Retrospective survival analysis in patients with metastatic pancreatic ductal adenocarcinoma with insulin-treated type 2 diabetes mellitus

INTRODUCTION

The association between pancreatic ductal adenocarcinoma (PDAC) and type 2 diabetes mellitus (DM2) has long been evaluated and the role of antidiabetic medications such as metformin has also been investigated. The objective of this study was to examine the association between insulin use and overall survival (OS) in patients with advanced PDAC and DM2.

METHODS

We retrospectively collected data from 164 patients, including an exploratory cohort of 96 patients from Medical Oncology Unit, University Hospital and University of Cagliari, Italy, and a validation cohort of 68 patients from Medical Oncology of Modena University Hospital. Patients had metastatic disease and received a first-line gemcitabine-based chemotherapy and, subsequently, a second-line fluoropyrimidines-based chemotherapy. We performed univariate analysis to evaluate correlation between long-term diabetes and overall survival. Then we performed multivariate analysis, adjusting for sex, metastatic sites, Eastern Cooperative Oncology Group Performance Status, Ca19.9 levels, N/L ratio, and lactate dehydrogenase levels at diagnosis, to confirm the independence of the variable.

RESULTS

In the exploratory cohort, DM2 was significantly associated with higher median OS at univariate analysis (16 vs 10 months; p = 0.004). This result was confirmed by validation cohort (11 months vs 6 months; p = 0.01). In multivariate analysis, insulin-treated patients compared with non diabetic patients showed a significantly increased survival of 4.6 months (p = 0.03).

CONCLUSIONS

Patients with insulin-treated metastatic PDAC showed better OS than non diabetic patients, as demonstrated by both cohorts. The correlation between OS and insulin-treated DM2 should be investigated further through a prospective clinical trial.

Liquid biopsy-driven anti-EGFR rechallenge in patients with metastatic colorectal cancer

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Background: The rechallenge with EGFR inhibitors represents an emerging strategy for anti-EGFR pre-treated patients with RAS wild type colorectal cancer (CRC). Unfortunately definitive selection criteria for anti-EGFR rechallenge in this setting are lacking. Very recently RAS wild type status on circulating tumor DNA (ct-DNA) at the time of rechallenge along with already known clinical criteria emerged as a potential watershed for this strategy. In the present study we explored liquid biopsy-driven anti-EGFR rechallenge strategy in the clinical practice for patients with metastatic colorectal cancer. Methods: Ct-DNA from RAS and BRAF wild type metastatic CRC patients previously treated with an anti-EGFR containing therapy was analyzed for RAS/BRAF mutations with the aim to evaluate the rechallenge strategy with anti-EGFR. The ct-DNA was analyzed for RAS-BRAF mutations using pyro-sequencing (PyroMark Q24 MDx Workstation) and nucleotide sequencing (Genetic Analyzer ABI3130) assays. Real-time PCR (Idylla) and droplet digital PCR (QX200 System) were performed to confirm the RAS-BRAF mutation status. Several clinical variables including previous response to anti EGFR containing therapy, tumor sidedness and anti-EGFR free interval were evaluated in relation to outcome. Tumor response evaluation was performed according to RECIST 1.1. Differences between categorical variables were evaluated using the Fisher’s exact test. Survival probability over time was estimated by the Kaplan–Meier method. Significant differences in the probability of survival between the strata were evaluated by log-rank test. Results: Twenty patients were included in the study. All patients were tested for RAS-BRAF mutations in ct-DNA. Fourteen patients (70%) showed a RAS-BRAF WT molecular profile, six patients (30%) showed a KRAS mutation. All the patients with ct-DNA RAS-BRAF WT profile underwent rechallenge with anti-EGFR. In details 11 patients (78.6%) underwent irinotecan+ cetuximab treatment, whereas 3 patients (21.4%) underwent panitumumab monotherapy. As for the outcome results to the rechallenge strategy, the median OS was 7 months (95% CI 5.0 to 13.0), the median PFS was 3 months (95% CI 2.0 to 6.0), the ORR was 27.3% with a DCR of 54.5%. Among the clinical variables evaluated as putative predictive/prognostic factors, previous response to anti-EGFR treatment was related to a not statistically significant improved OS (12 months vs 5 months HR:0.19 p: 0.06) and to a statistically significant improved ORR (75% vs 0% p:0.03). Conclusions: The rechallenge strategy with anti-EGFR confirmed to be feasible in clinical practice. The clinical outcome resulted consistent with the literature data. In addition to the molecular selection through the analysis of ct-DNA for RAS, previous response to anti EGFR treatment is confirmed as a prospective selection criteria for this therapeutic option.

