Skin and self-injury: a possible link between peripheral innervation and immune function?

The aim of this preliminary case study series was to investigate epidermal innervation in pediatric patients with significant neurological impairment and self-injurious behavior. We enrolled four pediatric patients with self-injury (two males, two females; mean age 12y, range 9-14y) and used archival specimens from healthy, age-matched children with typical development for comparison purposes. Epidermal nerve fiber density, peptide content, and mast cell degranulation patterns from non-damaged skin were tested between the patients and the comparison group. The male patients with self-injury had significantly increased epidermal nerve fiber densities, increased substance P positive fiber count and extensive mast cell degranulation compared with sex- and age-matched individuals with typical development. Our case series shows for the first time altered peripheral innervation from non-damaged tissue in children with significant self-injury and developmental disability compared with a healthy comparison group. Establishing the role of peripheral nociceptive and immune modulatory neural pathways may offer new treatment avenues for this devastating neurobehavioral disorder.

Ofatumumab for refractory opsoclonus-myoclonus syndrome following treatment of neuroblastoma

Opsoclonus-myoclonus syndrome (OMS) may be associated with ANNA-1 (anti-Hu) autoantibodies. The standard treatment with IVIG, steroids, and anti-CD20 monoclonal antibody may fail, and optimal therapy is unknown. A patient developed OMS with high-titer ANNA-1 following recovery from neuroblastoma. She failed standard therapy and had only transient response to rituximab. Treatment with the humanized anti-CD20 monoclonal antibody ofatumumab combined with methotrexate resulted in transient neurologic improvement and decrease of ANNA-1. This suggests that ofatumumab combined with methotrexate should further be considered OMS patients, particularly in refractory disease.

Abstract P1-07-11: Characterization of progesterone receptor biomarker for predicting antiprogestin activity in human cancers

BACKGROUND: Progesterone receptors (PR) are important prognostic biomarkers of estrogen receptor (ER) action in breast cancer (BC). More recently, PRs have emerged as independent (from ER) mediators of early BC progression. In advanced BC phase II trials, the antiprogestin (antiPg) onapristone demonstrated a 10% and 56% OR in second line and first line therapies respectively, while mifepristone demonstrated 10% and 12%. Upon ligand binding, transcriptionally active PR in normal tissues form a discrete focal subnuclear distribution pattern (FDP) that can be visualized by immunofluorescence (Arnett-Mansfield, 2004, 2007). Importantly, PR nuclear foci are indicative of transcriptional activity. FDP is also observed in breast and endometrial cancers independently of hormonal status. The goal of this study was to devise a method to identify patients that are more likely to benefit from antiPg treatment.

METHOD: 12 PR [+] BC paraffin-embedded blocks were analyzed. Standard IHC was used with 4 Abs: anti-PR-A (PRA), PR-B (PRB), anti-PR-A+B, anti-PR A and B (PRAB). Samples were analyzed for each Ab, and a control for the primary Ab, with and without background staining. After standard histologic evaluation subnuclear structures were analyzed at 100X. IHC was performed using Abs directed to the following PR phosphorylated sites (pAb) pSer 162, 190, 294, 400 and 554. Six samples were selected for IHF using a secondary fluorescent Ab.

RESULTS: All cases were PR [+]. At high magnification (100X), 2 PR nuclear distribution patterns were observed: a diffuse finely granular staining (D) or an aggregated pattern (A). This resulted in 3 tumor phenotypes (PR B Ab): A cells only in 2 cases, D cells only in 6, and a mixture of both A and D cells (AD) in 4. PR [−] malignant cells were present in various proportions. The IHF results were consistent with IHC studies. Only pAb to pSER190 was specific and sensitive, with a smaller number of [+] malignant cells relative to the standard PRB.

