Rapid switching from levetiracetam to brivaracetam in pharmaco-resistant epilepsy in people with and without intellectual disabilities: a naturalistic case control study

BACKGROUND

Approximately one quarter of people with an intellectual disability (PwID) have epilepsy of whom nearly three-quarters are pharmaco-resistant. There are higher reported neuropsychiatric side-effects to anti-seizure medication (ASM) in this group. Levetiracetam (LEV) is a first-line ASM with a stronger association with neuropsychiatric symptoms for PwID than other ASMs. Brivaracetam (BRV) is a newer ASM. Recent studies suggest a beneficial effect of swapping people who experience neuropsychiatric events with LEV to BRV. However, there is limited evidence of this for PwID. This evaluation analyses real world outcomes of LEV to BRV swap for PwID compared to those without ID.

METHODS

We performed a multicentre, retrospective review of clinical records. Demographic, clinical characteristics and reported adverse events of patients switched from LEV to BRV (2016-2020) were recorded at 3 months pre and 6- and 12-month post-BRV initiation. Outcomes were compared between PwID and those without and summarised using cross-tabulations and logistic regression models. A Bonferroni correction was applied.

RESULTS

Of 77 participants, 46 had ID and 52% had a past psychiatric illness. 71% participants switched overnight from LEV to BRV. Seizure reduction of > 50% was seen in 40% patients. Psychiatric illness history was predictive of having neuropsychiatric side-effects with LEV but not BRV (p = 0.001). There was no significant difference for any primary outcomes between PwID versus without ID.

CONCLUSIONS

Switching from LEV to BRV appears as well tolerated and efficacious in PwID as those without ID with over 90% still on BRV after 12 months.

Choice of first line systemic treatment in pancreatic cancer among national experts

BACKGROUND

Treatment options for patients with metastatic pancreatic cancer depend on various factors, including performance status, tumor burden and patient preferences. Metastatic pancreatic cancer is incurable and many systemic treatment options have been investigated over the past decades. This analysis of patterns of practice was performed to identify decision criteria and their impact on the choice of first-line management of metastatic pancreatic cancer.

MATERIALS AND METHODS

Members of the Swiss Group for Clinical Cancer Research (SAKK) Gastrointestinal Cancer Group were contacted and agreed to participate in this analysis. Decision trees for the first line treatment of metastatic pancreatic cancer from 9 centers in Switzerland were collected and analyzed based on the objective consensus methodology to identify consensus and discrepancies in clinical decision-making.

RESULTS

The final treatment algorithms included 3 decision criteria (comorbidities, performance status and age) and 5 treatment options: FOLFIRINOX, FOLFOX, gemcitabine + nab-paclitaxel, gemcitabine mono and best supportive care.

CONCLUSION

We identified multiple decision criteria relevant to all participating centers. We found consensus for the treatment of young (age below 65) patients with good performance status with FOLFIRINOX. For patients with increasing age and reducing performance status there was a decreasing trend to use gemcitabine + nab-paclitaxel. Gemcitabine monotherapy was typically offered to patients in the presence of comorbidities. For patients with ECOG 3-4, most of the experts recommended BSC.

Bevacizumab continuation versus no continuation after first-line chemotherapy plus bevacizumab in patients with metastatic colorectal cancer: a randomized phase III non-inferiority trial (SAKK 41/06)

BACKGROUND

Chemotherapy plus bevacizumab is a standard option for first-line treatment in metastatic colorectal cancer (mCRC) patients. We assessed whether no continuation is non-inferior to continuation of bevacizumab after completing first-line chemotherapy.

PATIENTS AND METHODS

In an open-label, phase III multicentre trial, patients with mCRC without disease progression after 4-6 months of standard first-line chemotherapy plus bevacizumab were randomly assigned to continuing bevacizumab at a standard dose or no treatment. CT scans were done every 6 weeks until disease progression. The primary end point was time to progression (TTP). A non-inferiority limit for hazard ratio (HR) of 0.727 was chosen to detect a difference in TTP of 6 weeks or less, with a one-sided significance level of 10% and a statistical power of 85%.

RESULTS

The intention-to-treat population comprised 262 patients: median follow-up was 36.7 months. The median TTP was 4.1 [95% confidence interval (CI) 3.1-5.4] months for bevacizumab continuation versus 2.9 (95% CI 2.8-3.8) months for no continuation; HR 0.74 (95% CI 0.58-0.96). Non-inferiority could not be demonstrated. The median overall survival was 25.4 months for bevacizumab continuation versus 23.8 months (HR 0.83; 95% CI 0.63-1.1; P = 0.2) for no continuation. Severe adverse events were uncommon in the bevacizumab continuation arm. Costs for bevacizumab continuation were estimated to be ∼30,000 USD per patient.

