Thermo-chemical behaviour of Dunaliella salina biomass and valorising their biochar for naphthalene removal from aqueous rural environment

Thermo-chemical behavior of a microalgal biomass; Dunaliella salina was investigated through thermo-gravimetric analyses. Fully-grown D. salina biomass were subjected for biochar conversion using pyrolytic treatment at three distinct heating rates such as 2.5, 5, and 15 °C min-1. The kinetic appraisals were explained by using model-free kinetics viz., Kissinger-Akahira-Sanose, Flynn-Waal-Ozawa and Starink iso-conversional correlations with concomitant evaluation of activation energies (Ea). The Ea value is 194.2 kJ mol-1 at 90% conversion in FWO model, which is higher as compared to other two models. Moisture, volatile substances, and other biochemical components of the biomass were volatilized between 400 and 1000 K in two separate thermo-chemical breakdown regimes. Microscopic and surface characterization analyses were carried out to elucidate the elemental and morphological characteristics of the biomass and biochar. Further, the proficiency of the prepared biochar was tested for removing naphthalene from the watery media. The novelty of the present study lies in extending the applicability of biochar prepared from D. salina for the removal of a model polyaromatic hydrocarbon, naphthalene.

Molten salt mediated single-step synthesis of reusable nanostructured CaTiO3 for the removal and recovery of Sr2+: A potential adsorbent for the contaminated water bodies

The facile synthesis approach for the adsorbent preparation and recyclability during decontamination of radioactive pollutants is a significant concern in water treatment. The objective of this study is to, synthesis via solid-state reaction of the nanostructured CaTiO3 for the removal and recovery of strontium (Sr2+) from the various water sources. The influence of the adsorption-dependent parameters including, initial concentration, adsorbent dose, pH, contact time and co-existing ions interference were investigated. The prepared adsorbent was characterized by different analytical techniques like FT-IR, SEM with EDAX, TEM, TGA-DTG, Powder XRD and BET surface analysis. The kinetic models were also used, and according to the kinetic models, a pseudo-second-order kinetic model (R2 = 0.999) was better fitted to the adsorption of Sr2+ ions onto CaTiO3 rather than pseudo-first-order kinetics, which could properly represent the observed adsorption of Sr2+. For the isotherm study, the results are best fitted to the Langmuir isotherm model (R2 = 0.98) with a maximum adsorption capacity of 102.04 mg/g. The common ions (Na+, Mg2+, Ca2+, and K+) and Sr2+ having a concentration of 1:2, 1:3, and 1:4, where 82.8, 79.5, and 68.2 % removal was achieved of Sr2+ in each respective matrix. In addition, the adsorption and corresponding recovery and removal for the different Sr2+spiked matrices in deionized water, tap water, well water, lake water, and seawater were investigated with 97, 65.6, 76.5, 73.9 and 17.8 % removal respectively. Also, the CaTiO3 showed excellent recyclability with minimal loss even after 5 consecutive recyclability cycles and >90% removal of strontium achieved. Hence, prepared nanostructured CaTiO3 could be considered a promising adsorbent for the removal and recovery of Sr2+ions from contaminated water bodies.

Conversion of solid wastes and natural biomass for deciphering the valorization of biochar in pollution abatement: A review on the thermo-chemical processes

This overview addresses the formation of solid trash and the various forms of waste from a variety of industries, which environmentalists have embraced. The paper investigates the negative effects on the environment caused by unsustainable management of municipal solid trash as well as the opportunities presented by the formal system. This examination looks at the origins of solid waste as well as the typical treatment methods. Pyrolysis methods, feedstock pyrolysis, and lignocellulosic biomass pyrolysis were highlighted. Explain in detail the various thermochemical processes that take place during the pyrolysis of biomass. Due to its carbon content, low cost, accessibility, ubiquitousness, renewable nature, and environmental friendliness, biomass waste is a unique biochar precursor. This study looks at the different types of biomass waste that are available for treating wastewater. This study discussed a wide variety of reactors. Adsorption is the standard method that is used the most frequently to remove hazardous organic, dye, and inorganic pollutants from wastewater. These pollutants cause damage to the environment and water supplies, thus it is important to remove them. Adsorption is both simple and inexpensive to utilize. Temperature-dependent conversions explain the kinetic theories of biomaterial biochemical degradation. This article presents a review that explains how pyrolytic breakdown char materials can be used to reduce pollution and improve environmental management.

