A systematic review about the importance of neuropsychological features in heart failure: is at heart the only failure?

Heart failure can lead to cognitive impairment that is estimated to be present in over a quarter of patients. It is important to intervene at a cognitive level to promote brain plasticity through cognitive training programs. Interventions transformed by technology offer the promise of improved cognitive health for heart failure patients. This review was conducted on studies evaluating the role of cognitive rehabilitation in patients with heart failure. We examined clinical trials involving patients with heart failure. Our search was performed on Pubmed, Web of Science and Cochrane library databases. Of the initial 256 studies, 10 studies met the inclusion criteria. Cognitive rehabilitation training has important implications for the treatment and prevention of cognitive decline in heart failure patients with significant recovery for delayed recall memory and a significant time effect for total recall memory and delayed, psychomotor speed and IADL performance. It is important to include the assessment of cognitive functioning in the routine clinical examinations of patients with heart failure, discover the relationship between cognitive function and heart failure, and target cognitive rehabilitation programs that promote brain plasticity.

A Set of Possible Markers for Monitoring Heart Failure and Cognitive Impairment Associated: A Review of Literature from the Past 5 Years

BACKGROUND

Heart failure is an epidemiologically relevant disease because of the aging population and widespread lifestyles that promote it. In addition to the acute event, it is possible for the disease to become chronic with periodic flare-ups. It is essential to study pathology from a diagnostic and prognostic point of view and to identify parameters for effective monitoring. In addition, heart failure is associated with multiple comorbidities, including cognitive impairment, which is monitored clinically but not through specific biomarkers in these patients. The purpose of this review is to gather the most recent scientific evidence on a few possible biomarkers previously identified for monitoring heart failure and associated cognitive impairment.

METHODS

We surveyed studies inherent to a set of previously identified markers, evaluating English-language articles from the past five years conducted in adult heart failure patient populations. We used the databases PubMed, Web of Sciences, and Cochrane Library for search studies, and we considered articles published in journals with an impact factor greater than five in the publication year.

RESULTS

Among the biomarkers evaluated, a concordant indication for serial measurements for heart failure monitoring emerged only for interleukin-6. For the other markers, there is still little evidence available, which is interesting but sometimes conflicting. Interesting studies have also emerged for biomarkers of cognitive decline assessed in patients with heart failure, confirming the hypotheses of the increasingly studied heart-brain correlation.

CONCLUSION

Certainly, further studies in large populations are needed to identify effective biomarkers for monitoring heart failure and associated cognitive impairment.

Pembrolizumab plus chemotherapy versus chemotherapy in untreated advanced pleural mesothelioma in Canada, Italy, and France: a phase 3, open-label, randomised controlled trial

BACKGROUND

Pleural mesothelioma usually presents at an advanced, incurable stage. Chemotherapy with platinum-pemetrexed is a standard treatment. We hypothesised that the addition of pembrolizumab to platinum-pemetrexed would improve overall survival in patients with pleural mesothelioma.

METHODS

We did this open-label, international, randomised phase 3 trial at 51 hospitals in Canada, Italy, and France. Eligible participants were aged 18 years or older, with previously untreated advanced pleural mesothelioma, with an Eastern Cooperative Oncology Group performance status score of 0 or 1. Patients were randomly assigned (1:1) to intravenous chemotherapy (cisplatin [75 mg/m2] or carboplatin [area under the concentration-time curve 5-6 mg/mL per min] with pemetrexed 500 mg/m2, every 3 weeks for up to 6 cycles), with or without intravenous pembrolizumab 200 mg every 3 weeks (up to 2 years). The primary endpoint was overall survival in all randomly assigned patients; safety was assessed in all randomly assigned patients who received at least one dose of study therapy. This trial is registered with ClinicalTrials.gov, NCT02784171, and is closed to accrual.

FINDINGS

Between Jan 31, 2017, and Sept 4, 2020, 440 patients were enrolled and randomly assigned to chemotherapy alone (n=218) or chemotherapy with pembrolizumab (n=222). 333 (76 %) of patients were male, 347 (79%) were White, and median age was 71 years (IQR 66-75). At final analysis (database lock Dec 15, 2022), with a median follow-up of 16·2 months (IQR 8·3-27·8), overall survival was significantly longer with pembrolizumab (median overall survival 17·3 months [95% CI 14·4-21·3] with pembrolizumab vs 16·1 months [13·1-18·2] with chemotherapy alone, hazard ratio for death 0·79; 95% CI 0·64-0·98, two-sided p=0·0324). 3-year overall survival rate was 25% (95% CI 20-33%) with pembrolizumab and 17% (13-24%) with chemotherapy alone. Adverse events related to study treatment of grade 3 or 4 occurred in 60 (27%) of 222 patients in the pembrolizumab group and 32 (15%) of 211 patients in the chemotherapy alone group. Hospital admissions for serious adverse events related to one or more study drugs were reported in 40 (18%) of 222 patients in the pembrolizumab group and 12 (6%) of 211 patients in the chemotherapy alone group. Grade 5 adverse events related to one or more drugs occurred in two patients on the pembrolizumab group and one patient in the chemotherapy alone group.

INTERPRETATION

In patients with advanced pleural mesothelioma, the addition of pembrolizumab to standard platinum-pemetrexed chemotherapy was tolerable and resulted in a significant improvement in overall survival. This regimen is a new treatment option for previously untreated advanced pleural mesothelioma.

FUNDING

The Canadian Cancer Society and Merck & Co.

Water column distribution of zooplanktonic size classes derived from in-situ plankton profilers: Potential use to contextualize contaminant loads in plankton

Pollution is one of the main anthropogenic threats to marine ecosystems. Studies analysing the accumulation and transfer of contaminants in planktonic food webs tend to rely on samples collected in discrete water bodies. Here, we assessed the representativeness of measurements at the chlorophyll-a maximum layer during the MERITE-HIPPOCAMPE cruise for the entire water column by investigating the vertical distribution of particles and plankton obtained by in-situ optical profilers at nine stations across the Mediterranean Sea. We identified specific conditions where the interpretation of results from contaminant analyses can be improved by detailing plankton size structure and vertical distributions. First, the presence of higher than usual plankton concentrations can result in sampling issues that will affect biomass estimation within each size class and therefore bias our understanding of the contaminant dynamics. Secondly, the presence of an unsampled water layer with high zooplankton biomass might imply non-resolved contaminant pathways along the trophic structure. This study lays the basis for optimizing sampling strategy in contaminant studies.

Coping and Quality of Life Differences between Emergency and Rehabilitation Healthcare Workers

Audit and Feedback (A&F) is a systematic process involving the collection of data, which are subsequently compared with the established reference standards and then subsequently disseminated to healthcare providers through feedback meetings. This allows continuous improvement to be ensured in the quality of care processes. Often, the parameters taken into account concern only the patient and the treatment processes, neglecting other variables. Quality of life in the workplace and coping skills are determining variables for the clinical performance of all healthcare professionals. For this reason, in this study, these variables were investigated and differences were highlighted in two different role categories and context: cardiovascular emergency and neurological rehabilitation. A psychological screening was carried out by sending the computerized Coping Orientation to Problems Experienced-Nuova Versione Italiana (COPE-NVI) and Professional Quality of Life Scale-5 (ProQoL) questionnaires to all healthcare workers involved. Ninety-five healthcare providers (mean ± SD age: 47 ± 10.4 years; 37.9% male) answered the questionnaire and were assigned into two groups (G1 and G2) based on the ward in which they worked. These were further divided into two subgroups (R1 and R2) based on their role. The obtained results show that avoidance strategies are used more by health professionals working in rehabilitation (G2) wards than in intensive-care units (G1). Moreover, in G1 nurses, physical therapists and speech therapists (R2) obtained higher scores in terms of turning to religion (TR) and compassion satisfaction (CS), while physicians and psychologists (R1) obtained higher scores on the burnout scale (BO). The TR score for R2 was found to be higher, even in G2. The response trend of the two groups in the different departments was analyzed and commented on.

