ESMO study on the availability and accessibility of biomolecular technologies in oncology in Europe

BACKGROUND

Access to biomolecular technologies has become an essential requirement to ensure optimal and timely treatment of patients with cancer. This study sought to provide a comprehensive overview of the availability and accessibility of biomolecular technologies to patients, the status of their use and prescription, barriers to access, and potential economic issues related to cost and reimbursement.

MATERIALS AND METHODS

A total of 201 field reporters from 48 European countries submitted data through an electronic survey tool between July and December 2021. The survey methodology mirrored that from previous ESMO studies addressing the availability and accessibility of antineoplastic medicines, in Europe and worldwide. The preliminary data were posted on the ESMO website for open peer-review, and amendments were incorporated into the final report.

RESULTS

Overall, basic single-gene techniques are widely available, whereas access to advanced biomolecular technologies, including large next-generation sequencing panels and complete genomic profiles, is highly heterogeneous. In most countries, advanced biomolecular technologies remain largely inaccessible in clinical practice, are limited to clinical trials or basic research, and associated with progressively increasing cost as the technique becomes more advanced. Differences also exist regarding national sequencing initiatives or molecular tumour boards. The most important barriers to multiple versus single-gene sequencing techniques are the reimbursement of the test (59% versus 24%), and the availability of a suitable medicine, either through reimbursement of treatment (48% versus 30%), off-label treatment (52% versus 35%), or clinical trial enrolment (53% versus 39%).

CONCLUSIONS

Cost and availability of both treatment and test are the two main factors limiting patients' access to advanced biomolecular technologies and as a consequence to innovative anticancer strategies. In the era of precision medicine, tackling the accessibility to biomolecular technologies is a key step to reduce inequalities to transformative cancer care.

Essential cancer medicines: adding feasibility to the magnitude of clinical benefit value chain

BACKGROUND

Cancer is a global public health problem, requiring efficient health system investments to deliver sustainable impact on population health. Access to medicines is a critical component of health systems, having a crucial role in delivering therapeutic benefits. Since 1977, the World Health Organization (WHO) has published a Model List of Essential Medicines (EML) that includes key health interventions for the prevention and control of conditions of public health relevance. Essential medicines are selected for inclusion in the EML based on the evidence of efficacy, safety, therapeutic value, and the potential to impact population health. With the rapid changes in the therapeutic landscape of cancer treatment with new medicine approvals, there is a critical need to select and prioritise specific cancer interventions based on their intrinsic value.

MATERIALS AND METHODS

The European Society for Medical Oncology (ESMO) has developed a decisional methodology based on a threshold with a minimum set of technical specifications and a consensus-based procedure for decisions to select candidate cancer medicines to be submitted to the WHO for consideration for the WHO EML.

RESULTS

ESMO recognises the WHO EML as an important reference guide for medicines that all countries should include in their national EMLs. Cancer medicines on the WHO EML are used in the treatment of the majority of cancers, and are recommended in the evidence-based ESMO Clinical Practice Guidelines that medical oncologists use to treat patients. ESMO's submissions to the WHO EML in 2019 and 2021 and their respective outcomes are presented in the manuscript.

CONCLUSION

Due to the rising costs associated with newly available therapies, structured, reproducible, and field-tested tools to evaluate the added clinical benefit from these therapies need to be implemented in pre-selecting potential candidate medicines to be included in the WHO EML. ESMO is proud to collaborate closely with WHO on this important global public health initiative.

Off-label despite high-level evidence: a clinical practice review of commonly used off-patent cancer medicines

INTRODUCTION

Off-label use of medicines is generally discouraged. However, several off-patent, low-cost cancer medicines remain off-label for indications in which they are commonly used in daily practice, supported by high-level evidence based on results of phase III clinical trials. This discrepancy may generate prescription and reimbursement obstacles as well as impaired access to established therapies.

METHODS

A list of cancer medicines that remain off-label in specific indications despite the presence of high-level evidence was generated and subjected to European Society for Medical Oncology (ESMO) expert peer review to assess for accountability of reasonableness. These medicines were then surveyed on approval procedures and workflow impact. The most illustrative examples of these medicines were reviewed by experts from the European Medicines Agency to ascertain the apparent robustness of the supporting phase III trial evidence from a regulatory perspective.

RESULTS

A total of 47 ESMO experts reviewed 17 cancer medicines commonly used off-label in six disease groups. Overall, high levels of agreement were recorded on the off-label status and the high quality of data supporting the efficacy in the off-label indications, often achieving high ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS) scores. When prescribing these medicines, 51% of the reviewers had to implement a time-consuming process associated with additional workload, in the presence of litigation risks and patient anxiety. Finally, the informal regulatory expert review identified only 2 out of 18 (11%) studies with significant limitations that would be difficult to overcome in the context of a potential marketing authorisation application without additional studies.

CONCLUSIONS

We highlight the common use of off-patent essential cancer medicines in indications that remain off-label despite solid supporting data as well as generate evidence on the adverse impact on patient access and clinic workflows. In the current regulatory framework, incentives to promote the extension of indications of off-patent cancer medicines are needed for all stakeholders.

Streamlining clinical research: an ESMO awareness call to improve sponsoring and monitoring of clinical trials

BACKGROUND

During recent years, the burden of bureaucracy in clinical research has increased dramatically, adversely impacting the activity of investigators and clinical research teams. Although compliance with the Declaration of Helsinki, the guidelines for Good Clinical Practice (GCP), and other applicable regulations remains unquestionable, their overinterpretation and substitution by the internal operating procedures of sponsors and Contract Research Organizations (CROs) have increased the administrative burden. A survey conducted by the European Society for Medical Oncology (ESMO) Clinical Research Observatory (ECRO) among 940 investigators confirmed that they considered that the administrative burden in clinical research is excessive; that administrative procedures could be reduced without affecting the safety and the rights of the patients and the quality of the data; and that bureaucracy represents an obstacle for clinical research.

METHODS

A panel of physicians with extensive experience in clinical research, composed by members of the ECRO and the ESMO Scientific Medical and Public Policy divisions, analyzed clinical trial procedures related to administrative workflow, pharmacovigilance, and medical care.

RESULTS

The panel identified situations that generate debate between investigators and sponsors/CROs and selected real clinical scenarios that exemplify such situations. The panel discussed and proposed specific recommendations for those situations, based on GCP.

CONCLUSIONS

This initiative aspires to streamline clinical research procedures and to become a platform for discussion among all clinical trial stakeholders, with the aim of promoting the sustainability of clinical research and the care of cancer patients.

Distribution of the workforce involved in cancer care: a systematic review of the literature

Background

A skilled health workforce is instrumental for the delivery of multidisciplinary cancer care and in turn a critical component of the health systems. There is, however, a paucity of data on the vast inequalities in cancer workforce distribution, globally. The aim of this study is to describe the global distribution and density of the health care workforce involved in multidisciplinary cancer management.

