Interaction Between Baseline Participant Factors and Treatment Effects Following Peanut Oral Immunotherapy

BACKGROUND

The Probiotic Peanut Oral Immunotherapy-003 multicenter randomized trial found that both probiotic peanut oral immunotherapy (PPOIT) and peanut OIT alone (OIT) were effective compared with placebo in inducing clinical remission after 18 months of treatment, and improving health-related quality of life (HRQL) at 12 months after treatment. Understanding treatment effect modifiers can optimize outcomes through precision care.

OBJECTIVES

This post hoc study examined baseline clinical and demographic participant factors that modified treatment effects.

METHODS

The study sample included 201 children (aged 1-10 years) with challenge-confirmed peanut allergy. Exposure variables were baseline clinical and demographic factors. Outcomes were remission (double-blind, placebo-controlled food challenge, cumulative 4,950-mg peanut protein at 8 weeks after treatment) and HRQL (change in Food Allergy Quality of Life Questionnaire-Parent Form score). Interactions between baseline factors and treatment effects on remission and HRQL were explored with regression models.

RESULTS

A higher degree of peanut sensitivity (large peanut skin prick test, high peanut specific IgE, and low reaction-eliciting dose at study entry challenge) and other concurrent allergic conditions (multiple food allergies, asthma, or wheeze) were associated with the decreased likelihood of attaining remission after both PPOIT and OIT treatment. History of anaphylaxis was associated with the reduced likelihood of remission after PPOIT compared with OIT. For the HRQL outcome, there was evidence that sex, history of anaphylaxis, and age modified treatment effects.

CONCLUSIONS

Baseline participant factors modify PPOIT and OIT effects on remission and HRQL. Considering modifiers of treatment effect during participant selection may optimize treatment success and clinical trial design toward specific outcomes, such as the achievement of remission.

Differential anti-viral response to respiratory syncytial virus A in preterm and term infants

BACKGROUND

Preterm infants are more likely to experience severe respiratory syncytial virus (RSV) disease compared to term infants. The reasons for this are multi-factorial, however their immature immune system is believed to be a major contributing factor.

METHODS

We collected cord blood from 25 preterm (gestational age 30.4-34.1 weeks) and 25 term infants (gestation age 37-40 weeks) and compared the response of cord blood mononuclear cells (CBMCs) to RSVA and RSVB stimulation using neutralising assays, high-dimensional flow cytometry, multiplex cytokine assays and RNA-sequencing.

FINDINGS

We found that preterm and term infants had similar maternally derived neutralising antibody titres to RSVA and RSVB. Preterm infants had significantly higher myeloid dendritic cells (mDC) RSV infection compared to term infants. Differential gene expression analysis of RSVA stimulated CBMCs revealed enrichment of genes involved in cytokine production and immune regulatory pathways involving IL-10, IL-36γ, CXCL1, CXCL2, SOCS1 and SOCS3 in term infants, while differentially expressed genes (DEGs) in preterm infants were related to cell cycle (CDK1, TTK, ESCO2, KNL1, CDC25A, MAD2L1) without associated expression of immune response genes. Furthermore, enriched genes in term infants were highly correlated suggesting an increased co-ordination of their immune response to RSVA. When comparing DEGs in preterm and term infants following RSVB stimulation, no differences in immune response genes were identified.

INTERPRETATION

Overall, our data suggests that preterm infants have a more restricted immunological response to RSVA compared with term infants. While further studies are required, these findings may help to explain why preterm infants are more susceptible to severe RSV disease and identify potential therapeutic targets to protect these vulnerable infants.

FUNDING

Murdoch Children's Research Institute Infection and Immunity theme grant.

Variability and magnitude of brain glutamate levels in schizophrenia: a meta and mega-analysis

Glutamatergic dysfunction is implicated in schizophrenia pathoaetiology, but this may vary in extent between patients. It is unclear whether inter-individual variability in glutamate is greater in schizophrenia than the general population. We conducted meta-analyses to assess (1) variability of glutamate measures in patients relative to controls (log coefficient of variation ratio: CVR); (2) standardised mean differences (SMD) using Hedges g; (3) modal distribution of individual-level glutamate data (Hartigan's unimodality dip test). MEDLINE and EMBASE databases were searched from inception to September 2022 for proton magnetic resonance spectroscopy (1H-MRS) studies reporting glutamate, glutamine or Glx in schizophrenia. 123 studies reporting on 8256 patients and 7532 controls were included. Compared with controls, patients demonstrated greater variability in glutamatergic metabolites in the medial frontal cortex (MFC, glutamate: CVR = 0.15, p < 0.001; glutamine: CVR = 0.15, p = 0.003; Glx: CVR = 0.11, p = 0.002), dorsolateral prefrontal cortex (glutamine: CVR = 0.14, p = 0.05; Glx: CVR = 0.25, p < 0.001) and thalamus (glutamate: CVR = 0.16, p = 0.008; Glx: CVR = 0.19, p = 0.008). Studies in younger, more symptomatic patients were associated with greater variability in the basal ganglia (BG glutamate with age: z = -0.03, p = 0.003, symptoms: z = 0.007, p = 0.02) and temporal lobe (glutamate with age: z = -0.03, p = 0.02), while studies with older, more symptomatic patients associated with greater variability in MFC (glutamate with age: z = 0.01, p = 0.02, glutamine with symptoms: z = 0.01, p = 0.02). For individual patient data, most studies showed a unimodal distribution of glutamatergic metabolites. Meta-analysis of mean differences found lower MFC glutamate (g = -0.15, p = 0.03), higher thalamic glutamine (g = 0.53, p < 0.001) and higher BG Glx in patients relative to controls (g = 0.28, p < 0.001). Proportion of males was negatively associated with MFC glutamate (z = -0.02, p < 0.001) and frontal white matter Glx (z = -0.03, p = 0.02) in patients relative to controls. Patient PANSS total score was positively associated with glutamate SMD in BG (z = 0.01, p = 0.01) and temporal lobe (z = 0.05, p = 0.008). Further research into the mechanisms underlying greater glutamatergic metabolite variability in schizophrenia and their clinical consequences may inform the identification of patient subgroups for future treatment strategies.

Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

Longitudinal antibody responses to peanut following probiotic and peanut oral immunotherapy (PPOIT) in children with peanut allergy

INTRODUCTION

Probiotic and Peanut Oral Immunotherapy (PPOIT) is effective at inducing sustained unresponsiveness (SU) at end-of-treatment and this effect persists up to four years post-treatment, referred to as persistent SU. We sought to evaluate (i) how PPOIT altered peanut-specific humoral immune indices, and (ii) how such longitudinal indices relate to persistent SU.

METHODS

Longitudinal serum/plasma levels of whole peanut- and peanut component- (Ara-h1, -h2, -h3, -h8, -h9) specific-IgE (sIgE) and specific-IgG4 (sIgG4) antibodies were measured by ImmunoCAP and salivary peanut-specific-IgA (sIgA) by ELISA in children (n=62) enrolled in the PPOIT-001 randomised trial from baseline (T0) to 4-years post-treatment (T5). Multivariate regression analyses of log-transformed values were used for point-in-time between group comparisons. Generalised estimating equations (GEE) were used for longitudinal comparisons between groups.

RESULTS

PPOIT was associated with changes in sIgE and sIgG4 over time. sIgE levels were significantly reduced post-treatment [T5, PPOIT v.s. Placebo ratio of geometric mean (GM): Ara-h1 0.07, p=0.008; Ara-h2 0.08, p=0.007; Ara-h3 0.15, p=0.021]. sIgG4 levels were significantly increased by end-of-treatment (T1, PPOIT v.s. Placebo ratio of GM: Ara-h1 3.77, p=0.011; Ara-h2 17.97, p<0.001; Ara-h3 10.42, p<0.001) but levels in PPOIT group decreased once treatment was stopped and returned to levels comparable with Placebo group by T5. Similarly, salivary peanut sIgA increased during treatment, as early as 4 months of treatment (PPOIT v.s. Placebo, ratio of GM: 2.04, p=0.014), then reduced post-treatment.

CONCLUSION

PPOIT was associated with broad reduction in peanut specific humoral responses which may mediate the clinical effects of SU that persists to 4-years post-treatment.

Neoadjuvant chemotherapy induces genomic and transcriptomic changes in ovarian cancer

The growing use of neoadjuvant chemotherapy to treat advanced-stage high-grade serous ovarian cancer (HGSOC) creates an opportunity to better understand chemotherapy-induced mutational and gene expression changes. Here we performed a cohort study including 34 patients with advanced stage IIIC or IV HGSOC to assess changes in the tumor genome and transcriptome in women receiving neoadjuvant chemotherapy. RNA-sequencing and panel DNA-sequencing of 596 cancer-related genes was performed on paired FFPE specimens collected before and after chemotherapy, and differentially expressed genes (DEGs) and CNVs in pre- and post-chemotherapy samples were identified. Following tissue and sequencing quality control, the final patient cohort consisted of 32 paired DNA and 20 paired RNA samples. Genomic analysis of paired samples did not reveal any recurrent chemotherapy-induced mutations. Gene expression analyses found that most DEGs were upregulated by chemotherapy, primarily in the chemotherapy resistant specimens. AP-1 transcription factor family genes (FOS, FOSB, FRA-1) were particularly upregulated in chemotherapy resistant samples. CNV analysis identified recurrent 11q23.1 amplification, which encompasses SIK2. In vitro, combined treatment with AP-1 or SIK2 inhibitors with carboplatin or paclitaxel demonstrated synergistic effects. These data suggest that AP-1 activity and SIK2 copy number amplification are induced by chemotherapy and may represent mechanisms by which chemotherapy resistance evolves in HGSOC. AP-1 and SIK2 are druggable targets with available small molecule inhibitors and represent potential targets to circumvent chemotherapy resistance.