CONCLUSION: We have developed an IHC method that utilizes formalin-fixed paraffin-embedded tissue allowing the technique to be applied on a routine basis. Three classes of PR nuclear distribution have been defined: D, A and AD. D is consistent with the expression of PR that is weakly transcriptionally active or inactive and thus potentially predictive of poor patient response to antiPg. The A or AD pattern of PR nuclear distribution indicates active PR; patients with this pattern may exhibit a increased probability of benefiting from an antiPg. Preclinical studies have demonstrated that activated PR [+] cells can in turn stimulate PR [−] (stem or progenitor) mammary epithelial cells via secreted factors. In light of these findings, we are expanding the cohort to refine and confirm this biomarker technique. Additional preclinical work is ongoing to expand the biological rationale and to evaluate this technique alongside other technologies such as PR gene expression analysis. We anticipate that approximately 50% of PR+ BC cases contain the A/AD phenotye and therefore may benefit from antiPg. The method of IHC described herein is a clinically applicable tool that may allow for selection of patients most likely to respond to antiPg treatment.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-07-11.

EZN-2968, a novel hypoxia-inducible factor-1α (HIF-1α) messenger ribonucleic acid (mRNA) antagonist: Results of a phase I, pharmacokinetic (PK), dose-escalation study of daily administration in patients (pts) with advanced malignancies

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Background: HIF-1 is a transcription factor that regulates expression of many key genes, notably those switching cell metabolism to anaerobic glycolysis and inducing neovascularization in response to hypoxia. Increased HIF-1α levels are associated with poor prognosis in several neoplasms. EZN-2968 is a potent locked nucleic acid antisense oligonucleotide suppressing HIF-1α mRNA translation in vitro (IC50 ∼1–5 nM). Methods: This study was designed to determine the safety, tolerability, PK, maximum tolerated dose, recommended dose, and preliminary evidence of antitumor activity of EZN-2968. Pts with advanced malignancies were treated with EZN-2968 administered as a daily 2-hr IV infusion x 5 days every 4 weeks using a 3+3 dose-escalating design. Dose escalation was based on toxicities observed during Cycle 1. Results: 19 pts (11 men; median age = 60 y [47–79 y]) were treated with EZN-2968 doses of 0.5 (3 pts), 0.8 (3 pts), 1.2 (3 pts), 1.8 (4 pts), 2.7 (3 pts), and 4.1 (3 pts) mg/kg/day. Tumor types included colorectal cancer (7 pts); renal cancer (4 pts); soft-tissue sarcoma (STS; 2 pts); angiosarcoma (1 pt); melanoma (1 pt); and breast, ovarian, pancreatic, and prostate cancers (1 pt each). No dose-limiting toxicities were observed. The most common adverse events (Aes) were vomiting (32%); fatigue (26%); and anemia, diarrhea, nausea, and tumor pain (each 21%). Most Aes were Grade 1 or 2. Plasma PK for Day 1 is tabulated below. Stable disease was observed for 1 pt with angiosarcoma (28 wks) and 1 pt with renal cancer (12 wks). Conclusions: EZN-2968 was well tolerated in previously treated pts with advanced malignancies. PK data do not show accumulation of EZN-2968. Dose escalation is ongoing; final results will be presented at the meeting. Durable stable disease has been observed.

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Cerebral MRI abnormalities associated with vigabatrin therapy

PURPOSE

Investigate whether patients on vigabatrin demonstrated new-onset and reversible T(2)-weighted magnetic resonance imaging (MRI) abnormalities.

METHODS

MRI of patients treated during vigabatrin therapy was reviewed, following detection of new basal ganglia, thalamus, and corpus callosum hyperintensities in an infant treated for infantile spasms. Patients were assessed for age at time of MRI, diagnosis, duration, and dose, MRI findings pre-, on, and postvigabatrin, concomitant medications, and clinical correlation. These findings were compared to MRI in patients with infantile spasms who did not receive vigabatrin.

RESULTS

Twenty-three patients were identified as having MRI during the course of vigabatrin therapy. After excluding the index case, we detected new and reversible basal ganglia, thalamic, brainstem, or dentate nucleus abnormalities in 7 of 22 (32%) patients treated with vigabatrin. All findings were reversible following discontinuation of therapy. Diffusion-weighted imaging (DWI) was positive with apparent diffusion coefficient (ADC) maps demonstrating restricted diffusion. Affected versus unaffected patients, respectively, had a median age of 11 months versus 5 years, therapy duration 3 months versus 12 months, and dosage 170 mg/kg/day versus 87 mg/kg/day. All affected patients were treated for infantile spasms; none of 56 patients with infantile spasms who were not treated with vigabatrin showed the same abnormalities.