Methods

We carried out a systematic review of the literature to determine ratios of health workers in each occupation involved in cancer care per 100 000 population and per 100 cancer patients (PROSPERO: protocol CRD42018095414).

Results

We identified 33 eligible papers; a majority were cross-sectional surveys (n = 16). The analysis of the ratios of health providers per population and per patients revealed deep gaps across the income areas, with gradients of workforce density, highest in high-income countries versus low-income areas. Benchmark estimates of optimal workforce availability were provided in a secondary research analysis: mainly high-income countries reported workforce capacities closer to benchmark estimates. A paucity of literature was defined for critical health providers, including for pediatric oncology, surgical oncology, and cancer nurses.

Conclusion

The availability and distribution of the cancer workforce is heterogeneous, and wide gaps are described worldwide. This is the first systematic review on this topic. These results can inform policy formulation and modelling for capacity building and scaleup.

•

Workforce is an essential component of the health systems.

•

Stark inequalities are reported for the distribution of health workforce worldwide, but data are limited.

•

We aimed at portraying the first global figure of the comprehensive cancer workforce for cancer management.

•

Inequalities in density and distribution of the workforce regard all the key health personnel involved in cancer management.

•

These data will inform the development of evidence-informed policies for the workforce in low- and middle-income countries.

Impact of COVID-19 epidemic on Lombardy’s prisons (Italy): transmission and measure of prevention

Background

Early on in the COVID-19 pandemic, scientific community highlighted the potential risk of epidemics occurring inside prisons. Consequently, specific operational guidelines were promptly released and stringent containment measures quickly implemented, including access restriction to essential staff only. During the 2nd epidemic wave prevention strategies were gradually relaxed, visitors were readmitted and people in prison (PiP) activities were repristinated. Here, we describe the spread of COVID-19 in 18 detention facilities in Lombardy region, Italy, during the 1st(Mar-Jul 2020) and 2nd(Oct 2020-Feb 2021) waves and the impact of prevention and control measures implemented in prison.

Methods

We conducted a descriptive retrospective analysis of cases' distribution. Moreover, a comparison among the epidemic burden affecting POs and PiP and a correlation analysis between the number of cases occurred and prevention measures implemented were carried out.

Results

Our population consists of a monthly average of 2269 prison officers (POs) and 7604 PiP. POs were at higher risk of contracting COVID-19 during both waves. Occurrence of cases among PiP was temporally associated with cases among POs. There was heterogeneity in the size of outbreaks across different prison facilities. During the second wave, COVID-19 spread more widely in prison both among POs (2ndwave attack rate (AR) per 1000 individuals: 27.2; monthly range (MR): 0.9-64.5 vs 1stwave AR 2.4; MR: 0.0-12.1) and PiP (2ndwave AR: 23.5; MR: 11.6-50.8 vs 1stwave AR 1.6; MR: 0-5.2).

Conclusions

Prevention and control measures adopted timely during the first wave were effective to limit Sars-CoV-2 spread within prison facilities. According to our findings, POs and PiP are population groups at high risk for acquiring and transmitting COVID-19 and should be prioritized for testing, active case finding and vaccination. This study highlights the importance of including prison settings within emergency preparedness plans.

Key messages

Stringent prevention and control measures when adopted timely were effective to protect detention facilities from Sars-CoV-2 spread. Our study, reporting the burden of COVID-19 epidemic experienced by prison of Lombardy, Italy, highlights the importance of including prison settings within emergency preparedness plans.

The EMA review of trastuzumab emtansine (T-DM1) for the adjuvant treatment of adult patients with HER2-positive early breast cancer

Trastuzumab emtansine (T-DM1) is an antibody-drug conjugate of trastuzumab [a monoclonal antibody against human epidermal growth factor receptor 2 (HER2)] and DM1 (an inhibitor of tubulin polymerisation). It was initially approved in the European Union for the treatment of adult patients with HER2-positive unresectable locally advanced or metastatic breast cancer (BC) who had previously received trastuzumab and taxanes. On 18 December 2019, a variation of the marketing authorisation was approved extending this use to the adjuvant therapy of adult patients with HER2-positive early BC who have residual invasive disease in the breast and/or lymph nodes after neoadjuvant taxane-based and HER2-targeted therapy. A phase III randomised, multicentre, open-label trial compared T-DM1 with trastuzumab as adjuvant therapy in patients with HER2-positive early BC who had received preoperative chemotherapy and HER2-targeted therapy followed by surgery, with a finding of invasive residual disease in the breast and/or axillary lymph nodes. The study met its primary endpoint by showing an increased 3-year invasive disease-free survival rate in the T-DM1 arm (88.3%) compared with the trastuzumab arm (77.0%), with an unstratified hazard ratio of 0.50 (95% confidence interval: 0.39-0.64). There was a higher incidence of hepatotoxicity (37.3% versus 10.6%), thrombocytopenia (28.5% versus 2.4%), peripheral neuropathy (32.3% versus 16.9%), haemorrhage (29.2% versus 9.6%) and pulmonary toxicity (2.8% versus 0.8%) in the T-DM1 arm compared with the control arm. The aim of this manuscript was to summarise the scientific review of the application leading to regulatory approval of this additional indication in the European Union.

•

T-DM1 was approved for the adjuvant therapy of HER2+ early BC not in pathological complete response after taxanes + anti-HER2 neoadjuvant therapy.

•

A phase III randomised trial revealed an increased 3-year invasive disease-free survival rate in patients receiving T-DM1 compared with trastuzumab.

•

Patients receiving T-DM1 experienced more hepatotoxicity, thrombocytopenia, neuropathy, bleeding and lung toxicity.

The FOODia-Net Protocol

The increasing of chronic diseases represents a worldwide issue and conceiving effective operating models of preventive care looks mandatory to satisfy new health and social needs. It is known from Evidence-Based Medicine that to combine a multidisciplinary/multiprofessional care approach with the promotion of patients’ health literacy and correct lifestyle can improve chronic diseases management at global level.

Five Italian Regions are currently collaborating in the framework of the National Centre for Diseases Prevention and Control Research Call funded by the Italian Ministry of Health. The Project ultimate goal is the implementation of an innovative skill-mix-change operating Protocol aimed to promote patient engagement and food literacy about diabetes and its complications. To pursuit this objective and to conduct the Project dissemination activities, the creation of a dedicated web-based platform is scheduled. The assessment of the effectiveness and sustainability of the whole Project is foreseen.

A non-systematic review of available publications about existing skill-mix-change approaches designed to promote food literacy and patient engagement has been performed and a cross-sectional study to investigate food literacy of diabetic patients has been drawn up. It was approved by Local Review Board in February 2020. Meanwhile a requirements audit among Partners has been carried out to outline the ICT framework for commissioning the creation of the web-based platform to support dissemination activities.