Implementation of a novel antimicrobial stewardship strategy for rural facilities utilising telehealth

A significant portion of healthcare takes place in small hospitals, and many are located in rural and regional areas. Facilities in these regions frequently do not have adequate resources to implement an onsite antimicrobial stewardship programme and there are limited data relating to their implementation and effectiveness. We present an innovative model of providing a specialist telehealth antimicrobial stewardship service utilising a centralised service (Queensland Statewide Antimicrobial Stewardship Program) to a rural Hospital and Health Service. Results of a 2-year post-implementation follow-up showed an improvement in adherence to guidelines [33.7% (95% CI 27.0-40.4%) vs. 54.1% (95% CI 48.7-59.5%)] and appropriateness of antimicrobial prescribing [49.0% (95% CI 42.2-55.9%) vs. 67.5% (95% CI 62.7-72.4%) (P < 0.001). This finding was sustained after adjustment for hospitals, with improvement occurring sequentially across the years for adherence to guidelines [adjusted odds ratio (aOR) = 2.44, 95% CI 1.70-3.51] and appropriateness of prescribing (aOR = 2.48, 95% CI 1.70-3.61). There was a decrease in mean total antibiotic use (DDDs/1000 patient-days) between the years 2016 (52.82, 95% CI 44.09-61.54) and 2018 (39.74, 95% CI 32.76-46.73), however this did not reach statistical significance. Additionally, there was a decrease in mean hospital length of stay (days) from 2016 (3.74, 95% CI 3.08-4.41) to 2018 (2.55, 95% CI 1.98-3.12), although this was not statistically significant. New telehealth-based models of antimicrobial stewardship can be effective in improving prescribing in rural areas. Programmes similar to ours should be considered for rural facilities.

A Randomised Trial of Different Compression Dressings following Varicose Vein Surgery

Objective:

TED antiembolism stockings, Panelast self-adhesive elasticated bandages and Medi Plus class II stockings are three different dressings commonly used to provide compression following surgery for varicose veins. The aim of this study was to determine which of the three dressings was most acceptable to patients.

Design:

Forty-two patients undergoing bilateral varicose vein surgery were randomised to receive a different dressing on each leg in order to determine if a particular type of dressing was superior in its ability to reduce postoperative pain and provide adequate comfort without reducing mobility. The dressings were worn for 1 week, during which daily pain scores were recorded for each leg followed by a simple questionnaire to determine comfort and mobility.

Results:

There was a significant reduction of mobility experienced by patients wearing Panelast bandages compared with the other two dressings ( p<0.05). However, there were no significant differences between the dressings with regard to the degree of postoperative pain experienced, and in all other respects the dressings were equally tolerated.

Conclusion:

The choice of compression dressings used for varicose vein surgery should depend primarily on the personal preference of surgeons as well as financial considerations.

Epigenetic Regulation in Early Childhood: A Miniaturized and Validated Method to Assess Histone Acetylation

INTRODUCTION

Chronic inflammatory diseases including allergies and asthma are the result of complex interactions between genes and environmental factors. Epigenetic mechanisms comprise a set of biochemical reactions that regulate gene expression. In order to understand the cause-effect relationship between environmental exposures and disease development, methods capable of assessing epigenetic regulation (also) in large cohorts are needed.

METHODS

For this purpose, we developed and evaluated a miniaturized chromatin immunoprecipitation (ChIP) assay allowing for a cost-effective assessment of histone acetylation of candidate genes in a quantitative fashion. This method was then applied to assess H3 and H4 histone acetylation changes in cord blood (CB) samples from an established cohort of Australian children exposed in the fetal period to either very low or very high levels of maternal folate.

RESULTS

Our ChIP assay was validated for a minimum requirement of 1 × 105 target cells (e.g. CD4+ T cells). Very high levels of maternal folate were significantly associated with increased H3/H4 acetylation at GATA3 and/or IL9 promoter regions in CD4+ T cells in CB.

CONCLUSION

We developed a ChIP method allowing reliable assessment of H3/H4 acetylation using 1 × 105 cells only. Practical application of this assay demonstrated an association between high maternal folate exposure and increased histone acetylation, corresponding to a more transcriptionally permissive chromatin status in the promoter regions of some Th2-related genes.

Chronic venous leg ulcers: Effects of foam sclerotherapy on healing and recurrence

Introduction

Ultrasound-guided foam sclerotherapy is a minimally invasive treatment option used for ablation of axial and perforator reflux for chronic venous ulceration. Active ulceration presents a significant health burden in both the primary and secondary care setting. The objective of this study is to determine ulcer healing rates at 24 weeks and 12 months, and ulcer recurrence rates at one year for chronic venous ulcers after ultrasound-guided foam sclerotherapy.

Methods

Between 2007 and 2012, 54 patients underwent ultrasound-guided foam sclerotherapy for clinical, aetiological, anatomical and pathological C6 ulcers. All patients were followed up clinically, and venous duplex was performed on all legs before and after treatment. A prospectively maintained database was analysed to determine venous truncal occlusion rates, 24-week and 12-month healing and recurrence rates (using Kaplan–Meier survival analysis).