ExPert ConsEnsus on the management of Advanced clear-cell RenaL celL carcinoma: INDIAn Perspective (PEARL-INDIA)

In advanced Renal Cell Carcinoma (aRCC), systemic therapy is the mainstay of treatment, with no or little role for surgery in these patients. Tyrosine kinase inhibitors (TKIs) and immune-oncological (IOs) therapies, either alone or in combination, are recommended in these patients depending on patient and tumour factors. The sequencing of therapies is critical in RCC because the choice of subsequent line therapy is heavily dependent on the response and duration of the previous treatment. There are additional barriers to RCC treatment in India. Immunotherapy is the cornerstone of treatment in ccRCC, but it is prohibitively expensive and not always reimbursed, effectively putting it out of reach for the vast majority of eligible patients in India. Furthermore, in advanced RCC (particularly the clear cell variety), Indian oncologists consider the disease burden of the patients, which is particularly dependent on the quantum of the disease load, clinical symptoms, and performance status of the patient, before deciding on treatment. There are no India-specific guidelines for clear cell RCC (ccRCC) treatment or the positioning and sequencing of molecules in the management of advanced ccRCC that take these country-specific issues into account. The current consensus article provides expert recommendations and treatment algorithms based on existing clinical evidence, which will be useful to specialists managing advanced ccRCC.

Consensus guidelines for the management of HR-positive HER2/neu negative early breast cancer in India, SAARC region and other LMIC by DELPHI survey method

BACKGROUND

Precise prognostication is the key to optimum and effective treatment planning for early-stage hormone receptor (HR) positive, HER2/neu negative breast cancer patients. Differences in the breast cancer incidence and tumor anatomical features at diagnosis, pharmacogenomics data between Western and Indian women along with the vast diversity in the economic status and differences in insurance policies of these regions; suggest recommendations put forward for Western women might not be applicable to Indian/Asian women. Opinions from oncologists through a voting survey on various prognostic factors/tools to be considered for planning adjuvant therapy are consolidated in this report for the benefit of oncologists of the sub-continent, SAARC and Asia's LMIC (low and middle-income countries).

METHODS

A three-phase DELPHI survey was conducted to collect opinions on prognostic factors considered for planning adjuvant therapy in early-stage HR+/HER2/neu negative breast cancer patients. A panel of 25 oncologists with expertise in breast cancer participated in the survey conducted in 2021. The experts provided opinions as 'agree' or disagree' or 'not sure' in phases-1 and 2 which were conducted virtually; in the final phase-3, all the panel experts met in person and concluded the survey.

RESULTS

Opinions on 41 statements related to prognostic factors/tools and their implications in planning adjuvant endocrine/chemotherapy were collected. All the statements were supported by the latest data from the clinical trials (prospective/retrospective). The statements with opinions of consensus less than 66% were disseminated in phase-2, and later in phase-3 with supporting literature. In phase-3, all the opinions from panelists were consolidated and guidelines were framed.

CONCLUSIONS

This consensus guideline will assist oncologists of India, SAARC and LMIC countries in informed clinical decision-making on adjuvant treatment in early HR+/HER2/neu negative breast cancer patients.

Remediation of phthalate acid esters from contaminated environment—Insights on the bioremedial approaches and future perspectives

Phthalates are well-known emerging pollutants that are toxic to the environment and human health. Phthalates are lipophilic chemicals used as plasticizers in many of the items for improving their material properties. These compounds are not chemically bound and are released to the surroundings directly. Phthalate acid esters (PAEs) are endocrine disruptors and can interfere with hormones, which can cause issues with development and reproduction, thus there is a huge concern over their existence in various ecological surroundings. The purpose of this review is to explore the occurrence, fate, and concentration of phthalates in various environmental matrices. This article also covers the phthalate degradation process, mechanism, and outcomes. Besides the conventional treatment technology, the paper also aims at the recent advancements in various physical, chemical, and biological approaches developed for phthalate degradation. In this paper, a special focus has been given on the diverse microbial entities and their bioremedial mechanisms executes the PAEs removal. Critically, the analyses method for determining intermediate products generated during phthalate biotransformation have been discussed. Concluisvely, the challenges, limitations, knowledge gaps and future opportunities of bioremediation and their significant role in ecology have also been highlighted.

