonitrile

Acrylonitrile (AN) is an important intermediary for the synthesis of a variety of organic products, such as artificial fibres, household articles and resins. Although acute effects are the primary concern for an exposure to AN, potential genotoxic, carcinogenic and teratogenic risks of AN have to be taken seriously in view of the large number of workers employed in such industries and the world-wide population using products containing and possibly liberating AN. An understanding of the effect of acrylonitrile must be based on a characterization of its metabolism as well as of the resulting products and their genotoxic properties. Tests for mutagenicity in bacteria have in general been positive, those in plants and on unscheduled DNA synthesis doubtful, and those on chromosome aberrations in vivo negative. Wherever positive results had been obtained, metabolic activation of AN appeared to be a prerequisite. The extent to which such mutagenic effects are significant in man depends, however, also on the conditions of exposure. It appears from the limited data that the ultimate mutagenic factor(s), such as 2-cyanoethylene oxide, may have little opportunity to act under conditions where people are exposed because it is formed only in small amounts and is rapidly degraded. The carcinogenic action of AN has been evaluated by various agencies and ranged from 'reasonably be anticipated to be a human carcinogen' to 'cannot be excluded', the most recent evaluation being 'possibly carcinogenic to humans'. Animal data that confirm the carcinogenic potential of AN have certain limitations with respect to the choice of species, type of tumors and length of follow up. Epidemiological studies which sometimes, but not always, yielded positive results, encounter the usual difficulties of confounding factors in chemical industries. Exposure of workers to AN should continue to be carefully monitored, but AN would not have to be considered a cancer risk to the population provided limitations on releases from consumer products and guidelines on AN in water and air are enforced. AN is teratogenic in laboratory animals (rat, hamster) at high doses when foetal/embryonic (and maternal) toxicity already is manifest. Pregnant workers should not be exposed to AN. In view of the small concentrations generally encountered outside plants, women not professionally exposed would appear not to be at risk of teratogenic effects due to AN. Future research should concentrate on the elucidation of the different degradation pathways in man and on epidemiological studies in workers including pregnant women, assessing also, if possible, individual exposure by bio-monitoring.

HGV/GBV-C in liver tissue and in sera from patients with chronic hepatitis C

Forty-eight persons (M = 45, F = 3; age range = 20-53, mean = 32.2) affected with chronic hepatitis C were tested for HGV/GBV-C RNA and HCV-RNA by nested PCR and DEIA in serum and in liver specimens to evaluate the prevalence and the impact of HGV/GBV-C coinfection in patients with chronic HCV-related hepatitis. Sera were also assayed for antibodies to HGV/GBV-C E2 protein. Serum HGV/GBV-RNA could be detected in nine (19%) patients, and anti-E2 antibodies in 22 (46%) patients. The presence of HGV/GBV-C RNA or anti-E2 antibodies was mutually exclusive. The cumulative prevalence of HGV/GBV-C infection was 65% (31/48); the majority of these patients (26/31, 84%) were intravenous drug users (IVDUs). In eight of nine patients viraemic for HGV/GBV-C, RNA positivity could be revealed even in liver specimens; these eight patients were also positive for HCV-RNA both in serum and the liver and did not exhibit any specific association with HCV genotype. HGV/GBV-C RNA negative strand RT-PCR testing was negative in all of the eight liver specimens, providing little support to the hypothesis that liver represents the primary site of HGV/GBV-C replication. Moreover, patients with HGV/GBV-C and HCV coinfection were comparable to those with HCV infection alone in terms of biochemistry and liver histology.

Adaptive response to DNA-damaging agents: a review of potential mechanisms

The study of the adaptive response, i.e. a reduced effect from a higher challenging dose of a stressor when a smaller inducing dose had been applied a few hours earlier, has opened many new vistas into the mechanisms by which cells can adapt to hazardous environments. Although the entire chain from the initial event, supposedly the presence of DNA damage, to the end effect, presumably improved DNA repair, has not been fully elucidated, many individual links have been postulated. Initial elements--following the still unknown signal for the presence of radiation damage--are various kinases (protein kinase C and stress-activated protein kinases), which, in turn, induce early response genes whose products initiate a cascade of protein-DNA interactions that regulate gene transcription and ultimately result in specific biological responses. These responses include the activation of later genes that can promote production of growth factors and cytokines, trigger DNA repair, and regulate progress through the cell cycle. Indeed, there appears to be a relation between the induction of the adaptive response and the effects of radiation and cytostatic agents on the cell cycle, although these effects, especially the G1 delay, occur at much higher doses than the adaptive response, and one may not indiscriminately extrapolate mechanisms responsible for cell cycle changes observed at high doses, e.g. for radiation in the order of grays, to those involved in the adaptive responses at much lower doses, i.e. some tens of milligrays.