Results

Fifty-seven ulcerated legs, 39 primary and 18 with recurrent superficial venous reflux were analysed. Median time of active ulceration at presentation was 15.2 months (range 5 months to 17 years). At a median follow-up of 2.7 months, 90% (51 legs) achieved full truncal occlusion after one session, 4% (2) short segment occlusion and 5% (3) failed to occlude and one patient died and was lost to follow-up; 13/57 (23%) required a second session of treatment for completion of treatment, recanalisations and to treat perforator disease, 88% (50/57) ulcers healed at a median of 5.3 months (interquartile range 2.9–8.4 months) following their first ultrasound-guided foam sclerotherapy treatment. The 24-week and 12-month estimated healing rates were 53% and 72%, respectively. The estimated 12-month recurrence rate was 9.2%. There were no reported incidences of deep venous thrombosis or neurological symptoms.

Conclusion

This study affirms the role of ultrasound-guided foam sclerotherapy as a safe and effective option for abolition of superficial reflux.

Genome-wide DNA methylation profiling identifies a folate-sensitive region of differential methylation upstream of ZFP57-imprinting regulator in humans

Folate intake during pregnancy may affect the regulation of DNA methylation during fetal development. The genomic regions in the offspring that may be sensitive to folate exposure during in utero development have not been characterized. Using genome-scale profiling, we investigated DNA methylation in 2 immune cell types (CD4(+) and antigen-presenting cells) isolated from neonatal cord blood, selected on the basis of in utero folate exposure. High-folate (HF; n=11) and low-folate (LF; n=12) groups were selected from opposite extremes of maternal serum folate levels measured in the last trimester of pregnancy. A comparison of these groups revealed differential methylation at 7 regions across the genome. By far, the biggest effect observed was hypomethylation of a 923 bp region 3 kb upstream of the ZFP57 transcript, a regulator of DNA methylation during development, observed in both cell types. Levels of H3/H4 acetylation at ZFP57 promoter and ZFP57 mRNA expression were higher in CD4(+) cells in the HF group relative to the LF group. Hypomethylation at this region was replicated in an independent sample set. These data suggest that exposure to folate has effects on the regulation of DNA methylation during fetal development, and this may be important for health and disease.

British Dietetic Association evidence-based guidelines for the dietary management of Crohn's disease in adults

BACKGROUND

Crohn's disease is a debilitating chronic inflammatory bowel disease. Appropriate use of diet and nutritional therapy is integral to the overall management strategy of Crohn's disease. The aim was to develop evidence-based guidelines on the dietary management of Crohn's disease in adults.

METHODS

Questions relating to the dietary management of Crohn's disease were developed. These included the roles of enteral nutrition to induce remission, food re-introduction diets to structure food re-introduction and maintain remission, and dietary management of stricturing disease, as well as whether probiotics or prebiotics induce or maintain remission. A comprehensive literature search was conducted and relevant studies from January 1985 to November 2009 were identified using the electronic database search engines CINAHL, Cochrane Library, EMBASE, MEDLINE, Scopus and Web of Science. Evidence statements, recommendations, practical considerations and research recommendations were developed.

RESULTS

Fifteen research papers were critically appraised and the evidence formed the basis of these guidelines. Although corticosteroids appear to be more effective, enteral nutrition (elemental or non-elemental) can be offered as an alternative option to induce disease remission. After a course of enteral nutrition, food re-introduction diets may be useful to structure food re-introduction and help maintain disease remission. Dietary fibre is contraindicated in the presence of strictures as a result of the risk of mechanical obstruction. The use of probiotics and prebiotics is not currently supported.

CONCLUSIONS

As an alternative to corticosteroids, evidence supports enteral nutrition to induce disease remission. Food re-introduction diets provide structure to food re-introduction and help maintain disease remission. These guidelines aim to reduce variation in clinical practice.

Achieving the relocation accuracy of stereotactic frame-based cranial radiotherapy in a three-point thermoplastic shell

AIMS

To compare the accuracy of fractionated cranial radiotherapy in a standard three-point thermoplastic shell using daily online correction with accuracy in a Gill-Thomas-Cosman relocatable stereotactic frame.

MATERIALS AND METHODS

All patients undergoing fractionated radiotherapy for benign intracranial tumours between March 2009 and August 2010 were included. Patients were immobilised in the frame with those unable to tolerate it immobilised in the shell. The ExacTrac imaging system was used for verification/correction. Daily online imaging before and after correction was carried out for shell patients and systematic and random population set-up errors calculated. These were compared with frame patients who underwent standard departmental imaging/correction with fractions 1-3 and weekly thereafter. Set-up margins were calculated from population errors.

RESULTS

Systematic and random errors were 0.3-0.7 mm/° before correction and 0.1-0.2 mm/° after correction in all axes in the frame, and 0.6-1.5 mm/° before correction and 0.1-0.4 mm/° after correction in the shell. Isotropic margins required for patient set-up could be reduced from 2 mm to <1 mm in the frame and from 5 mm to <1 mm in the shell.