Improving Knowledge of Audit and Feedback among Health Care Professionals in Sicily

Audit and Feedback (A&F) is considered one of the most significant tools for implementing continuous Quality Improvement (QI) in the healthcare field. The audit process is a structured inspection of professional practice against known standards or targets. The results of this inspection are subsequently feedback from professionals in order to implement an improvement process. The Italian Ministry of Health has recently funded the network project EASY-NET, with the main objective of evaluating the effectiveness of A&F strategies to improve healthcare practice and equity in various clinical and organizational settings in seven Italian regions. The Sicily region is represented within the EASY-NET project by the IRCCS Centro Neurolesi Bonino-Pulejo of Messina as the Work Package 7 (WP7). One of the objectives of the WP7 is to assess mechanisms and tools to enhance the effectiveness of A&F strategies. The purpose of this study is to investigate the influence that training interventions can have on improving knowledge of A&F strategies among healthcare professionals. The study employed a quasi-experimental design with a pretest-posttest evaluation strategy. The participants' initial knowledge of A&F strategies was evaluated through a baseline survey. Subsequently, the participants attended an online training workshop led by A&F experts, and a follow-up survey consisting of the same set of questions was conducted at the end of the process. Results showed statistically significant positive changes in the level of knowledge of A&F among participants following the training intervention. Furthermore, dividing the participants into two subgroups based on their professional background revealed significant differences in the level of knowledge of A&F methodologies between the observed categories of healthcare professionals. In conclusion, the study revealed that training interventions can be facilitators to implementing effective A&F programs.

Changes in the Histology of Lung Cancer in Northern Italy: Impact on Incidence and Mortality

This study assessed the incidence, mortality, and survival of lung cancer subtypes of NSCSLC (non-small-cell lung cancer), SCLC (small-cell lung cancer), and other morphologies. It is an observational epidemiological study using 7197 cases from the Reggio Emilia Cancer Registry recorded between 2001 and 2020 in males and females. The incidence of NSCLC in 5104 males indicates a significant 3% annual increase until 2013 and then a decline of -3.2% that is not statistically significant; until 2014, mortality increased significantly (3.2%), but it then decreased non-significantly (-12.1%), especially squamous cell cancer. In 2093 females, the incidence and mortality trends continued to rise significantly through 2012, and then they began to slightly decline (not statistically significant). The two-year relative survival of NSCLC increased from 32% to 38% in males and from 42% to 56% in females. SCLC in males decreased significantly both in incidence and mortality, while in women, it showed a slight increase (significantly for incidence but not for mortality). This study is important because it analyzes the decrease in lung cancer in males and the increase in females in relation to the different histotypes. Our study's findings confirmed a decline in male incidence and death beginning in 2013. We were unable to determine if the drop in cigarette smoking and the introduction of new drugs such as EGFR in first-line therapy were responsible for the lower incidence.

Multi-characteristic toxicity of enantioselective chiral fungicide tebuconazole to a model organism Mediterranean mussel Mytilus galloprovincialis Lamarck, 1819 (Bivalve: Mytilidae)

The survey of available scientific literature shows a lack of data on the chronic effects of tebuconazole (TEB) on non-target aquatic organisms. Therefore, this study evaluates toxicity (10 and 20 days) of two considered concentrations 2 ng/L (E1) and 2 μg/L (E2) of TEB to bioindicator species Mytilus galloprovincialis. To this end, the TEB concentrations measured in soft mussel tissues showed a time-dependent increasing trend. The viability of haemocyte and digestive gland (DG) cells was higher than 95 % during the experiment. However, DG cells lost the ability to regulate their volume in both groups after 20-d. The E1 treatment increased Cl^- and Na⁺ levels, and E2 decreased Na⁺ levels in the haemolymph. In addition, levels of superoxide dismutase (SOD) activity and oxidatively modified protein (OMP) increased after 10- and 20-d in both treatments. Histopathological findings showed abnormalities in the E2, e.g., haemocyte infiltration, hypertrophy, and hyperplasia in gills and DG. This study reveals the potential risks of TEB usage in the model organism M. galloprovincialis, primarily via bioaccumulation of TEB in food web links, and improves knowledge about its comprehensive toxicity.

A first insight into haemocytes of Pinctada imbricata radiata: A morpho-functional characterization

The pearl oyster Pinctada imbricata radiata (Leach, 1814), from the Pacific Ocean, was one of the first species to reach via Suez the Mediterranean, colonizing the eastern basin and recently spreading to the western. The species showed to be able to adapt to a wide range of climatic, hydrological, and ecological conditions. Since 2000 it reached the Strait of Messina, where is now infesting the transitional waters of the oriented natural reserve "Laguna di Capo Peloro." Due to such resistance and adaptation ability, various assays were performed. Haemocyte morpho-functional aspects were evaluated in haemolymph samples fixed with 1% and 2% glutaraldehyde for optical and electron microscopy (TEM). The following assays were carried out: cell characterization using several dyes, detection of intra- and extracellular lipids, the capability of phagocytosis using the yeast Saccharomyces cerevisiae and to produce superoxide anion (O^2- ). Detection of several enzymes, such as acid and alkaline phosphatase, arylsulfatase, chloro-acetylesterase and β-glucuronidase was also assessed. Cell count was demonstrated to be abundant with a mean of 8.263 × 106 mm²  ± 0.935 × 106 (SD). Two main cell populations were noticed: granulocytes and hyalocytes, both competent for phagocytosis, to produce O^2- , and characterized by lipids. Based on the granule analysis, enzymatic activity was also demonstrated. The observations under TEM confirmed all the results obtained. This study supports the hypothesis that P. imbricata radiata can be usefully employed as a model organism in environmental biomonitoring. Moreover, since the species represent potential threats to native species and ecosystems, further insights into its biological adaptations in invaded ecosystems are recommended.

Brief Report: Canadian Cancer Trials Group IND.227: A Phase 2 Randomized Study of Pembrolizumab in Patients With Advanced Malignant Pleural Mesothelioma (NCT02784171)

Immune checkpoint inhibitors have activity in mesothelioma. IND.227 was a phase 2 trial (120 patients planned) comparing progression-free survival of standard platinum and pemetrexed (CP) versus CP + pembrolizumab (pembro) versus pembro. Accrual to the pembro arm was discontinued on the basis of interim analysis (IA-16 wk disease control rate). CP + pembro was tolerable, with progression-free survival similar between arms and median survival and overall response rate higher than those of CP alone (19.8 mo [95% confidence interval or CI: 8.4-41.36] versus 8.9 mo [95% CI: 5.3-12.8] and 47% [95% CI: 24%-71%] versus 19% [95% CI: 5%-42%], respectively). The subsequent phase 3 trial has completed accrual; results are expected in 2023.

Clinical profile and outcome of cardiomyopathies in infants and children seen at a tertiary centre

INTRODUCTION

Due to their rare prevalence and marked heterogeneity, pediatric cardiomyopathies (CMPs) are little known and scarcely reported. We report the etiology, clinical profile and outcome of a consecutive cohort of children diagnosed with CMP and followed at Meyer Children's Hospital over a decade.

PATIENTS AND METHODS

We retrospectively reviewed patients consecutively referred from May 2008 to May 2019 for pediatric onset CMP (<18 years). Heart disease caused by arrhythmic disorders, toxic agents, rheumatic conditions and maternal disease were excluded.

RESULTS

We enrolled 110 patients (65 males), diagnosed at a median age of 27 [4-134] months; 35% had an infant onset (<1 year of age). A positive family history was more often associated with childhood-onset (38.8%). Hypertrophic cardiomyopathy (HCM; 48 patients) was the most frequent phenotype, followed by dilated cardiomyopathy (DCM; 35 patients). While metabolic and idiopathic etiologies were preponderant in infants, metabolic and sarcomeric diseases were most frequent in the childhood-onset group. Major adverse cardiac events (MACE) occurred in 31.8% of patients, including hospitalization for acute heart failure in 25.5% of patients, most commonly due to DCM. Overall, the most severe outcomes were documented in patients with metabolic diseases.

CONCLUSIONS

In a consecutive cohort of pediatric patients with CMP, those with infantile onset and with a metabolic etiology had the worst prognosis. Overall, MACE occurred in 41% of the entire population, most commonly associated with DCM, inborn errors of metabolism and genetic syndromes. Systematic NGS genetic testing was critical for etiological diagnosis and management.

