Efficacy of Platinum Rechallenge in Metastatic Urothelial Carcinoma After Previous Platinum-Based Chemotherapy for Metastatic Disease

BACKGROUND

Fit patients with metastatic urothelial carcinoma (mUC) receive first-line platinum-based combination chemotherapy (fPBC) as standard of care and may receive additional later-line chemotherapy after progression. Our study compares outcomes with subsequent platinum-based chemotherapy (sPBC) versus subsequent non-platinum-based chemotherapy (sNPBC).

MATERIALS AND METHODS

Patients from 27 international centers in the Retrospective International Study of Cancers of the Urothelium (RISC) who received fPBC for mUC and at least two cycles of subsequent chemotherapy were included in this study. A multivariable Cox proportional hazards model compared overall survival (OS) and progression-free survival (PFS).

RESULTS

One hundred thirty-five patients received sPBC and 161 received sNPBC. Baseline characteristics were similar between groups, except patients who received sPBC had higher baseline hemoglobin, higher disease control rate with fPBC, and longer time since fPBC. OS was superior in the sPBC group (median 7.9 vs 5.5 months) in a model adjusting for comorbidity burden, performance status, liver metastases, number of fPBC cycles received, best response to fPBC, and time since fPBC (hazard ratio, 0.72; 95% confidence interval, 0.53-0.98; p = .035). There was no difference in PFS. More patients in the sPBC group achieved disease control than in the sNPBC group (57.4% vs 44.8%; p = .041). Factors associated with achieving disease control in the sPBC group but not the sNPBC group included longer time since fPBC, achieving disease control with fPBC, and absence of liver metastases.

CONCLUSION

After receiving fPBC for mUC, patients who received sPBC had better OS and disease control. This may help inform the choice of subsequent chemotherapy in patients with mUC.

IMPLICATIONS FOR PRACTICE

Patients with progressive metastatic urothelial carcinoma after first-line platinum-based combination chemotherapy may now receive immuno-oncology agents, erdafitinib, enfortumab vedotin, or sacituzumab govitecan-hziy; however, those ineligible for these later-line therapies or who progress after receiving them may be considered for subsequent chemotherapy. In this retrospective study of 296 patients, survival outcomes and disease control rates were better in those receiving subsequent platinum-based rechallenge compared with non-platinum-based chemotherapy, suggesting that patients should receive platinum rechallenge if clinically able. Disease control with platinum rechallenge was more likely with prior first-line platinum having achieved disease control, longer time since first-line platinum, and absence of liver metastases.

Prognostic utility of global longitudinal strain (GLS) in patients with severe primary mitral regurgitation undergoing mitral valve surgery: a systematic review and meta-analysis

Background

Mitral valve (MV) surgery is recommended for the treatment of chronic severe mitral regurgitation (MR). However, the optimal timing of surgery in patients with asymptomatic severe primary MR remains elusive. Global longitudinal strain (GLS) may provide additional prognostic value in predicting postoperative outcomes in patients with chronic severe primary mitral regurgitation (MR) undergoing MV surgery.

Purpose

We aimed to determine the prognostic value of GLS in predicting postoperative mortality and LV dysfunction among patients with chronic severe primary MR.

Methods

Systematic search of Pubmed, Cochrane library, Clinicaltrials.gov, and Herdin.ph from inception to July 2019, using the terms “mitral insufficiency”, “mitral regurgitation”, “mitral valve surgery”, and “global longitudinal strain” was done without language restriction. We included and extracted data from cohort studies of patients with chronic severe primary MR who underwent MV surgery and which GLS, mortality and ejection fraction. We used the Newcastle Ottawa Scale to assess the quality of included studies. Review Manager 5.3 was used to perform analysis. Forest plots with summary hazard ratios (HR) and odds ratios (OR) with 95% confidence intervals (CI), I2 test for heterogeneity, and funnel plots were reported.

Results

Our search yielded 12 cohort studies with 2,843 patients; 7 prospective and 5 retrospective studies were included in the qualitative synthesis with 11 good quality studies. Cut-off GLS values ranged from −21.7% to −18.1%. In terms of postoperative all-cause mortality, the summary HR for worse versus better preoperative GLS is 1.22 (95% CI 1.04–1.44, p value <0.ehab724.16031, I2 95%). In terms of postoperative LV dysfunction, the summary OR is 1.74 (95% CI 1.14–2.66, p value 0.01, I2 94%) with significant heterogeneity.