CONCLUSION

Similar set-up accuracy can be achieved in the standard thermoplastic shell as in a relocatable frame despite less precise immobilisation. The use of daily online correction precludes the need for larger set-up margins.

Optimising stereotactic body radiotherapy for non-small cell lung cancer with volumetric intensity-modulated arc therapy--a planning study

AIMS

The potential advantages of stereotactic body radiotherapy (SBRT) for early stage non-small cell lung cancer (NSCLC) over conventional fractionated radiotherapy include a higher biological effective dose, a reduction in accelerated repopulation, greater patient convenience and reduced demand on radiotherapy resources. Before introducing SBRT in our department, a review of planning and delivery was undertaken, starting with an assessment of optimum beam number and arrangement.

MATERIALS AND METHODS

Radiotherapy planning computed tomography scans for five patients previously treated for T1 peripheral NSCLC were selected. In each the contoured tumour had planning target volume (PTV) margins of 1cm in all directions. Forward-planned three-field coplanar and non-coplanar plans and a seven-field coplanar plan were produced and optimised. In-house inverse-planning software (AutoBeam) was used to generate three-, five-, seven- and nine-field coplanar and non-coplanar plans and two volumetric intensity-modulated arc therapy (VMAT) plans. The resulting V(20), V(11), PTV(90), PTV(95) and mean lung dose were compared.

RESULTS

Analysis of variance showed non-coplanar plans to have lower V(11) and higher PTV(90) and PTV(95) than coplanar plans. VMAT showed equivalent V(20) and target coverage when compared with the best non-coplanar plans, but with a faster delivery time (2min 8s versus 12min 40s).

CONCLUSIONS

Inverse-planned five-field non-coplanar plans and VMAT improve target coverage while minimising the higher dose to normal lung tissue for SBRT of NSCLC compared with coplanar beam arrangements. VMAT is preferable because of significantly shorter treatment delivery times.

A phase II study of ¹⁸F-fluorodeoxyglucose PET-CT in non-small cell lung cancer patients receiving erlotinib (Tarceva); objective and symptomatic responses at 6 and 12 weeks

BACKGROUND

The aim of this study was to assess if (18)F-fluorodeoxyglucose (FDG) Positron Emission Tomography (PET)-CT scanning could minimise the time non-responding patients were exposed to erlotinib (Tarceva).

METHODS

Patients were selected for clinical factors that would predict response to erlotinib. A FDG PET-CT and diagnostic contrast-enhanced (traditional) CT scan were carried out at baseline, and then a FDG PET-CT at 6 weeks and a traditional CT at 12 weeks were repeated. The primary end-point was rate of early progression in patients after 6 weeks, of which a minimum 12 out of 35 were required to make the study worthwhile. The responses at 6 (PET-CT) and 12 weeks (traditional CT) were compared and correlated with symptomatic response at both these time points.

RESULTS

Forty seven patients were recruited with 38 and 33 patients assessable by FDG PET-CT at 6 weeks and traditional CT at 12weeks, respectively. There was good correlation between Partial response (PR) at both time points and all 10 patients who had a PR at 12 weeks had a PR at 6 weeks. Of the 13 patients with progressive disease (PD) at 12 weeks, seven had PD at 6 weeks and could have had their treatment stopped early. No evaluable patient with stable disease (SD) (8/38) or PD (9/38) on FDG PET-CT at 6 weeks went on to have a later response. Symptomatic response at 6 or 12 weeks did not correlate well with objective response on scanning at either time point.

CONCLUSIONS

The primary end-point of this study was met as >12 (15/38) patients could have stopped treatment early on the basis of the FDG PET-CT scan result. A FDG PET-CT evaluable response of SD or PD at 6 weeks does predict future lack of response. No correlation was found between response and symptomatic response at either 6 or 12 weeks.

Abstract P6-11-11: Trastuzumab beyond Progression in HER2-Positive Advanced Breast Cancer: The Royal Marsden Experience

Background: Routine clinical practice and a growing body of evidence support the continuation of trastuzumab (T) in patients with HER-2 positive (+ve) advanced breast cancer progressing on previous T-based therapy. Despite this, recent UK clinical guidance advises against continuing T on evidence of disease progression (PD) in the absence of brain metastases. This retrospective study therefore evaluated the outcome of patients (pts) with HER-2+ve locally advanced (LA) or metastatic breast cancer (MBC) who continued T beyond PD, treated in our Unit. Patients and methods: HER-2+ve pts receiving T for LA or MBC were identified from our prospectively maintained database and pharmacy records. Those receiving T beyond PD after adjuvant or one line of T for advanced disease were assessed for response and outcome. From thetimepoint of T continuation beyond PD we calculated the overall disease control rate (response or stable disease), time to progression (TTP), and overall survival (OS).