Impact of low skeletal muscle mass and quality on clinical outcomes in patients with head and neck cancer undergoing (chemo)radiation

The study aimed to explore the impact of low skeletal muscle mass and quality on survival outcomes and treatment tolerance in patients undergoing radical chemo-radiation therapy for head and neck cancer (HNC). This is significant given the growing interest in sarcopenia as a possible negative predictive/prognostic factor of disease progression and survival. From 2010 to 2017, 225 patients were included in the study. Pre-treatment computed tomography (CT) scans of HNC patients undergoing (chemo)radiation therapy were retrospectively reviewed. The skeletal muscle area, normalized for height to obtain the skeletal muscle index (SMI), the skeletal muscle density (SMD) and the intramuscular adipose tissue area (IMAT) were measured at the level of the L3 vertebra. Low SMD and low SMI were defined according to previously reported thresholds, while high IMAT was defined using population-specific cut-point analysis. SMI, SMD, and IMAT were also measured at the proximal thigh (PT) level and tested as continuous variables. Clinical morpho-functional parameters, baseline nutritional markers with a known or suspected impact on HNC treatment, clinical outcomes and sarcopenia were also collected. In multivariate analyses, adjusted by age, sex, stage, diabetes, body mass index (BMI), and weight loss, L3-SMI was not significantly associated with survival, while poor muscle quality was negatively associated with overall survival (OS) (HR = 1.88, 95% CI = 1.09-3.23, p = 0.022 and HR = 2.04, 95% CI = 1.27-3.27, p = 0.003, for low L3-SMD and high L3-IMAT, respectively), progression-free survival (PFS) (HR = 2.26, 95% CI = 1.39-3.66, p = 0.001 and HR = 1.97, 95% CI = 1.30-2.97, p = 0.001, for low L3-SMD and high L3-IMAT, respectively) and cancer-specific survival (CSS) (HR = 2.40, 95% CI = 1.28-4.51, p = 0.006 and HR = 1.81, 95% CI = 1.04-3.13, p = 0.034, for low L3-SMD and high L3-IMAT, respectively). Indices at the PT level, tested as continuous variables, showed that increasing PT-SMI and PT-SMD were significant protective factors for all survival outcomes (for OS: HR for one cm²/m² increase in PT-SMI 0.96; 95% CI = 0.94-0.98; p = 0.001 and HR for one HU increase in PT-SMD 0.90; 95% CI = 0.85-0.94; p < 0.001, respectively). PT-IMAT was a significant risk factor only in the case of CSS (HR for one cm² increase 1.02; 95% CI = 1.00-1.03; p = 0.046). In conclusion, pre-treatment low muscle quality is a strong prognostic indicator of death risk in patients affected by HNC and undergoing (chemo)radiotherapy with curative intent.

Identification of haemocytes and histological examination of gills of the spiny oyster Spondylus gaederopus (Linnaeus, 1758)

In the framework of investigations aimed to detect new available bioindicators in marine environment, haemolymph cells and ctenidia of the Mediterranean spiny oyster, Spondylus gaederopus, have been investigated. Haemocyte count and characterisation, phagocytosis and superoxide anion production and enzyme activity assays, have been carried out. TEM observations have been performed. After gross anatomy observations, cito-histological determinations have been carried out, especially focused on ctenidia structure and function. Main results concerned the relatively low number of circulating cells, and the rich in granules granulocytes, most of which were lysosomes. Release of lysosomal enzymes was confirmed a shared trait inside bivalves. Glycogen deposits as probable result of conversion of bacteria carbohydrates, have been detected, as well as the occurrence of both acidophilic and basophilic haemocytes. Phagocytosis, both in granulocytes and agranulocytes, has been recorded, together with the production of superoxide anion. Haemocytes were found positive to acid phosphatase, alkaline phosphatase, β-glucuronidase, chloroacetylesterase and arylsulphatase. Ctenidia showed a complex organization, including two demibranch to each ctenidium, two different kinds of lamellae filament and specialized structures as ciliated disks connecting filaments in "eutherorhabdic ctenidia". The occurrence of three different types of mucous cells in the same region of ordinary filaments has been underlined. Such features, suggesting high resistance to environmental stress and disease, allow to consider spiny oysters as promising bioindicators, although deserving of further investigations to evaluate the physiological responses to stress in controlled conditions. Present data, moreover, providing basic information on the biology of S. gaederopus, notably implement the present knowledge on the Mediterranean spiny oysters, whose under-evaluated ecological role should be carefully considered.

Toxicological Evaluation of Acetylsalicylic Acid in Non-Target Organisms: Chronic Exposure on Mytilus galloprovincialis (Lamarck, 1819)

Pharmaceuticals are now considered to be established contaminants, and their presence in water poses a real risk not only to the marine ecosystem, as they may adversely affect non-target organisms that are exposed to them, but also indirectly to humans. This is particularly true for the model organism considered in this work, Mytilus galloprovincialis (Lamarck, 1819), a suspensivore and bioaccumulating organism that enters the human food chain. Among the most commonly used over-the-counter medicines, anti-inflammatory drugs certainly feature prominently, with acetylsalicylic acid (ASA) at the top. In this work, M. galloprovincialis specimens were exposed to two concentrations of ASA (10 and 100 μg/L) for 10 and 20 days to evaluate possible alterations in the decrease in regulatory volume (RVD) in digestive gland cells and cell viability of both these cells and hemocytes. In addition, the histopathological condition index of the gills and digestive gland was evaluated. The data obtained showed that chronic exposure to ASA did not alter the cell viability of hemocytes and digestive gland cells but alters the physiological mechanisms of volume regulation in the digestive gland and, in addition, a time-dose reaction to ASA in the gills and digestive gland showing numerous alterations such as lipofuscin deposits and hemocyte infiltration was found. These results confirm the potential toxicity to the marine biota, highlighting the necessity to deepen the knowledge regarding the link between over-the-counter pharmaceuticals and non-target organisms.

Phase III study with atezolizumab versus placebo in patients with malignant pleural mesothelioma after pleurectomy/decortication (AtezoMeso study)

TPS8591

Background: Surgery for malignant pleural mesothelioma (MPM) is indicated mainly in multimodal approaches and in clinical trial settings. Different studies have shown significantly lower complication rates, lower peri-operative morbidity and mortality with pleural/decortication (P/D), with similar overall survival rates. The biology of mesothelioma shows significant heterogeneity. Surgical tumor reduction may create a host environment more amenable to immunotherapy by reducing the ratio of tumor cells versus antitumor effector T lymphocytes, reducing the quantities of intratumor and/or systemic immunosuppressive cells, and ablating tumor-derived paracrine factors that promote local recruitment of immunosuppressive cells. Encouraging clinical data emerging in the field of tumor immunotherapy have demonstrated that therapies focused on enhancing T-cell responses against cancer can result in a significant survival benefit. The AtezoMeso Study evaluates the introduction of atezolizumab-ATEZO in MPM, patients (pts) after P/D and platinum/pemetrexed perioperative therapy. Methods: This is a double-blind, placebo controlled, phase III trial, in 20 Italian centers. Main inclusion criteria are P/D without macroscopic residual and ECOG-PS 0-1. Pts who underwent to P/D without macroscopic residual disease and have received at least 4 cycles of perioperative therapy with cisplatin/carboplatin and pemetrexed, will be randomized (2:1) to receive ATEZO or placebo. Therapy will be administered at dose of 1,200 mg iv, every 21 days, for 12 months or until recurrence, unacceptable toxicity or patient/physician decision. Randomization will be done through a centralized system, using histology (epithelioid vs nonepithelioid) and stage (I vs > I) as stratification factors. Pts will be radiologically evaluated after surgical before starting therapy and then every 12 weeks for 24 months or until recurrence. Quality of life (QoL) will be evaluated with the EQ-5D questionnaire administered at baseline and every 12 weeks. Tissue tumor samples will be centrally analyzed to determinate the genomic profile using FoundationOne CDx platform. The primary endpoint is the evaluation of the atezolizumab efficacy in terms of disease free survival (DFS). Secondary endpoints include the safety and efficacy in terms of overall survivall and QoL. Assuming a median DFS equal to 9 months in placebo arm, an accrual time of 24 months and a follow-up time of 24 months, a sample size of 162 pts will allow to detect true hazard ratios of 0.62 with power 0.8, at a confidence level of 95%. At February 14th, 2022, 3 pts have been enrolled. Clinical trial information: 2020-003762-39; GOIRC-02-2019.

