Simulation as an effective means of preparing trainees for active participation in MDT meetings

Introduction

Cancer multi-disciplinary team (MDT) meetings are an important component of consultant workload, however previous literature has suggested trainees are not satisfied with their current curriculum in preparing for MDT working.

Methods

This educational pilot assessed whether multi-speciality simulated scenarios with pre-defined learning objectives, could prepare specialist registrars for interacting within an MDT. Participants completed pre- and post-questionnaires assessing a number of areas including: current experience of training, confidence presenting patients and whether the course would alter future practice.

Results

Trainee confidence increased significantly from a mean of 5 to 7 (mean to nearest whole number, p < 0.01). Trainees rated the session highly for utility and altering their future practice (mean scores of 9 for both respectively, out of 10).

Conclusion

Simulation has shown success in other multidisciplinary teaching, however to our knowledge there are no cancer specific training programmes. Our results highlight a potential gap in UK specialist training, and suggest simulation may be beneficial in preparing trainees to present in MDT meetings.

The potential of using circulating tumour cells and their gene expression to predict docetaxel response in metastatic prostate cancer

Background

Docetaxel improves overall survival (OS) in castration-resistant prostate cancer (PCa) (CRPC) and metastatic hormone-sensitive PCa (mHSPC). However, not all patients respond due to inherent and/or acquired resistance. There remains an unmet clinical need for a robust predictive test to stratify patients for treatment. Liquid biopsy of circulating tumour cell (CTCs) is minimally invasive, can provide real-time information of the heterogeneous tumour and therefore may be a potentially ideal docetaxel response prediction biomarker.

Objective

In this study we investigate the potential of using CTCs and their gene expression to predict post-docetaxel tumour response, OS and progression free survival (PFS).

Methods

Peripheral blood was sampled from 18 mCRPC and 43 mHSPC patients, pre-docetaxel treatment, for CTC investigation. CTCs were isolated using the epitope independent Parsortix^® system and gene expression was determined by multiplex RT-qPCR. We evaluated CTC measurements for post-docetaxel outcome prediction using receiver operating characteristics and Kaplan Meier analysis.

Results

Detection of CTCs pre-docetaxel was associated with poor patient outcome post-docetaxel treatment. Combining total-CTC number with PSA and ALP predicted lack of partial response (PR) with an AUC of 0.90, p= 0.037 in mCRPC. A significantly shorter median OS was seen in mCRPC patients with positive CTC-score (12.80 vs. 37.33 months, HR= 5.08, p= 0.0005), ≥3 total-CTCs/7.5mL (12.80 vs. 37.33 months, HR= 3.84, p= 0.0053), ≥1 epithelial-CTCs/7.5mL (14.30 vs. 37.33 months, HR= 3.89, p= 0.0041) or epithelial to mesenchymal transitioning (EMTing)-CTCs/7.5mL (11.32 vs. 32.37 months, HR= 6.73, p= 0.0001). Significantly shorter PFS was observed in patients with ≥2 epithelial-CTCs/7.5mL (7.52 vs. 18.83 months, HR= 3.93, p= 0.0058). mHSPC patients with ≥5 CTCs/7.5mL had significantly shorter median OS (24.57 vs undefined months, HR= 4.14, p= 0.0097). In mHSPC patients, expression of KLK2, KLK4, ADAMTS1, ZEB1 and SNAI1 was significantly associated with shorter OS and/or PFS. Importantly, combining CTC measurements with clinical biomarkers increased sensitivity and specificity for prediction of patient outcome.

Conclusion

While it is clear that CTC numbers and gene expression were prognostic for PCa post-docetaxel treatment, and CTC subtype analysis may have additional value, their potential predictive value for docetaxel chemotherapy response needs to be further investigated in large patient cohorts.

The essentials of acute oncology

The general medical physician will often encounter patients who develop acute complications of their cancer diagnosis or anti-cancer treatment. Here we provide an overview of emergency solid tumour oncology to guide the initial management of these patients.