CONCLUSIONS

Non-inferiority could not be demonstrated for treatment holidays versus continuing bevacizumab monotheray, after 4-6 months of standard first-line chemotherapy plus bevacizumab. Based on no impact on overall survival and increased treatment costs, bevacizumab as a single agent is of no meaningful therapeutic value. More efficient treatment approaches are needed to maintain control of stabilized disease following induction therapy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, number NCT00544700.

Abstract P2-16-19: Fulvestrant with or without selumetinib (Sel, AZD6244), a mitogen-activated protein kinase kinase (MEK) 1/2 inhibitor, in advanced stage breast cancer progressing after aromatase inhibitor (AI): A multicenter randomized placebo-controlled double-blind phase II trial, SAKK21/08

Background:

Mitogen-activated protein kinase (MAPK) pathway is one of the major signaling cascades responsible for resistance to endocrine therapy by promoting estrogen-independent tumor growth. Sel is a potent selective MEK1 and MEK2 inhibitor active in melanoma, ovarian, colorectal and non-small cell lung cancers. Fulvestrant (Fulv) is a pure antagonist and downregulator of nuclear and membranous/cytoplasmic estrogen receptor (ER). The combination of a MEK inhibitor with Fulv may improve the efficacy of endocrine therapy by reversing and/or delaying the development of resistance.

Material and methods:

Postmenopausal patients with advanced stage endocrine-sensitive (ER and/or progesterone receptors ≥10%) breast cancer progressing after aromatase inhibitor were randomized to intramuscular Fulv 500 mg (day 1, 15, 29 then every 28±2 days) combined with either oral Sel 75 mg bid or placebo bid. The primary endpoint was disease control (DC = CR + PR + stable disease ≥ 24 weeks). Sample size was calculated according to Simon's optimal two-stage design. A DC rate of ≤30% in the experimental arm was considered as not interesting and ≥50% as promising. Using a 5% significance level and 80% power, 46 patients were needed, 15 in the first stage and 31 in the second stage. In the control arm a total of 43 patients was needed to estimate the DC rate with a confidence interval width of ≤30%. An interim efficacy analysis was planned according to Herndon's modification of Simon's optimal two-stage design.

Results:

Forty-six patients were included (23 per arm). Seventy percent of the patients in the experimental arm had measurable disease and 57% had visceral metastases. Patients had received AI in the metastatic (61%) or adjuvant (39%) setting (65% had also prior tamoxifen). Five of 23 patients (22%) reached DC in the experimental arm. DC rate being inferior to the statistical hypothesis the study was terminated following the planned interim efficacy analysis. Most frequently reported adverse events (AEs) were rash and other skin disorders, fatigue, diarrhea, hypertension, edema, nausea/vomiting, anorexia, musculoskeletal symptoms, dry mouth and paresthesia. AEs were mainly grade 1 and 2 (NCI-CTCAE v4.0), but they often precluded treatment continuation. Most of the first patients exposed to Sel 75 mg bid stopped treatment before disease progression. Seven of the 23 patients (30%) were exposed to Sel for only 1 cycle or less. After an amendment facilitating early dose-reduction, patients decreasing to 75 mg qd had much better tolerance and improved treatment duration with Sel. Four out of the 5 patients reaching DC had Sel dose reduction.

Conclusion:

The combination of Sel with fulvestrant did not reach the prespecified disease control rate. The toxicity of Sel 75 mg bid led to frequent treatment interruptions/dose reductions and poor exposure to the drug.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-16-19.

Neoadjuvant chemoradiotherapy with or without panitumumab in patients with wild-type KRAS, locally advanced rectal cancer (LARC): a randomized, multicenter, phase II trial SAKK 41/07

BACKGROUND

We conducted a randomized, phase II, multicenter study to evaluate the anti-epidermal growth factor receptor (EGFR) mAb panitumumab (P) in combination with chemoradiotherapy (CRT) with standard-dose capecitabine as neoadjuvant treatment for wild-type KRAS locally advanced rectal cancer (LARC).

PATIENTS AND METHODS

Patients with wild-type KRAS, T3-4 and/or N+ LARC were randomly assigned to receive CRT with or without P (6 mg/kg). The primary end-point was pathological near-complete or complete tumor response (pNC/CR), defined as grade 3 (pNCR) or 4 (pCR) histological regression by Dworak classification (DC).