Combi-TED: A multicenter, phase II, open-label, randomized trial evaluating efficacy of OSE2021 plus docetaxel or OSE2021 plus nivolumab as second-line therapy in metastatic NSCLC progressing after first-line chemo-immunotherapy

TPS9140

Background: First line combination of chemotherapy and immune checkpoint inhibitors (ICIs) improves overall survival (OS) compared with chemotherapy alone in non-small cell lung cancer (NSCLC) patients. However, only few options are available at chemoimmunotherapy failure, with docetaxel representing the standard of care. Tedopi is a cancer vaccine which stimulates killer T cells, currently under development for the therapy of HLA-A2+ lung cancer. In the ATALANTE-1 Phase III trial (EudraCT no. 2015-003183-36), Tedopi provided clinical benefits in patients with advanced NSCLC who failed to respond to checkpoint inhibitors. Given the need for new therapeutic options in patients failing first-line chemo-immunotherapy and the encouraging preliminary data with Tedopi, there is a strong rationale for investigating the activity of Tedopi plus nivolumab or Tedopi plus docetaxel in patients with metastatic NSCLC failing standard first-line therapy. Methods: This is a phase II, non-comparative, randomized multicenter study assessing the combination of Tedopi with docetaxel or nivolumab in NSCLC patients failing after first-line chemoimmunotherapy (EudraCT no. 2020-005170-10). All NSCLC patient candidates for second-line therapy are considered eligible for the study if they are HLA-A2+, with no evidence of EGFR mutations or ALK/ROS1 rearrangement and if they progressed after at least 4 cycles of previous first-line chemo-immunotherapy. Patients are randomly assigned to Tedopi plus docetaxel, Tedopi plus nivolumab (treatment arms) or docetaxel monotherapy (standard arm). The primary endpoint is 1-year OS rate. Secondary endpoints include OS, 2-year OS rate, progression-free survival (PFS), objective response rate (ORR), and safety. An explorative analysis of the correlation of efficacy with several tumor or blood biomarkers (PD-L1 expression, tumor mutational burden, Tedopi neoantigen expression, T cell infiltration), is also performed. Sample size was calculated assuming a 1-year OS rate in the standard arm of 20%. According to the single-stage design, in both treatment arms a 1-year OS rate of 20% would imply that treatment does not warrant further investigation and a 1-year OS rate of 40%, would imply that treatment has a sufficient activity. With a one-sided significance level of 5% and a power of 80%, a total number of 105 patients (35 per treatment arm) need to be enrolled. At the drafting of this abstract, 7 patients have already been enrolled. Total follow-up will be 24 months from last enrolment, for an approximate duration of 48 months. Clinical trial information: NCT04884282.

Multicenter Observational Study on Metastatic Non-Small Cell Lung Cancer Harboring BRAF Mutations: Focus on Clinical Characteristics and Treatment Outcome of V600E and Non-V600E Subgroups

Simple Summary

Around 2–4% of lung adenocarcinoma harbors BRAF mutations. Dabrafenib and Trametinib represent the first treatment-choice for BRAF V600E^mut NSCLC, regardless of the line of therapy, while non-V600E^mut receive standard immunotherapy or chemo-immunotherapy. Our real-life multicenter study on 44 BRAF mutant NSCLC responds to the urgent need to characterize this subset of patients in-depth, potentially offering new valuable biological and clinical insights. We specifically focused on similarities/discrepancies between V600E and non-V600E populations, providing consistent data about clinicopathologic characteristics, treatment response, and survival outcome.

Abstract

Introduction: BRAF mutation involved 2–4% of lung adenocarcinoma. Differences in clinicopathologic features and patient outcome exist between V600E and non-V600E BRAF mutated NSCLC. Thus, we sought to assess the frequency and clinical relevance of BRAF mutations in a real-life population of advanced-NSCLC, investigating the potential prognostic significance of distinct genetic alterations. Materials and Methods: The present multicenter Italian retrospective study involved advanced BRAF mutant NSCLC. Complete clinicopathologic data were evaluated for BRAF V600E and non-V600E patients. Results: A total of 44 BRAF^mut NSCLC patients were included (V600E, n = 23; non-V600E, n = 21). No significant differences in survival outcome and treatment response were documented, according to V600E vs. non-V600E mutations, although a trend towards prolonged PFS was observed in the V600E subgroup (median PFS = 11.3 vs. 6.0 months in non-V600E). In the overall population, ECOG PS and age significantly impacted on OS, while bone lesions were associated with shorter PFS. Compared to immunotherapy, first-line chemotherapy was associated with longer OS in the overall population, and especially in the BRAF V600E subtype. Conclusions: Here, we report on real-life data from a retrospective cohort of advanced-NSCLC harboring BRAF alterations. Our study offers relevant clues on survival outcome, therapeutic response, and clinicopathologic correlations of BRAF-mutant NSCLC.

Effects of long-term exposure of Mytilus galloprovincialis to thiacloprid: A multibiomarker approach

Thiacloprid is a neonicotinoid insecticide widely exploited in agriculture and easily mobilized towards aquatic environments by atmospheric agents. However, little information about its toxicological effects on aquatic invertebrate bioindicators is available. In this study, specimens of the mussel Mytilus galloprovincialis were exposed to thiacloprid at environmental (4.5 μg L^-1) and 100 times higher than environmental (450 μg L^-1) concentrations for 20 days. Thiacloprid affected haemolymph biochemical parameters, cell viability in the digestive gland, antioxidant biomarkers and lipid peroxidation in the digestive gland and gills at environmentally relevant concentrations (4.5 μg L^-1). In addition, thiacloprid exposure caused histological damage to the digestive gland and gills. Interestingly, the pesticide was detected at levels equal to 0.14 ng g^-1 in the soft tissues of sentinels exposed for 20 days to 450 μg L^-1 thiacloprid in seawaterμ. Due to its harmful potential and cumulative effects after long-term exposure of M. galloprovincialis, thiacloprid may pose a potential risk to nontarget aquatic organisms, as well as to human health. This aspect requires further in-depth investigation.

Gemcitabine with or without ramucirumab as second-line treatment for malignant pleural mesothelioma (RAMES): a randomised, double-blind, placebo-controlled, phase 2 trial

BACKGROUND

There is a preclinical rationale for inhibiting angiogenesis in mesothelioma. We aimed to assess the efficacy and safety of the anti-VEGFR-2 antibody ramucirumab combined with gemcitabine in patients with pretreated malignant pleural mesothelioma.

METHODS

RAMES was a multicentre, randomised, double-blind, placebo-controlled, phase 2 trial done at 26 hospitals in Italy. Eligible patients were aged 18 years or older, had Eastern Cooperative Oncology Group performance status 0-2, and histologically proven malignant pleural mesothelioma progressing during or after first-line treatment with pemetrexed plus platinum. Patients were randomly assigned (1:1) to receive intravenous gemcitabine 1000 mg/m2 on days 1 and 8 every 3 weeks plus either intravenous placebo (gemcitabine plus placebo group) or ramucirumab 10 mg/kg (gemcitabine plus ramucirumab group) on day 1 every 3 weeks, until tumour progression or unacceptable toxicity. Central randomisation was done according to a minimisation algorithm method, associated with a random element using the following stratification factors: ECOG performance status, age, histology, and first-line time-to-progression. The primary endpoint was overall survival, measured from the date of randomisation to the date of death from any cause. Efficacy analyses were assessed in all patients who had been correctly randomised and received their allocated treatment, and safety analyses were assessed in all patients who received at least one dose of their assigned treatment. This trial is registered with ClinicalTrials.gov, NCT03560973, and with EudraCT, 2016-001132-36.

FINDINGS

Between Dec 22, 2016, and July 30, 2018, of 165 patients enrolled 161 were correctly assigned and received either gemcitabine plus placebo (n=81) or gemcitabine plus ramucirumab (n=80). At database lock (March 8, 2020), with a median follow-up of 21·9 months (IQR 17·7-28·5), overall survival was longer in the ramucirumab group (HR 0·71, 70% CI 0·59-0·85; p=0·028). Median overall survival was 13·8 months (70% CI 12·7-14·4) in the gemcitabine plus ramucirumab group and 7·5 months (6·9-8·9) in the gemcitabine plus placebo group. Grade 3-4 treatment-related adverse events were reported in 35 (44%) of 80 patients in the gemcitabine plus ramucirumab group and 24 (30%) of 81 in the gemcitabine plus placebo group. The most common treatment-related grade 3-4 adverse events were neutropenia (16 [20%] for gemcitabine plus ramucirumab vs ten [12%] for gemcitabine plus placebo) and hypertension (five [6%] vs none). Treatment-related serious adverse events were reported in five (6%) in the gemcitabine plus ramucirumab group and in four (5%) patients in the gemcitabine plus placebo group; the most common was thromboembolism (three [4%] for gemcitabine plus ramucirumab vs two [2%] for gemcitabine plus placebo). There were no treatment-related deaths.

INTERPRETATION

Ramucirumab plus gemcitabine significantly improved overall survival after first-line standard chemotherapy, with a favourable safety profile. This combination could be a new option in this setting.

FUNDING

Eli Lilly Italy.

TRANSLATION

For the Italian translation of the abstract see Supplementary Materials section.