Introducing immunotherapy for advanced hepatocellular carcinoma patients: Too early or too fast?

Advanced hepatocellular carcinoma (HCC) is the most frequent liver cancer. Immunotherapy has been explored in this disease in order to improve survival outcomes. Nowadays, scientific research is focusing especially on immune checkpoint inhibitors, in particular anti-PD1, anti-PD-L1 and anti-CTLA4 monoclonal antibodies (mAbs), as single-agent or in combination with other immunotherapy agents, target therapies, anti-vascular endothelial growth factor (VEGF) and other agents targeting specific molecular pathways. Other immunotherapy strategies have been assessed or are under investigation in advanced HCC, namely cytokines, adoptive cell therapy, oncolytic virus, cancer vaccines. Each treatment presents specific efficacy and toxicity profiles, strictly related to their mechanism of action and to advanced HCC tumour microenvironment (TME). The aim of this review is to outline the state-of-the-art of immunotherapy in advanced HCC treatment, highlighting data on already investigated treatment strategies, safety and toxicity (including HBV/HCV-related HCC), and ongoing clinical trials focusing on new promising therapeutic weapons.

Molecular-Biology-Driven Treatment for Metastatic Colorectal Cancer

BACKGROUND

Metastatic CRC (mCRC) is a molecular heterogeneous disease. The aim of this review is to give an overview of molecular-driven treatment of mCRC patients.

METHODS

A review of clinical trials, retrospective studies and case reports was performed regarding molecular biomarkers with therapeutic implications.

RESULTS

RAS wild-type status was confirmed as being crucial for anti-epidermal growth factor receptor (EGFR) monoclonal antibodies and for rechallenge strategy. Antiangiogenic therapies improve survival in first- and second-line settings, irrespective of RAS status, while tyrosine kinase inhibitors (TKIs) remain promising in refractory mCRC. Promising results emerged from anti-HER2 drugs trials in HER2-positive mCRC. Target inhibitors were successful for BRAFV600E mutant mCRC patients, while immunotherapy was successful for microsatellite instability-high/defective mismatch repair (MSI-H/dMMR) or DNA polymerase epsilon catalytic subunit (POLE-1) mutant patients. Data are still lacking on NTRK, RET, MGMT, and TGF-β, which require further research.

CONCLUSION

Several molecular biomarkers have been identified for the tailored treatment of mCRC patients and multiple efforts are currently ongoing to increase the therapeutic options. In the era of precision medicine, molecular-biology-driven treatment is the key to impro patient selection and patient outcomes. Further research and large phase III trials are required to ameliorate the therapeutic management of these patients.

New therapeutic targets in pancreatic cancer

Pancreatic ductal adenocarcinoma (PDAC) is associated with poor survival. Of all newly diagnosed patients, only about 20% can benefit from a potentially curative surgical resection, the remaining 80% presenting with unresectable locally advanced (LAPC) or metastatic (MPC) disease. Currently, there are limited therapeutic options for LAPC and MPC patients. Furthermore, despite intensive research efforts to better understand the molecular bases of PDAC and the biological relevance of its tumor microenvironment, treatments still largely consist of classical cytotoxic chemotherapy agents. Several studies of genetic and epigenetic sequencing have demonstrated the existence of 4 molecular PDAC subtypes, with heterogeneous genetic characteristics and different biological behaviour: squamous, pancreatic progenitor, immunogenic and aberrantly differentiated endocrine exocrine (ADEX). These distinct subtypes derive from alterations at multiple levels. Apart from the DNA repair pathway, however, none of these has so far been validated as a clinically relevant therapeutic target. Also, PDAC is unique from an immunological perspective and many studies have recently tried to elucidate the role of intratumoral effector T-cells, RAS oncogene, immunosuppressive leukocytes and desmoplastic reaction in maintaining the immunological homeostasis of this disease. However, there still remains much to be learned about the mechanisms whereby the pancreatic immune microenvironment promotes immune escape of cancer cells. Furthermore, while therapies targeting the stroma as well as immunotherapies hold promise for the future, these are not yet standard of care. This review aims to outline the state-of-the-art of LAPC and MPC treatment, highlighting data on the target therapies failure and current ongoing clinical trials on new promising therapeutic strategies.

