Pneumonitis After Chemoradiotherapy and Adjuvant Durvalumab in Stage III Non-Small Cell Lung Cancer

PURPOSE

Adjuvant durvalumab after definitive chemoradiotherapy (CRT) for unresectable stage III non-small cell lung cancer (NSCLC) is well-tolerated in clinical trials. However, pneumonitis rates outside of clinical trials remain poorly defined with CRT followed by durvalumab. We aimed to describe the influence of durvalumab on pneumonitis rates among a large cohort of patients with stage III NSCLC.

METHODS AND MATERIALS

We studied patients with stage III NSCLC in the national Veterans Health Administration from 2015 to 2021 who received concurrent CRT alone or with adjuvant durvalumab. We defined pneumonitis as worsening respiratory symptoms with radiographic changes within 2 years of CRT and graded events according to National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03. We used Cox regression to analyze risk factors for pneumonitis and the effect of postbaseline pneumonitis on overall survival.

RESULTS

Among 1994 patients (989 CRT alone, 1005 CRT followed by adjuvant durvalumab), the 2-year incidence of grade 2 or higher pneumonitis was 13.9% for CRT alone versus 22.1% for CRT plus durvalumab (unadjusted P < .001). On multivariable analysis, durvalumab was associated with higher risk of grade 2 pneumonitis (hazard ratio, 1.45; 95% CI, 1.09-1.93; P = .012) but not grade 3 to 5 pneumonitis (P = .2). Grade 3 pneumonitis conferred worse overall survival (hazard ratio, 2.51; 95% CI, 2.06-3.05; P < .001) but grade 2 pneumonitis did not (P = .4).

CONCLUSIONS

Adjuvant durvalumab use was associated with increased risk of low-grade but not higher-grade pneumonitis. Reassuringly, low-grade pneumonitis did not increase mortality risk. We observed increased rates of high-grade pneumonitis relative to clinical trials; the reasons for this require further study.

Synthesis, spectroscopic, chemical reactivity, topology analysis and molecular docking study of ethyl 5-hydroxy-2-thioxo-4-(p-tolyl)-6-(trifluoromethyl)hexahydropyrimidine-5-carboxylate

The organofluorine hexahydropyrimidine derivatives are used in the drug discovery due to its steric nature to hydrogen and its extreme electronegativity. The Ethyl 5-hydroxy-2-thioxo-4-(p-tolyl)-6-(trifluoromethyl)hexahydropyrimidine-5-carboxylate (ETP5C) compound was synthesized and characterized by NMR (13C and 1H), FT-IR and UV-Vis spectroscopic techniques for experimentally and theoretically and elemental analyses, mass spectra also investigated. The most stable structure of synthesized molecule was studied by PES analysis in gas and liquid medium. The structural parameters such as bond length and bond angle of the title molecule have been obtained by DFT/B3LYP/6-311++G (d,p) set and compared with the structurally related experimental data of the compounds. The π-to-π* transition of the ETP5C molecule is identified using UV-Vis absorption spectral analysis. In addition, the chemical stability and reactivity are investigated using HOMO-LUMO analysis. The minimal HOMO-LUMO energy gap (4.6255 eV) clearly explains that the ETP5C molecule is more reactive for receptors. The nucleophilic and electrophilic regions such as active sites have been shown by MEP, ELF, LOL and Fukui functions. The second order optical effect has been explained by NLO analysis. The docking was performed with antineoplastic proteins that exhibit against the development of tumor cells.

Consolidation Osimertinib Versus Durvalumab Versus Observation After Concurrent Chemoradiation in Unresectable EGFR-Mutant NSCLC: A Multicenter Retrospective Cohort Study

INTRODUCTION

Durvalumab improves survival when used as consolidation therapy after chemoradiation (CRT) in patients with stage III NSCLC. The optimal consolidation therapy for patients with EGFR-mutant (EGFRmut) stage III NSCLC remains unknown.

METHODS

In this multi-institutional, international retrospective analysis across 24 institutions, we evaluated outcomes in patients with stage III EGFRmut NSCLC treated with concurrent CRT followed by consolidation therapy with osimertinib, durvalumab, or observation between 2015 and 2022. Kaplan-Meier method was used to estimate real-world progression-free survival (rwPFS, primary end point) and overall survival (secondary end point). Treatment-related adverse events (trAEs) during consolidation treatment were defined using Common Terminology Criteria for Adverse Events version 5.0. Multivariable Cox regression analysis was used.

RESULTS

Of 136 patients with stage III EGFRmut NSCLC treated with definitive concurrent CRT, 56 received consolidation durvalumab, 33 received consolidation osimertinib, and 47 was on observation alone. Baseline characteristics were similar across the three cohorts. With a median follow-up of 46 months for the entire cohort, the median duration of treatment was not reached (NR) for osimertinib (interquartile range: NR-NR) and was 5.5 (interquartile range: 2.4-10.8) months with durvalumab. After adjusting for nodal status, stage III A/B/C, and age, patients treated with consolidation osimertinib had significantly longer 24-month rwPFS compared to those treated with durvalumab or in the observation cohorts (osimertinib: 86%, durvalumab: 30%, observation: 27%, p < 0.001 for both comparisons). There was no difference in rwPFS between the durvalumab and the observation cohorts. No significant difference in overall survival across the three cohorts was detected, likely due to the limited follow-up. Any-grade trAE occurred in 52% (2 [6.1%] grade ≥3) and 48% (10 [18%] grade ≥3) of patients treated with osimertinib and durvalumab, respectively. Of 45 patients who progressed on consolidation durvalumab, 37 (82%) subsequently received EGFR tyrosine kinase inhibitors. Of these, 14 (38%) patients developed trAEs including five patients with pneumonitis (14%; 2 [5.4%] grade ≥3) and five patients with diarrhea (14%; 1 [2.7%] grade ≥3).

CONCLUSIONS

This study suggests that among patients with stage III unresectable NSCLC with a sensitizing EGFR mutation, consolidation osimertinib was associated with a significantly longer rwPFS compared to durvalumab or observation. No unanticipated safety signals were observed with consolidation osimertinib.

Recent advances in the management of hepatocellular carcinoma

Liver cancer remains a challenge of global health, being the 4th leading cause of cancer death worldwide. Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer, and is usually precipitated by chronic viral infections (hepatitis B and C), non-alcoholic steatohepatitis, heavy alcohol use, and other factors which may lead to chronic inflammation and cirrhosis of the liver. There have been significant advances in the systemic treatment options for HCC over the past decades, with several approvals of both immune checkpoint inhibitors and tyrosine kinase inhibitors in patients with preserved liver function. These advances have led to improvement in survival outcomes, with expected survival of greater than 18 months, in those with sensitive tumors, adequate liver function, and those functionally fit to receive sequential therapies. Several ongoing and promising trials are now evaluating combinational strategies with novel systemic agents and combinations of systemic therapy with locoregional therapy. In view of these trials, further advances in the treatment of HCC are foreseen in the near future.