Pre-to-post COVID-19 lockdown and their environmental impacts on Ghoghla beach and Somnath beach, India

Environmental impact of COVID-19 imposed lockdown (2020) and the new normal condition (2021) on two different beaches of India (Ghoghla beach, Diu and Somnath beach, Veraval) were compared with the pre-lockdown era, 2013. The lockdown phase favored the natural restoration of the beaches and showed infinitesimal values of the parameters tested when compared with the pre-lockdown regime. However, the new normal situation in 2021 opened up the accessibility of these beaches to the tourists and pilgrims resulting in significant changes of water quality. The release of diluted sewage mixed with freshwater from the Somnath town to the sea has led to the drastic change in beach water quality. The mean cadmium concentration increased drastically in beach waters (Ghoghla: 1.35, 0.28 and 7.09 μg/L; Somnath: 0.45, 0.28 and 0.58 μg/L) during pre-to-post lockdown, respectively. However, post-lockdown resulted in the rise of toxic heavy metals in the sediments of Somnath beach but Ghoghla beach remained to be pristine which may be due to the Blue Flagship status. The total number of marine bacteria was higher during 2013 and 2021 when compared during lockdown describing greater human interventions. For instance, Vibrio spp. count in Ghoghla beach water during pre-lockdown phase was 7733 CFU/mL and this value reduced to 70 and 5 CFU/mL in the lockdown and post-lockdown phases. Interestingly, the diversity of planktonic and benthic components showed a different trend from pre-to-post lockdown due to significant change in the inorganic nutrients and metal bioaccumulation. To our knowledge, this will be the first comprehensive assessment to report the environmental and ecological health of Ghoghla beach and Somnath beach during the pre-to-post lockdown.

Remedial strategies for abating 1,4-dioxane pollution-special emphasis on diverse biotechnological interventions

1,4-dioxane is a heterocyclic ether used as a polar industrial solvent and are released as waste discharges. 1,4-dioxane deteriorates health and quality, thereby attracts concern by the environment technologists. The need of attaining sustainable development goals have resulted in search of an eco-friendly and technically viable treatment strategy. This extensive review is aimed to emphasis on the (a) characteristics of 1,4-dioxane and their occurrence in the environment as well as their toxicity, (b) remedial strategies, such as physico-chemical treatment and advanced oxidation techniques. Special reference to bioremediation that involves diverse microbial strains and their mechanism are highlighted in this review. The role of macronutrients, stimulants and other abiotic cofactors in the biodegradation of 1,4-dioxane is discussed lucidly. We have critically discussed the inducible enzymes, enzyme-based remediation, distinct instrumental method of analyses to know the fate of intermediates produced from 1,4-dioxane biotransformation. This comprehensive survey also tries to put forth the different toxicity assessment tools used in evaluating the extent of detoxification of 1,4-dioxane achieved through biotransforming mechanism. Conclusively, the challenges, opportunities, techno-economic feasibility and future prospects of implementing 1,4-dioxane through biotechnological interventions are also discussed.

Impact of 2nd wave of COVID-19-related lockdown on coastal water quality at Diu, western coast of India and role of total alkalinity on bacterial loads

A detailed coastal water monitoring near Diu coast, western part of India was performed from October, 2020 to May, 2021 covering the 2nd lockdown time. Average monthly fluctuation from 7 different sampling stations of total 9 physico-chemical parameters such as pH, salinity, turbidity, nitrite (NO₂), nitrate (NO₃), ammonia (NH₃), phosphate (PO₄), total alkalinity and silicate were recorded. Initially, Mann-Kendall trend test for all the 9 parameters showed non-zero trend, which may be either linear or non-linear. During 2nd lockdown period, there was a fluctuation of value for parameters like pH, salinity, nitrate, nitrite and phosphate. Average total bacterial count and differential bacterial count also gradually decreased from March, 2021 sampling. Principal component analysis (PCA) plot covering all the physico-chemical parameters as well as the differential bacterial count showed a distinct cluster of all bacterial count with total alkalinity value. Subsequently, mathematical equation was formulated between total alkalinity value and all differential bacterial count. Upto our knowledge, this is the first report where mathematical equation was formulated to obtain value of different bacterial load based on the derived total alkalinity value of the coastal water samples near Diu, India.