The Project is ongoing. With the aim to preliminary map existing educational initiatives on diabetes an initial scenario analysis shows that: counselling initiatives are performed in 89% of GPs groups; patient engagement initiatives in 52% and training initiatives in 58%. Training initiatives for professionals take place in 27% of clinics; at least 1 initiative, on diabetes prevention or food literacy promotion, is carried out in each of the 9 Associations registered.

HCV test&treat in Milan prisons-an effective strategy for microelimination and health gaps reduction

Background

People in prison represent a high-risk population for HCV infection control due the overrepresentation of people with a history of intravenous drug use, psychiatric patients and other vulnerable populations who have often reduced access to healthcare. With the advent of new direct antiviral agents (DAAs) HCV micro-elimination in prison setting became a feasible strategy.

Methods

We conducted in 2017 and 2018 a cross-sectional evaluation of HCV treatment cascade in one detention prison, Opera (OP), and one pre-trial detention center, San Vittore (SV) in Milan. A dedicated protocol for HCV eligibility and care was applied. We collected data on demographics, HCV testing and treatment on all inmates on October 31st 2017 and 2018. Data collection ended on December 31st of each year.

Results

On October 31st 2017, 2366 inmates were living in the two facilities, 2369 in 2018, of these, 1036 (43,7%) were already present in 2017 (71,3% in OP; 28,7% in SV). In both years the majority were men (95.4%; 96,4%) with a median age of 41 years and Italians (57%; 61,9%). Prevalence of reported drug use remained high (46,5%; 44,2%). HCV screening coverage was 89% in both years, while HCV-RNA test coverage increased (90,6%; 99%). HCV Ab+ was stable (212, 10.1%; 194, 9,2%). At the end of 2017 and 2018, 106 (50%) and 117 (60,3%) started treatment eligibility process of which 90 (42,4%) and 106 (54,6%) completed DAAs in prison. Considering last available viremia, 41 inmates (19,3%) were viremic in 2017 (OP 16.1%; SV 24,4%), while only 13 inmates (6,7%) in 2018 (OP < 1%, SV 15,4%). On December 31st 2018, among HCV Ab+ detainees 122 (62,9%) were never linked to care before incarceration.

Conclusions

Our study shows the success of the HCV testing and treatment strategy to achieve HCV micro-elimination in a prison setting with a significant drop in the pool of viremic individuals. We highlight how prison health care may represent a unique point of access for vulnerable population.

Key messages

HCV micro-elimination is a feasible and effective strategy in prison settings. High-quality healthcare in prison contributes to reduce health gaps and improve access for socially deprived population.

Intra-Arterial Liver Chemotherapy and Hormone Therapy in Malignant Insulinoma: Case Report and Review of the Literature

Background

Malignant insulinoma is a rare tumor. Metastatic disease confined to the liver can be treated with various locoregional treatments.

Case report

We report a case of a young woman who developed liver metastases twelve years following resection of a pancreatic insulinoma positive to anti-insulin antibodies. With five cycles of intra-arterial locoregional chemotherapy (fluorouracil and epirubicin) to the liver and monthly hormone therapy (octreotide) the patient obtained a clinical complete response. After twelve months she is still disease free.

Conclusion

Locoregional therapy for insulinoma metastatic to the liver might represent the treatment of choice; hepatic intra-arterial chemotherapy is an interesting therapeutic approach which deserves attention. The role of somatostatin analogs is limited to symptom control.

The Use of Lausanne Trilogue Play in Three Cases of Gastroschisis Diagnosed during Pregnancy

From pregnancy to the 1st years of a child’s life, families develop and increase representations and interactive competences toward the child. Prenatal diagnosis of a severe fetus’ defect could profoundly alter the parental perception and development of these representations. The aim of the study was to evaluate triadic interactions in families, whose baby was prenatally diagnosed with severe gastroschisis. Three families took part in the preliminary case study, which was carried out when the babies were 6 months old. The Lausanne Trilogue Play shows that prenatal diagnosis of fetal malformation may affect family triadic interactions as follows: (a) parents, especially mothers, tend to be intrusive during the play; (b) parents presents maladjustments in the child stimulations, especially during the third part, when both parents have to simultaneously interact with the baby; (c) parents experience difficulties in creating a space that allows them to communicate directly with each other, leaving the child in a peripheral position. Observational data and clinical implications are discussed.

PRE- AND POSTNATAL MODIFICATIONS IN PARENTAL MENTAL REPRESENTATIONS IN THREE CASES OF FETAL GASTROSCHISIS DIAGNOSED DURING PREGNANCY

The aim of this study was to identify possible effects of gastroschisis on parents' intrapsychic dynamics by applying an observational clinical approach. More specifically, we intend to (a) evaluate the representational style of parents informed about the diagnosis of fetal gastroschisis during pregnancy using the Interview of Maternal Representations During Pregnancy and the Interview of Paternal Representations During Pregnancy (M. Ammaniti, C. Candelori, M. Pola, & R. Tambelli, ) and (b) observe whether the baby's birth influences the parents' representational styles through the application of the same tools (the Interview of Maternal Representations After the Birth, M. Ammaniti & R. Tambelli, , and the Interview of Paternal Representations After the Birth, M. Ammaniti & R. Tambelli, ), adapted to the postnatal period. During the prenatal period, all parents showed a restricted/disinvested style. Three parents-one mother and two fathers-changed their styles from restricted/disinvested to integrated between pregnancy and Month 6 after the birth of their child. Clinical data from the interviews and observations are discussed in an attempt at better defining intrapsychic dynamics of parents after a diagnosis of gastroschisis.

Influence of different blanching methods on colour, ascorbic acid and phenolics content of broccoli

Lack of nutrients in cooking water, high energetic costs, high water consumption and recycling are some drawbacks of vegetable blanching. Those disadvantages could be bypassed using microwave blanching. Three blanching methods (microwave, boiling water and steaming) were compared in this study in order to determine their effects on some functional properties of broccoli. In addition, the thermal damage on broccoli colour was evaluated. The effectiveness of each blanching process was performed measuring the lost of peroxidase activity, that results more rapidly in microwaves and steam treatments (50 and 60 s respectively) than in boiling water treatment (120 s). The colour indexes did not allow to discriminate a significant difference among treatments. The increase of treatment time caused a vitamin C decrease in samples blanched by boiling water and steam; this trend was not observed in microwaved samples. The phenols content did not significantly vary depending both on type and on time of treatment.