Immunotherapy and Transarterial Radioembolization Combination Treatment for Advanced Hepatocellular Carcinoma

INTRODUCTION

The efficacy and safety of combined immunotherapy and transarterial radioembolization (TARE) were suggested in preclinical and early-phase trials, but these were limited by small sample sizes. We sought to compare the efficacy of combined therapy and immunotherapy alone in patients with advanced hepatocellular carcinoma (HCC).

METHODS

The National Cancer Database was used to identify patients with advanced HCC diagnosed between January 1, 2017, and December 31, 2019. We included patients who received combined therapy or immunotherapy alone as first-line treatment. Multivariable logistic regression was conducted to determine predictors of combined therapy. Kaplan-Meier and Cox regression approaches were used to identify predictors of overall survival and to compare hazards of mortality between the patients who received combined therapy and immunotherapy alone.

RESULTS

Of 1,664 eligible patients with advanced-stage HCC, 142 received combined TARE/immunotherapy and 1,522 received immunotherapy alone. Receipt of combination therapy was associated with care at an academic center and inversely associated with racial/ethnic minority status (Hispanic and Black individuals). The median overall survival was significantly higher in the combination group than in the immunotherapy alone group (19.8 vs 9.5 months). In multivariable analysis, combined therapy was independently associated with reduced mortality (adjusted hazard ratio 0.50, 95% confidence interval: 0.36-0.68, P < 0.001). Results were consistent across subgroups and in sensitivity analyses using propensity score matching and inverse probability of treatment weighting.

DISCUSSION

The combination of TARE and immunotherapy was associated with improved survival compared with immunotherapy alone in patients with advanced-stage HCC. Our findings underly the importance of large clinical trials evaluating combination therapy in these patients.

Symptomatic Pneumonitis Rates Among Patients with Stage III Non-Small Cell Lung Cancer Receiving Adjuvant Durvalumab

PURPOSE/OBJECTIVE(S)

Adjuvant durvalumab after definitive chemoradiation for stage III non-small cell lung cancer (NSCLC) has improved overall survival with low reported pneumonitis rates in clinical trials. However, real-world rates of treatment-associated pneumonitis remain poorly defined. We sought to describe pneumonitis rates among a largest-to-date real-world cohort of stage III NSCLC patients receiving adjuvant durvalumab.

MATERIALS/METHODS

We performed a retrospective cohort study of patients with stage III NSCLC in the national Veterans Health Administration who received concurrent chemoradiation alone from 2015-2016 or concurrent chemoradiation followed by at least one dose of adjuvant durvalumab from 2017-2021. Incident pneumonitis was defined as new or worsening symptoms, radiographic changes on CT chest, at least one steroid prescription, and a likely diagnosis of pneumonitis by the treating physician within 2 years of the final radiation treatment; severity was graded by CTCAE v4.03 criteria. Pneumonitis events were ascertained by manual chart review assisted by keyword searches and steroid prescription data. Cox regression was used to identify baseline clinical factors associated with Grade 2+ pneumonitis.

RESULTS

Our cohort included 1,994 patients with stage IIII NSCLC, 989 of whom received concurrent chemoradiation alone and 1005 of whom received adjuvant durvalumab. The overall incidence of symptomatic pneumonitis among patients receiving concurrent chemoradiation alone vs those receiving adjuvant immunotherapy was 6.8% vs 11% (Grade 2, p = 0.0005), 6% vs 8.4% (Grade 3, p = 0.007) and 1.1% vs 1.6% (Grade 5, p = 0.292), respectively. The cumulative incidence of Grade 2-5 pneumonitis at 2 years was 13.8% among patients treated with chemoradiation alone versus 22.1% for patients treated with chemoradiation followed by durvalumab (p ≤0.0001). Of those with Grade 2 pneumonitis, pneumonitis occurred in 85% of patients within one year of receiving radiation, and 84% of those with Grade 3-5 pneumonitis developed pneumonitis within one year. Patients prescribed outpatient steroids for pneumonitis had active prescriptions lasting a mean of 153 days, and among those hospitalized for pneumonitis, ¾ needed supplemental oxygen support. On multivariate analysis, the use of durvalumab is associated with higher risk of Grade 2-5 pneumonitis (HR 1.4, p = 0.004). Current smokers have a 50% risk reduction for Grade 2+ pneumonitis relative to never smokers (p≤0.001).

CONCLUSION

In this largest-to-date cohort, we found that adjuvant immunotherapy is associated with higher risk of Grade 2+ pneumonitis. The increase in symptomatic pneumonitis associated with durvalumab should spur future work to refine patient selection, balance the risk/benefit of adjuvant immunotherapy, and potentially modify radiation dosimetric constraints to decrease pneumonitis rates.

Impact of immune tolerance mechanisms on the efficacy of immunotherapy in primary and secondary liver cancers

The liver is a functionally unique organ with an immunosuppressive microenvironment. The liver is the sixth most common site of primary cancer in humans and is a frequent site of metastasis from other solid tumors. The development of effective therapies for primary and metastatic liver cancer has been challenging due to the complex metabolic and immune microenvironment of the liver. The liver tumor microenvironment (TME) in primary and secondary (metastatic) liver cancers is heterogenous and consists of unique immune and stromal cell populations. Crosstalk between these cell populations and tumor cells creates an immunosuppressive microenvironment within the liver which potentiates cancer progression. Immune checkpoint inhibitors (ICIs) are now clinically approved for the management of primary and secondary liver cancer and can partially overcome liver immune tolerance, but their efficacy is limited. In this review, we describe the liver microenvironment and the use of immunotherapy in primary and secondary liver cancer. We discuss emerging combination strategies utilizing locoregional and systemic therapy approaches which may enhance efficacy of immunotherapy in primary and secondary liver cancer. A deeper understanding of the immunosuppressive microenvironment of the liver will inform novel therapies and therapeutic combinations in order to improve outcomes of patients with primary and secondary liver cancer.