Coraco-clavicular endobutton and fiber tape fixation for Neer’s type II unstable lateral clavicular fracture: a case series with literature review

Neer’s type II lateral end clavicle fracture is inherently unstable due to coraco-clavicular ligament disruption. Timely surgery can avoid complications of conservative management. Our study is based on open reduction and fixation with double endobutton and fibre tape in 12 patients. Radiological and functional outcome were assessed using Quick DASH score and SPADI score at regular interval. All the fractures achieved both clinical and radiological union. No intra-operative or post-operative complication was noted. Functional out come and range of motion at 1-year follow-up was quite satisfactory. Open reduction and fixation with double endobutton and fibre tape for lateral end clavicle fracture is a quite rewarding surgery with less steep learning curve, economical and enough stable fixations leading to union and good functional outcome without need of re-surgery for implant removal.

New normal baseline data during nationwide lock down due to Covid 19 pandemic in the world's largest ship recycling yard at Alang, India

A detailed study to generate the new normal baseline data has been carried out during nationwide lockdown (May 12 to May 16, 2020) covering sampling for ambient air, coastal water, coastal sediments, fish and bioaccumulation of heavy metals, in an around Alang, the world's biggest ship recycling yard. The lockdown data were compared with 2018 and 2019 observed data. PM10 values during lockdown were reduced by 3.75 to 4.5 times as compared with previous 2 years. Similarly, four-fold reduction of PM2.5 and SPM values was observed during lockdown. The gaseous pollutants like NO2 and O3 are within safe limit. Overall air quality index (AQI) improved significantly during lockdown. Similarly, there was drastic reduction in the majority of the nutrient parameters in the coastal water. Different heavy metal concentration in the coastal sediments samples also showed strong reduction during lockdown sampling in comparison with other two sampling. This proves that the coastal environment has its efficient self-cleaning potentials if there is considerable reduction in the anthropogenic as well as industrial activities. Diversity of phytoplankton and zooplankton also increased. The results were validated using statistical techniques like analysis of variance and least significance difference (LSD).

Practical consensus recommendations on ovarian suppression in early breast cancer (adjuvant)

Substantial survival benefits exist for patients with early-stage breast cancer who undergo treatment with single-modality ovarian suppression, but its value is uncertain. Expert oncologist discussed to determine whether additional benefits exist with ovarian suppression plus multiple adjuvant therapy which provides a new treatment option that reduces the risk of recurrence in early breast cancer. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Molecularly targeted therapies in non-small cell lung cancer: The evolving role of tyrosine kinase inhibitors

Non-small cell lung cancer (NSCLC) is a major subtype of lung cancer. Patients with NSCLC are diagnosed at a locally advanced or metastatic stage where prognosis with palliative chemotherapy is poor. The discovery of epidermal growth factor receptor (EGFR) mutations has revolutionized cancer treatment for NSCLC by promoting the development of molecularly targeted therapies like tyrosine kinase inhibitors (TKIs). This review summarizes the clinical efficacy and tolerability of EGFR-TKIs, including osimertinib, in EGFR-mutated advanced NSCLC. EGFR-TKIs have demonstrated superior response and overall survival rates compared with chemotherapy in EGFR-mutated NSCLC. However, despite the initial rapid and durable clinical responses, acquired resistance to first- and second-generation TKIs eventually develops in most cases, with disease progression observed mostly within 12 months of treatment initiation. Osimertinib, a potent third-generation TKI, irreversibly inhibits mutated EGFR alleles, including T790M. In addition to longer survival and higher response rate, osimertinib has a favorable safety profile with a lower incidence of grade ≥3 treatment-related adverse events compared with other TKIs. Based on the efficacy and safety results, recently the National Comprehensive Cancer Network (NCCN) has included osimertinib as the "preferred first-line of treatment" in patients with metastatic EGFR mutationpositive NSCLC. Thus, osimertinib as first-line therapy for EGFRpositive patients irrespective of the T790M mutation status could be an ideal choice in the Indian setting where only 50% of patients opt for any second-line therapy after first-line failure.

Current Treatment Options for Human Epidermal Growth Factor Receptor 2-Directed Therapy in Metastatic Breast Cancer: An Indian Perspective

Human epidermal growth factor receptor 2 (HER2)-positive is an aggressive subtype of breast cancer and has historically been associated with poor outcomes. The availability of various anti-HER2 therapies, including trastuzumab, lapatinib, pertuzumab, and trastuzumab emtansine (TDM-1), has remarkably improved the clinical outcomes in patients with HER2-positive metastatic breast cancer (mBC). However, there is a need to optimize treatment within this population, given the wide variability in clinical presentation. Additionally, geographical and socio-economic considerations too need to be taken into account. To clarify and collate evidence pertaining to HER2-positive metastatic breast cancer, a panel of medical and clinical oncologists from across India developed representative clinical scenarios commonly encountered in clinical practice in the country. This was followed by two meetings wherein each clinical scenario was discussed in detail and relevant evidence appraised. The result of this process is presented in this manuscript as evidence followed by therapeutic recommendations of this panel for management of HER2-positive mBC in the Indian population.