Intranasal adminsitration of oxytocin in postnatal depression: implications for psychodynamic psychotherapy from a randomized double-blind pilot study

Oxytocin is a neuropeptide that is active in the central nervous system and is generally considered to be involved in prosocial behaviors and feelings. In light of its documented positive effect on maternal behavior, we designed a study to ascertain whether oxytocin exerts any therapeutic effects on depressive symptoms in women affected by maternal postnatal depression. A group of 16 mothers were recruited in a randomized double-blind study: the women agreed to take part in a brief course of psychoanalytic psychotherapy (12 sessions, once a week) while also being administered, during the 12-weeks period, a daily dose of intranasal oxytocin (or a placebo). The pre-treatment evaluation also included a personality assessment of the major primary-process emotional command systems described by Panksepp () and a semi-quantitative assessment by the therapist of the mother's depressive symptoms and of her personality. No significant effect on depressive symptomatology was found following the administration of oxytocin (as compared to a placebo) during the period of psychotherapy. Nevertheless, a personality trait evaluation of the mothers, conducted in our overall sample group, showed a decrease in the narcissistic trait only within the group who took oxytocin. The depressive (dysphoric) trait was in fact significantly affected by psychotherapy (this effect was only present in the placebo group so it may reflect a positive placebo effect enhancing the favorable influence of psychotherapy on depressive symptoms) but not in the presence of oxytocin. Therefore, the neuropeptide would appear to play some role in the modulation of cerebral functions involved in the self-centered (narcissistic) dimension of the suffering that can occur with postnatal depression. Based on these results, there was support for our hypothesis that what is generally defined as postnatal depression may include disturbances of narcissistic affective balance, and oxytocin supplementation can counteract that type of affective disturbance. The resulting improvements in well-being, reflected in better self-centering in post-partuent mothers, may in turn facilitate better interpersonal acceptance of (and interactions with) the child and thereby, improved recognition of the child's needs.

Pregnancy and postpartum following a prenatal diagnosis of fetal thoracoabdominal malformation: the parental perspective

PURPOSE

The study's aim was to evaluate how information related to a prenatal diagnosis of fetal malformation could modify parenthood experience descriptions during pregnancy and after the child's birth.

METHODS

A longitudinal case-control clinical study was conducted. Data on parenthood experience descriptions collected using a validated semantic differential technique during pregnancy and after the child's birth were compared between seven couples of parents receiving a prenatal diagnosis of fetal malformation and seven couples without any fetal diagnosis.

RESULTS

Our results show that during pregnancy parents in the clinical group describe themselves as more fragile, passive, and timid [p=0.007] than those in the control group. On the other hand, after the child's birth, there are no significant differences between groups.

CONCLUSIONS

Data are discussed with reference to better knowledge of the psychological dynamics involved in becoming a parent and to rational planning of support for parents receiving a diagnosis of fetal malformation.

Randomized trial of safinamide add-on to levodopa in Parkinson's disease with motor fluctuations

Levodopa is effective for the motor symptoms of Parkinson's disease (PD), but is associated with motor fluctuations and dyskinesia. Many patients require add-on therapy to improve motor fluctuations without exacerbating dyskinesia. The objective of this Phase III, multicenter, double-blind, placebo-controlled, parallel-group study was to evaluate the efficacy and safety of safinamide, an α-aminoamide with dopaminergic and nondopaminergic mechanisms, as add-on to l-dopa in the treatment of patients with PD and motor fluctuations. Patients were randomized to oral safinamide 100 mg/day (n = 224), 50 mg/day (n = 223), or placebo (n = 222) for 24 weeks. The primary endpoint was total on time with no or nontroublesome dyskinesia (assessed using the Hauser patient diaries). Secondary endpoints included off time, Unified Parkinson's Disease Rating Scale (UPDRS) Part III (motor) scores, and Clinical Global Impression-Change (CGI-C). At week 24, mean ± SD increases in total on time with no or nontroublesome dyskinesia were 1.36 ± 2.625 hours for safinamide 100 mg/day, 1.37 ± 2.745 hours for safinamide 50 mg/day, and 0.97 ± 2.375 hours for placebo. Least squares means differences in both safinamide groups were significantly higher versus placebo. Improvements in off time, UPDRS Part III, and CGI-C were significantly greater in both safinamide groups versus placebo. There were no significant between-group differences for incidences of treatment-emergent adverse events (TEAEs) or TEAEs leading to discontinuation. The addition of safinamide 50 mg/day or 100 mg/day to l-dopa in patients with PD and motor fluctuations significantly increased total on time with no or nontroublesome dyskinesia, decreased off time, and improved parkinsonism, indicating that safinamide improves motor symptoms and parkinsonism without worsening dyskinesia.

Exposure to bisphenol A modulates hormone concentrations in Gammarus pseudolimnaeus

Bisphenol A (BPA) is an endocrine-disrupting compound that can enter aquatic systems through landfill leachate or wastewater effluent. Although impacts of BPA on vertebrates are well documented, its effects on invertebrates are less clear. Amphipods such as Gammarus pseudolimnaeus Bousfield, 1958 are often prevalent invertebrates in freshwater ecosystems and can provide a powerful invertebrate model system to investigate the endocrine-disruptive capabilities of BPA. However, techniques to assay hormone concentrations in amphipods, especially vertebrate-like steroid sex hormones, are not widespread. In this study, we (i) quantified estrogen concentrations in juveniles and in adult female amphipods; (ii) quantified testosterone concentrations in juveniles and in adult male amphipods; and (iii) delineated changes to estrogen and testosterone concentrations of adults and juveniles following a 9-day exposure to BPA at four levels: 0 (control), 10, 50, and 100 µg/L BPA. Tissue extracts from homogenized samples were analyzed for estrogen or testosterone concentrations via radioimmunoassay for each reproductive class of amphipod. Low concentrations of BPA significantly increased estrogen concentrations in adult females and in juveniles. Moderate and high concentrations of BPA significantly increased testosterone concentrations in adult males, and low and moderate concentrations of BPA significantly increased testosterone concentrations of juveniles.

Long-term efficacy and safety of safinamide as add-on therapy in early Parkinson's disease

BACKGROUND AND PURPOSE

Safinamide is an α-aminoamide with both dopaminergic and non-dopaminergic mechanisms of action in Phase III clinical development as a once-daily add-on to dopamine agonist (DA) therapy for early Parkinson's disease (PD).

METHODS

Study 017 was a 12-month, randomized, double-blind, placebo-controlled pre-planned extension study to the previously reported Study 015. Patients received safinamide 100 or 200 mg/day or placebo added to a single DA in early PD. The primary efficacy endpoint was the time from baseline (Study 015 randomization) to 'intervention', defined as increase in DA dose; addition of another DA, levodopa or other PD treatment; or discontinuation due to lack of efficacy. Safinamide groups were pooled for the primary efficacy endpoint analysis; post hoc analyses were performed on each separate dose group.