Predictive Biomarkers for Immune-Checkpoint Inhibitor Treatment Response in Patients with Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) has one of the highest mortality rates among solid cancers. Late diagnosis and a lack of efficacious treatment options contribute to the dismal prognosis of HCC. Immune checkpoint inhibitor (ICI)-based immunotherapy has presented a new milestone in the treatment of cancer. Immunotherapy has yielded remarkable treatment responses in a range of cancer types including HCC. Based on the therapeutic effect of ICI alone (programmed cell death (PD)-1/programmed death-ligand1 (PD-L)1 antibody), investigators have developed combined ICI therapies including ICI + ICI, ICI + tyrosine kinase inhibitor (TKI), and ICI + locoregional treatment or novel immunotherapy. Although these regimens have demonstrated increasing treatment efficacy with the addition of novel drugs, the development of biomarkers to predict toxicity and treatment response in patients receiving ICI is in urgent need. PD-L1 expression in tumor cells received the most attention in early studies among various predictive biomarkers. However, PD-L1 expression alone has limited utility as a predictive biomarker in HCC. Accordingly, subsequent studies have evaluated the utility of tumor mutational burden (TMB), gene signatures, and multiplex immunohistochemistry (IHC) as predictive biomarkers. In this review, we aim to discuss the current state of immunotherapy for HCC, the results of the predictive biomarker studies, and future direction.

Integrated hydrogeophysical and GIS based demarcation of groundwater potential and vulnerability zones in a hard rock and sedimentary terrain of Southern India

This research has identified the groundwater potential and vulnerability zones in Tiruchirappalli district of Tamil Nadu, India. The Schlumberger electrode array has been used to conduct vertical electrical sounding (VES) at 95 sites with a maximum electrode spacing of 150 m. The study area comprises of hard rock and sedimentary formations. Geographical Information System (GIS) has been used to integrate the geoelectrical data and to prepare spatial variation maps for various parameters. Finally, groundwater potential and vulnerability zones have been demarcated, and these outputs have been validated using water level and nitrate data, respectively. The Dar-Zarrouk parameters such as longitudinal conductance (S), transverse unit resistance (T), and aquifer anisotropy (λ) have been used along with the spatial variation of resistivity and aquifer thickness to find out groundwater potential areas with the support of GIS. The thickness of topsoil, weathered zone and fractured zone are not uniform in the research area. Top soil plus weathered zone acts as a water table (phreatic) aquifer, which extends up to 38 m from the surface. Fractured zone extends up to 45 m, which acts as a kind of confined/semi-confined aquifer. Open and bore wells have been constructed to tap groundwater from the unconfined (water table) and confined/semi-confined aquifers, respectively. High to very high groundwater potential areas are associated with low resistivity, high thickness, low longitudinal conductance, high transverse unit resistance and high aquifer anisotropy areas. Very high groundwater potential areas are mostly confined to flood plain (alluvium) deposits in the central portion of the study area. High potential areas are noticed in the northern part, whereas low potential areas are noticed in the southern part. The areas with high longitudinal conductance indicate low permeable zones with less possibility of external pollution. Since agriculture is an important activity in the study region, this work will be useful to provide water supply for irrigation as well as for domestic needs.

Finite element analysis of fractured femur bone with prosthetic bone plates using ANSYS software

Bones are living tissues made of calcium and phosphorus among other elements. In the early years, they replenish themselves and expand quickly. The bone is viewed as a homogenous, isotropic, linear-elastic material. The foundation of the human skeleton are the bones. It aids in supporting the body's softer areas. Trauma is a significant factor in both industrialised and developing nations in terms of mortality and disability. According to the World Health Organization (WHO), trauma will account for the majority of years of life lost in both developed and developing countries by the year 2020. One of the frequent traumas is a bone fracture. Using bone plates to connect the fractured bone is one way to treat the broken bone. This study compares bone plates constructed of several biomaterials (Stainless Steel, Titanium, Alumina, Nylon, and PMMA) to determine which one is the best. SOLIDWORKS is used to model the femur bone, while ANSYS is used for analysis. Also modelled, attached to a fractured bone, and examined are the fracture fixation plates.

A Unique Metro Choice Behaviour of Suburban Rail Passengers in India

This study aims to analyse the inter-rail modal shift behaviour of suburban rail passengers to examine ridership for the proposed metro extension corridor in Chennai, India. This investigation was conducted in 2019 as part of a feasibility study for the extension of the metro line spanning between Chennai Airport and Kilambakkam, a southern suburb of Chennai. The same origin-destination pair is also served by the suburban rail system. It is an extension of the operating line from Washermenpet to the airport of the Phase I metro project. For this inter-rail competition study, a sample of 272 suburban rail passengers covering work, education and other trip purposes were interviewed using a stated preference questionnaire. Six stated scenarios were considered for analyses which included travel time saving by using the metro along with the fare difference between metro and bus. The study revealed that suburban rail passengers were less concerned about travel time saving and gave priority to fare difference irrespective of trip purpose. This shows the unique metro choice behaviour of suburban rail travellers in the Indian context.

Intersection of immune and oncometabolic pathways drives cancer hyperprogression during immunotherapy

Immune checkpoint blockade (ICB) can produce durable responses against cancer. We and others have found that a subset of patients experiences paradoxical rapid cancer progression during immunotherapy. It is poorly understood how tumors can accelerate their progression during ICB. In some preclinical models, ICB causes hyperprogressive disease (HPD). While immune exclusion drives resistance to ICB, counterintuitively, patients with HPD and complete response (CR) following ICB manifest comparable levels of tumor-infiltrating CD8+ T cells and interferon γ (IFNγ) gene signature. Interestingly, patients with HPD but not CR exhibit elevated tumoral fibroblast growth factor 2 (FGF2) and β-catenin signaling. In animal models, T cell-derived IFNγ promotes tumor FGF2 signaling, thereby suppressing PKM2 activity and decreasing NAD+, resulting in reduction of SIRT1-mediated β-catenin deacetylation and enhanced β-catenin acetylation, consequently reprograming tumor stemness. Targeting the IFNγ-PKM2-β-catenin axis prevents HPD in preclinical models. Thus, the crosstalk of core immunogenic, metabolic, and oncogenic pathways via the IFNγ-PKM2-β-catenin cascade underlies ICB-associated HPD.