Mitochondrial ATP production is impaired in neural stem/progenitor cells derived from olfactory neuroepithelium of patients with schizophrenia

Introduction

Neural stem/progenitor cells derived from olfactory neuroepithelium (hereafter OE-NS/PCs) are emerging as a viable proxy and a valuable tool for translational studies on severe mental illnesses (SMI). In this respect, the use of OE-NS/PCs as a surrogate cellular model of schizophrenia (SZ) has enabled insights into cell signaling and cell cycle dynamics in this disease.

Objectives

We explored whether mitochondrial dysfunction, which has been already associated with SZ, may have a role in the altered proliferation pattern previously observed in OE-NS/PCs of SZ patients.

Methods

OE-NS/PCs were collected from 20 patients and 20 healthy controls (Hcs) by nasal brushing, cultured in proper medium and expanded. Fresh OE-NS/PCs at passage 3 of both groups underwent BrdU proliferation assays or were frozen for later use. Mitochondrial ATP production was measured in both fresh and thawed OE-NS/PCs by using the ATPlite Luminescence Assay kit.

Results

Fresh OE-NS/PCs of patients grew at a higher rate than those of HCs (M-W U=0; p<0.001), whereas the proliferation of thawed OE-NS/PCs of both groups exhibited an opposed pattern (at passage 6, p=0.002). Mitochondrial ATP production was significantly lower in OE-NS/PCs of patients than in those of HCs (M-W U=0; p=0.02), regardless of freeze-thaw conditions (M-W U=6; p=0.77).

Conclusions

Mitochondrial ATP production is negatively affected in OE-NS/PCs of SZ patients as compared to those of HCs. This evidence does not differ in fresh OE-NS/PCs and OE-NS/PCs undergoing freeze-thaw cycles, which instead perturb the proliferation pattern of SZ OE-NS/PCs.

Double-edged sword: Fluoxetine and ibuprofen as development jeopardizers and apoptosis' inducers in common toad, Bufo bufo, tadpoles

Nowadays the presence of pharmaceuticals in the environment is a real problem. Ending up in aquatic environments they negatively affect non-target organisms. Considering the limited studies on the negative effects of pharmaceuticals in amphibians, a better understanding of the mechanisms underlying the sub-lethal effects of drug mixtures in wildlife is an urgent call. Representing particularly vulnerable organisms currently at risk of extinction, amphibians are perfect non-target organisms to explore the consequences of pharmaceuticals during sensitive life-stages. To address this existing research gap, the effects of two drugs, the antidepressant fluoxetine and the anti-inflammatory ibuprofen, as well as their combination has been studied. Tadpoles of Bufo bufo were exposed for seven days to two environmentally realistic concentrations of fluoxetine, ibuprofen and their mixture. The development, behavior and erythron profile were then evaluated as endpoints of exposure response. Both drugs negatively affected tadpoles' growth and development by significantly delayed their time to metamorphosis and reduced body weight. Behaviors were also impaired with a significant increase of unresponsiveness to different stimuli. Mutagenic analysis of blood revealed a significant increase in the frequency of cellular and nuclear abnormalities. Given the complexity of systems and functions affected, our work confirms the toxicological potential of fluoxetine and ibuprofen in B. bufo tadpoles by emphasizing their role as tadpole development delayers and erythrocyte apoptosis-inducers. To our knowledge, this is the first study trying to elucidate the potentially toxic effects of a mixture of an antidepressant with a non-steroidal anti-inflammatory drug using bullfrog tadpole as model organism. Both drugs interacted in impairing development and fitness in tadpoles, which might affect long-term species perpetuation and population dynamic. More in-depth research is needed to elucidate the nature of interaction and molecular mechanisms of mixed pharmaceutical compounds on non-targeted organisms.

Androgenic activation, impairment of the monoaminergic system and altered behavior in zebrafish larvae exposed to environmental concentrations of fenitrothion

Fenitrothion is an organophosphorus insecticide usually found in aquatic ecosystems at concentrations in the range of low ng/L. In this manuscript we show that 24 h exposure to environmental concentrations of fenitrothion, from ng/L to low μg/L, altered basal locomotor activity, visual-motor response and acoustic/vibrational escape response of zebrafish larvae. Furthermore, fenitrothion and expression of gap43a, gfap, atp2b1a, and mbp exhibited a significant non-monotonic concentration-response relationship. Once determined that environmental concentrations of fenitrothion were neurotoxic for zebrafish larvae, a computational analysis identified potential protein targets of this compound. Some of the predictions, including interactions with acetylcholinesterase, monoamine-oxidases and androgen receptor (AR), were experimentally validated. Binding to AR was the most suitable candidate for molecular initiating event, as indicated by both the up-regulation of cyp19a1b and sult2st3 and the non-monotonic relationship found between fenitrothion and the observed responses. Finally, when the integrity of the monoaminergic system was evaluated, altered levels of L-DOPA, DOPAC, HVA and 5-HIAA were found, as well as a significant up-regulation of slc18a2 expression at the lowest concentrations of fenitrothion. These data strongly suggest that concentrations of fenitrothion commonly found in aquatic ecosystems present a significant environmental risk for fish communities.

Prevalence of adverse cardiovascular events in pediatric cardiomyopathies: an analysis of 110 patients followed at a long-standing tertiary care paediatric centre

Introduction

Pediatric cardiomyopathies (CMP) are disorders of the morphology and function of the heart, with a greater heterogeneity concerning etiology and clinical presentation than adult CMP. The assessment of etiology and genetic status is of paramount importance for prognosis, family screening, and therapeutic choices.

Purpose

To report clinical presentation, etiology, and outcome of a cohort of children diagnosed with CMP followed at tertiary care pediatric referral centre.

Methods

We retrospectively reviewed clinical, laboratory and imaging data of all patients referred to our cardiomyopathy centre from May 2008 to May 2019 for pediatric CMP (&lt;18 years). CMP due to arrhythmic disorders, toxic agents' exposure, rheumatic conditions and maternal disease (i.e. maternal diabetes) were excluded. Primary endpoint was a composite of major adverse cardiovascular events (MACE: cardiovascular death, heart failure [HF] hospitalization, arrhythmic events, need for surgery or heart transplant referral).

Results

We enrolled 110 patients (65 males, age at diagnosis 67±71 months). Hypertrophic cardiomyopathy (HCM, N=48, 44%) was most frequent, followed by dilated cardiomyopathy (DCM, N=35 32%) and left ventricular non-compaction phenotype (LVNC, N=12, 11%). Mixed phenotype (N=7, 6%) and restrictive cardiomyopathy (RCM, N=3, 3%) were less common. No cases of arrhythmogenic right ventricular cardiomyopathy (ARVC) were detected. Five genotype-positive patients presented with negative clinical phenotype. A diagnosis was confirmed in all patients; the most common was sarcomere disease (30%, N=33) followed by metabolic (28%,N=31) disease, genetic syndromes (11%, N=12), neuromuscular (7,3%, N=8) diseases, and post-myocarditis cases (4,5%,N=5). Twenty-one patients (19%) were identified as idiopathic. At referral, 4,5% of children presented with NYHA class III/IV.

At 35 [14–72] months, 4 (3.7%) patients required ICD implantation, 8 (7.4%) underwent cardiac surgery, and 1 (1%) underwent heart transplant. Furthermore, 28 (26%) patients required hospitalization due to acute HF, with DCM patients being at higher risk (p&lt;0.01), 7 (6.8%) experienced arrhythmic events and 4 (3.9%) had syncope. Overall, 13 (12%) died (7 with metabolic disorders, 3 with genetic syndromes, 1 with a sarcomeric mutation, 1 post myocarditis, and 1 idiopathic).

Conclusions

In our cohort, HCM was the most common cause of pediatric CMP followed by DCM and non-compaction. MACE were present in 41% of patients. While HCM had a less severe phenotype (characterized by a higher arrhythmic burden), DCM was characterized by a higher prevalence of HF hospitalizations. DCM, inborn errors in metabolism and genetic syndromes had the worst outcome in terms mortality and heart failure long term.

Widespread availability of genetic testing provides several benefits to the clinician, confirming diagnosis in ambiguous cases and defining etiology in order to guide management and identifying relatives at risk.