RESULTS

Of the 269 patients randomized in Study 015, 227 (84%) enrolled in Study 017 and 187/227 (82%) patients completed the extension study. Median time to intervention was 559 and 466 days in the pooled safinamide and placebo groups, respectively (log-rank test; P = 0.3342). In post hoc analyses, patients receiving safinamide 100 mg/day experienced a significantly lower rate of intervention compared with placebo (25% vs. 51%, respectively) and a delay in median time to intervention of 9 days (P < 0.05; 240- to 540-day analysis).

CONCLUSIONS

The pooled data from the safinamide groups failed to reach statistical significance for the primary endpoint of median time from baseline to additional drug intervention. Post hoc analyses indicate that safinamide 100 mg/day may be effective as add-on treatment to DA in PD.

Different approaches in the molecular analysis of the SHOX gene dysfunctions

Deficit of the short stature homeobox containing gene (SHOX) accounts for 2.15% of cases of idiopathic short stature (ISS) and 50-100% of cases of Leri-Weill dyschondrosteosis (LWD). It has been demonstrated that patients with SHOX deficit show a good response to treatment with GH. Thus, the early identification of SHOX alterations is a crucial point in order to choose the best treatment for ISS and LWD patients. In this study, we analyze the most commonly used molecular techniques for the detection of SHOX gene alterations. multiple ligation-dependent probe amplification analysis appears to represent the gold standard for the detection of deletion involving the SHOX gene or the enhancer region, being able to show both alterations in a single assay.

Peritoneal disease in breast cancer: A specific entity with an extremely poor prognosis

e12023

Background: We are observing increasing numbers of patients with advanced breast cancer and peritoneal metastases. There are few published data regarding the prognosis, clinical characteristics, and management of such individuals. Methods: The electronic imaging database at Charing Cross Hospital was searched for the terms ’breast,’ ’cancer or tumor,’ ’peritoneal,’ and ’ascites’ from 2000–2008. Those with confirmed peritoneal disease from breast cancer, as described on ultrasound or staging CT reports with a clinico-pathologic confirmed diagnosis, were included in the study. Results: A total of 1,628 scans were screened and initially 168 patients were identified. A subsequent total of 44 individuals (2.7% of the metastatic cohort) were included in this study, as having breast cancer with peritoneal secondaries. Of these, the majority (77%) had invasive ductal carcinomas (IDC). While the median survival from the diagnosis of metastatic breast cancer measured 20.5 months (range 0.1 -125 months), the median survival of patients with peritoneal disease was 1.56 months (range 0.2 - 27 months). Conclusions: Our data shows that the median survival of patients with peritoneal breast cancer metastasis is surprisingly poor, with only a minority surviving more than six months. A specific association with invasive lobular carcinoma (ILC) was not observed. The dismal outcome of these individuals despite further active therapy merits their inclusion into trials of new treatments.

No significant financial relationships to disclose.

Dose finding study of the combination of satraplatin and gemcitabine in patients with advanced solid tumors

e13534

Background: The potential advantage of combining satraplatin (S) a novel oral platinum with Gem is attractive. MTD and DLT of combination S and Gem in patients (pts) with advanced solid tumors was evaluated. Methods: Cohorts of 3–6 pts (modified Fibonacci) received escalating doses of i.v. Gem on days (d) 1, 8 and 15 Q 28 d followed by oral S on d 1–5. Seventeen pts with metastatic solid tumors were separated into 2 groups: A) Pts that had progressed following cytotoxic therapy and B) Pts who had received no prior chemotherapy. Starting dose was Gem 800 mg in both groups, S 40 mg and 60 mg for A and B respectively. Results: Group A. 6 previously treated pts with 1 or 2 regimens (3 prostate, 1 hepatocarcinoma, 1 bladder and 1 thymic ca) received 25 cycles, median 2 (2–12). 2 DLTs (G3 transaminases) were observed in 6 pts treated at level 1. Other G3 major toxicities were: thrombocytopenia (1 pt) and diarrhea (1 pt). 2 pts had PSA declines, with TTP of 630 days in 1 of them. Group B. 11 pts with no prior chemotherapy (4 hepatocarcinoma, 4 pancreas, 1 renal, 1 unknown origin and 1 gallbladder), received 38 cycles, median 2 (1–12). 1 DLT (G3 diarrhea) was observed in 8 pts treated at level 1 (2 not evaluable; received Gem d1 only), DLT (G3 thrombocytopenia) was observed in 3 pts treated at level 2 (Gem 1000, S 60). Other G3 toxicities were: thrombocytopenia (3 pts) and neutropenia (3 pts). 1 CR (pancreas) and 1 PR (gallbladder) were observed. Gem d8 or d15 was omitted in 11 of 17 pts during the 1st cycle. Conclusions: In this study the combination of S and Gem showed a clinically acceptable toxicity profile with promising antitumor activity. However, since in cycle 1, it was not possible to administer Gem on both d8 and d15 on 11 occasions, a 2nd study was initiated with S d1–3 and Gem d1 and 8 given on a Q 21 d schedule. Sponsored by GPC Biotech

No significant financial relationships to disclose.

A comparative in vitro study of the toxic potency of five inorganic lead compounds on a rat liver epithelial cell line (REL)

Relative insolubility of inorganic Pb compounds is one of the major problems in the evaluation of the toxicological profile of this metal. Different characteristics of Pb-containing solutions may, in fact, alter the biological properties of Pb compounds and influence their toxic potency. To investigate these aspects, we used selected experimental conditions to evaluate and compare the specific biological effects of five inorganic Pb compounds (soluble salts and oxide) on the viability and proliferation rate of a rat liver-derived cell line (REL cells). The study was performed according to classical toxicological criteria (dose- and time-response, reversibility/transience of the effect). Each Pb compound was accurately solubilised and the quantification of the real concentration of Pb(II) ions was performed either on the culture media used for each treatment, or on the extracts of exposed cells. Our study shows that four, out of the five Pb compounds we tested, induce the same dose- and time-related anti-proliferative effects on REL cells, being these effects also reversible, transient and directly related to the intracellular content of the metal. Since the intracellular concentration of the metal and, consequently, its biological effects on REL cells, directly depends on the bioavailability of the Pb(II) cation present in the treatment solutions, our results indicate that, in the experimental procedures aimed to assess the toxic potency of this metal, the solubility of each Pb compound should be carefully evaluated and taken into account.

Human herpesvirus-8-related Kaposi's sarcoma after liver transplantation successfully treated with cidofovir and liposomal daunorubicin

The iatrogenic form of Kaposi's sarcoma (KS) is typically observed among transplant recipients, and the most appropriate therapeutic approach (usually including reduction of immunosuppression, specific chemotherapy, and/or administration of antiviral agents against human herpes virus-8) is still controversial. Available experiences on the effect of the anti-herpes viruses drug cidofovir provide conflicting results. Herein, we report the clinical, histological, and virological features of a liver transplant recipient successfully treated with a combined therapy of cidofovir and liposomal daunorubicin, associated with a reduction of the immunosuppressive regimen, for an advanced cutaneous and visceral KS.