DISCUSSION

MRI abnormalities attributable to vigabatrin, characterized by new-onset and reversible T(2)-weighted hyperintensities and restricted diffusion in thalami, globus pallidus, dentate nuclei, brainstem, or corpus callosum were identified in 8 of 23 patients. Young age and relatively high dose appear to be risk factors.

Clinical observation of self-injurious behavior correlated with changes in scalp morphology in a child with congenital hydrocephalus

We report the case of a 12-year-old girl born with cerebral dysgenesis and congenital hydrocephalus first shunted shortly after birth. She had severe tissue-damaging self-injurious behavior, profound mental retardation, quadriparesis, as well as multiple cranial anomalies including turricephaly. After stage 1 cranial remodeling, a bone window was left pending second stage remodeling. Episodic changes in fluctuation of the scalp overlying the bone window were easily observed. During the course of a behavioral assessment for her self-injury, it was observed that the overall frequency of occurrence of self-injury increased significantly (P < .01) when the scalp was protruding and bulging compared with when the scalp was flush with the skull table. Periods of increased scalp protrusion were also associated with higher scores on a pain scale developed for children with communicative impairments associated with severe neurological impairment. After shunt replacement, there was remarkable improvement in functional status and decreased episodic self-injury.

Perspectives on pain and intellectual disability

Historically, individuals with intellectual disability (ID) have been excluded from pain research and assumed to be insensitive or indifferent to pain. The weight of the evidence suggests that individuals with ID have been subject to practices and procedures with little regard for their ability to experience or express pain. A number of issues central to improving understanding of pain in ID will be introduced and current research related to the definition of pain and its social context, underlying sensory and metabolic systems and factors influencing judgments about the ability to experience pain will be reviewed. Accumulating evidence from interdisciplinary research designed to improve assessment, understand individual differences, and evaluate bias and beliefs about pain suggests that new perspectives are emerging and beginning to shape an innovative frontier of research that will ultimately pay tremendous dividends for improving the quality of life of individuals with ID.

Long-term administration of oblimersen (OBL) plus chemotherapy: An analysis of safety in patients with solid tumors and hematologic cancers

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Background: Oblimersen (OBL; Genasense®) is designed to increase the efficacy of cancer therapy by reducing Bcl-2 protein. The agent has been studied in several randomized clinical trials, which prompted an evaluation of safety after extended administration in combination with various anticancer agents. Methods: We evaluated safety data from more than 900 patients (pts) with solid tumors or hematologic cancers who received OBL alone or in combination with chemotherapy in phase I-III studies. A total of 84 pts (65 with solid tumors, 19 multiple myeloma) who received OBL for = 6 months of on-cycle and between-cycle days were identified. We then compared the incidence of adverse events (AEs) in the Day (D) 1 to D180-period with the > D180 day period. Pts with solid tumors received OBL (0.6 to 12 mg/kg/d) in combination with dacarbazine, docetaxel, or mitoxantrone; pts with myeloma received OBL (7 mg/kg/d) combined with high-dose dexamethasone. Results: Among pts with solid tumors, the mean (± SD) number of 21 to 28-day cycles initiated was 12.3 (± 3.7; range, 7–25); the mean number of OBL treatment days was 65.6 (± 24.0; range, 45–156). In pts with myeloma, the mean number of 21 to 28-day cycles initiated was 13.3 (± 3.3; range, 9–20); the mean number of OBL treatment days was 105.3 (± 23.2; range, 77–148). Across both data sets, the incidence of AEs was lower or comparable in most system-organ classes (SOCs) in the > 180-day period compared with the D1 to D180-period. Events were consistent with those reported with short-term administration in multiple studies, and common AEs (including fatigue, fever, nausea, and vomiting) were similar in both periods. Conclusions: Oblimersen can be safely combined with multiple types of anticancer therapy. Prolonged treatment with these combinations for > 180 days has not been associated with the emergence of AEs qualitatively different from those reported with treatment for shorter periods.