Amphotericin B as primary therapy for cryptococcosis in patients with AIDS: reliability of relatively high doses administered over a relatively short period

Thirty-one consecutive AIDS patients with cryptococcal disease were enrolled in a study of the efficacy and safety of short-course primary treatment with a relatively high dose of amphotericin B (1 mg/[kg.d] for 14 days); 26 patients also received flucytosine (100-150 mg/[kg.d], given either intravenously or orally). Twenty-five patients had cryptococcal meningitis confirmed by culture, three had presumed cryptococcal meningitis, and three had disseminated extrameningeal cryptococcosis. After successful primary treatment, all patients were given oral itraconazole or fluconazole as suppressive therapy, and their lifelong clinical and mycologic follow-up was planned. Successful primary therapy was defined as the resolution of symptoms and the documentation of negative cultures of cerebrospinal fluid and/or blood 2 months after the initial diagnosis. Therapy was successful in 29 (93.5%) of all 31 cases and in 26 (92.8%) of the 28 cases of culture-proven or presumed cryptococcal meningitis. Nephrotoxicity developed as a result of amphotericin B administration in seven cases; this adverse reaction required a reduction of the dose in two cases and the discontinuation of therapy in five. No deaths due to cryptococcosis were documented during primary therapy. Treatment failed in two cases. During a mean observation period of 10.7 months, three relapses of the underlying infection occurred. Our results indicate that an aggressive approach to the primary treatment of cryptococcosis in AIDS patients, with the administration of a relatively high dose of amphotericin B for a relatively short period, is effective and well tolerated.

Prevalence of anti-HCV and risk factors for hepatitis C virus infection in healthy pregnant women

The prevalence of anti-HCV antibodies and the risk factors for HCV infection were assessed in 5,672 pregnant women living in North Italy. All reactive sera were confirmed by RIBA-2 test. Anti-HCV positive pregnant women together with an anti-HCV negative control group, were interviewed by standardised questionnaire to identify "known" or "potential" risk factors for HCV infection. The anti-HCV prevalence was 0.7% (40/5,672), higher than that observed among blood donors in the same geographical area (0.2%). The RIBA-2 assay was positive in 60% (24/40) of cases, indeterminate in 10% (4/40) and negative in 30% (12/40). As for "known" risk factors, considering RIBA-2 positivity, intravenous drug use was by far the main risk factor for HCV infection, resulting in a significantly higher risk than in the control group (50% versus 5.9% [O. R. 15.8, CI 5.4-45.5]). The ten RIBA-2 positive women without histories of transfusion or IV drug use had a significantly higher frequency of "sexual contacts with IV drug users" compared to controls (50% vs 4.9% [O. R. 19.0, CI 3.6-94.0]). In conclusion, our study provides evidence that in our geographical area the anti-HCV antibody prevalence is higher in pregnant women than in blood donors and that IV drug use and sexual contacts with IV drug users represent the most important risk factors for HCV infection among young women in North Italy.

Regional and systemic prophylaxis with teicoplanin in monolateral and bilateral total knee replacement procedures: study of pharmacokinetics and tissue penetration

Twenty-four patients undergoing monolateral or bilateral total knee replacement (TKR) procedures were randomized to receive teicoplanin (T) either systemically or regionally. Subjects scheduled for systemic prophylaxis and undergoing monolateral (six patients) or bilateral (five patients) TKR received a single 800-mg dose of T in 100 ml of saline as a 5-min infusion into a forearm vein 2.5 h before surgery. For regional prophylaxis, patients undergoing monolateral surgery (eight subjects) received 400 mg of T in 100 ml of saline as a 5-min infusion into a foot vein of the leg to be operated on immediately after the tourniquet was inflated. For the five patients scheduled for bilateral operation and regional prophylaxis, the administration of T was also repeated for the second knee operation. The tourniquet, as the standard TKR surgical technique, was inflated to 400 mm Hg (c. 50 kPa) in all 24 patients immediately before the beginning of surgery and kept in place for the duration of the operation. Samples of serum, bone, skin, synovia, and subcutaneous tissue were collected at timed intervals during surgery. They were microbiologically assayed for T by using Bacillus subtilis as the test organism. Overall, the mean T concentrations obtained with regional route prophylaxis were found to be 2 to 10 times higher than those achieved following systemic prophylaxis. Moreover, peak levels in different tissues after regional prophylaxis were significantly higher (P < 0.05). None of the patients experienced adverse effects due to regional or systemic T administration; no prosthetic or wound infections were observed in the follow-up period (from 12 to 26 months).