The Identification of Plasma Exosomal miR-423-3p as a Potential Predictive Biomarker for Prostate Cancer Castration-Resistance Development by Plasma Exosomal miRNA Sequencing

Castration-resistant prostate cancer (CRPC) is the major cause of death from prostate cancer. Biomarkers to improve early detection and prediction of CRPC especially using non-invasive liquid biopsies could improve outcomes. Therefore, we investigated the plasma exosomal miRNAs associated with CRPC and their potential for development into non-invasive early detection biomarkers for resistance to treatment. RNA-sequencing, which generated approximately five million reads per patient, was performed to identify differentially expressed plasma exosomal miRNAs in 24 treatment-naive prostate cancer and 24 CRPC patients. RT-qPCR was used to confirm the differential expressions of six exosomal miRNAs, miR-423-3p, miR-320a, miR-99a-5p, miR-320d, miR-320b, and miR-150-5p (p = 7.3 × 10^-8, 0.0020, 0.018, 0.0028, 0.0013, and 0.0058, respectively) firstly in a validation cohort of 108 treatment-naive prostate cancer and 42 CRPC patients. The most significant differentially expressed miRNA, miR-423-3p, was shown to be associated with CRPC with area under the ROC curve (AUC) = 0.784. Combining miR-423-3p with prostate-specific antigen (PSA) enhanced the prediction of CRPC (AUC = 0.908). A separate research center validation with 30 treatment-naive and 30 CRPC patients also confirmed the differential expression of miR-423-3p (p = 0.016). Finally, plasma exosomal miR-423-3p expression in CRPC patients was compared to 36 non-CRPC patients under androgen depletion therapy, which showed significantly higher expression in CRPC than treated non-CRPC patients (p < 0.0001) with AUC = 0.879 to predict CRPC with no difference between treatment-naive and treated non-CRPC patients. Therefore, our findings demonstrate that a number of plasma exosomal miRNAs are associated with CRPC and miR-423-3p may serve as a biomarker for early detection/prediction of castration-resistance.

Abstract 2580: Investigation of plasma exosomal miRNA as a biomarker and its potential function in prostate cancer castration resistant development

Prostate cancer (PCa) ranks as the second most frequent cancer and the fifth leading cause of cancer death in men worldwide. Androgen-deprivation therapy is the principal treatment for locally advanced and metastatic disease. Although a majority of patients initially respond well to ADT, most will progress to castration-resistant prostate cancer (CRPC), which contributes to the majority of PCa deaths. Exosomes are small vesicles that contain numerous molecular constituents, including lipids, proteins, RNAs and DNAs, and can mediate cell-cell communications. The aim of this study is to identify plasma exosomal miRNAs correlated with CRPC development, which may serve as a biomarker to monitor disease status and may reveal new role of exosome in CRPC development. Next-generation sequencing (NGS) of plasma exosomal miRNAs was performed in 24 treatment-naive PCa patients and 24 CPRC patients. Quantitative real-time polymerase chain reaction (qRT-PCR) was performed to validate candidate miRNAs in 108 treatment-naive PCa patients and 42 CRPC patients and a group of 38 non-CRPC patients under hormone therapy (treated non-CRPC). To study the miRNA function, hormone-dependent PCa cell line LNCaP was cultured in hormone-depleted media. MiRNA was overexpressed by transient transfection of miRNA mimic. Post transfection, transwell assays and cell viability assays were performed to determine the effect of miRNA on cell migration and proliferation. RNA NGS generated an average of approximately 5-million reads per sample and identified differentially expressed miRNAs. QRT-PCR validation showed six miRNAs were significantly differentially expressed between treatment-naïve PCa and CRPC (p-value&lt;0.05). It also showed that five of these miRNAs were differently expressed in CRPC compared treated non-CRPC patients (p-value&lt;0.001). When receiver operating characteristic curve was applied, one of the exosomal miRNAs, miR-423-3p, achieved area under the curve (AUC) = 0.784 when predicting CRPC from treatment-naïve PCa and AUC = 0.883 when predicting CRPC from treated non-CRPC. Overexpression of miR-423-3p had no effect on LNCaP proliferation, but significantly increased cell migration. This study demonstrated that plasma exosomal miRNAs play important roles in CRPC development and may serve as a biomarker for CRPC occurrence prediction.