Figure 1

Funding Acknowledgement

Type of funding source: None

Impacts of salicylic acid in Mytilus galloprovincialis exposed to warming conditions

While many studies have been conducted on drug-inducing alterations in the aquatic environment, little is known about their interaction with climate change, such as rising temperatures. To increase knowledge on this topic, Mytilus galloprovincialis mussels were exposed to two different temperatures 17 ± 1 °C (control) and 21 ± 1 °C in the absence and presence of salicylic acid (SA) (4 mg/L) for 28 days. Salicylic acid in the water and tissues was measured and its impact reported through biomarker responses including: energy metabolism (electron transport system (ETS) activity, glycogen (GLY), protein (PROT) and lipids (LIP) contents), oxidative stress markers (activity of the enzymes superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPx)), glutathione balance between the reduced and the oxidized forms (GSH/GSSG), and damage to membrane lipids (lipid peroxidation - LPO). The mussels responded differently if the stresses imposed were single or combined, with greater impacts when both stressors were acting together. Contaminated mussels exposed to high temperatures were unable to increase their metabolic capacity to restore their defence mechanisms, reducing the expenditure of LIP. In the presence of SA and increased temperature antioxidant defences respond differently, with higher SOD levels and inhibition of CAT. The present study highlights not only the negative impact of warming and SA, but especially how temperature increase will promote the impact of SA in M. galloprovincialis, which under predicted climate change scenarios may greatly impair population maintenance and ecosystem biodiversity.

Acute effects of neonicotinoid insecticides on Mytilus galloprovincialis: A case study with the active compound thiacloprid and the commercial formulation calypso 480 SC

Pesticides can enter aquatic environments potentially affecting non-target organisms. Unfortunately, the effects of such substances are still poorly understood. This study investigated the effects of the active neonicotinoid substance thiacloprid (TH) and the commercial product Calypso 480 SC (CA) (active compound 40.4% TH) on Mytilus galloprovincialis after short-term exposure to sublethal concentrations. Mussels were tested for seven days to 0, 1, 5 and 10 mg L^-1 TH and 0, 10, 50 and 100 mg L^-1 CA. For this purpose, several parameters, such as cell viability of haemocytes and digestive cells, biochemical haemolymph features, superoxide dismutase (SOD) and catalase (CAT) enzymatic activity of gills and digestive gland, as well as histology of such tissues were analysed. The sublethal concentrations of both substances lead to abatement or completely stopping the byssal fibres creation. Biochemical analysis of haemolymph showed significant changes (P < 0.01) in electrolytes ions (Cl^-, K⁺, Na⁺, Ca²⁺, S-phosphor), lactate dehydrogenase (LDH) enzyme activity and glucose concentration following exposure to both substances. The TH-exposed mussels showed significant imbalance (P < 0.05) in CAT activity in digestive gland and gills. CA caused significant decrease (P < 0.05) in SOD activity in gills and in CAT activity in both tissues. Results of histological analyses showed severe damage in both digestive gland and gills in a time- and concentration-dependent manner. This study provides useful information about the acute toxicity of a neonicotinoid compound and a commercial insecticide on mussels. Nevertheless, considering that neonicotinoids are still widely used and that mussels are very important species for marine environment and human consumption, further researches are needed to better comprehend the potential risk posed by such compounds to aquatic non-target species.

Effectiveness of Social Media Approaches to Recruiting Young Adult Cigarillo Smokers: Cross-Sectional Study

BACKGROUND

The prevalence of social media use among youth and young adults suggests it is an appropriate platform for study recruitment from this population. Previous studies have examined the use of social media for recruitment, but few have compared platforms, and none, to our knowledge, have attempted to recruit cigarillo users.

OBJECTIVE

The purpose of this study was to examine the effectiveness of different social media platforms and advertisement images for recruiting cigarillo users aged 14-28 years to complete a cigarillo use survey.

METHODS

We obtained objective data for advertisement impressions for a 39-week social media recruitment campaign. Advertisements were targeted to users based on their age, geography, and interests. Effectiveness was defined as the percentage of approved surveys per advertising impression. Chi-square tests were performed to compare the effectiveness of different advertisement images and platforms.

RESULTS

Valid survey completers (n=1089) were predominately older (25-28 years old, n=839, 77%). Of the 1089 survey completers, 568 (52%) identified as male, 335 (31%) as African American, and 196 (18%) as Hispanic. Advertisements delivered via Facebook/Instagram were more effective than Twitter; 311/1,027,738 (0.03%) vs 661/2,998,715 (0.02%); χ²₁=21.45, N=4,026,453); P<.001. Across platforms, ads featuring exclusively an image of cigarillos were more effective (397/682,994, 0.06%) than ads with images of individuals smoking (254/1,308,675, 0.02%), individuals not smoking (239/1,393,134, .02%), and groups not smoking (82/641,650, 0.01%); χ²₃133.73, N=4,026,453; P<.001.

CONCLUSIONS

The campaign was effective in recruiting a diverse sample representative of relevant racial/ethnic categories. Advertisements on Facebook were more effective than Twitter. Advertisements that featured an image of a cigarillo were consistently the most effective and should be considered by others recruiting cigarillo users via social media.

Randomized phase II study on gemcitabine with or without ramucirumab as second-line treatment for advanced malignant pleural mesothelioma (MPM): Results of Italian Rames Study

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Background. The RAMES Study (EudraCT Number 2016-001132-36) is a multicenter, double-blind, randomized phase II trial exploring the efficacy and the safety of the addition of ramucirumab to gemcitabine as the second-line treatment in MPM patients (pts) after platinum/pemetrexed regimens. Methods. The pts were assigned (1:1) to receive Gemcitabine 1000 mg/m2 i v on days 1 and 8 every 21 days with Placebo (Arm A) or Ramucirumab 10 mg/kg i v on day 1, of a 21-day cycle (Arm B), until tolerability or progressive disease. Pts was stratified by ECOG/PS (0-1 vs 2), age (≤ 70 vs > 70 yrs), histology (epithelioid vs non-epithelioid) and time to progression (TTP) after first-line therapy. The primary endpoint was overall survival (OS). Assuming a proportion of OS equal to 40% at 1 year in arm A, a 12% absolute improvement in OS at 1 yrs was expected in Arm B (hazard ratio = 0.70).114 events (156 subjects) are required for a one-sided log-rank test with α = 0.15 to have 80% power. Results. From December 2016 to July 2018, 164 pts were randomized, 81 pts in Arm A and 80 Arm B; 3 pts were randomized but not treated. Characteristics of pts were: median age 69 yrs (44-81), males 119 (73.9%), females 42 (26.1%); ECOG/PS0 96 (59.6%) ECOG/PS1-2 65 (40.4%); histotype epithelioid 132 (81.9%), non-epithelioid 29 (18.1%); stage III 98 (60.7%), stage IV 60 (37.3%), 3 (2.0%) missing; asbestos exposure assessed 80 (49.7%). Median of courses was 3.50 in Arm A and 7.50 in Arm B. OS was significantly longer in Arm B with median 13.8 mths (70% CI 12.7-14.4) vs Arm A with 7.5 mths (70% CI 6.9-8.9), HR 0.71 (70% CI 0.59-0.85, p = 0.057). OS at 6 and 12 mths was in Arm A 63.9% and 33.9%, and in Arm B 74.7% and 56.5%, respectively. In Arm B OS was not correlated to TTP at first-line therapy (13.6 mths in TTP ≤6 mths and 13.9 mths in TTP > 6 mths) and histotypes (13.8 months in the epithelioid and 13.0 months in non-epithelioid). No significant differences in thromboembolism G3-4 events were observed in Arm A vs Arm B (p= 0.64). None hypertension G3-4 was reported in Arm A vs 5 pts (6.3%) in Arm B (p= 0.022). No significant differences in G3-4 haematological toxicities between the two arms were reported. Conclusion: In the RAMES Study the addition of Ramucirumab to Gemcitabine significantly improved OS regardless of age of pts, tumor histotype and TTP at the first-line treatment. Gemcitabine plus Ramucirumab can be considered a manageable regimen in second-line treatment of advanced MPM pts. Clinical trial information: NTC03560973.

Detection of EGFR-Activating and T790M Mutations Using Liquid Biopsy in Patients With EGFR-Mutated Non-Small-Cell Lung Cancer Whose Disease Has Progressed During Treatment With First- and Second-Generation Tyrosine Kinase Inhibitors: A Multicenter Real-Life Retrospective Study

BACKGROUND

In advanced epidermal growth factor receptor (EGFR)-mutated non-small-cell lung cancer (NSCLC) patients whose disease has progressed during treatment with first- and second-generation tyrosine kinase inhibitors (TKIs), liquid biopsy (LB) is routinely used to evaluate the presence of EGFR T790M as an acquired resistance mechanism. The objective of this study was to assess a real-life picture of EGFR T790M detection in LB.