[Inorganic lead stimulates endothelin secretion in the MDCK cell line]

BACKGROUND

Lead (Pb) is an environmental toxin whose acute intoxication causes haematological, gastrointestinal and neurological dysfunctions. Moreover it is well-established that prolonged exposure to low levels of inorganic Pb compounds is closely related to hypertension in experimental animals and occupationally exposed humans. Previous reports have suggested that endothelins (ETs), a family of peptides with potent vasoconstrictive properties, might be involved in the pathogenesis of lead-induced hypertension. In vivo studies demonstrated that rats chronically exposed to Pb low levels exhibited blood pressure elevation coupled with an increase of ET-3 concentration in plasma and urine in comparison with control animals.

OBJECTIVE

Since kidney is one of the target organs of lead injury, as well as the site of production/action of ETs, we investigated the effects of an inorganic Pb compound (Pb chloride) on the synthesis and secretion of these peptides, using, as in in vitro model, a renal-derived cell line (MDCK).

METHODS

The ETs assays in culture media of sub-confluent cell cultures exposed to different concentration of PbCl2 were performed by Enzyme linked Immunoassay (EIA), using two experimental procedures: a) cultures were exposed to 1100 and 200 microM PbCl2 for 30 min, next cells received Pb-free culture medium up to 24 h (pulse/chase experiment); b) cultures were fed continuously up to 24 h with treatment media containing the same PbCl2 concentrations (pulse experiment). Concomitantly, the Pb influence on cell viability was evaluated by different cytotoxicity assays (LDH release, DAPI staining and cell density assays). The mRNA expression of ET-1 was evaluated in pulse experiments by RT-PCR analysis before and after cell exposure to PbCl2. The Pb2+ cellular content of parallel MDCK cell cultures was assessed by AAS analysis.

RESULTS

In our experimental conditions, the administration of PbCl2 to sub-confluent MDCK cell cultures did not significantly affect cell viability. Either in pulse or in pulselchase experiments, the ETs content, evaluated in culture media of cells exposed to 100 microM PbCl2, significantly increased. On the contrary, cell treatment with 1 or 200 microM PbCl2 did not modify the ETs secretion. Because the amounts of ETs released in culture media were similar in both kinds of experiment, our results suggest that the metal induces the ETs secretion already after 30 min of cell exposure to the toxicant. Moreover, the ET-3 EIA specific assay did not reveal any immunoreactivity, excluding the involvement of this isoform in the Pb-induced secretion of ETs. Additionally, our results seem to exclude any Pb-induced up-regulation of ET-1 transcripts. The Pb2+ quantification in cell extracts demonstrated that the uptake of the metal is dose- and time-dependent and, in pulse experiments, it was maximum after six hours from the beginning of treatments, then the intracellular Pb2+ content decreased. This last phenomenon suggests the involvement of an ATP-dependent transporter in the mechanism of Pb cell excretion. Moreover, the ETs cell release in culture media of MDCK cells appears to depend on the intracellular content of Pb ions reached within 30 min of treatment.

CONCLUSION

Our results indicate that there is a range of PbCl2 doses (100 microM) at which MDCK cells enhance their ETs secretion. Lower doses (1 microM) of Pb salt seem to be ineffective to stimulate ETs release, while, doses equivalent to 200 microM seem to inhibit this phenomenon.

Cytosolic sialidase Neu2 upregulation during PC12 cells differentiation

The cytosolic sialidase Neu2 is known to be involved in myoblast differentiation. Here, we observed a Neu2 transcriptional induction during nerve growth factor, fibroblast growth factor 2 and epidermal growth factor treatments of PC12 cells, a favored model to study neuronal differentiation. The expression analysis of Neu2 deleted promoter revealed a remarkable increase of luciferase activity in treated PC12 cells, suggesting that in this cell line the Neu2 transcriptional levels are highly regulated. The enzymatic activity of cytosolic sialidase Neu2 was found to increase transiently only during differentiation, whereas was undetectable in untreated PC12 cells. These data suggest a possible involvement of cytosolic sialidase Neu2 in differentiation of PC12 cells.

The pipeline of new anticancer agents for breast cancer treatment in 2003

In recent years, strategy in cancer therapy in general, and breast cancer in particular, has been the use of maximum tolerated doses of toxic non-specific agents as well as the investigation of a range of new agents that specifically target tumor-related molecules, in a variety of biological pathways. The trial of chemotherapy (CT) versus chemotherapy+trastuzumab (Herceptin) in HER-2-overexpressing metastatic breast cancer (MBC) was one of the first to use a biological agent in combination with chemotherapy with success and, together with some trials of taxanes in anthracycline-resistance patients one of the few to demonstrate an overall survival (OS) advantage in MBC. Five main molecular pathways are of particular interest in terms of new drug development in breast cancer: the estrogen receptor (ER) pathway, the tyrosine kinase signal transduction pathway, the cell cycle regulation pathway, the apoptosis pathway and the angiogenesis pathway. This review will focus on new agents, cytotoxic, hormonal and molecular-targeted, which are in advanced clinical stages of development for the treatment of MBC.

Antioxidant potential and gap junction-mediated intercellular communication as early biological markers of mercuric chloride toxicity in the MDCK cell line

In this study, the early nephrotoxic potential of mercuric chloride (HgCl(2)) has been evaluated in vitro, by exposing a renal-derived cell system, the tubular epithelial Madin-Darby canine kidney (MDCK) cell line, to the presence of increasing HgCl(2) concentrations (0.1-100 microM) for different periods of time (from 4 to 72 h). As possible biological markers of the tubular-specific toxicity of HgCl(2) in exposed-MDCK cultures we analysed: (i) critical biochemical parameters related to oxidative stress conditions and (ii) gap-junctional function (GJIC). HgCl(2) cytotoxicity was evaluated by cell-density assay. The biochemical analysis of the pro-oxidant properties of the mercuric ion (Hg(2+)) was performed by evaluating the effect of the metal salt on the antioxidant status of the MDCK cells. The cell glutathione (GSH) content and the activity of glutathione peroxidase (Gpx) and catalase (Cat), two enzymes engaged in the H(2)O(2) degradation, were quantified. HgCl(2) influence on MDCK GJIC was analysed by the microinjection/dye-transfer assay. HgCl(2)-induced morphological changes in MDCK cells were also taken into account. Our results, proving that subcytotoxic (0.1-10 microM) HgCl(2) concentrations affect either the antioxidant defences of MDCK cells or their GJIC, indicate these critical functions as suitable biological targets of early mercury-induced tubular cell injury.