No significant financial relationships to disclose.

LDH is a prognostic factor in stage IV melanoma patients (pts) but is a predictive factor only for bcl2 antisense treatment efficacy: Re-analysis of GM301 and EORTC18951 randomized trials

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Background: Two large studies with identical eligibility criteria and using serum LDH as stratification for randomization were re-analyzed in order to 1) confirm the prognostic importance of LDH in advanced melanoma; 2) to assess whether an interaction between LDH and treatment efficacy exists. Methodology: Oblimersen (OBL) trial GM301 randomized 771 pts between DTIC vs. DTIC+OBL, whereas EORTC trial 18951 randomized 365 pts between biochemotherapy vs biochemotherapy+IL2 (JCO, 2004). LDH was divided into 5 groups: 5 UNL. Cox model was used to asses the prognostic importance of LDH, treatment difference and LDH-treatment interaction regarding the main endpoint, overall survival (OS). Results: In each study LDH appeared to be of strong and incremental prognostic importance (p<0.0001): the higher the LDH the shorter the OS. Median OS in pts with LDH<0.8 UNL was ±1 yr vs. 5 UNL. In both trials, pts with LDH 0.8–1.1 UNL had already a shorter median OS (± 9 months) as compared to the <0.8 group. In each study, overall, treatment differences were not significant. However, an interaction between LDH and treatment difference was observed in GM301 (p=0.01), but not in 18951 (p=0.51). In GM301, the largest benefit in favor of OBL was confined to the LDH <0.8 UNL subgroup (see table ), whereas in EORTC18951 the trend for an IL2 advantage was spread over several LDH groups. The observation was consistent also for response and PFS, and was not related to known confounding variables including metastatic disease site and PS. Conclusion: LDH is a biomarker with remarkable prognostic value for OS in advanced melanoma, and our analysis provides evidence for its prognostic value already below the UNL. Furthermore, OBL only had an effect in pts with low pretreatment LDH levels representing more favorable biology.

No significant financial relationships to disclose.

[Table: see text]

ELYPSE 2: A prospective randomized trial comparing filgrastim (G-CSF) in primary and secondary prophylaxis in patients (pts) at high risk for febrile neutropenia (FN)

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Background: FN is a frequent life-threatening consequence of cytotoxic chemotherapy (CT). G-CSF reduces the risk of FN, but primary (1ry) prophylaxis using G-CSF may be cost efficient only if FN incidence is ≥20%. The identification of pts at high risk for FN with simple criterias would be useful in clinical practice. Here we report a randomized phase II trial comparing G-CSF in 1ry vs 2ry prophylaxis in a high risk group of pts (based on our risk model JCO 1996;14:737, Br J Cancer 2003;88:181). Methods: Pts ≥18 years with solid tumors or NHL at high risk for FN after CT were incluable: these were pts with day 1 or day 5 lymphocytes (Ly) count ≤700/μL AND “high risk CT” (HRCT) In pts with d1 and d5 Ly ≤700/μL, the observed incidence of FN was 40% and 66% respectively G-CSF (300 to 480μg/d from d6–12) was randomized either as in 1ry prophylaxis (Arm 1), or as 2ry prophylaxis after FN (Arm 2). Primary endpoint was the rate of grade 4 FN. Hypothesis was a reduction of 40% of the risk of FN with 1ry prophylaxis. Results: Between 03/97 and 12/04, 137 pts were included in 7 centers. The median age was 53 years (range 18–80) with 54% males. Most frequent tumors were sarcomas (36%), breast carcinomas (18%), lymphomas (15%), head and neck carcinomas (10%), and lung carcinomas (6%). 23% patients had PS>1 at the first line of chemotherapy. No difference was observed in terms of duration of hospitalization or antibiotherapy. Median number of days of G-CSF administration was 14 days (0–24) vs 0 (0–17) days (p<0.0000). After the 1st course, grade 4 FN was 38% in Arm 2 (2ry prophylaxis) and 25% in Arm 1 (1ry prophylaxis), showing a 34% reduction of FN in arm 1 (p=0.14): 1ry prophylaxis was associated with a significant reduction of FN using logistic regression (p=0.04). Incidence of FN after the 2 course in pts receiving 2ry prophylaxis was 22%. Among the subgroup of pts with PS>2 and Ly ≤700/μL, (a group with a reported 20% risk for early death, Br J Cancer 2001;85:816), 2 of 8 patients (25%) died after the 1st course, vs 0/13 in the G-CSF group (p=0.05). This difference was not significant in the whole group. Conclusions: This study confirms that lymphopenic pts receiving HRCT are a high risk group of pts for FN for whom 1ry prophylaxis with G-CSF reduces the incidence of FN.