Metabolic activation by a supernatant from human hepatoma cells: a possible alternative in mutagenic tests

The supernatant from human Hep G2 hepatoma cells was examined for typical enzymatic activities involved in the metabolism of xenobiotics. Neither cytochrome P-450 nor b5 was detectable, but associated enzymatic activities were found especially after induction with hydrocortisone (HC) and benzanthracene (BA) suggesting that this Hep G2 supernatant contains cyt P-450 IA1 and IA2. Other critical enzymes are also present, but, as expected, at lower activities than in Aroclor 1254 rat liver S9, except for NADH and NADPH cytochrome c reductase. Results of the Ames test indicate that the induced Hep G2 supernatant is a suitable activator for the evaluation of genotoxicity of indirect mutagens.

Oxidative activation of 2-aminofluorene by human red blood cell cytosol

Purified red blood cell cytosol is able to activate 2-aminofluorene (2AF) to N-hydroxy-2-aminofluorene. Apparent kinetic parameters are determined with and without methylene blue. The latter, which maintains haemoglobin in the reduced form and stimulates NADPH production, increases the affinity of the enzyme for the 2AF. This activity is inhibited by carbon monoxide while cyanide is without effect. The involvement of a peroxidative reaction or a one-electron oxidative mechanism involving free radicals may be excluded.

Mutagenic activation of benzo[a]pyrene by human red blood cells

The induction of sister-chromatid exchanges (SCEs) and micronuclei (MN) was used as an endpoint to evaluate the cytogenetic effects of benzo[a]pyrene (B(a)P) activated by human red blood cells and S9 mix. Human erythrocytes can metabolically activate B(a)P. It was shown that both human erythrocytes and S9 mix activate B(a)P and that the resulting excess SCE and MN depend in a linear manner on the B(a)P dose. HPLC analysis suggested that quinone derivatives formed by the red blood cells are responsible for the cytogenetic abnormalities observed.

Enzymic N-demethylation reaction catalysed by red blood cell cytosol

Red blood cell cytosol promotes enzymic N-demethylation reactions which display typical Michaelis-Menten kinetics with respect to N-methylaniline as substrate. The demethylase activity is linked with hemoglobin (Hb) and is enhanced in the presence of NADH and the NADH-methemoglobin reductase system. It has been adduced that Hb in its oxygenated form is involved in the reaction.

Mutagenicity of some heterocyclic amines in Salmonella typhimurium with metabolic activation by human red blood cell cytosol

Purified human red blood cell cytosol was used to activate the heterocyclic amines 2-amino-3-methylimidazo[4,5-f]quinoline (IQ), 2-amino-3,4-dimethylimidazo[4,5-f]quinoline (MeIQ), 3-amino-1,4-dimethyl-5H-pyrido[4,3-b]indole (Trp-P-1) and 3-amino-1-methyl-5H-pyrido[4,3-b]indole (Trp-P-2) into mutagenic intermediate(s) in the Salmonella test. The liquid preincubation method in the presence of strain TA98 was utilized. In order to understand the mechanism involved in this metabolic activation, some modulators were incorporated in the medium. The results suggest that an oxygenated hemoprotein, probably oxyhemoglobin, is involved in the activation into genotoxic intermediate(s).

Activation of some aromatic amines to mutagenic products by human red blood cell cytosol

The ability of human red blood cell cytosol to activate aromatic amines was evaluated with the Ames test using Salmonella typhimurium TA98 in the liquid preincubation condition. While negative results were obtained with 4-acetylaminofluorene (4AAF) and 1-naphtylamine (1NA), a slight response was observed for 4-aminobiphenyl (4ABP) and 2-naphthylamine (2NA). Human red blood cell cytosol was able to activate 2-aminofluorene (2AF), 2-acetylaminofluorene (2AAF) and 2-aminoanthracene (2AA) to mutagenic intermediates. Extracts of human red blood cell cytosol incubated with 2AF were analyzed by gas chromatography: N-hydroxy-2-aminofluorene was identified as a metabolite.

Detection of mutagenic activity in urine samples using a new concentration procedure

A study performed with cyclophosphamide (CP) and nor-nitrogen mustard (NNM), one of its main urinary metabolites, has shown that separation on Polygosil C-18 resin is preferable to one on XAD-2 resin as a means of concentrating the mutagenic activity present in urine of rats given cytostatics such as CP. Mutagenic activity was detected, using Salmonella typhimurium tester strain TA1535. While NNM is irreversibly bound to XAD-2 resin, it can be recovered after elution with methanol on Polygosil C-18. The better efficacity of Polygosil C-18 in concentrating CP and its metabolite(s) was confirmed with experiments with urine of rats treated with increasing doses of CP.