HIV-1, HAART and bone metabolism

Much attention has been paid to the emerging complications of HIV infection in patients receiving HAART. Recently, there emerged a potentially increased risk of bone problems like osteopenia, osteoporosis and osteonecrosis as patients live longer. It could be a drug side effect, a consequence of prolonged exposure to HIV and/or activated immune cells characteristic of HIV infection, or a consequence of immune system changes that accompany suppression of virus by the drugs. Future research should focus on the etiologic mechanisms, define the incidence and prevalence prospectively, determine the relationship with HAART (especially the rule of protease inhibitors), and help to guide management. Only when the mechanism for HIV-related versus HAART-related changes can be defined, will we be much closer to designing specific interventions.

[In vitro study of the nephrotoxic mechanism of mercuric chloride]

OBJECTIVES

Mercury (Hg), one of the most diffused and hazardous organ-specific environmental contaminants, exists in a wide variety of physical and chemical states, each of which with unique characteristics of target organ specificity. Exposure to Hg vapour and to organic mercurials specifically affects the CNS, while the kidney is the target organ for inorganic Hg compounds. Despite the increasing number of studies, the molecular bases of the nephrotoxic potential of Hg has not, up to now, been clarified, even if there is evidence suggesting that the ability of the metal to interact with proteins (thiol groups) or to generate oxygen radicals may play a major role. Within this context, the aim of the present study was to investigate, in vitro, the mechanism(s) of the early nephrotoxic potential of mercury chloride (HgCl2), one of the most diffused and biologically active mercury (Hg2+) compounds. For this purpose, two kidney-derived in vitro systems (the MDCK and the LLC-PK1 cell lines) were tested for their sensitivity to the salt, and MDCK was chosen as the most suitable in vitro model for our study. As possible biological markers of the organ-specific toxicity of the metal we analysed: i) critical biochemical parameters related to oxidative stress conditions (effect of Hg2+ on the anti-oxidant status of the cell), and ii) gap-junctional function (GJIC).

METHODS

Classical toxicity tests (MTT and NR) were used for assessing the sensitivity (IC50) of LLP-CK1 and MDCK cell lines to the mercuric salt. Complete solubilisation of the salt in the culture media was verified by inductively coupled plasma mass spectrometry (ICP-MS). The influence of the metal on cell growth rate and viability were evaluated by conventional proliferation assays. For the following mechanistic studies, cells were exposed for different time periods (4 to 72 hours) to non-cytotoxic (0.1-50 microM) HgCl2 concentrations. The biochemical analysis of the pro-oxidant properties of the mercuric compound was performed by the measurement of anti-oxidant cellular defences against H2O2 [catalase (Cat), glutathione peroxidase (Gpx), and total glutathione (GSH)]. The influence of the metal on the GJIC capacity of MDCK cells was assessed by the "microinjection/dye-coupling" assay.

RESULTS

Among the two kidney-derived in vitro systems, MDCK cell line was the most specifically sensitive to the toxic effect of HgCl2: it was, consequently, chosen as a "tubular cell model" for the following experimental steps. Tested for various time periods at increasing concentrations, the HgCl2 effect on MDCK cell proliferation and viability was found to be time- and dose-related. For concentrations < or = 50 microM, HgCl2 inhibits MDCK cell growth rate, being this effect significant (> 50% in respect to untreated controls) from the 24th from the beginning of the treatment, while, for concentrations > 50 microM, the metal causes cell death. Concerning the influence of HgCl2 on MDCK anti-oxidant defences, the most interesting results were obtained by analysing the influence of the mercury salt on the GSH cell content and Gpx activity. Both were, in fact, significantly affected by the presence of the mercury ion. HgCl2 also induced a rapid, dose- and time-related inhibitory effect on the GJIC capacity of the cells.

CONCLUSIONS

Even if further investigations are needed to better clarify the possible causal relationship between our findings, they indicate that: a) MDCK cells represent a suitable in vitro model for the study of Hg nephrotoxicity; b) GJIC function is, among those considered in our study, one of the most sensitive biological endpoints for investigating the mechanism(s) of Hg2+ specific toxicity.

Independent lung ventilation in patients with unilateral pulmonary contusion. Monitoring with compliance and EtCO(2)

OBJECTIVE

a) to describe a non-barotraumatic ventilatory setting for independent lung ventilation (ILV); b) to determine the utility of single lung end-tidal CO(2) (EtCO(2)) monitoring to evaluate the ventilation to perfusion (V/Q) matching in each lung during ILV and for ILV weaning.

DESIGN

prospective study.

SETTING

general intensive care unit in a university teaching hospital.

PATIENTS

twelve patients with unilateral thoracic trauma needing ILV.

INTERVENTIONS AND RESULTS

ILV was started with each lung ventilated with the same tidal volume (Vt): plateau airway pressure (Pplat) was 34.2+/-3.2 cmH2O in diseased lungs (DL) and 18.1+/-1.9 cmH2O in normal lungs (NL) ( P<0.01). Static compliance (Cst) was 9.9+/-1.1 ml/cmH(2)O in DL and 19.3+/-1.7 ml/cmH(2)O in NL ( P<0.01). EtCO2 was 22.5+/-2.2 mmHg in DL and 36.6+/-1.9 mmHg in NL ( P<0.01). PaO(2)/FiO(2) was at 151+/-20. PEEP was applied on the DL and each lung was ventilated with a Vt that developed Pplat < or =26 cmH2O. With this setting, Vt given to the NL was unchanged, whereas it was reduced in the DL (238+/-30 ml vs 350+/-31 ml; P<0.01). Cst and EtCO2 were still significantly lower in the DL ( P<0.01, respectively), while the PaO(2)/FiO(2) ratio remained unchanged. Vt was then progressively increased in the DL as Pplat decreased, but remained unchanged in the NL. ILV was discontinued when Vt, Cst and EtCO(2) were the same in each lung. PaO(2)/FiO(2) ratio had then increased to 295+/-18.

CONCLUSIONS

a) during ILV, adequate oxygenation and a reduction in V/Q mismatch can be obtained by setting Vt and PEEP to keep Pplat below a safe threshold for barotrauma; b) measurement of single lung EtCO2 can be useful to evaluate progressive V/Q matching.

Role of gancyclovir and HAART administration in the treatment of a rare complication of HIV disease: cytomegalovirus-associated Guillain-Barré syndrome

Peripheral nerve disorders are very common in patients with HIV infection, including inflammatory demyelinating polyneuropathies, such as Guillain-Barré syndrome. Causes of these neuropathies are probably multiple, and often dictated by the stage of the underlying HIV disease. Acute demyelinating polyneuropathy is usually preceded by infections, generally sustained by cytomegalovirus or Campylobacter jejuni, and a co-infection with HIV may represent the initial etiopathogenetic event leading to the neurological disorder. An extraordinary case report of a cytomegalovirus-associated Guillain-Barré syndrome occurred in one of our patients with advanced HIV infection, who was cured by gancyclovir and HAART administration, and gives us the opportunity to briefly discuss the intriguing pathogenetic and clinical correlations among HIV disease, cytomegalovirus infection, this neurological syndrome, and its specific treatment.