Results: 114 pts with HER-2+ve LA or MBC treated with T beyond PD were identified. At the time of analysis 35 (31%) pts were still alive with a median follow up of 20 months (mo). The main site of disease was visceral in 84 (74%) pts, including 37 (32%) pts with CNS involvement. 30 (26%) pts had soft tissue or bone metastases only. Fifty nine (52%) pts had received adjuvant chemotherapy and 13 (11%) pts had received adjuvant T. Seventy six (66%) pts had 1 line of chemotherapy prior to continuation of T beyond PD and 21 (19%) had 2 or more lines. Fifty three (46%) pts had previously received taxanes + T for their LA or MBC. Post-progression, 66 (58%) pts received T combined with chemotherapy; 12 (11%) taxane-based, 32 (28%) capecitabine and 22 (19%) vinorelbine. Information regarding response was not available in 21(18%) pts. Of the ninety three (82%) pts with documented clinical (n=16) or radiological (n=77) response evaluation, 68 (60%) pts were considered as having stable disease (SD) or better and 25 (22%) as having PD. The median duration of T was 10 mo (95% CI: 8-11 mo), the median TTP was 24wks (95% CI: 21-28 wks) and the median OS was 19 mo (95% CI:12-24mo). In a sub-group analysis of the 81(71%) pts who received T as first-line Rx or relapsed within 12 wks of adjuvant T, overall disease control was achieved in 50 (61%) pts, the median TTP was 25wks (95% CI:18-33 wks) and the median OS was 22 mo(95% CI:17-27mo). In terms of safety, only 6 (5%) pts overall had to discontinue T secondary to decline in left ventricular ejection fraction.

Conclusion: Our results from an unselected group of patients are supported by positive results from other studies and provide additional evidence that continuation of trastuzumab beyond disease progression is of clinical benefit.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-11-11.

Moderate dose capecitabine in older patients with metastatic breast cancer: a standard option for first line treatment?

Single agent capecitabine is effective and well tolerated in metastatic breast cancer (MBC). We have retrospectively analysed capecitabine outcome as 1st, 2nd or 3rd line chemotherapy in 89 elderly patients ≥70 years with locally advanced or MBC treated in our Unit, 55 (62%) as 1st line and 34 (38%) as 2nd or 3rd line. Starting dose was 1000 mg/m(2) twice daily, days 1-14 every 3 weeks, but 36 (41%) started on a 25% dose reduction because of frailty and 12 (13%) reduced dose after the 1st or the 2nd cycle. Overall response rate (ORR) was 45% (95% CI: 35-55%). A further 19 (21%) achieved stable disease (SD) for ≥6 months. Median time to progression (TTP) and overall survival (OS) were 30 (95% CI: 23-37) and 61 (95% CI: 44-77) weeks, respectively. The ORR for 1st line treatment was 51% compared with 35% for 2nd and 3rd line treatment (p = 0.03). No significant difference in efficacy was seen between patients receiving the full versus reduced dose. Capecitabine was well tolerated, although 35% had treatment delays and 57% required dose reduction. Grade 3-4 toxicities were hand-foot syndrome in 11%, lethargy 9% and diarrhoea 2%. Capecitabine is an effective and well-tolerated drug in elderly patients with MBC including for 1st line treatment. Dose reduction is frequently required but does not appear to affect outcome.

Treatment of HER2-positive metastatic breast cancer with lapatinib and capecitabine in the lapatinib expanded access programme, including efficacy in brain metastases--the UK experience

BACKGROUND

The global lapatinib expanded access programme provided access to lapatinib combined with capecitabine for women with HER2-positive metastatic breast cancer (MBC) who previously received anthracycline, taxane and trastuzumab.

METHODS

Progression-free survival (PFS) and safety data for 356 patients recruited from the United Kingdom are reported. Efficacy was assessed in 162 patients from the five lead centres, including objective tumour response rate (ORR), time to disease progression (TTP) and efficacy in those with central nervous system (CNS) metastases. Correlation of PFS and ORR with previous capecitabine treatment was also documented.

RESULTS

Overall, PFS for the 356 UK patients was 21 weeks (95% CI: 17.6-24.7). In the 162 assessable patients, ORR was 21% (95% CI: 15-27%) and median TTP was 22 weeks (95% CI: 17-27). Efficacy was greater in capecitabine-naive patients (ORR 23 vs 16.3%, P=0.008). For 34 patients with CNS metastases, ORR was 21% (95% CI: 9-39%), with evidence of improvement in neurological symptoms, and median TTP was 22 weeks (95% CI: 15-28).

CONCLUSIONS

Lapatinib combined with capecitabine is an active treatment option for women with refractory HER2-positive MBC, including those with progressive CNS disease.

Histology classification is not a predictor of clinical outcomes in advanced non-small cell lung cancer (NSCLC) treated with vinorelbine or gemcitabine combinations

BACKGROUND

Until recently, histology has not been clearly or consistently described in the literature as a prognostic or predictive variable in advanced NSCLC studies. We have categorised patients treated with vinorelbine and gemcitabine based first line chemotherapy regimes for advanced NSCLC as either squamous or non-squamous, and also as either adenocarcinoma and non-adenocarcinoma, and compared outcome.