RESULTS

Forty of 68 patients were randomly assigned to P + CRT and 28 to CRT. pNC/CR was achieved in 21 patients (53%) treated with P + CRT [95% confidence interval (CI) 36%-69%] versus 9 patients (32%) treated with CRT alone (95% CI: 16%-52%). pCR was achieved in 4 (10%) and 5 (18%) patients, and pNCR in 17 (43%) and 4 (14%) patients. In immunohistochemical analysis, most DC 3 cells were not apoptotic. The most common grade ≥3 toxic effects in the P + CRT/CRT arm were diarrhea (10%/6%) and anastomotic leakage (15%/4%).

CONCLUSIONS

The addition of panitumumab to neoadjuvant CRT in patients with KRAS wild-type LARC resulted in a high pNC/CR rate, mostly grade 3 DC. The results of both treatment arms exceeded prespecified thresholds. The addition of panitumumab increased toxicity.

Prognostic value of different CT measurements in early therapy response evaluation in patients with metastatic colorectal cancer

Objectives: Patients with advanced stage colorectal carcinoma (CRC) display hepatic metastases on initial staging in up to 20% of cases. The effectiveness of chemotherapy is generally evaluated by computed tomography (CT) imaging using standardized criteria (RECIST). However, RECIST is not always optimal, and other criteria have been shown to correlate with pathologic response and overall survival. The aim of this study was to evaluate the prognostic value of different CT measurement for response assessment after initiation of chemotherapy in patients with synchronous colorectal cancer liver metastases. Methods: Fifty-five patients with CRC and synchronous hepatic metastases were evaluated retrospectively at 2 academic centers. Different size, volume, ratio and attenuation parameters were determined at baseline and after 3 cycles of chemotherapy. The prognostic value of baseline measurements and of the change between baseline and second measurements was analyzed using Kaplan–Meier estimates. Results: Median time to progression was 279 days, median overall survival was 704 days. In this selective patient population, neither a significant prognostic value of initial baseline CT parameters nor a prognostic value of the change between the first and the second CT measurements was found. Conclusion: Initial morphological response assessment using different CT measurements has no prognostic value concerning time to progression or overall survival in patients with synchronous colorectal liver metastases.

Combining gemcitabine, oxaliplatin and capecitabine (GEMOXEL) for patients with advanced pancreatic carcinoma (APC): a phase I/II trial

BACKGROUND

Gemcitabine remains the mainstay of palliative treatment of advanced pancreatic carcinoma (APC). Adding capecitabine or a platinum derivative each significantly prolonged survival in recent meta-analyses. The purpose of this study was to determine dose, safety and preliminary efficacy of a first-line regimen combining all three classes of active cytotoxic drugs in APC.

PATIENTS AND METHODS

Chemotherapy-naive patients with locally advanced or metastatic, histologically proven adenocarcinoma of the pancreas were treated with a 21-day regimen of gemcitabine [1000 mg/m² day (d) 1, d8], escalating doses of oxaliplatin (80-130 mg/m² d1) and capecitabine (650-800 mg/m² b.i.d. d1-d14). The recommended dose (RD), determined in the phase I part of the study by interpatient dose escalation in cohorts of three to six patients, was further studied in a two-stage phase II part with the primary end point of response rate by RECIST criteria.

RESULTS

Forty-five patients were treated with a total of 203 treatment cycles. Thrombocytopenia and diarrhea were the toxic effects limiting the dose to an RD of gemcitabine 1000 mg/m² d1, d8; oxaliplatin 130 mg/m² d1 and capecitabine 650 mg/m² b.i.d. d1-14. Central independent radiological review showed partial remissions in 41% [95% confidence interval (CI) 26% to 56%] of patients and disease stabilization in 37% (95% CI 22% to 52%) of patients.

CONCLUSION

This triple combination is feasible and, by far, met the predefined efficacy criteria warranting further investigations.

Undifferentiated carcinoma of nasopharyngeal type (UCNT): a Swiss single-institutional experience during 1990-2005

BACKGROUND

Nasopharyngeal carcinoma is a rare tumor entity in Switzerland. In contrast, it is endemic in Asian and African countries. Retrospective studies have been conducted in order to identify risk factors and prognostic determinants of nasopharyngeal carcinoma. Nonetheless, these trials were mostly conducted in regions with high prevalence for the disease and little is known about the risk factors and prognosis of nasopharyngeal carcinoma for a non-endemic population in Western Europe.

METHODS

This retrospective trial was conducted to identify risk factors and prognostic determinants of nasopharyngeal carcinoma for a non-endemic population in Switzerland.