Assessment of respiratory system mechanics by artificial neural networks: an exploratory study

We evaluated 1) the performance of an artificial neural network (ANN)-based technology in assessing the respiratory system resistance (Rrs) and compliance (Crs) in a porcine model of acute lung injury and 2) the possibility of using, for ANN training, signals coming from an electrical analog (EA) of the lung. Two differently experienced ANNs were compared. One ANN (ANN(BIO)) was trained on tracings recorded at different time points after the administration of oleic acid in 10 anesthetized and paralyzed pigs during constant-flow mechanical ventilation. A second ANN (ANN(MOD)) was trained on EA simulations. Both ANNs were evaluated prospectively on data coming from four different pigs. Linear regression between ANN output and manually computed mechanics showed a regression coefficient (R) of 0.98 for both ANNs in assessing Crs. On Rrs, ANN(BIO) showed a performance expressed by R = 0.40 and ANN(MOD) by R = 0.61. These results suggest that ANNs can learn to assess the respiratory system mechanics during mechanical ventilation but that the assessment of resistance and compliance by ANNs may require different approaches.

Examining new models for the study of autocrine and paracrine mechanisms of angiogenesis through FGF2-transfected endothelial and tumour cells

Angiogenesis is the process of generating new capillary blood vessels. Uncontrolled endothelial cell proliferation is observed in tumour neovascularization. Several growth factors and cytokines have been shown to stimulate endothelial cell proliferation in vitro and in vivo and among them FGF2 was one of the first to be characterised. FGF2 is a Mr 18,000 heparin-binding cationic polypeptide that induces proliferation, migration, and protease production in endothelial cells in culture and neovascularization in vivo. FGF2 interacts with endothelial cells through two distinct classes of receptors, the high affinity tyrosine-kinase receptors (FGFRs) and low affinity heparan sulfate proteoglycans (HSPGs) present on the cell surface and in the extracellular matrix. Besides experimental evidence for paracrine mode of action for FGF2, some observations raise the hypothesis that FGF2 may also play an autocrine role in endothelial cells. FGF2 may therefore represent a target for anti-angiogenic therapies. In order to assess the angiostatic potential of different classes of compounds, novel experimental models have been developed based on the autocrine and/or the paracrine capacity of FGF2.

Modulation of tumor angiogenesis by conditional expression of fibroblast growth factor-2 affects early but not established tumors

Fibroblast growth factor-2 (FGF2) is a pleiotropic heparin-binding growth factor endowed with a potent angiogenic activity in vitro and in vivo. To investigate the impact of the modulation of FGF2 expression on the neovascularization at different stages of tumor growth, we generated stable transfectants (Tet-FGF2) from the human endometrial adenocarcinoma HEC-1-B cell line in which FGF2 expression is under the control of the tetracycline-responsive promoter (Tet-off system). After transfection, independent clones were obtained in which FGF2 mRNA and protein were up-regulated compared with parental cells. Also, the conditioned medium of Tet-FGF2 transfectants caused proliferation, urokinase-type plasminogen activator up-regulation, migration, and sprouting of cultured endothelial cells. A 3-day treatment of Tet-FGF2 cell cultures with tetracycline abolished FGF2 overexpression and the biological activity of the conditioned medium without affecting their proliferative capacity. Tet-FGF2 cells formed tumors when nude mice received s.c. injections. The administration of 2.0 mg/ml tetracycline in the drinking water before cell transplantation, continued throughout the whole experiment, inhibited FGF2 expression in Tet-FGF2 tumor lesions. This was paralleled by a significant decrease in the rate of tumor growth and vascularization to values similar to those observed in lesions generated by parental HEC-1-B cells. Tetracycline administration 20 days after tumor cell implant, although equally effective in reducing FGF2 expression and inhibiting tumor vascularity, only minimally impaired the growth of established Tet-FGF2 tumors. The results indicate that FGF2 expression deeply affects the initial tumor growth and neovascularization of HEC-1-B human endometrial adenocarcinoma in nude mice. On the contrary, the growth of established tumors appears to be independent of the inhibition of FGF2 expression and decreased vascular density. The possibility that a significant reduction of angiogenesis may not affect the progression of large tumors points to the use of antiangiogenic therapy in early tumor stage.

Schedule specific biochemical modulation of 5-fluorouracil in advanced colorectal cancer: a randomized study. GISCAD, IOR and collaborating centers

BACKGROUND

We have recently suggested that bolus 5-fluorouracil (5-FU) may work via a RNA directed mechanism while continuous infusion 5-FU may kill cells via a thymidylate synthase related pathway. It may thus be possible to selectively modulate each schedule biochemically. We have compared an alternating regimen of bolus and continuous infusion 5-FU, selectively modulated for the schedule of administration, with modulated bolus 5-FU in advanced colorectal cancer patients.

PATIENTS AND METHODS

Two hundred fourteen patients from nineteen Italian centers were randomized to the control arm consisting of biweekly cycles of MTX, 200 mg/m2 on day 1, followed by bolus 5-FU 600 mg/m2 on day 2 and 6-S-leucovorin rescue, or to the experimental arm consisting of two biweekly cycles of the same regimen as in the control arm alternated to three weeks of continuous infusion 5-FU (200 mg/m2 day) + weekly bolus 6-S-leucovorin, 20 mg/m2.

RESULTS

Nine CR and twenty-seven PR were obtained on one hundred eleven evaluable patients treated in experimental arm (RR = 32%, 95% confidence interval (95% CI): 24%-42%), while two CR and eleven PR were observed among one hundred three evaluable patients in control arm (RR = 13%, 95% CI: 7%-21%). WHO grade 3-4 toxicity occurred in 13% of cycles of experimental arm and in 8% of cycles in control arm. The PFS was significantly longer in experimental arm (6.2 vs. 4.3 months, odds ratio 0.66, P = 0.003), while the overall survival was similar in both arms (14.8 months in experimental arm vs. 14.1 months in control arm); quality of life was similar as well. Eighty percent of patients receiving second-line chemotherapy in control arm were treated with continuous infusion 5-FU.

CONCLUSIONS

Alternating, schedule-specific biochemical modulation of FU is more active than MTX --> 5-FU as first-line treatment of advanced colorectal cancer. However, the overall survival was similar suggesting that alternating bolus and infusional 5-FU upfront may be as effective as giving them in sequence as first- and second-line treatment.