Plasma central carbon metabolite changes associated with KRAS mutation and circulating tumor DNA (ctDNA) status in colorectal cancer (CRC)

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Background: KRAS mutations have been widely characterized as markers of poor prognosis in CRC. In stage IV CRC, KRAS mutations are predictive of benefit to anti-EGFR therapy. ctDNA has increasingly been recognized as a prognostic biomarker in CRC as well. We evaluated the association between plasma metabolites and KRAS mutation or ctDNA status in a longitudinal, observational cohort of patients with stage I-IV CRC. Methods: This was a retrospective analysis of prospectively collected blood samples from a single-institute cohort of patients with stage I-IV CRC. All blood samples were collected at pre-chemotherapy baseline. A modified Epi proColon 2.0 CE (Epigenomics AG) assay was used for plasma ctDNA testing on the methylated SEPTIN9 gene (mSEPT9). ctDNA positivity was defined as a mSEPT9 percentage of methylation reference (PMR) value greater than zero. Up to 150 metabolites of central carbon metabolism were analyzed by mass spectrometry and high-performance liquid chromatography. Analytes were compared by relative area under the curve (AUC) and differences evaluated by ANOVA. The mean AUC was used in patients with metabolites measured from > 1 timepoint of collection. Patients were stratified by ctDNA status (positive or negative) and KRAS mutant (MT) or wildtype (WT) status. Results: A total of 32 patients were included with median age 65 years (range 20-90). The majority were female (53%) and had stage IV disease (78%). Of 25 patients with stage IV CRC, 88% had pre-chemotherapy blood samples collected in the first-line setting. Most patients were KRAS MT (44%) compared to KRAS WT (37%) or unknown KRAS status (19%). The most common KRAS MT subtypes were G12D (29%), G12V (29%), G13D (21%), and G12C (14%). The mean overall survival in this cohort was 27.4 months while the mean mSEPT9 PMR value was 2553.6. When stratified by ctDNA status, ctDNA positivity was associated with decreased levels of essential amino acids (lysine, methionine, threonine) and the non-essential amino acid arginine (all p < 0.05). Compared to KRAS WT tumors, KRAS MT tumors were associated with increased levels of proline, phenylalanine, and intermediates of glycolysis (lactate), MTA cycle (SAM, 5-Methioadenosine), and O-GlcNAcylation (GlcNac, all p < 0.05). Conclusions: We are the first to demonstrate the feasibility of associating central carbon metabolites with ctDNA and KRAS mutation status. As ctDNA positivity and KRAS MT status have evolving prognostic potential in CRC, associated metabolic signatures may identify metabolic pathways for novel biomarker development. Our findings also show that KRAS MT CRC appears to be enriched in intermediates of glycolytic, methyl donor, and O-GlcNAcylation pathways.

An evaluation of sotorasib for the treatment of patients with non-small cell lung cancer with KRAS G12C mutations

INTRODUCTION

Improving the clinical outcomes of patients with KRAS^G12C-mutated non-small cell lung cancer (NSCLC), the majority of whom are current or former smokers, has been a barrier to improving population-level outcomes in NSCLC. Novel, effective KRAS^G12C inhibitors are emerging and sotorasib is the first member of that class to achieve commercial availability.

AREAS COVERED

In this review, we survey the epidemiology of KRAS^G12C-mutated NSCLC, as well as sotorasib's chemistry, pharmacology, and clinical trial data.

EXPERT OPINION

While sotorasib's development has been unique and exciting, questions persist regarding its intracranial penetrance, optimal dose, and efficacy relative to standard-of-care therapy. Improvements in the clinical activity of KRAS inhibition will hinge on better understanding of resistance mechanisms, the development of broad-spectrum inhibitors with activity beyond G12C mutations, and combination therapy targeting multiple mediators of KRAS signaling and alternative pathways. From a regulatory perspective, sotorasib's development may, in time, prove to be an instructive example for early-phase clinical trialists and regulators focused on dose optimization.

De-escalating adjuvant durvalumab treatment duration in stage III non-small cell lung cancer

BACKGROUND

One year of adjuvant durvalumab following concurrent chemoradiotherapy significantly improves progression-free survival (PFS) and overall survival (OS) for patients with stage III non-small cell lung cancer (NSCLC). However, the optimal length of adjuvant therapy has not been determined.

METHODS

We identified patients with stage III NSCLC treated with definitive chemoradiation and adjuvant durvalumab from November 2017 to April 2021 from the United States Veterans Affairs system. Predictors of early durvalumab discontinuation were evaluated with Cox proportional hazards regression. The effect of differing durations of durvalumab treatment (up to 6, 9, and 12 months) on PFS and OS were compared with a marginal structural model and time-dependent Cox modelling.

RESULTS

We included 1006 patients with stage III non-small cell lung cancer who received concurrent chemoradiotherapy and at least one dose of adjuvant durvalumab. The median duration of durvalumab treatment was 7 months (interquartile range 2.8-11.5) and 31% completed the intended durvalumab course. The most common reasons for early discontinuation were tumour progression (22%), immune-related adverse events (15%), and non-immune-related toxicity (6.0%), Marginal structural models suggested similar PFS for 9 months versus 12 months of durvalumab treatment and inferior PFS for 6 months versus 12 months.

CONCLUSIONS

A substantial proportion of patients undergoing adjuvant durvalumab discontinue therapy early due to toxicity, and shorter durvalumab treatment durations may provide similar disease control to 12 months of therapy. Prospective randomised controlled studies are needed to characterise the optimal durvalumab treatment duration in locally advanced NSCLC patients.

Prognostic and Predictive Role of PD-L1 Expression in Stage III Non-small Cell Lung Cancer Treated With Definitive Chemoradiation and Adjuvant Durvalumab

PURPOSE

It is unclear whether programmed death ligand 1 (PD-L1) expression is prognostic or predictive of immunotherapy benefit among patients with stage III non-small cell lung cancer (NSCLC) treated with definitive chemoradiation and adjuvant durvalumab.

METHODS AND MATERIALS

We determined pretreatment tumor PD-L1 expression for 312 patients with stage III NSCLC treated with definitive chemoradiation and at least 1 dose of adjuvant durvalumab between November 2017 and April 2021 across the national Veterans Health Administration. Progression-free survival (PFS) and overall survival (OS) in PD-L1 expression subgroups (<1%, 1%-49%, and 50%-100%) were compared with 994 patients with stage III NSCLC treated without adjuvant durvalumab from 2015 to 2016.

RESULTS

PD-L1 expression was <1%, 1% to 49%, and 50% to 100% in 109 (34.9%), 96 (30.7%), and 107 (34.3%) patients, respectively. Increasing PD-L1 expression was associated with longer PFS (adjusted hazard ratio [aHR], 0.84 per 25% absolute increase in expression; 95% confidence interval [CI], 0.75-0.94; P = .003) and OS (aHR, 0.86 per 25% absolute increase in expression; 95% CI, 0.74-0.99; P = .036). Compared with the no-durvalumab group, PFS was longer for PD-L1 50% to 100% (aHR, 0.44; 95% CI, 0.32-0.60; P < .001) and PD-L1 1% to 49% (aHR, 0.64; 95% CI, 0.47-0.86; P = .003) but not PD-L1 <1% (aHR, 0.84; 95% CI, 0.64-1.10; P = .19). Similar results were found for OS, with no significant difference between the no-durvalumab group and PD-L1 <1% (aHR, 0.81; 95% CI, 0.58-1.13; P = .22).

CONCLUSIONS

Increasing tumor PD-L1 expression is prognostic for PFS and OS among patients with stage III NSCLC treated with adjuvant durvalumab, and patients with PD-L1 expression <1% may have limited benefit from adjuvant durvalumab.