Citation Format: Tianyu Guo, Yang Wang, Xueying Mao, Lei Xu, Jacek Marzec, Edwina Burke, Glenda Scandura, Elzbieta Stankiewicz, Caitlin R. Davies, John Hines, Greg Shaw, Jonathan Shamash, Daniel Berney, Prabhakar Rajan, Karen Tipples, Alistair Grey, Yong-jie Lu. Investigation of plasma exosomal miRNA as a biomarker and its potential function in prostate cancer castration resistant development [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2580.

Assessment of 2,000 patients presenting to a multidisciplinary prostate cancer clinic in the United Kingdom

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Background: Multidisciplinary clinics (MDCs) involving both oncologists and urologists are recommended for managing radical prostate cancer patients. The effectiveness of MDCs in arriving at best treatment decisions is unknown. We analysed patient characteristics and management decisions over 8 years in a MDC at Bart’s Hospital, London. Methods: Clinical data were collected in real time and analysed retrospectively, including demographics, tumour stage and grade, D’amico risk group, treatment choice and first clinician seen. We compared variables in 1000 consecutive patients presenting between 2011-2015 (cohort A) to 1000 patients presenting 2016-18 (cohort B) to investigate trends over time. Results: 2000 patients were included, age 65.2 ± 8.6 years and 65.9 ± 9.1 years (p=0.08), with presenting PSA 9.0 (6.3-14.4) and 9.2 (6.4-15.0) ng/ml (p=0.36), in cohort A and B respectively. Disease severity and initial treatment decision are shown in the table. In low risk disease, 126 (75%) patients had active surveillance in cohort A, and 158 (90%) in cohort B (p=0.0003). In high risk disease, 202 (59%) patients had radiotherapy compared to 194 (50%) in cohort B (p=0.011). In cohort B, 127 (39%) patients seeing oncology first had radiotherapy compared to 143 (25%) patients who saw urology first (p<0.0001). 76 (23%) and 154 (27%) patients had surgery, that saw oncology and urology first, respectively (p=0.11). Conclusions: In 2000 patients presenting to a prostate MDC over 8 years, active surveillance in low risk disease increased, radiotherapy in high risk disease reduced, and the proportion undergoing surgery was unchanged. The initial clinician seen influenced treatment choice; having both specialists in the same consultation may improve consistency of treatment decisions. Disease severity and treatment choice before and after 2016. [Table: see text]

Encephalopathy secondary to capecitabine chemotherapy: a case report and discussion

Introduction. Capecitabine is an oral prodrug of 5-fluorouracil (5-FU) chemotherapy and is licenced for the treatment of breast and gastrointestinal cancers. Multifocal inflammatory leukoencephalopathy has been associated with intravenous 5-FU, but only a few cases of capecitabine-induced encephalopathy have been reported.

Setting. We describe here a case of encephalopathy following administration of Epirubicin/ Cisplatin/Capecitabine chemotherapy, review those cases previously described and suggest recommendations for management.

Results. Symptoms of neurotoxicity from 5-FU and capecitabine usually include confusion, ataxia, nystagmus, dysarthria, sensory loss, and memory loss. Withdrawal of the drug generally leads to improvement of symptoms and steroids are of only questionable benefit.

Conclusion. Patients on fluouropyrimidine drugs with new neurological symptoms should be investigated with brain MRI scan and the drug should be withdrawn until symptoms resolve. Dihydropyrimidine dehydrogenase deficiency should be excluded and ideally an alternative chemotherapy regime sought. We would encourage reporting of such incidences to gain a clearer picture of the incidence and optimal management. J Oncol Pharm Practice (2009) 15: 237—239.