MATERIALS AND METHODS

Liquid biopsies performed between June 2016 and October 2018 for advanced EGFR-mutated NSCLC at disease progression during treatment with first- and second-generation TKIs were retrospectively evaluated in 5 Italian centers. Circulating tumor DNA was extracted from plasma and tested with different commercial kits. The detection rate in LBs and the patients' characteristics were correlated.

RESULTS

We enrolled 120 consecutive patients. The overall T790M detection rate observed using LB was 25.8%. Fifty-four of 89 (60.7%) patients with negative LB results underwent tissue rebiopsy, and 56% were positive for T790M. The overall rate of T790M positivity in the study cohort was 49.2%. LB performed before formal tumor progression according to Response Evaluation Criteria In Solid Tumors criteria was negative for T790M in all patients (n = 21; P = .012). T790M positivity was statistically significantly higher in cases of disease progression at extrathoracic metastatic sites (P = .008) and, specifically, in the case of worsening bone disease (P = .003).

CONCLUSION

Our study shows that the detection of T790M-positive patients whose disease progressed during treatment with first- and second-generation TKIs in real life was according to the literature. However, this result was obtained with a specific clinical course (repeat LBs and tissue rebiopsy), thus implying the necessity for multidisciplinary management.

Assessing the effects of neonicotinoid insecticide on the bivalve mollusc Mytilus galloprovincialis

In the present work, the marine invertebrate Mytilus galloprovincialis was used as model organism to evaluate the toxic effects of the neonicotinoid Calypso 480 SC (CAL) following 20 days of exposure to sub-lethal concentrations of 7.77 mg L^-1 (0.1% 96 h-LC50) and 77.70 mg L^-1 (1% 96 h-LC50), and a recovery period of 10 days in uncontaminated seawater. Results revealed that exposure to both concentrations of CAL increased significantly mortality rate in the cells of haemolymph and digestive gland, while digestive gland cells were no longer able to regulate cell volume. Exposure significantly reduced haemolymph parameters (Cl^-, Na⁺), affected the enzymatic activities of superoxide dismutase of digestive gland and catalase of gill, and caused also histopathological alterations in digestive gland and gills. Main histological damages detected in mussels were lipofuscin accumulation, focal points of necrosis, mucous overproduction and infiltrative inflammations. Interestingly, alterations persisted after the recovery period in CAL-free water, especially for haemocyte parameters (K⁺, Na⁺, Ca²⁺, lactate dehydrogenase, glucose). A slight recovery of histological conditions was detected. These findings suggested that sub-chronic exposure to the neonicotinoid insecticide caused significant alterations in both cell and tissue parameters of M. galloprovincialis. Considering the ecologically and commercially important role of mussels in coastal waters, a potential risk posed by neonicotinoids to this essential aquatic resource can be highlighted.

Be-TeaM: An Italian real-world observational study on second-line therapy for EGFR-mutated NSCLC patients

OBJECTIVES

Molecular diagnostics and care of non-small cell lung cancer (NSCLC) are continuously evolving. Few data document the current strategies to manage advanced NSCLC patients beyond progression in clinical practice.

PATIENTS AND METHODS

Be-TeaM is an Italian multi-center observational study conducted on consecutive EGFR-mutated stage IV NSCLC patients, progressed during/after a first-line EGFR-TKI. It consists of a retrospective phase, from first-line EGFR-TKI therapy start until study entry (i.e. beginning of the diagnostic process), and a prospective phase, until treatment choice or for 3 months if no therapy was prescribed. Primary objective was to describe the diagnostic and therapeutic approaches adopted after progression in a real-world setting.

RESULTS

Of 308 patients enrolled in 63 centers from July 2017 to June 2018, 289 were included in the analysis. In first line, 53.3 % received gefitinib, 32.5 % afatinib and 14.2 % erlotinib. The testing rate (i.e. rate of all patients undergone any biopsy -liquid and/or tissue- for the T790 M detection) was 90.7 %, with liquid biopsy being the most frequently executed. Of 262 biopsied patients, 64.5 % underwent only 1 liquid biopsy, 10.7 % only 1 tissue biopsy and 18.3 % >1 biopsy, both liquid and solid in 85.4 %. The T790M positivity rate was 45.3 %; of 166 patients undergone only a liquid biopsy and tested for the mutation, 39.8 % were T790M+ and 60.2 % T790M-/undetermined. By the observation end, 87.9 % patients had a post-progression treatment chosen, osimertinib being the most frequent among the T790M+.

CONCLUSION

Be-TeaM provides the first snapshot of current practices for the management of NSCLC patients beyond progression in Italy; in clinical practice, assessing the T790M status is not always feasible.

Results of an Italian CORE-IMMUNO study: Safety and clinical-related biomarkers as predictors of immunotherapy (IT) benefit in real-world treatment of various advanced tumors (ATs)

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Background: Checkpoint inhibitors in cancer therapy have shown survival benefits in the treatment of several ATs. However, the risk of serious side effects seems greater in certain types of tumors presenting reduced compliance with therapy. The aim of this study is to evaluate the safety profile and clinical benefits of IT, as appraised using clinically related biomarkers of pts outside clinical trials. Methods: In this retrospective study, data were evaluated on pts in the Reggio Emilia Provincial Oncology Network who were treated for ATs using Nivolumab, Pembrolizumab and Ipilimumab monotherapy in clinical practice. The pts included in the study had received at least 1 dose of IT by June 2018. LDH and neutrophil–lymphocyte ratio (NLR) were collected at baseline, antibiotic therapy (ATB) was considered during IT, and immunorelated adverse events (irAEs) were assessed with CTCAE v.4.1. Results: A total of 169 pts were examined: 78 with NSCLC, 57 with melanoma, 29 with kidney cancer, 3 with head-neck cancer and 2 with colorectal cancer. 123 pts (73%) were treated with Nivolumab, 36 (21%) with Pembrolizumab and 10 (6%) with Ipilimumab. Overall, 62 pts (37%) experienced irAES of any degree: 17/29 (59%) pts with kidney cancer presented irAES, while only 35% (20/57) and 31% (24/78) of pts with melanoma and lung cancer did, respectively. A total of 27/62 (43%) pts delayed IT due to toxicity, but only 7/62 (11%) pts discontinued treatment due to irAEs. Statistically significant increases in PFS (11 vs. 5 months, p = 0.002) and OS (19.9 vs. 8.7 months, p = 0.002) were found between pts who experienced irAEs and those who did not. As previously demonstrated in other groups of pts, in the Cox regression performed for OS, a baseline value of LDH≥1.5xULN and median NLR ≥2.93 correlates with poor prognosis. Unlike what is already known, the use of ATB during IT (35% of pts) correlates with increased survival (HR 0.59; IC95% 0.37-0.94, p = 0.028). Conclusions: These data confirm the tolerability of IT in an unselected real-world population. In particular, the development of irAEs could be considered a positive predictor of outcome, but with a different incidence among MTS.

Malignant pleural mesothelioma (MPM) genomic profile in the randomized phase II RAMES Study

8547

Background: Since MPM is an uncommon neoplasia, its rarity has limited available data on molecular drivers. Methods: RAMES study evaluated the second-line efficacy of gemcitabine/ramucirumab treatment vs. gemcitabine/placebo. From December 2016 to July 2018 (end of enrolment), 164 patients (pts) were admitted to this study, which involved the collection of tumor samples - with diagnosis - to evaluate 34 genes by NGS (ACTB, ACTG1, ACTG2, ACTR1A, BAP1,CDH8, CDK4, CDKN2A, CDKN2B, COL3A1, COL5A2, CUL1, DHFR, GOT1, KDR, KIT, MXRA5, NF2, NFRKB, NKX6,-2, NOD2, PCBD2, PDZK1IP1, PIK3CA, PIK3CB, PSMD13, RAPGEF6, RDX, SETDB1, TAOK1, TP53,TXNRD1, UQCRC1, XRCC6). We reported the results of the first 87 pts (54%): hystotype was epithelioid in 70 pts (80%), biphasic in 14 pts (16%) and sarcomatoid in 3 pts (4%). Median age was 63 years (range 45-81). 70 pts were male (80%) and 17 pts were female (20%). In the present analysis, we included 55 pts in stage III (63%), 26 pts in stage IV (30%) and 6 pts whose stage was unknown. Median first-line PFS platinum/pemetrexed therapy was for 5.75 months (I.C. 95% 4.75-6.76). PFS was ≤6 months for 40 pts (49%), and 6 months for 41 pts (51%). Results: 187 functional somatic mutations were identified. Genomic alterations/patient were 1 gene in 29 pts (33%), 3 genes in 18 pts (21%) and ≥5 genes in 2 pts (2%). The most frequent somatic mutations were RDX in 35 pts (40%), MXRA5 in 20 pts (23%), BAP1 in 13 pts (15%) and ACTG 1 in 9 pts (11%). When patients were collated by stage, the most frequent mutations were: MXRA5 in 16 pts in stage III (29%), BAP1 in 5 pts in stage IV (19%) and RDX in 16 pts in stage IV (62%). The percentage of somatic mutations in patients with PFS as first-line chemotherapy for ≤6 and >6 months was 2.2 and 1.6 (p=0.032), respectively. The most frequent mutations/patient for ≤6 and >6 months PFS were: RDX in 14 pts (35%) with PFS < 6, RDX in 19 pts (46%) with PFS >6 and MXRA5 in 11 pts (27%) with PFS >6. Conclusions: This preliminary data suggests a possible role that a genetic signature may play in distinguishing MPM with different clinical-pathological features. The results are expected to be clarified further in the second step of the study, which is ongoing. Clinical trial information: 2016-001132-36.