Molecular biomarkers and liquid biopsies in lung cancer

Liquid biopsy refers to the identification of tumor-derived materials in body fluids including in blood circulation. In the age of immunotherapy and targeted therapies used for the treatment of advanced malignancies, molecular analysis of the tumor is considered a crucial step to guide management. In lung cancer, the concept of liquid biopsies is particularly relevant given the invasiveness of tumor biopsies in certain locations, and the potential risks of biopsy in a patient population with significant co-morbidities. Liquid biopsies have many advantages including non-invasiveness, lower cost, potential for genomic testing, ability to monitor tumor evolution through treatment, and the ability to overcome spatial and temporal intertumoral heterogeneity. The potential clinical applications of liquid biopsy are vast and include screening, detection of minimal residual disease and/or early relapse after curative intent treatment, monitoring response to immunotherapy, and identifying mutations that might be targetable or can confer resistance. Herein, we review the potential role of circulating tumor DNA and circulating tumor cells as forms of liquid biopsies and blood biomarkers in non-small cell lung cancer. We discuss the methodologies/platforms available for each, clinical applications, and limitations/challenges in incorporation into clinical practice. We additionally review emerging forms of liquid biopsies including tumor educated platelets, circular RNA, and exosomes.

Effect of Local Anaesthesia with and without Adrenaline on Blood Glucose Concentration in Patients Undergoing Tooth Extractions - A Comparative Study

Introduction

Local anaesthesia (LA) is the usual drug used in dentistry to reduce intraoperative pain. The efficacy of lignocaine is improved by adding adrenaline as a vasoconstrictor. Adrenaline decreases the systemic absorption of LA and reduces blood loss during the surgical procedure. The study was conducted to observe the effect of adrenaline on blood glucose concentration in patients undergoing tooth extraction.

Materials and Methods

The study was conducted on 100 patients needing multiple teeth extraction. On the first appointment, extraction was done using lignocaine without adrenaline (plain), and for the second appointment, extraction was done using lignocaine with adrenaline (1:200,000). Serial blood glucose estimations were carried out at identical intervals on both occasions.

Results

Significant difference in blood glucose level was noted when the patients received lignocaine with adrenaline before administration and after 10 min/20 min intervals (P < 0.05).

Discussion

Constant vigilance and prudence are recommended while using lignocaine with adrenaline in patients suffering from diabetes mellitus.

The role of biomarkers in personalized immunotherapy

BACKGROUND

Immune checkpoint inhibitors have revolutionized cancer therapeutic paradigm and substantially improved the survival of patients with advanced malignancies. However, a significant limitation is the wide variability in clinical response.

MAIN TEXT

Several biomarkers have been evaluated in prior and ongoing clinical trials to investigate their prognostic and predictive role of patient response, nonetheless, most have not been comprehensively incorporated into clinical practice. We reviewed published data regarding biomarkers that have been approved by the United States Food and Drug Administration as well as experimental tissue and peripheral blood biomarkers currently under investigation. We further discuss the role of current biomarkers to predict response and response to immune checkpoint inhibitors and the promise of combination biomarker strategies. Finally, we discuss ideal biomarker characteristics, and novel platforms for clinical trial design including enrichment and stratification strategies, all of which are exciting and dynamic to advance the field of precision immuno-oncology.

CONCLUSION

Incorporation and standardization of strategies to guide selection of combination biomarker approaches will facilitate expansion of the clinical benefit of immune checkpoint inhibitor therapy to appropriate subsets of cancer patients.

Timing of Adjuvant Durvalumab Initiation Is Not Associated With Outcomes in Stage III Non-small Cell Lung Cancer

PURPOSE

It is unclear whether time from radiation therapy (RT) completion to durvalumab initiation influences the outcomes of stage III non-small cell lung cancer (NSCLC) treated with definitive chemoradiation and adjuvant durvalumab.

METHODS AND MATERIALS

Using the US Veterans Health Administration database, we retrospectively identified 728 patients with stage III NSCLC treated with definitive chemoradiation who started durvalumab within 120 days of radiation completion. Time between the last radiation treatment and first durvalumab infusion was analyzed in multivariable Cox regression models for the primary outcomes of progression-free survival (PFS) and overall survival (OS), adjusting for baseline patient and disease characteristics. The primary analysis used a 120-day landmark, measuring OS and PFS from 120 days after radiation completion.

RESULTS

Among 728 patients, the median time from RT completion to durvalumab start was 41 days (interquartile range 30-58). In multivariable Cox regression, time from RT completion to durvalumab start showed no association with PFS (adjusted hazard ratio [aHR] 1.01 per week, 95% confidence interval [CI] 0.98-1.04, P = .4) or OS (aHR 1.02 per week, 95% CI 0.98-1.06, P = .3). Starting durvalumab ≤14 days after RT was also not associated with improved PFS or OS. Results were robust in sensitivity analyses varying analytical technique.

CONCLUSIONS

Timing of durvalumab initiation up to 120 days after RT completion is not associated with PFS or OS in this real-world patient cohort.

Real World Outcomes versus Clinical Trial Results of Durvalumab Maintenance in Veterans with Stage III Non-Small Cell Lung Cancer

Simple Summary

The standard of care for patients with stage III non-small cell lung cancer is concurrent chemoradiotherapy followed by maintenance durvalumab based on outcomes from the PACIFIC trial. The efficacy of this regimen in a real-world population has not been extensively studied. We found that the addition of durvalumab has significantly improved both progression-free and overall survival in veterans with stage III non-small cell lung cancer as compared to veterans who received concurrent chemoradiotherapy alone, but overall survival of veterans is reduced compared to patients in the PACIFIC trial. Additional studies will need to be performed to understand this efficacy-effectiveness gap.

Abstract

One year of durvalumab following concurrent chemoradiotherapy improves progression-free (PFS) and overall survival (OS) for patients with stage III non-small cell lung cancer (NSCLC). However, the real-world efficacy of durvalumab has not been determined. We conducted a multi-center observational cohort study across the Veterans Health Administration, including patients with stage III NSCLC who received concurrent chemoradiotherapy and durvalumab, compared to patients who received concurrent chemoradiotherapy alone. Kaplan–Meier and Cox regression approaches were used to identify factors associated with PFS and OS. We calculated a hazard ratio and efficacy-effectiveness factor to compare OS of veterans to the referenced clinical trial population. A total of 1006 patients with stage III NSCLC who received concurrent chemoradiotherapy and at least one dose of durvalumab from November 2017 to April 2021 were compared to 989 patients who received concurrent chemoradiotherapy alone from January 2015 to December 2016. Adjuvant durvalumab was associated with higher PFS (HR 0.62, 95% CI 0.55–0.70, p < 0.001) and OS (HR 0.57, 95% CI 0.50–0.66, p < 0.001). OS was shorter in veterans compared to PACIFIC (HR 1.24, 95% CI 1.03–1.48, p = 0.02: EE gap 0.73). OS of veterans with stage III NSCLC treated with adjuvant durvalumab is improved compared to a modern comparator but is reduced compared to the PACIFIC population.