Conclusion

Left ventricular GLS has prognostic value in terms of predicting postoperative mortality and LV dysfunction. However, significant heterogeneity exists between studies. Larger studies with well-defined inclusion criteria need to be performed and standardized GLS cut-offs need to be determined.

Funding Acknowledgement

Type of funding sources: None. GLS in Predicting All-Cause MortalityGLS in Predicting Post-op Dysfunction

Diversity of Floral Visitors in Apple Orchards: Influence on Fruit Characteristics Depends on Apple Cultivar

Most cultivars of apple trees are highly dependent on insects for successful pollination and fruit production. In this study, we evaluated the insect diversity in apple orchards of southern Brazil and verified whether or not there is a relationship between the diversity of insect visitors and the characteristics (weight, seed number, and symmetry) of the fruits of 'Fuji' and 'Gala' apples produced by the orchards. We also evaluated the diversity of insects on flowering weeds within apple orchards and compared it with the apple flowers. Diversity of anthophilous insects was low, in general, and differed between the regions. Furthermore, regarding insect diversity, orchards were grouped by management system: organic orchards were more similar to each other than to conventional orchards. The insect diversity of weed flowers was higher than apple flowers, but insect abundance was greater on apple flowers, suggesting that weeds may increase insect diversity within apple orchards and may sustain pollinators. We found a positive effect of insect diversity on the number of seeds of 'Fuji' apples and of honeybee abundance on their weight, suggesting that honeybee management is important in the studied areas. In contrast, we found no significant effect of insect diversity and abundance on 'Gala' apple characteristics. Despite this, the analyses of the seeds of 'Gala' apples indicate that the orchards may suffer a pollination deficit, which could be overcome by improving insect pollination. These results reinforce previous findings that insect diversity is important for apple yield, but its influence varies with cultivar.

P15 Serum chloride as marker for prognosis for patient with acute decompensated heart failure: a systematic review and meta-analysis on prognosis

Background

 Several studies have suggested that hypochloremia is associated with adverse outcomes among patients with heart failure. The association appears to be more marked in those with acute decompensation.

Research Question: What is the association of hypochloremia with mortality and worsening heart failure among patients in acute decompensation?

Objective

Determine the association of admission hypochloremia to all-cause mortality, heart failure death and worsening heart failure among patients with acute decompensated heart failure.

Criteria for Inclusion of Studies: Studies were included if they satisfied the following criteria 1) observational cohort studies; 2) included patients admitted for acute decompensated heart failure; and 3) reported data on mortality and worsening heart failure in association with admission hypochloremia.

Methods

A systematic search using MEDLINE, Clinical Key, ScienceDirect, Scopus, and Cochrane Central Register of Controlled Trials databases was done, from June 2018 to January 31, 2019. The characteristics of included studies were collated. Data abstraction and quality assessment, using the Newcastle-Ottawa Quality Assessment Scale, were done independently by two reviewers, and disagreements were settled by a third reviewer. Review Manager (RevMan) 5.3 was utilized to perform Mantel-Haenzel analysis of random effects and compute for relative risk.

Results

We included three high quality cohort studies involving 3,444 patients admitted for acute decompensated heart failure and having low serum chloride levels on admission. Our study shows that admission hypochloremia is associated with increased risk for all-cause mortality [RR 1.63, (95% CI 1.60 to 2.28, p < 0.00001]. Risks for heart failure death as mentioned in one study and worsening heart failure also in one study are likewise increased with hypochloremia on admission. 

Conclusion

Admission hypochloremia is associated with higher all-cause mortality among patients admitted for acute decompensated heart failure. The risk for heart failure death and worsening heart failure are also increased. Admission hypochloremia may be a useful prognosticator for heart failure patients.

Management of cytokine release syndrome and neurotoxicity in chimeric antigen receptor (CAR) T cell therapy