RESULTS

Overall survival was 91%, 77% and 58% for one, three and five years, respectively. Factors with favourable prognostic value were concomitant radiochemotherapy regimens, photon radiotherapy, and a delay between diagnosis and first therapy session of less than ten weeks, respectively. Factors with unfavourable prognostic values were age over 65 years at time of diagnosis and nasopharyngeal carcinoma of WHO type I.

CONCLUSION

Risk factors, biological behaviour and survival are well comparable between endemic and non-endemic populations for nasopharyngeal carcinoma. Nonetheless, an aggressive diagnostic procedure and sophisticated interdisciplinary therapy are indispensable in order to achieve favourable outcome. Therefore, diagnosis and therapy of nasopharyngeal carcinoma in non-endemic populations should be limited to highly specialized tertiary centres.

Analysis of c-erb-1 (EGFR) and c-erb-2 (HER2) expression in bronchial dysplasia: Evaluation of potential targets for chemoprevention of lung cancer

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Background: Lung cancer is preceded by a premalignant phase during which intervention could decrease associated morbidity and mortality. Molecular characterization of factors involved in controlling progression of bronchial dysplasia (BD) will provide markers of premalignant change and identify targets for chemoprevention. Methods: Immunohistochemical (IHC) analysis of EGFR, HER2, Ki67 and MCM2 expression in BD was undertaken in 268 bronchoscopically obtained biopsies from 134 consecutive subjects recruited to University of Colorado protocols as study subjects with prior sputum atypia and >20 pack years tobacco use or FEV1 < 75% predicted or as never- or healthy-smoker controls. IHC on the worst and best histologic biopsies from each subject were scored and linear regression tests were used to determine significance of correlation between marker expression and histology or proliferation. Results: Analysis of biopsies with the most severe diagnosis from each subject showed a linear relationship between increasing marker expression and severity of dysplastic change for EGFR (p < 0.001), Ki67 (p < 0.001) and MCM2 (p = 0.001) but not HER2 (p = 0.102). Increased expression of either EGFR or HER2 was associated with increased expression of proliferation markers Ki67and MCM2, and combined overexpression of these receptors was associated with the highest levels of proliferation. Finally, in a comparison of subjects that were grouped according to the degree of difference between their best and worst biopsy histology, the absence of an associated trend toward increased EGFR expression with increased difference in histology suggested a field effect in the induction of EGFR expression. Conclusions: Our results 1) demonstrate a direct correlation between levels of EGFR expression and degree of BD, 2) suggest a field effect in the induction of EGFR expression in the airways of subjects with BD and 3) indicate a potential synergistic effect on epithelial proliferation in lesions with increased expression of both EGFR and HER2. These findings suggest that EGFR plays a prominent role in the development and progression of BD and could provide a promising target for chemoprevention of lung cancer.

[Table: see text]

Glucagon-like peptide-1: a potent regulator of food intake in humans

BACKGROUND/AIMS

Studies in animals suggest a physiological role for glucagon-like peptide-1-(7-36)-amide (GLP-1) in regulating satiety. The role of GLP-1 in regulating food intake in man has, however, not been investigated. Subjects-Sixteen healthy male subjects were examined in a double blind placebo controlled fashion.

METHODS

The effect of graded intravenous doses (0, 0.375, 0.75, and 1.5 pmol/kg/min) of synthetic human GLP-1 on food intake and feelings of hunger and satiety was tested in healthy volunteers.

RESULTS

Graded GLP-1 infusions resulted in a dose dependent reduction in food intake (maximal inhibition 35%, p<0.001 v control) and a similar reduction in calorie intake (32%; p<0.001). Fluid ingestion was also reduced by GLP-1 (18% reduction, p<0.01). No overt side effects were produced by GLP-1, but subjects experienced less hunger and early fullness in the period before a meal during GLP-1 infusion at the highest dose (p<0.05).

CONCLUSIONS

Intravenous infusions of GLP-1 decrease spontaneous food intake even at physiological plasma concentrations, implying an important role for GLP-1 in the regulation of the early satiety response in humans.

Muscle lipofuscin content and satellite cell volume is increased after high altitude exposure in humans

Muscle ultrastructural changes during a typical expedition to the Himalayas were analyzed by taking muscle biopsies from seven climbers before and after their sojourn at high altitude (over 5000 m for 8 weeks). M. vastus lateralis samples were analyzed morphometrically from electron micrographs. A quantitative evaluation was made of lipofuscin, satellite cells and myonuclei. Significant increases of the volume densities of lipofuscin (+ 235%) and satellite cells (+ 215%) were observed.