[Table: see text]

Psychogenic status epilepticus in children: psychiatric and other risk factors

The authors studied six children with repetitive psychogenic seizures severe enough to mimic status epilepticus. All received IV antiepileptic drugs in an emergency setting. Most had a family history of epilepsy. Affective and anxiety disorders predominated as comorbid psychiatric diagnoses. Acutely stressful situations precipitated all episodes of nonepileptic status epilepticus. With aggressive psychotherapeutic intervention and pharmacologic treatment of their underlying psychiatric diagnosis, the patients improved.

[Salvage therapy of relapsing or refractory malignant lymphoma with non-myelotoxic combined chemotherapy. Results of combination of cisplatin, bleomycin, methyl-GAG and prednisolone (Cis-BMP)]

Fifty-one patients with primary refractory or relapsed malignant lymphoma (47 non-Hodgkin's lymphoma and four Hodgkin's disease) were treated with a new chemotherapeutic regimen (cisplatinum, methyl GAG, bleomocyin, methyl prednisolon). Among these 51 patients, 41 had measurable disease. Three of these 41 patients achieved complete remissions (7.3%) and 17 showed partial response (41.5%). The low hematological toxicity of this chemotherapeutic combination allowed us to give the full dose at the planned cycle date in 90% of the cycles. No major toxicity were observed (two minor neurological toxicities, one ototoxicity associated with oral mucositis toxicity, 6 febrile episodes) during 164 courses. With a median follow-up of 12 months, 18% of patients were alive without disease. We conclude that in this particular population of malignant lymphomas, Cis-BMP is an effective therapy with minimal toxicity.

Wegener's granulomatosis presenting as diffuse pulmonary hemorrhage

A 35-year-old woman experienced diffuse intraalveolar haemorrhage with respiratory distress and acute renal failure. Renal histology and evolution confirmed Wegener's granulomatosis. Early use of immunosuppressive drugs allowed weaning from mechanical ventilation and temporary improvement of the renal failure. A review of the literature emphasizes the rarity of alveolar hemorrhage as an initial symptom of Wegener's granulomatosis and the necessity of aggressive management.

Salvage therapy with methyl-gag, high-dose Ara-C, M-Amsa, and ifosfamide (MAMI) for recurrent or refractory lymphoma

Thirty adult patients with relapsed or refractory malignant lymphoma underwent a Phase I-II trial of salvage chemotherapy combining methyl-gag, high-dose Ara-C, M-Amsa, and ifosfamide (MAMI protocol). All patients had been extensively pretreated. At the time of salvage therapy, 21 patients had visceral involvement and 23 patients were refractory. The overall response rate was 50% (11 patients in complete remission and 3 patients in partial remission). The main toxicity was myelosuppression; 4 treatment-related deaths occurred and 17 patients died of tumor progression with a median of 5 months. The MAMI protocol showed similar antitumoral efficacy to that of other salvage chemotherapy regimens used for poor prognosis malignant lymphoma but was more toxic. However, a response rate of 45% in refractory patients should be taken into account and this drug association deserves further investigation with regard to the selection of patients for bone marrow transplants.