Prognostic and predictive value of neutrophil-to-lymphocyte ratio with adjuvant immunotherapy in stage III non-small-cell lung cancer

BACKGROUND

Elevated pre-treatment neutrophil-to-lymphocyte ratio (NLR) may reflect immune dysfunction and is negatively prognostic in cancer patients treated with immunotherapy, but it is unclear if NLR is predictive of immunotherapy benefit.

METHODS

We identified stage III non-small-cell lung cancer (NSCLC) patients treated with definitive chemoradiation and adjuvant durvalumab within the national Veterans Affairs system from 2017 to 2021. We compared the prognostic value of NLR measured before durvalumab start to a control group of stage III NSCLC patients treated with definitive chemoradiation alone from 2015 to 2016 (no-durvalumab group) before the approval of adjuvant durvalumab. We estimated the predictive value of NLR through the statistical interaction of durvalumab group by NLR level. Outcomes included progression-free survival (PFS) and overall survival (OS).

RESULTS

The primary analysis for NLR included 821 durvalumab patients and 445 no-durvalumab patients. Higher NLR was associated with inferior PFS in both groups (no-durvalumab: adjusted HR [aHR] 1.14 per 7.43 unit increase in NLR, 95% confidence interval [CI] 1.06-1.23; durvalumab: aHR 1.42, 95% CI 1.23-1.64), though this effect was greater in durvalumab patients (p for interaction = 0.009). Similar results were found for OS (no-durvalumab: aHR 1.16, 95% CI 1.09-1.24; durvalumab: aHR 1.48, 95% CI 1.25-1.76; p for interaction = 0.010). Absolute lymphocytes, eosinophils, and basophils were not prognostic in either group. Estimates of durvalumab treatment efficacy suggested declining efficacy with higher NLR.

CONCLUSION

Pre-treatment NLR is especially prognostic among stage III NSCLC patients treated with adjuvant immunotherapy compared to control patients treated without immunotherapy and may be a predictive biomarker of immunotherapy benefit.

Mucoepidermoid Carcinoma of Sublingual Salivary Gland: A Rare Case Report

Rationale

Sublingual salivary gland tumours are very rare but are mostly malignant. As very limited literature is available, we present a rare case of mucoepidermoid carcinoma (MEC) of sublingual salivary gland.

Patient Concerns

A56-year-old female presented with an asymptomatic swelling of 15-year duration in the floor of the mouth and chin region.

Diagnosis

Mandibular occlusal view, computed tomography scan, and ultrasonogram revealed calcification and the tumour to be of salivary origin. Incisional biopsy showed clear cell changes.

Treatment

The sublingual and submandibular salivary gland along with the associated nodes was excised through transoral approach with midline osteotomy.

Outcomes

The histopathologic diagnosis of excised specimen was "Intermediate grade MEC" with clear cell changes, stromal hyalinization, and local invasion. The patient was followed up for 12 months, and there was no evidence of any recurrence.

Takeaway Lessons

Sublingual salivary gland malignancies show early invasion and a higher rate of metastases, thus requiring a vigilant intervention.

Doubling of median overall survival in a nationwide cohort of veterans with stage III non-small cell lung cancer in the durvalumab era

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Background: The standard of care for patients with unresectable stage III non-small cell lung cancer (NSCLC) is concurrent chemoradiotherapy followed by durvalumab maintenance based on outcomes from the PACIFIC trial. However, PACIFIC did not include Veterans, a unique population with significant co-morbidities; thus, the impact of durvalumab on survival of Veterans with stage III NSCLC is unknown. Methods: Using the U.S. Department of Veterans Affairs Corporate Data Warehouse, patients with stage III non-small cell lung cancer who received chemoradiotherapy and at least one dose of durvalumab were selected. Kaplan-Meier survival analysis and univariate Cox proportional hazards modeling were used to determine progression-free survival (PFS), overall survival (OS) and independent predictors of PFS and OS. PFS was manually extracted by review of serial surveillance scans. All statistical computations were performed using SAS 9.4 software. Results: 1106 Veterans met our inclusion criteria. The median age was 69. 95.1% (n = 1052) were male. The median Charlson Comorbidity Index was 1. 86.4% (n = 956) reported current or former tobacco use. 48.1% (n = 532) had adenocarcinoma histology, 48.4% (n = 535) squamous cell, 0.5% (n = 5) large cell, 0.3% (n = 3) neuroendocrine, and 0.1% (n = 1) sarcomatoid. 60% (n = 619) had AJCC 8th edition stage IIIA disease, 34.5% (n = 382) stage IIIB, and 3.3% (n = 36) stage IIIC. Median PFS was 19.9 months (95% CI: 16.9 – 23.6) and median OS was 34.9 months (95% CI: 29.7 – not reached). In univariate survival analyses, adenocarcinoma histology (HR 1.14, p = 0.03) predicted progression. Older age (HR 1.03, p < 0.0001) and stage IIIB/IIIC disease (HR 1.05, p = 0.008) predicted inferior OS. 18.4% (n = 204) of patients completed all planned cycles of adjuvant durvalumab. The median number of durvalumab infusions received was 6 (range: 1 – 38). Among evaluable patients, 175 (19.4%) discontinued durvalumab for progression, 211 (23.4%) discontinued for suspected immune-related toxicity and 17 (1.9%) died during treatment. Conclusions: While several factors have led to the improvement of OS in patients with stage III NSCLC over time, we report a doubling of median OS in Veterans with stage III NSCLC who received chemoradiotherapy plus durvalumab as compared to historical cohorts who received chemoradiotherapy alone (1). Veterans in our study received a lower median number of durvalumab infusions as compared to patients in the PACIFIC trial (6 vs. 14), and a significant proportion discontinued durvalumab due to suspected immune-mediated toxicity (23.4%). If further analyses confirm our findings, investigation of alternative dosing regimens and/or dosing intervals of durvalumab in order to balance safety and efficacy of durvalumab therapy in Veterans is warranted. (1) Santana-Davila R et al. J Clin Oncol. 2015 Feb 20;33(6):567-74.