[Multi-organ failure after massive Levothyroxine ingestion: case report]

Levothyroxine is the drug of choice prescribed worldwide for the treatment of Hypothyroidism. The exact daily dosage, mode of consumption and refractoriness to therapy are still subject of discussion. The intoxication with levothyroxine is rare and with severe complications in adults; on the contrary, high prevalence and benign course is observed in pediatric age. We report the case of a 56 year-old woman, presented to the emergency department after intentional ingestion of massive levothyroxine overdose , with acute renal failure, severe disturbances of cardiovascular and central nervous system, that required intensive care support. In absence of a specific treatment, plasmapheresis has been used with good results, despite important clinical complications. In fact the clinical applications of plasmapheresis are rapidly increasing in number and scope: the plasmapheresis appears to be a very important tool for the treatment of acute and severe forms of thyrotoxicosis due to l-thyroxine intoxication.

Review of thrombotic thrombocytopenic purpura in the setting of systemic lupus erythematosus

OBJECTIVE

Thrombotic thrombocytopenic purpura (TTP) has been described in association with systemic lupus erythematosus (SLE) rarely. The diagnosis of TTP as a process separate from SLE may be difficult because both share similar features, including thrombotic microangiopathy.

METHODS

A case is described of the simultaneous occurrence of TTP and SLE. The clinical, laboratory, and histologic findings of the patient are reported. The association of TTP and SLE in the literature is analyzed. We review separately the pathogenesis, role of antiphospholipid antibodies, and the differential diagnosis of TTP complicating the course of SLE.

RESULTS

Forty cases of TTP in association with SLE are reported in the world literature. Three distinct groups were defined by the presentation of TTP that occurred subsequent to, before, or simultaneous with SLE (groups 1, 2, and 3, respectively). Renal biopsy in a patient with lupus nephritis may reveal thrombotic microangiopathy, which may be seen independently or represent a concomitant systemic thrombotic process such as TTP, disseminated intravascular coagulation, or antiphospholipid antibody syndrome.

CONCLUSION

TTP in association with SLE is rare, and the diagnosis may be challenging. Although the etiology of TTP remains elusive, certain autoimmune mechanisms, platelet abnormalities, and fibrinolytic disorders may be shared with SLE and provide the basis for their association. Management requires timely diagnosis and aggressive treatment by therapeutic plasma exchange.

Pasteurella multocida peritonitis in peritoneal dialysis

Pasteurella multocida infection may occur in multiple sites to include rare involvement of the peritoneal cavity in peritoneal dialysis patients. Six cases of peritonitis associated with this organism have been reported in patients undergoing continuous peritoneal dialysis. A history of close contact with household cats was noted in all cases, with direct trauma to the dialysis tubing frequently seen. In this setting the organism appears to have a short incubation period with florid growth within 24 hours of known contamination. We report a case of Pasteurella multocida peritonitis in a patient treated with continuous cycling peritoneal dialysis and review the literature.

Effect of glycine on cisplatin nephrotoxicity and heat-shock protein 70 expression in the rat kidney

Glycine has been shown to protect against cisplatin (CP) nephrotoxicity in rats and to enhance the in vitro expression of heat-shock protein (hsp) 70 in renal epithelial cells following sublethal heat shock. We hypothesized that the protective effect of glycine against CP nephrotoxicity may be due to an up-regulation of Hsp 70 protein expression. Male Sprague-Dawley rats were divided into 4 treatment groups based upon infusion of glycine and injection of CP or their respective vehicles. At 5 days after treatment animals administered CP alone demonstrated a significant decrease in creatinine clearance compared to baseline (0.77 +/- 0.32 mL/min vs. 3.90 +/- 0.87 mL/min, p < 0.05). Treatment with glycine and CP attenuated this response, with no significant decline seen in creatinine clearance at day 5 compared to baseline (2.25 +/- 0.31 mL/min vs. 3.40 +/- 0.86 mL/min). Semiquantitative histological study revealed a marked decrease in proximal tubular injury at the juxtamedullary and outer medullary regions among animals treated with glycine and CP compared to those animals treated with CP alone. There were no differences in renal cortical and medullary Hsp 70 levels by Western immunoblotting between animals treated with glycine and CP compared to CP alone at 4 h and 5 days after treatment. Immunohistochemical studies of animals treated with CP alone revealed the diffuse presence of Hsp 70 in the cytoplasm of injured and necrotic proximal tubular cells 5 days after treatment. Animals receiving CP and glycine demonstrated a more focal presence of Hsp 70 restricted to injured proximal tubular cells, with no staining of uninjured cells. The protective effect of glycine in CP-induced acute and renal failure in the rat does not appear to be associated with enhancement of Hsp 70 expression.