INTRODUCTION

Chimeric antigen receptor (CAR) T cell immunotherapy has demonstrated remarkable anti-tumor activity in B-cell malignancies and is under investigation in other hematologic malignancies and solid tumors. While highly efficacious, post-infusion T cell activity often results in massive cytokine release precipitating cytokine release syndrome (CRS), the signature toxicity of CAR T cells. This toxicity is characterized by systemic immune activation resulting in fever, hypotension, respiratory insufficiency and capillary leak. Either in conjunction with or in the absence of CRS, a subset of patients may also develop mild to severe neurotoxicity. Although the precise pathogenesis of CRS and neurotoxicity aren't fully elucidated, risk factors and mitigation strategies have been reported. Areas covered: This manuscript provides an in-depth overview of the pathogenesis, clinical characteristics, current toxicity management strategies, and future perspectives pertaining to CRS and neurotoxicity. Expert Opinion: As CAR T cell based therapies gain popularity in the management of various malignancies, the complimentary toxicities of CRS and neurotoxicity pose a clinical challenge in practice. Risk adaptive modeling incorporating disease profile, patient demographics, lymphodepletion, cell dosing, CAR T construct, and potentially cytokine gene polymorphisms may be instructive to assess individualized risk and optimal CRS/neurotoxicity management.

Chemotherapy regimen is associated with venous thromboembolism risk in patients with urothelial tract cancer

OBJECTIVE

To assess the association of venous thromboembolism (VTE) with different chemotherapy regimens in patients with urothelial tract cancer.

PATIENTS AND METHODS

We identified patients aged ≥66 years, diagnosed with urothelial tract cancer in the period 1998 to 2011 in the Surveillance, Epidemiology, and End Results (SEER) Medicare-linked database. The chemotherapy regimens analysed were gemcitabine/cisplatin (GC), methotrexate/vinblastine/doxorubicin/cisplatin (MVAC), or gemcitabine/carboplatin (CarboG). Propensity scores for treatment regimen based on comorbidities, tumour characteristics, age, and year of diagnosis were calculated. VTE rates within 120 days of chemotherapy initiation were calculated. VTE risk stratified by chemotherapy regimen was modelled using multivariable logistic regression, adjusting for treatment propensity scores and additional demographic characteristics. Overall survival stratified by VTE and chemotherapy regimen was estimated using Kaplan-Meier methods and the log-rank test.

RESULTS

Of 5594 identified patients, a VTE occurred in 13.0%. The VTE rates within 120 days of chemotherapy initiation were 15.3% for GC, 8.7% for MVAC, and 12.0% for CarboG. On multivariable analysis, MVAC (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.39-0.94) and CarboG (OR 0.71, 95% CI: 0.59-0.85) were associated with lower VTE risk compared with GC. VTE was associated with worse overall survival (P < 0.001).

CONCLUSIONS

Compared with GC, MVAC and CarboG were associated with a lower rate of VTE. This finding suggests that gemcitabine may add to the increased thrombosis risk from cisplatin. Additionally, patients with a VTE had worse survival outcomes than those without a VTE. Analysis of the risk of blood clots with different chemotherapy regimens in patients with urothelial tract cancer showed that GC was associated with the highest rate. We also found that blood clots were associated with worse patient outcomes.

Venous Thromboembolism Risk in Patients With Locoregional Urothelial Tract Tumors

BACKGROUND

Venous thromboembolism (VTE) is common in cancer patients, but there is limited data on patients with urothelial tract tumors (UTT). We previously identified several associative factors for increased VTE rates in patients with metastatic UTT. In this study, we assessed the frequency, associative factors, and impact on survival of VTE in patients with locoregional UTT.

METHODS

Patients with locoregional bladder, upper urinary tract, or urethral cancer were included in this multi-center study from 29 academic institutions. Patients with < cT2, > N1, or M1 disease at diagnosis were excluded. Patients with incomplete clinical staging or miscoded/missing data were excluded. Cumulative, unadjusted VTE incidence was calculated from time of diagnosis of muscle-invasive disease, excluding VTEs diagnosed in the metastatic setting. χ2 statistics tested differences in VTE rates across baseline and treatment-related factors. Significant covariates were incorporated into a multivariate, logistic regression model. Overall survival stratified by VTE was estimated using Kaplan-Meier methods and evaluated using the log-rank test.

RESULTS

A total of 1732 patients were eligible. There were 132 (7.6%) VTEs. On multivariate analysis, non-urothelial histology (P < .001), clinical Nx stage (P < .001), cardiovascular disease (P = .01), and renal dysfunction (P = .04) were statistically significant baseline factors associated with VTE. Using surgery alone as reference, surgery with perioperative chemotherapy (P = .04) and radiation with concurrent chemotherapy (P = .04) also were significant.

CONCLUSIONS

The VTE incidence of 7.6% in locoregional disease is comparable with our previously reported rate in the metastatic setting (8.2%). Similar to our findings in metastatic UTT, non-urothelial histology, renal dysfunction, and CVD was associated with increased VTE risk.