Great saphenous vein reflux treatment in patients with femoral valve incompetence, the Excluded Saphenous Vein Technique (ESVT): a pilot study

OBJECTIVE

To describe and evaluate feasibility and efficacy of a saphenous ablation technique performed in patients with varicose veins (VVs), great saphenous vein (GSV) incompetence, and proximal femoral valve incompetence: the Excluded Saphenous Vein Technique (ESVT).

PATIENTS AND METHODS

Patients with primary great saphenous and proximal femoral valve incompetence underwent ESVT. This technique is composed of selective crossectomy, GSV ligation next to the thigh incompetent tributary vein, and saphenous vein sclerosing performed from the proximal zone. Demographic, clinical and instrumental data were collected. CEAP classification was used to describe VVs severity. The primary outcome was perioperative complications. Secondary outcomes were 30-days, 6-months and 1-years GSV occlusion rate, and VVs recurrence rate.

RESULTS

During a ten months period, 104 patients were analyzed. Among these, 82 patients underwent ESVT (59 female, age 50 ± 21 years), eighty C2 and two C5, according to CEAP classification. The average length of GSV treated was 23 ± 9 cm. No intraoperative complications occurred. A 1-year follow-up analysis revealed no partial or complete saphenous recanalization, deep venous thrombosis, pulmonary embolism. No VVs recurrence was detected during the follow-up period among the entire population.

CONCLUSIONS

ESVT seems to be a safe and effective treatment for primary saphenous reflux and proximal femoral valve incompetence. Further studies are needed to assess long-term results.

Higher expression of miR-133b is associated with better efficacy of erlotinib as the second or third line in non-small cell lung cancer patients

Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (gefitinib, erlotinib and afatinib) are indicated as first-line therapy in patients with non-small cell lung cancer (NSCLC) whose tumors harbor activating mutations in the EGFR gene. Erlotinib is also used in second and third-line therapy for patients whose tumors have wild type EGFR but to date there are no validated biomarkers useful to identify which patients may benefit from this treatment. The expression level of four miRNAs: miR-133b, -146a, -7 and -21 which target EGFR was investigated by real-time PCR in tumor specimens from NSCLC patients treated with erlotinib administered as the second or third line. We found that miR-133b expression level better discriminated responder from non-responder patients to erlotinib. Higher levels of miR-133b in NSCLCs were associated with longer progression-free survival time of patients. Functional analyses on miR-133b through transfection of a miR-133b mimic in A549 and H1299 NSCLC cell lines indicated that increasing miR-133b expression level led to a decreased cell growth and altered morphology but did not affect sensitivity to erlotinib. The detection of miR-133b expression levels in tumors help in the identification of NSCLC patients with a better prognosis and who are likely to benefit from second and third-line therapy with erlotinib.

EGFR status evaluation by liquid biopsy during first-line therapy in patients with advanced NSCLC

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Background: over the past decade, personalized management based on the molecular features of tumours in patients with advanced non small-cell lung cancer (NSCLC) has entered routine clinical practice. The poor performance of many advanced NSCLC patients may limit invasive biopsies. The liquid biopsy is a diagnostic procedure performed on cancer-derived material obtained in blood samples. In this abstract, we will describe our experience with liquid biopsies. Methods: In the Reggio Emilia Clinical Cancer Centrefrom March 2016 to December 2016, 42 patients with advanced NSCLC were analyzed that had had or had already started first line therapy. The liquid biopsy was repeated at each imaging response evaluation by thoracic-abdominal compound tomography (CT) scan performed every 3 months. In the liquid biopsy, the mutational status of EGFR was analyzed with real time PCR (KIT cobas EGFR mutation test v2 CE-IVD Roche); in tissue, it was evaluated by pyrosequencing. Results: 21/42 liquid biopsies were EGFR-mutated (12/21 eson 19 and 9/21 eson 21). In 3/21 (14.3%) cases, the tissue biopsies showed wild type (WT) EGFR. 6 liquid biopsies were also performed at time 0 (diagnosis). All liquid biopsies of EGFR WT remained WT during treatment and imaging evaluation. The median number of liquid biopsy tests for patients was 2 (range 1-3). In 4/21 cases, T790M was performed: 3 cases in both liquid biopsies and tissue, and 1 case in tissue but not in liquid biopsy. TKi therapy was ineffective in this patient with T790M mutation detected in tissue, but not in liquid biopsy. In all patients, the disappearance of the T790M mutation during TKi therapy was related to disease progression. In 11 cases, modification of EGFR mutation status during treatment anticipated CT scan evidence of disease progression (median = three months). Conclusions: the liquid biopsy is an excellent resource. In our experience the liquid biopsy is the sensitive method of choice during treatment of advanced NSCLC patients. EGFR modification status during TKi therapy showed advanced disease progression.

Cytotoxicity, haemolymphatic parameters, and oxidative stress following exposure to sub-lethal concentrations of quaternium-15 in Mytilus galloprovincialis

The presence of a xenobiotic in the environment can often represent a risk for living organisms. Quaternium-15, a preservative, is one of the most used substances and is added to several cosmetics and other industrial products. For this reason,kwowing the bio-indicator of the marine environment, the toxicological effects potentially elicited by this preservative on the marine invertebrate Mytilus galloprovincialis were studied. The results of this work confirm that quaternium-15, used at 0.1 and 1mg/l concentrations, while metabolized in M. galloprovincialis, causes a decrease in cellular viability, and remarkable changes to the defense and antioxidant system. In fact, haemocyte viability is dramatically reduced, and haemolymphatic parameter measurements indicate a stress on the animal. Moreover, an increase in radical species production, in Thiobarbituric Acid Reactive Species (TBARS) concentration, and in the Heat Shock Protein 70 amount, were observed in hepatopancreas. These changes suggest that the antioxidant systems are activated to overwhelm the oxidative damage induced by quaternium-15. Quaternium-15 jeopardizes both the defense and antioxidant systems. These results provide essential information with the biological fate of quaternium-15 in aquatic organisms, and confirm that biomarkers represent an important tool for modern environmental assessments as they can help with the prediction of pollutants involved in the monitoring program.

Pinna nobilis: A big bivalve with big haemocytes?

The fan mussel Pinna nobilis (Linnaeus, 1758) is one of the biggest bivalves worldwide. Currently, no updated information is available in the literature concerning the morpho-functional aspects of haemocytes from this bivalve species. Consequently, in this study, we characterised P. nobilis haemocytes from both a morphological and functional point of view. The mean number of haemocytes was about 5 (×10(5)) cells mL haemolymph(-1), and the cell viability was about 92-100%. Two haemocyte types were distinguished under the light microscope: granulocytes (51.6%), with evident cytoplasmic granules, and hyalinocytes (48.4%), with a few granules. The granules of the granulocytes were mainly lysosomes, as indicated by the in vivo staining with Neutral Red. Haemocytes were further distinguished in basophils (83.75%), acidophils (14.75%) and neutrophils (1.5%). After adhesion to slides and fixation, the cell diameter was approximately 10 μm for granulocytes and 7 μm for hyalinocytes. The granulocytes and hyalinocytes were both positive to the Periodic Acid-Schiff reaction for carbohydrates. Only granulocytes were able to phagocytise yeast cells. The phagocytic index (6%) increased significantly up to twofold after preincubation of yeast in cell-free haemolymph, suggesting that haemolymph has opsonising properties. In addition, haemocytes produce superoxide anion and acid and alkaline phosphatases. Summarising, this preliminary study indicates that both the granulocytes and hyalinocytes circulate in the haemolymph of P. nobilis and that they are active immunocytes.