MATERIAL AND METHODS

420 patients treated with platinum/gemcitabine, platinum/vinorelbine or single agent gemcitabine or vinorelbine as first line chemotherapy for advanced NSCLC were identified. The influence of pathology on progression free survival (PFS) and overall survival (OS) has been investigated by means of a Cox regression analysis. Hazard ratios with 95% CIs have been given for each pathological type after adjusting for the effects of age, gender, stage (III vs. IV), PS (0/1 vs. 2/3) and treatment type (platinum doublet vs. single agent).

RESULTS

Neither univariate nor multivariate analysis suggested that there was a significant difference in the response rates for adenocarcinoma vs. non-adenocarcinoma or between squamous and non-squamous pathology. There was no difference in PFS between adenocarcinoma and non-adenocarcinoma pathologies until 8 months (p = 0.98), and there was a statistically significant advantage in PFS for squamous vs. non-squamous pathologies (p = 0.04). Using multivariate Cox regression analysis to adjust for the effects of age, gender, stage, PS, and treatment type, the pathology subtype was not significant. There was no difference in OS in any group.

CONCLUSIONS

These results suggest that histology may not be considered as a predictor of clinical outcome using these drugs.

Radiofrequency ablation is a feasible therapeutic option in the multi modality management of sarcoma

The role of radiofrequency ablation (RFA) in metastatic sarcoma is not well defined. The aim of this study was to evaluate the efficacy and safety of RFA in a series of sarcoma patients. A retrospective search of a prospectively maintained database identified 13 gastrointestinal stromal tumour (GIST) patients and 12 with other histological subtypes treated with RFA. All the GIST patients received RFA for metastatic disease in the liver: 12 of these responded to the first RFA procedure and one achieved stable disease. Two GIST patients received RFA on two occasions to separate lesions within the liver and both responded to the second RFA procedure. Of the other subtypes: 7 underwent RFA to liver lesions, 5 of these responded to RFA, one progressed and 1 was not assessable for response at the time of analysis. All 5 patients with lung metastases achieved a response following their first RFA procedure. RFA was effective and well tolerated in this series of sarcoma patients. RFA may have a role in patients with GIST who have progression in a single metastasis but stable disease elsewhere. Further larger studies are required to better define the role of this technique in this patient population.

Immunohistochemical Phenotype after 20-Year Follow-Up of the Royal Marsden Tamoxifen Breast Cancer Prevention Trial (RMTBCPT)

Background: 20-yrs after starting the randomized, double-blind RMTBCPT (13-year median follow-up) 186 women developed invasive breast cancer, 82 on tamoxifen and 104 on placebo1. There was a significant reduction in the incidence of invasive ER+ but not ER- breast cancer that was significant after but not during the 8yr treatment period. The phenotype of ER+ breast cancer is highly variable. We have therefore assessed PgR, HER2, EGFR and Ki67 expression in as many as possible of these tumours.Methods: Tumour blocks were available on 154 participants, 65 on tamoxifen and 89 on placebo a similar distribution to the whole population. Staining was conducted using the following antibodies: ER, clone 6F11(Vector); PgR, clone 16 (Vector); HER2, HercepTest + K5207 (Dako), FISH PathVysion (Abbott) for IHC 2+ cases; EGFR, clone 31G7 (Invitrogen); Ki67 clone Mib1(Dako). ER and PgR were quantified as H-scores, HER2 and EGFR as + or –, and Ki67 as % cells staining.Results: There were 47 and 18 ER+ and ER- tumours in the tamoxifen arm vs 76 and 13 in the placebo arm, showing a 37% (95% CI 10- 57%, p=0.01) reduction of ER+ tumours which was essentially the same as that in the whole population1.There were 38 and 27 PgR+ and PgR- tumours in the tamoxifen arm vs 58 and 31 in the placebo arm, showing a 33% (95% CI 0-56%, p=0.05) reduction of PgR+ tumours. The distribution of ER/PgR tumours according to arm and time on trial at tumour diagnosis is shown in the table (there were no ER-PgR+ cases).The decrement in ER+ tumours was predominantly in ER+PgR+ cases after 8yrs but extended to ER+PgR- cases. It is important to note that the post 8yr tumour phenotype cannot be affected by continued exposure to tamoxifen. ER levels were significantly lower in the tamoxifen-treated group even among tumours presenting as ER+ (median H-score 123 vs 161, p=0.02). There were 9 and 6 HER2+ and 11 and 12 EGFR+ cases in the tamoxifen and placebo arms, respectively (p=NS for both). The mean (95%CI) levels of Ki67 were 8.4% (6.3-11.1) and 8.5% (6.8-10.6) in the 2 arms, respectively.Discussion: The decrement in ER+ tumours in the tamoxifen-treated women was restricted to the post-treatment period and was similar to that seen in the overall population1. Among the ER+ group there was a similar proportional reduction of PgR+ and PgR- tumours by tamoxifen.There was no evidence of enhanced HER2 or EGFR expression or increased proliferation in tumours developing in the tamoxifen arm but ER expression was reduced even among ER+ tumours.1Powles et al, JNCI, 2007;99:283-90. Time on trialPlaceboTamoxifenER+PgR+&lt;8 years2622ER+PgR+&gt;8 years3216ER+PgR-&lt;8 years106ER+PgR-&gt;8 years83ER-PgR-&lt;8 years711ER-PgR-&gt;8 years67All&lt;8 years4339All&gt;8 years4626 Supported by the Da Costa International Fund for Breast Cancer Prevention

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1046.