Venous thromboembolism in metastatic urothelial carcinoma or variant histologies: incidence, associative factors, and effect on survival

Venous thromboembolism (VTE) is common in cancer patients. However, little is known about VTE risk in metastatic urothelial carcinoma or variant histologies (UC/VH). We sought to characterize the incidence, associative factors, including whether various chemotherapy regimens portend different risk, and impact of VTE on survival in metastatic UC/VH patients. Patients diagnosed with metastatic UC/VH from 2000 to 2013 were included in this multicenter retrospective, international study from 29 academic institutions. Cumulative and 6‐month VTE incidence rates were determined. The association of first‐line chemotherapy (divided into six groups) and other baseline characteristics on VTE were analyzed. Each chemotherapy treatment group and statistically significant baseline clinical characteristics were assessed in a multivariate, competing‐risk regression model. VTE patients were matched to non‐VTE patients to determine the impact of VTE on overall survival. In all, 1762 patients were eligible for analysis. There were 144 (8.2%) and 90 (5.1%) events cumulative and within the first 6 months, respectively. VTE rates based on chemotherapy group demonstrated no statistical difference when gemcitabine/cisplatin was used as the comparator. Non‐urotheilal histology (SHR: 2.67; 95% CI: 1.72–4.16, P < 0.001), moderate to severe renal dysfunction (SHR: 2.12; 95% CI: 1.26–3.59, P = 0.005), and cardiovascular disease (CVD) or CVD risk factors (SHR: 2.27; 95% CI: 1.49–3.45, P = 0.001) were associated with increased VTE rates. Overall survival was worse in patients with VTE (median 6.0 m vs. 10.2 m, P < 0.001). Thus, in metastatic UC/VH patients, VTE is common and has a negative impact on survival. We identified multiple associated potential risk factors, although different chemotherapy regimens did not alter risk.

The Khorana Score in Predicting Venous Thromboembolism for Patients With Metastatic Urothelial Carcinoma and Variant Histology Treated With Chemotherapy

BACKGROUND

The Khorana score is a predictive risk model for venous thromboembolism (VTE) in patients with cancer planning to receive chemotherapy. Urothelial carcinoma and variant histologies (UC/VH) were underrepresented in the model. We sought to evaluate whether the Khorana score predicts for VTE in a retrospective multinational data set of patients with metastatic UC/VH.

METHODS

Patients diagnosed with metastatic UC/VH who received chemotherapy were eligible. Those with incomplete or miscoded data were excluded. Khorana scores were calculated based on the pretreatment data and categorized into high (≥3) or intermediate (1-2) VTE risk. Other patient-, tumor-, and therapy-related factors were also analyzed. The χ² and logistic regression analyses were used to assess differences in VTE rates based on the clinical characteristics. Subgroup analyses were performed to evaluate the Khorana score and associated variables for early (<3 months) and late (>3 months) VTE.

RESULTS

A total of 943 patients were eligible for analysis. The cumulative VTE rate was 9.9%. There was no statistical difference in overall VTE rate between Khorana high- and intermediate-risk groups ( P = .16). In the multivariate analysis, nonurothelial histology (odds ratio [OR] = 2.56; P = .002) and the presence of cardiovascular disease (CVD) or CVD risk factors (OR = 2.14; P = .002) were associated with increased VTE risk. In the first 3 months from initiation of chemotherapy, Khorana high risk (OR = 2.08; P = .04) was associated with higher VTE rates. White blood cell (WBC) count (OR = 1.05; P = .04) was the only significant Khorana variable for early VTE.

CONCLUSIONS

The Khorana score stratifies early but not overall VTE risk in patients with metastatic UC/VH. The WBC count drives the increased early VTE risk seen with the Khorana score.

Characterizing the Morbidity of Postchemotherapy Retroperitoneal Lymph Node Dissection for Testis Cancer in a National Cohort of Privately Insured Patients

OBJECTIVE

To characterize morbidity of postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for testis cancer, we analyze a contemporary national database. PC-RPLND is the standard for residual radiographic masses ≥1 cm (nonseminoma) and positron emission tomography-avid masses ≥3 cm (seminoma). Morbidity for PC-RPLND is greater than primary RPLND, which may be mitigated by performing surgery at a high-volume cancer center.