Advanced therapeutic options and importance of rebiopsy in epidermal growth factor receptor-tyrosine kinase inhibitor-progressed nonsmall cell lung carcinoma patients: An expert opinion

Advanced nonsmall cell lung cancer (NSCLC) treatment is primarily based on platinum-based chemotherapy. Although epidermal growth factor receptor (EGFR) targeting has shifted the treatment paradigm toward personalized tyrosine kinase inhibitors (TKIs), resistance develops inevitably and EGFR T790M is the most common acquired resistance mechanism. Rebiopsy of resistant NSCLC cases can provide additional information on the underlying resistant mechanisms and therefore can help clinicians in taking better management decisions. An expert panel meeting of renowned cancer oncologists was held to discuss the management of advanced-stage NSCLC. The present paper is based on the recommendations made by the expert panel and is supported by an exhaustive literature search. It was suggested that identification of driver mutation leads to better treatment decisions. TKIs have proven to be better treatment option in EGFR-positive patients as compared to chemotherapy. Third-generation TKIs (osimertinib) promise to bring optimal and improved care for NSCLC cases failing first-line TKI treatment.

EGFR testing scenario across 111 centres in India: A questionnaire-based survey

e13111

Background: Lung cancer diagnosis now involves routine use of biomarker testing to identify the driver mutations. We conducted a survey of 111 medical oncologists across India to understand the current pattern of EGFR mutation testing at their respective centres. Methods: Medical oncologists from 111 institutes across India were interviewed face to face using a structured questionnaire. They were divided into two groups - Group 1 with in-house EGFR testing and Group 2 who send samples to central/commercial labs. Answers of the two groups were analysed to see the prevailing patterns of EGFR mutation testing and differences between the groups if any. Results: In India, 95% of medical oncologists recommend testing for EGFR mutations in patients with adenocarcinoma histology. 40% would also recommend testing in squamous histology. 80% of medical oncologists request for biomarker testing at the time of primary biopsy. From the time of biopsy, the average time duration to get EGFR test results is 18 days. In centres with in-house testing (Group 1), results are available in 10 days. 96% of the medical oncologists from Group 1 centres request for factoring additional sample for biomarker testing compared to only 69% from Group 2. 69% of medical oncologists in Group 1 centres would prefer to wait for the test results before initiating treatment compared to 46% in Group 2. EGFR TKIs are used in 60% of patients with diagnosed EGFR mutation in the first line. For patients in whom chemotherapy is initiated while waiting for test results, 50% of medical oncologists prefer completing 4-6 cycles before switching to targeted therapy. At the time of progression, rebiopsy is possible in 25% of the patients. Rapid disease progression and poor PS were the two most common reasons given for the low rebiopsy rates. Conclusions: Application of molecular testing is ‎improving. Yield can be improved by training of multidisciplinary team involved in tumor biopsy. There is scope and need to reduce the turnaround time. This will reduce the current scenario of commencing chemotherapy while waiting for test results. Increasing application of liquid biopsy will help in initial diagnosis as well as at relapse, especially for patients with poor PS or difficult access to tumor site.

PARAMOUNT: Final overall survival results of the phase III study of maintenance pemetrexed versus placebo immediately after induction treatment with pemetrexed plus cisplatin for advanced nonsquamous non-small-cell lung cancer

PURPOSE

In the phase III PARAMOUNT trial, pemetrexed continuation maintenance therapy reduced the risk of disease progression versus placebo (hazard ratio [HR], 0.62; 95% CI, 0.49 to 0.79; P < .001). Here we report final overall survival (OS) and updated safety data.

PATIENTS AND METHODS

In all, 939 patients with advanced nonsquamous non-small-cell lung cancer (NSCLC) received four cycles of pemetrexed-cisplatin induction therapy; then, 539 patients with no disease progression and Eastern Cooperative Oncology Group performance status 0 or 1 were randomly assigned (2:1) to maintenance pemetrexed (500 mg/m(2) on day 1 of 21-day cycles; n = 359) or placebo (n = 180). Log-rank test compared OS between arms as measured from random assignment (α = .0498).