Sublethal heat shock and cyclosporine exposure produce tolerance against subsequent cyclosporine toxicity

Sublethal heat shock has been shown to produce tolerance in cells and tissues subsequently exposed to heat or ischemia/ATP depletion. We tested whether heating LLC-PK1 cells for 2 h at 42 degrees C induced heat shock protein-70 (HSP-70) gene expression and conferred tolerance against subsequent cyclosporine A (CyA) toxicity. HSP-70 mRNA was increased immediately after heat shock, returning to baseline by 4 h. HSP-70 protein increased by 1 h after heat shock and declined thereafter, approaching baseline after 72 h. Cells heat shocked at 4 and 24 h prior to CyA exposure were significantly more viable than controls, at CyA concentrations near the median lethal dose (LD50). Cytoprotection declined with time after heat shock, concurrent with declining HSP-70 protein levels. Sublethal CyA exposure (50 micrograms/ml) for 24 h produced upregulation of HSP-70 mRNA and protein. Pretreatment with 50 micrograms/ml CyA for 24 h followed by exposure to a toxic concentration of CyA (200 micrograms/ml) produced significant cytoprotection compared with untreated controls. In conclusion, HSP-70 protein induction by sublethal heat shock or CyA exposure was associated with tolerance against subsequent lethal CyA exposure.

Case report: cerebral venous thrombosis as a manifestation of acute ulcerative colitis

Ulcerative colitis is associated with a number of extraintestinal complications, including the infrequent occurrence of thromboembolic disease. Cerebral venous thrombosis is extremely rare, with only 15 cases reported in the literature. The outcome in this group of patients is poor; the result in more than 80% of the cases is permanent neurologic sequelae or death. The precise mechanisms involved in thrombogenesis remain unclear. A hypercoagulable state may occur in ulcerative colitis because of well-documented associations of thrombocytosis, elevated factors V and VIII and fibrinogen, and decreased antithrombin III. Treatment regimens for cerebral venous thrombosis remain controversial and include anticoagulation with heparin, surgical thrombectomy, and systemic and local infusion of fibrinolytic regimens. A conservative approach with antiedemic agents, anticonvulsants, antiplatelet therapy, and acetazolamide also may be beneficial and offers a substantially reduced hemorrhagic potential. A case of primary superior sagittal sinus thrombosis associated with active ulcerative colitis treated by the latter method is reported. The patient's neurologic recovery was complete, with recanalization of the thrombosed venous sinus being demonstrated by magnetic resonance imaging studies.

Multiple, giant fibroadenoma

Multiple, giant fibroadenomas are histologic and clinical variants of "juvenile" or "giant" fibroadenomas. These tumors are rare and occur mainly in adolescent and young adult black females. The individual lesions are well encapsulated with a histologic pattern primarily of the "juvenile" type, although cases of the "adult" type have been reported. A high incidence of recurrence is noted upon local excision, although this may decrease as the patient becomes older. Management options include local excision with reconstruction, reduction mammoplasty, and simple mastectomy with reconstruction. A case is described of this condition with review of the literature.

Echinococcal diseases in an extended family and review of the literature

Echinococcal disease occurred in an extended family from Athens, Greece. Seven of the 11 family members were noted to be infected with Echinococcus granulosus, and five members have undergone surgical treatment. The potential sources of infection are discussed, although localization was impossible. There is no genetic basis for this disease and no apparent pattern of family member interrelationship or visceral involvement. Although echinococcal infection is frequently diagnosed in large urban centers, its transmission within a family is rare. Review of the literature and the current diagnostic and therapeutic measures are presented.