Immunotherapy for ALK-Rearranged Non-Small Cell Lung Cancer: Challenges Inform Promising Approaches

Rearrangements in the Anaplastic Lymphoma Kinase (ALK) gene have been implicated in 5-6% of all non-small cell lung cancers. ALK-rearranged non-small cell lung cancers are sensitive to ALK-directed tyrosine kinase inhibitors, but generally resistant to single-agent immune checkpoint inhibitors. Here, we aim to describe the mechanisms of ALK aberrations in non-small cell lung cancer by which an immunosuppressed tumor microenvironment is created, leading to host immune evasion. We report pre-clinical and clinical studies evaluating novel immunotherapeutic approaches and describe the promises and challenges of incorporating immune-based treatments for ALK-rearranged non-small cell lung cancer.

Validation of the American Joint Committee on Cancer Eighth Edition Staging of Patients With Metastatic Cutaneous Melanoma Treated With Immune Checkpoint Inhibitors

IMPORTANCE

Immune checkpoint inhibitors (ICIs) have transformed the survival of patients with metastatic melanoma. Patient prognosis is reflected by the American Joint Committee on Cancer (AJCC) staging system; however, it is unknown whether the metastatic (M) stage categories for cutaneous melanoma remain informative of prognosis in patients who have received ICIs.

OBJECTIVES

To evaluate the outcomes of patients with metastatic cutaneous melanoma based on the M stage category from the AJCC eighth edition and to determine whether these designations continue to inform the prognosis of patients who have received ICIs.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included patients with metastatic cutaneous melanoma who were treated between August 2006 and August 2019 at the University of Michigan. The estimated median follow-up time was 35.5 months. Patient data were collected via the electronic medical record system. Critical findings were externally validated in a multicenter nationwide cohort of patients treated within the Veterans Affairs health care system. Data analysis was conducted from February 2020 to January 2021.

EXPOSURES

All patients were treated with dual-agent concurrent ipilimumab and nivolumab followed by maintenance nivolumab or single-agent ipilimumab, nivolumab, or pembrolizumab therapy. Patients were staged using the AJCC eighth edition.

MAIN OUTCOMES AND MEASURES

Univariable and multivariable analyses were used to assess the prognostic value of predefined clinicopathologic baseline factors on survival.

RESULTS

In a discovery cohort of 357 patients (mean [SD] age, 62.6 [14.2] years; 254 [71.1%] men) with metastatic cutaneous melanoma treated with ICIs, the M category in the AJCC eighth edition showed limited prognostic stratification by both univariable and multivariable analyses. The presence of liver metastases and elevated levels of serum lactate dehydrogenase (LDH) offered superior prognostic separation compared with the M category (liver metastases: hazard ratio, 2.22; 95% CI, 1.48-3.33; P < .001; elevated serum LDH: hazard ratio, 1.73; 95% CI, 1.16-2.58; P = .007). An updated staging system based on these factors was externally validated in a cohort of 652 patients (mean [SD] age, 67.9 [11.6] years; 630 [96.6%] men), with patients without liver metastases or elevated LDH levels having the longest survival (median overall survival, 30.7 months).

CONCLUSIONS AND RELEVANCE

This study found that the AJCC eighth edition M category was poorly reflective of prognosis in patients receiving ICIs. Future staging systems could consider emphasizing the presence of liver metastases and elevated LDH levels. Additional studies are needed to confirm the importance of these and other prognostic biomarkers.

Effect of 2 h of room temperature storage on salivary glucose concentration

Background of the Study:

Although many studies are available validating the role of saliva as an alternative diagnostic tool, no reliable data are available on the duration of time, a salivary sample can be reliably stored at room temperature for estimation. It varies from one analyte to another and has to be researched.

Aim:

The aim of the study was to determine the effect of 2 h of room temperature storage on salivary glucose concentration.

Materials and Methods:

Saliva samples obtained by spitting method from thirty healthy volunteers were centrifuged and glucose concentration determined in the supernatant obtained. The test was repeated 2 h later following room temperature storage of the supernatant.

Results:

The data obtained were analyzed using wilcoxson signed rank test. No significant difference between was observed between the two values.

Conclusion:

Salivary glucose can reliably estimate on centrifuged samples following 2 h of room temperature storage.

Molecular therapeutic targets in non-small cell lung cancer

INTRODUCTION

Several targetable genetic alterations have been identified in non-small cell lung cancers (NSCLC) and drugs targeting these alterations have been approved for the management of advanced NSCLC patients. Driver mutations with emerging clinical trial data include EGFR exon 20 insertion mutations, MET amplification, KRAS G12 C point mutations, RET rearrangements, HER2 amplification and mutations, and FGFR amplification and translocations.

AREAS COVERED

We reviewed English-language articles indexed in Medline and PubMed up to the 1^st of June 2020. In addition, the proceedings of major conferences were reviewed for relevant abstracts. We report data published regarding targeted therapies which are currently approved and for those which are emerging in advanced or metastatic NSCLC.

EXPERT REVIEW

While these drugs have been shown to be efficacious and tolerable, resistance almost always develops. Though next-generation tyrosine kinase inhibitors (TKIs) have been developed, the appropriate sequencing of these drugs is not clear. Evaluating combination therapies to prevent or delay the onset of resistance and understanding mechanisms of resistance are critical areas of emerging research.

Thrombosis in the Philadelphia Chromosome-Negative Myeloproliferative Neoplasms

The myeloproliferative neoplasms (MPNs) are clonal stem cell-derived diseases. This chapter focuses on the subcategory of Philadelphia (Ph) chromosome-negative classical MPNs, polycythemia vera (PV), essential thrombocythemia (ET), primary myelofibrosis (PMF). These MPNs are associated with both microvascular and macrovascular thrombosis, which may occur in the venous and arterial circulation. Erythrocytosis, leukocytosis, and increased JAK2V617F allele burden are known to be risk factors. In this chapter, we review the thrombotic and hemostatic manifestations of the Philadelphia (Ph) chromosome-negative classical MPNs, including the clinical manifestations, the pathophysiology, as well as management.

Drainage morphometric analysis of the Nagavathi watershed, Cauvery river basin in Dharmapuri district, Tamil Nadu, India using SRTM data and GIS

A drainage morphometric analysis of Nagavathi watershed in Dharmapuri district has been chosen for the present study. Geospatial tools, such as remote sensing and GIS, are utilized for the extraction of watershed and its drainage networks. The Shuttle Radar Topographic Mission (SRTM) data have been used for drainage morphometric analysis and evaluating various morphometric parameters Linear aspect, Aerial aspect Relief aspect. The morphometric parameters of Nagavathi watershed have been analyzed and evaluated by pioneer methods, such as Horton and Strahler. The bifurcation ratio varies from 0.8 to 43.1. The elongation ratio of Microwatersheds varies from 0.13 to 0.43, indicates Microwatersheds fall under elongated pattern. This study would help the local people to utilize the resources for planning rainwater harvesting and watershed management.