RESULTS

The mean number of maintenance cycles was 7.9 (range, one to 44) for pemetrexed and 5.0 (range, one to 38) for placebo. After 397 deaths (pemetrexed, 71%; placebo, 78%) and a median follow-up of 24.3 months for alive patients (95% CI, 23.2 to 25.1 months), pemetrexed therapy resulted in a statistically significant 22% reduction in the risk of death (HR, 0.78; 95% CI, 0.64 to 0.96; P = .0195; median OS: pemetrexed, 13.9 months; placebo, 11.0 months). Survival on pemetrexed was consistently improved for all patient subgroups, including induction response: complete/partial responders (n = 234) OS HR, 0.81; 95% CI, 0.59 to 1.11 and stable disease (n = 285) OS HR, 0.76; 95% CI, 0.57 to 1.01). Postdiscontinuation therapy use was similar: pemetrexed, 64%; placebo, 72%. No new safety findings emerged. Drug-related grade 3 to 4 anemia, fatigue, and neutropenia were significantly higher in pemetrexed-treated patients.

CONCLUSION

Pemetrexed continuation maintenance therapy is well-tolerated and offers superior OS compared with placebo, further demonstrating that it is an efficacious treatment strategy for patients with advanced nonsquamous NSCLC and good performance status who did not progress during pemetrexed-cisplatin induction therapy.

PARAMOUNT: Final overall survival (OS) results of the phase III study of maintenance pemetrexed (pem) plus best supportive care (BSC) versus placebo (plb) plus BSC immediately following induction treatment with pem plus cisplatin (cis) for advanced nonsquamous (NS) non-small cell lung cancer (NSCLC)

LBA7507

Background: The PARAMOUNT trial showed that pem continuation maintenance therapy significantly reduced the risk of disease progression over plb (HR=0.62; 95% CI: 0.49-0.79; p <0.0001) in patients (pts) with advanced NS NSCLC who had not progressed during pem-cis induction. Here we present the final OS data. Methods: In a double-blind, plb-controlled study, alpha-controlled for OS, 939 pts received induction (4 cycles of pem 500 mg/m2 and cis 75 mg/m2 on d1 of 21d cycles), and 539 pts who had not progressed and had an ECOG performance status (PS) of 0/1 were randomized (2:1) to maintenance pem (500 mg/m2, on day 1 of 21-day cycles) plus BSC or plb plus BSC until disease progression. All received B12, folic acid, and dexamethasone. After 397 deaths, a log-rank test compared OS between arms using anominal α level of 0.0498. Results: Pt characteristics were balanced between arms: median age 61 years; 58% men; 32% PS 0; 95% Caucasian; 86% adenocarcinoma; 45% complete/partial response (CR/PR) to induction. Pem resulted in a statistically significant 22% reduction in risk of death (HR=0.78). The HR was the same when measured from the beginning of induction. Survival improvement was similar for pts with an induction outcome of CR/PR versus stable disease. Conclusions: Pem continuation maintenance therapy offers superior OS compared with plb. These final results confirm that pem-cis induction followed by continuation pem further benefits pts compared with induction therapy alone, offering a change in the treatment paradigm for advanced NS NSCLC. [Table: see text]

PARAMOUNT: Final overall survival (OS) results of the phase III study of maintenance pemetrexed (pem) plus best supportive care (BSC) versus placebo (plb) plus BSC immediately following induction treatment with pem plus cisplatin (cis) for advanced nonsquamous (NS) non-small cell lung cancer (NSCLC)

LBA7507

The full, final text of this abstract will be available at abstract.asco.org at 12:01 AM (EDT) on Monday, June 4, 2012, and in the Annual Meeting Proceedings online supplement to the June 20, 2012, issue of Journal of Clinical Oncology. Onsite at the Meeting, this abstract will be printed in the Monday edition of ASCO Daily News.

Maintenance therapy with pemetrexed plus best supportive care versus placebo plus best supportive care after induction therapy with pemetrexed plus cisplatin for advanced non-squamous non-small-cell lung cancer (PARAMOUNT): a double-blind, phase 3, randomised controlled trial

BACKGROUND

Patients with advanced non-squamous non-small-cell lung cancer (NSCLC) benefit from pemetrexed maintenance therapy after induction therapy with a platinum-containing, non-pemetrexed doublet. The PARAMOUNT trial investigated whether continuation maintenance with pemetrexed improved progression-free survival after induction therapy with pemetrexed plus cisplatin.