METHODS

Current Procedural Terminology and International Classification of Diseases, Ninth Edition codes identified men with testis cancer undergoing PC- or primary RPLND in MarketScan (2007-2012). Multivariable logistic regression assessed factors associated with receiving adjunctive procedures (ie, nephrectomy, vascular reconstruction), prolonged hospitalization, and 90-day readmission. Geographic variables assessed regionalization of PC-RPLND.

RESULTS

Of 559 men with claims for PC- or primary RPLND (206, 37% PC-RPLND), 19% of PC-RPLND underwent adjunctive procedures (vs 1% among RPLND, P  <  .01). For PC-RPLND, the nephrectomy rate was 10% and the vascular reconstruction rate was 8%. On multivariable analysis, PC-RPLND was associated with undergoing adjunctive procedures (odds ratio 41.9; 95% confidence interval 11.7, 150) and prolonged hospitalization (odds ratio 3.75; 95% confidence interval 1.68, 8.42) compared to primary RPLND. PC-RPLND was not associated with 90-day readmission. Up to 29% of PC-RPLNDs are performed in centers, billing just a single case through MarketScan in the 6 years studied.

CONCLUSION

PC-RPLND is associated with adjunctive procedures and longer hospitalizations. Given the morbidity of PC-RPLND in this young patient population, efforts are needed to establish quality benchmarks for, reduce the morbidity of, and to accurately discriminate risk during patient discussions prior to this complex, specialized surgery.

Automated lesion detectors in retinal fundus images

Diabetic retinopathy (DR) is a sight-threatening condition occurring in persons with diabetes, which causes progressive damage to the retina. The early detection and diagnosis of DR is vital for saving the vision of diabetic persons. The early signs of DR which appear on the surface of the retina are the dark lesions such as microaneurysms (MAs) and hemorrhages (HEMs), and bright lesions (BLs) such as exudates. In this paper, we propose a novel automated system for the detection and diagnosis of these retinal lesions by processing retinal fundus images. We devise appropriate binary classifiers for these three different types of lesions. Some novel contextual/numerical features are derived, for each lesion type, depending on its inherent properties. This is performed by analysing several wavelet bands (resulting from the isotropic undecimated wavelet transform decomposition of the retinal image green channel) and by using an appropriate combination of Hessian multiscale analysis, variational segmentation and cartoon+texture decomposition. The proposed methodology has been validated on several medical datasets, with a total of 45,770 images, using standard performance measures such as sensitivity and specificity. The individual performance, per frame, of the MA detector is 93% sensitivity and 89% specificity, of the HEM detector is 86% sensitivity and 90% specificity, and of the BL detector is 90% sensitivity and 97% specificity. Regarding the collective performance of these binary detectors, as an automated screening system for DR (meaning that a patient is considered to have DR if it is a positive patient for at least one of the detectors) it achieves an average 95-100% of sensitivity and 70% of specificity at a per patient basis. Furthermore, evaluation conducted on publicly available datasets, for comparison with other existing techniques, shows the promising potential of the proposed detectors.

cDNA cloning and expression of Blo t 11, the Blomia tropicalis allergen homologous to paramyosin

Blomia tropicalis is an important mite species in many parts of the world and the most predominant mite species in tropical countries. The prevalence of sensitization to this species has probably been underestimated because commercial extracts are largely unavailable. Identification and characterization of B. tropicalis allergens is an important step toward understanding the role of this species in allergic sensitization and could provide appropriate reagents for diagnostic and therapeutic procedures. This paper describes the isolation, sequence analysis, expression and allergenicity of a cDNA gene coding for a B. tropicalis allergen with homology to paramyosin, a high-molecular-weight allergen previously identified in Dermatophagoides farinae. The full-length Blo t 11 cDNA gene was isolated by cDNA library screening, 5'-rapid amplification of cDNA ends and long-distance PCR. Sequence analysis was performed with a combination of CLUSTAL W, CGC and BLAST program packages. The cDNA gene was expressed as a GST fusion protein in Escherichia coli and purified by affinity chromatography using the glutathione Sepharose column. Allergenicity of the rBlo t 11 was tested by human IgE dot blot immunoassay. Blo t 11 is a 3,111-bp cDNA gene with a 2,625-bp open reading frame coding for an 875-amino acid protein, exhibiting significant homology with different invertebrate paramyosins. The human IgE dot blot immunoassay showed that the rBlo t 11 reacted positively to 52% (33/63) of sera from asthmatic patients. Blo t 11 is the homolog of Der f 11 exhibiting potentially important allergenic activity.