The effect of Premium View post-processing software on digital mammographic reporting

The aim of this study was to identify the effect of the installation of Premium View post-processing software on our mammographic reporting performance, in particular the effects on our recall rate, biopsy rate and cancer detection rate. The case notes and imaging of all patients discussed at the weekly indeterminate imaging multidisciplinary team meeting were reviewed retrospectively before, immediately after and at a delayed interval following the installation of Premium View post-processing software. Factors recorded included the mammographic abnormality, further investigations and final histology. The indeterminate mammogram rate increased significantly from a baseline of 5.7% (before Premium View) to 8.7% in the time period immediately after the installation of Premium View (p=0.002). The stereotactic biopsy rate also increased from 0.8% to 2.4% (p=0.001), with a significant increase in the overall cancer detection rate from 3.4% to 4.4% (p=0.02). In the follow-up period several months after the installation of Premium View, the indeterminate mammogram rate returned to a level similar to that before Premium View (6%; p=0.7). The stereotactic biopsy rate remained significantly higher at 1.6% (p=0.07), as did the overall cancer detection rate of 5.0% (p=0.003). In conclusion, the use of Premium View may lead to higher cancer detection rates, at the expense of an initial increase in recall rate. Although prospective studies are suggested, this result is of interest in light of the proposed installation of digital mammography across the NHS Breast Screening Programme.

A randomised pilot Phase II study of doxorubicin and cyclophosphamide (AC) or epirubicin and cyclophosphamide (EC) given 2 weekly with pegfilgrastim (accelerated) vs 3 weekly (standard) for women with early breast cancer

Accelerated (dose-dense) chemotherapy, in which the frequency of administration is increased without changing total dose or duration, may increase the efficacy of cancer chemotherapy. We performed a randomised Phase II study to assess the safety and relative toxicity of AC (doxorubicin; cyclophosphamide) vs E(epirubicin)C given by conventional or accelerated schedules as neoadjuvant or adjuvant chemotherapy for early breast cancer. Furthermore, the relative toxicity of doxorubicin and epirubicin remains uncertain. Patients were randomised to one of four arms; four courses of standard 3 weekly cyclophosphamide 600 mg m⁻² in combination with doxorubicin 60 mg m⁻² (AC) vs epirubicin 90 mg m⁻² (EC) 3 weekly vs the same regimens administered every 2 weeks with pegfilgrastim (G-CSF). A total of 126 patients were treated, 42 with standard AC, 42 with accelerated AC, 19 with standard EC and 23 with accelerated EC. Significantly more grade 3/4 day one neutropenia was seen with standard (6/61, 10%) compared to accelerated (0/65,) regimens (P=0.01). A trend towards more neutropenic sepsis was seen in the combined standard and accelerated AC arms (12/84, 14%) compared to the combined EC arms (1/42, 2%), P=0.06. Falls in left ventricular ejection fraction were not increased with accelerated treatment. Accelerated AC and EC with pegfilgrastim are safe and feasible regimens in the treatment of early breast cancer with less neutropenia than conventional 3 weekly schedules.

Platinum-based chemotherapy in triple-negative breast cancer

BACKGROUND

Experimental data suggest that triple-negative (TN) breast cancer may have increased sensitivity to platinum-based chemotherapy but clinical data are limited. We present our long-term results with platinum-based chemotherapy for TN breast cancer.

PATIENTS AND METHODS

In all, 94 (17 TN), 79 (11 TN) and 155 (34 TN) patients receiving platinum-based chemotherapy in neo-adjuvant/adjuvant and advanced setting were included. Response rates and outcome were compared for TN tumours versus others.

RESULTS

Neo-adjuvant complete response rates were significantly higher for TN tumours (88%) than others (51%; P = 0.005). The 5-year overall survival (OS) for TN tumours following adjuvant/neo-adjuvant chemotherapy was 64% [95% confidence interval (CI) 44% to 79%] compared with 85% (95% CI 79% to 90%) for others. Five-year disease-free survival for TN tumours was 57% (95% CI 37% to 73%) compared with 72% (95% CI 64% to 78%) for others. For patients with advanced breast cancer, overall response rates were 41% for TN tumours and 31% for others (P = 0.3). Patients with TN tumours had a significantly prolonged progression-free survival of 6 months compared with 4 months for others (P = 0.05), though the OS was not significantly different between the two groups (11 versus 7 months).

CONCLUSION

Platinum-based chemotherapy achieves increased response rates for TN tumours, with a trend towards worse survival in early breast cancer through an improved survival in advanced disease. Prospective randomised trials are warranted.