METHODS

In this double-blind, multicentre, phase 3, randomised placebo-controlled trial, patients with advanced non-squamous NSCLC aged 18 years or older, with no previous systemic chemotherapy for lung cancer, with at least one measurable lesion, and an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1 participated. Before randomisation, patients entered an induction phase which consisted of four cycles of induction pemetrexed (500 mg/m(2)) plus cisplatin (75 mg/m(2)) on day 1 of a 21-day cycle. Patients who did not progress after completion of four cycles of induction and who had an ECOG performance status of 0 or 1 were stratified according to disease stage (IIIB or IV), ECOG performance status (0 or 1), and induction response (complete or partial response, or stable disease), and randomly assigned (2:1 ratio) to receive maintenance therapy with either pemetrexed (500 mg/m(2) every 21 days) plus best supportive care or placebo plus best supportive care until disease progression. Randomisation was done with the Pocock and Simon minimisation method. Patients and investigators were masked to treatment assignment. The primary endpoint was progression-free survival in the intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT00789373.

FINDINGS

Of the 1022 patients enrolled, 939 participated in the induction phase. Of these, 539 patients were randomly assigned to receive continuation maintenance with pemetrexed plus best supportive care (n=359) or with placebo plus best supportive care (n=180). Among the 359 patients randomised to continuation maintenance with pemetrexed, there was a significant reduction in the risk of disease progression over the placebo group (HR 0·62, 95% CI 0·49-0·79; p<0·0001). The median progression-free survival, measured from randomisation, was 4·1 months (95% CI 3·2-4·6) for pemetrexed and 2·8 months (2·6-3·1) for placebo. Possibly treatment-related laboratory grade 3-4 adverse events were more common in the pemetrexed group (33 [9%] of 359 patients) than in the placebo group (one [<1%] of 180 patients; p<0·0001), as were non-laboratory grade 3-5 adverse events (32 [9%] of 359 patients in the pemetrexed group; eight [4%] of 180 patients in the placebo group; p=0·080); one possibly treatment-related death was reported in each group. The most common adverse events of grade 3-4 in the pemetrexed group were anaemia (16 [4%] of 359 patients), neutropenia (13 [4%]), and fatigue (15 [4%]). In the placebo group, these adverse events were less common: anaemia (one [<1%] of 180 patients), neutropenia (none), and fatigue (one <1%]). The most frequent serious adverse events were anaemia (eight [2%] of 359 patients in the pemetrexed group vs none in the placebo group) and febrile neutropenia (five [1%] vs none). Discontinuations due to drug-related adverse events occurred in 19 (5%) patients in the pemetrexed group and six (3%) patients in the placebo group.

INTERPRETATION

Continuation maintenance with pemetrexed is an effective and well tolerated treatment option for patients with advanced non-squamous NSCLC with good performance status who have not progressed after induction therapy with pemetrexed plus cisplatin.

FUNDING

Eli Lilly and Company.

Maintenance therapy with pemetrexed plus best supportive care versus placebo plus best supportive care after induction therapy with pemetrexed plus cisplatin for advanced non-squamous non-small-cell lung cancer (PARAMOUNT): a double-blind, phase 3, randomised controlled trial

BACKGROUND

Patients with advanced non-squamous non-small-cell lung cancer (NSCLC) benefit from pemetrexed maintenance therapy after induction therapy with a platinum-containing, non-pemetrexed doublet. The PARAMOUNT trial investigated whether continuation maintenance with pemetrexed improved progression-free survival after induction therapy with pemetrexed plus cisplatin.

METHODS

In this double-blind, multicentre, phase 3, randomised placebo-controlled trial, patients with advanced non-squamous NSCLC aged 18 years or older, with no previous systemic chemotherapy for lung cancer, with at least one measurable lesion, and an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1 participated. Before randomisation, patients entered an induction phase which consisted of four cycles of induction pemetrexed (500 mg/m(2)) plus cisplatin (75 mg/m(2)) on day 1 of a 21-day cycle. Patients who did not progress after completion of four cycles of induction and who had an ECOG performance status of 0 or 1 were stratified according to disease stage (IIIB or IV), ECOG performance status (0 or 1), and induction response (complete or partial response, or stable disease), and randomly assigned (2:1 ratio) to receive maintenance therapy with either pemetrexed (500 mg/m(2) every 21 days) plus best supportive care or placebo plus best supportive care until disease progression. Randomisation was done with the Pocock and Simon minimisation method. Patients and investigators were masked to treatment assignment. The primary endpoint was progression-free survival in the intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT00789373.