Risk Factors for Post-Traumatic Endophthalmitis in Patients with Positive Intraocular Cultures

Purpose

To determine the risk factors for post-traumatic endophthalmitis in patients with positive intraocular culture.

Methods

An institutional-based prospective nonrandomized interventional study of patients older than 15 years who presented for primary repair of open globe injury between June 2003 and April 2005 was undertaken. The main outcomes measured were initial and final visual acuity, type of injury, presence of uveal and vitreous prolapse, time interval between injury and primary repair of the globe, length of wound, location of wound, and virulence of organism. Statistical analysis tests used were Student t-test, Fisher exact test, and chi-square test.

Results

Fifty patients were included in the study. They were divided into two groups: Group 1 (n=19) patients, who developed clinically significant endophthalmitis; and Group 2 (n=31) patients, who did not develop clinically significant endophthalmitis. Delay in primary repair more than 36 hours (p=0.042), length of wound more than 8 mm (p=0.050), and isolation of organisms like fungus (p=0.006, OR=14), Bacillus cereus (p=0.01, OR=11.25), and Pseudomonas aeruginosa (p=0.05–0.10, OR=11.3) significantly increased the risk of endophthalmitis. Mean initial and final visual acuity was better in Group 2 but was not statistically significant (p=0.21).

Conclusions

Final visual outcome in the presence of positive intraocular culture is poor. Isolation of virulent organisms, longer length of laceration, and delayed primary repair of open globe injuries have high risk of developing endophthalmitis. Prophylactic intraocular antibiotics should be considered in cases with longer length of wound and delayed primary closure.

Plasma renin activity, response to aliskiren, and clinical outcomes in patients hospitalized for heart failure: the ASTRONAUT trial

AIMS

The direct renin inhibitor, aliskiren, is known to reduce plasma renin activity (PRA), but whether the efficacy of aliskiren varies based on an individual's baseline PRA in patients hospitalized for heart failure (HF) is presently unknown. We characterized the prognostic value of PRA and determined if this risk is modifiable with use of aliskiren.

METHODS AND RESULTS

This pre-specified neurohormonal substudy of ASTRONAUT analysed all patients hospitalized for HF with ejection fraction (EF) ≤40% with available baseline PRA data (n = 1306, 80.9%). Risk associated with baseline PRA and short-term changes in PRA from baseline to 1 month was modelled with respect to 12-month clinical events. Median baseline PRA was 3.0 (interquartile range 0.6-16.4) ng/mL/h. Aliskiren significantly reduced PRA early after treatment initiation through 12-month follow-up compared with placebo (P < 0.001). The lowest baseline PRA quartile (<0.6 ng/mL/h) was independently predictive of lower all-cause mortality [adjusted hazard ratio (HR) 0.50, 95% confidence interval (CI) 0.31-0.81] and the composite of cardiovascular mortality and HF hospitalization (adjusted HR 0.57, 95% CI 0.40-0.79). Delta log-normalized PRA (from baseline to 1 month) was not predictive of either primary endpoint at 12 months (P ≥ 0.43). The prognostic value of baseline PRA and short-term changes in PRA did not vary by randomization to aliskiren or placebo (interaction P ≥ 0.13).

CONCLUSIONS

Plasma renin activity is reduced early and durably by aliskiren, but this did not translate into improved clinical outcomes in ASTRONAUT. Baseline PRA or short-term reduction in PRA do not identify a subgroup who may preferentially benefit from direct renin inhibition. Clinical Trial Registration ClinicalTrials.gov Unique Identifier: NCT00894387.

Fluoroquinolone prophylaxis in autologous hematopoietic stem cell transplant recipients

PURPOSE

Although fluoroquinolone prophylaxis is frequently utilized in autologous hematopoietic stem cell transplant (AHSCT) patients, its impact on morbidity and mortality is uncertain. This study investigates the role of quinolone prophylaxis after AHSCT in recent years.

METHODS

We conducted a retrospective review of 291 consecutive adult patients who underwent AHSCT for malignant disorders, between June 2013 and January 2015. Outcomes were compared between patients who received norfloxacin prophylaxis and those who did not. The endpoints were mortality during prophylaxis and at 100 days after transplant, frequency of ICU admissions, and incidence and type of bacteremia.

RESULTS

Of 291 patients, 252 patients received norfloxacin prophylaxis and 39 patients did not. The mortality during prophylaxis and at 100 days as well as the median number of days of hospitalization following AHSCT did not differ between the two groups. No differences were noted in the frequency of ICU admission, incidence of septic shock, and duration of ICU stay. Patients who did not receive prophylaxis had a significantly higher rate of neutropenic fever (97%) than patients who received prophylaxis (77%) (p = 0.005). The patients with prophylaxis demonstrated a significantly higher rate of gram-positive bacteremia as compared to those without prophylaxis (p = 0.002). Frequency of Clostridium difficile infection was similar during and post-prophylaxis. More antibiotic use was noted among patients without prophylaxis [97%; median 9 (range, 5-24) days] compared to patients with prophylaxis [79%; median 7 (range, 3-36) days, p = 0.04].

CONCLUSION

Although fluoroquinolone prophylaxis reduced the incidence of neutropenic fever and antibiotic use in AHSCT, it did not alter mortality or morbidity.

In vitro analysis of RNA degradation catalyzed by deadenylase enzymes

In this chapter, we describe a method for purification and analysis of the enzymatic activity of deadenylase enzymes. Nearly all eukaryotic messenger RNAs are modified at the 3' end by the addition of an adenosine polymer: the poly-adenosine tail. The poly(A) tail plays a central role in protein expression and mRNA fate. The poly(A) tail promotes translation of the mRNA. Shortening of the poly(A) tail, referred to as deadenylation, reduces protein synthesis and initiates destruction of the mRNA. A specialized class of exoribonucleases, called deadenylase enzymes, carries out this process. Deadenylases are found throughout eukarya, but their functions remain largely unexplored. We present a detailed protocol to analyze deadenylase activity in vitro. First, recombinant deadenylase enzyme is over-expressed and purified from bacteria. Next, labeled RNA substrate is prepared. Deadenylation reactions are performed, and reaction products are analyzed by denaturing gel electrophoresis. Reaction rates are then determined quantitatively. Crucial controls and experimental parameters are described along with practical tips that promote success.

Double-layered closure of oroantral fistula using buccal fat pad and buccal advancement flap

Some of the traditional methods that are being employed in the repair of oroantral communication can be broadly divided into local and distant flaps. Recently, because of various advantages, buccal fat pad is increasingly being employed in the repair of oroantral fistula and other oral defects worldwide. However, there are some problems that can be encountered while harvesting BFP which has to be taken care of. In this paper, we present a case with one of such problems, its management, and review of literature on the same.