FINDINGS

Of the 1022 patients enrolled, 939 participated in the induction phase. Of these, 539 patients were randomly assigned to receive continuation maintenance with pemetrexed plus best supportive care (n=359) or with placebo plus best supportive care (n=180). Among the 359 patients randomised to continuation maintenance with pemetrexed, there was a significant reduction in the risk of disease progression over the placebo group (HR 0·62, 95% CI 0·49-0·79; p<0·0001). The median progression-free survival, measured from randomisation, was 4·1 months (95% CI 3·2-4·6) for pemetrexed and 2·8 months (2·6-3·1) for placebo. Possibly treatment-related laboratory grade 3-4 adverse events were more common in the pemetrexed group (33 [9%] of 359 patients) than in the placebo group (one [<1%] of 180 patients; p<0·0001), as were non-laboratory grade 3-5 adverse events (32 [9%] of 359 patients in the pemetrexed group; eight [4%] of 180 patients in the placebo group; p=0·080); one possibly treatment-related death was reported in each group. The most common adverse events of grade 3-4 in the pemetrexed group were anaemia (16 [4%] of 359 patients), neutropenia (13 [4%]), and fatigue (15 [4%]). In the placebo group, these adverse events were less common: anaemia (one [<1%] of 180 patients), neutropenia (none), and fatigue (one <1%]). The most frequent serious adverse events were anaemia (eight [2%] of 359 patients in the pemetrexed group vs none in the placebo group) and febrile neutropenia (five [1%] vs none). Discontinuations due to drug-related adverse events occurred in 19 (5%) patients in the pemetrexed group and six (3%) patients in the placebo group.

INTERPRETATION

Continuation maintenance with pemetrexed is an effective and well tolerated treatment option for patients with advanced non-squamous NSCLC with good performance status who have not progressed after induction therapy with pemetrexed plus cisplatin.

FUNDING

Eli Lilly and Company.

Simultaneous occurrence of multiple myeloma and acute myeloid leukemia

Multiple myeloma and acute leukemia may sometimes occur in the same patient, usually in patients with myeloma who receive chemotherapy and subsequently develop acute leukemia. However, simultaneous occurrence of myeloma and acute leukemia on presentation is rare, with only a handful of such cases reported in the literature.

Unusual metastasis in colorectal cancer

Metastasis from colorectal carcinoma occurs by either lymphatic or hematogenous spread. The most common sites of colorectal metastasis are the liver and lung. Involvement of the skin, muscles and bones are quite rare. The prognosis in such patients is usually poor. Herewith, we are reporting a case of colonic carcinoma who had cutaneous metastasis, muscular involvement and diffuse skeletal metastasis. At the end, she had brain metastasis, but liver and lung involvement was not observed till the end.

Waldenstrom's macroglobulinemia

Waldenstrom's macroglobulinemia is an uncommon lymphoplasmacytic lymphoma presenting with hyperviscocity and autoimmune phenomenon. Disease is characterized by bone marrow infiltration by lymphoplasmacytic cells and raised IgM. Bone marrow morphology and immunohistochemistry is important for diagnosis. Course is indolent and anemia and age are most important prognostic factors. Treatment options include alkylating agents, anti-purine anti-metabolites, which though not curative but offer valuable responses. Newer agents like Rituximab and autologous transplant are being tried.

Sino-oral zygomycosis due toAbsidiacorymbiferain a patient with acute leukemia

Fungi belonging to class Zygomycetes become pathogenic in certain predisposing conditions; principally diabetes mellitus, immunosuppression, trauma or burns. We report a case of a 31-year-old man with acute promyelocytic leukemia who developed infection of the sino-oral cavity, due to Absidia corymbifera during a neutropenic phase following induction chemotherapy. A provisional diagnosis of zygomycosis was made by demonstration of broad aseptate branching filamentous hyphae in the scrapings of the palate, which was subsequently confirmed as A. corymbifera by culture. Surgical debridement could not be done due to the thrombocytopenic status of the patient; instead antifungal therapy with amphotericin B was instituted. However, the patient succumbed to the infection after 15 days of its diagnosis. Although infections with Absidia are infrequent, this case highlights the need for its awareness as a potentially lethal opportunistic fungal infection that can present even with short duration of exposure to the usual risk factors.