BEECH: a dose-finding run-in followed by a randomised phase II study assessing the efficacy of AKT inhibitor capivasertib (AZD5363) combined with paclitaxel in patients with estrogen receptor-positive advanced or metastatic breast cancer, and in a PIK3CA mutant sub-population

BACKGROUND

BEECH investigated the efficacy of capivasertib (AZD5363), an oral inhibitor of AKT isoforms 1-3, in combination with the first-line weekly paclitaxel for advanced or metastatic estrogen receptor-positive (ER+)/human epidermal growth factor receptor 2-negative (HER2-) breast cancer, and in a phosphoinositide 3-kinase, catalytic, alpha polypeptide mutation sub-population (PIK3CA+).

PATIENTS AND METHODS

BEECH consisted of an open-label, phase Ib safety run-in (part A) in 38 patients with advanced breast cancer, and a randomised, placebo-controlled, double-blind, phase II expansion (part B) in 110 women with ER+/HER2- metastatic breast cancer. In part A, patients received paclitaxel 90 mg/m2 (days 1, 8 and 15 of a 28-day cycle) with capivasertib taken twice daily (b.i.d.) at two intermittent ascending dosing schedules. In part B, patients were randomly assigned, stratified by PIK3CA mutation status, to receive paclitaxel with either capivasertib or placebo. The primary end point for part A was safety to recommend a dose and schedule for part B; primary end points for part B were progression-free survival (PFS) in the overall and PIK3CA+ sub-population.

RESULTS

Capivasertib was well tolerated, with a 400 mg b.i.d. 4 days on/3 days off treatment schedule selected in part A. In part B, median PFS in the overall population was 10.9 months with capivasertib versus 8.4 months with placebo [hazard ratio (HR) 0.80; P = 0.308]. In the PIK3CA+ sub-population, median PFS was 10.9 months with capivasertib versus 10.8 months with placebo (HR 1.11; P = 0.760). Based on the Common Terminology Criteria for Adverse Event v4.0, the most common grade ≥3 adverse events in the capivasertib group were diarrhoea, hyperglycaemia, neutropoenia and maculopapular rash. Dose intensity of paclitaxel was similar in both groups.

CONCLUSIONS

Capivasertib had no apparent impact on the tolerability and dose intensity of paclitaxel. Adding capivasertib to weekly paclitaxel did not prolong PFS in the overall population or PIK3CA+ sub-population of ER+/HER2- advanced/metastatic breast cancer patients.ClinicalTrials.gov: NCT01625286.

Intraluminal Brachytherapy for Malignant Endobronchial Tumors: An Update on Low-Dose Rate Versus High-Dose Rate Radiation Therapy

Although the evolution from low-dose rate (LDR) to high-dose rate (HDR) brachytherapy for malignant endobronchial tumors was presumably based on economy, patient convenience, and radiation protection, our experience with both modalities permits assessment of the pros and cons of each technique. In November 1991, our HDR remote afterloading brachytherapy unit became operational. By that time, we had treated 110 patients (group 1) with malignant endobronchial obstruction with LDR brachytherapy. Since then, all patients have been treated with HDR brachytherapy. The outcome of our first 110 patients (group 2) treated with HDR brachytherapy is presented in this communication, using group 1 as the historic control group. In group 1, patients were treated with 1 or 2 sessions of 30-60 Gy, each calculated at a 1-cm radius. In group 2, patients received 3 or 4 weekly treatments of 7 Gy, each calculated at a 1-cm radius. The majority of patients in each group had previously received a full course of external beam irradiation, and a history of laser bronchoscopy was also similar for the 2 groups. Differences in bronchoscopic response rate (82% vs. 96%, respectively) and complications (3.6% vs. 2.7%, respectively) were statistically insignificant between the LDR group and the HDR group. We believe HDR brachytherapy is the state-of-the-art modality in intraluminal therapy for endobronchial malignancies.

Endobronchial brachytherapy

Intraluminal endobronchial brachytherapy is a technique in which an encapsulated radioactive source is placed near a tumor for localized irradiation. It is effective, with or without other treatment modalities, in palliating problems caused by endobronchial malignancies, such as dyspnea, hemoptysis, cough, atelectasis, and postobstructive pneumonia. This article describes the different techniques and dosage schemes for brachytherapy, indications and contraindications, reported rates of efficacy and complications, and limitations of the technique.

Low dose rate versus high dose rate intraluminal brachytherapy for malignant endobronchial tumors

Although the evolution from low dose rate to high dose rate brachytherapy for malignant endobronchial malignancies was primarily based on economy, patient convenience, and radiation protection, the difference in therapeutic index, if any, between these two modalities must be kept in mind. Our experience with both methods permits assessment of the feasibility of replacing low dose rate brachytherapy with high dose rate brachytherapy. Results with our first 110 patients (group 1) treated with low dose rate brachytherapy (133 procedures) were compared with results with our initial 59 consecutive patients (group 2) treated with high dose rate brachytherapy (161 procedures). In group 1, patients were treated with one or two sessions of 30-60 Gy each calculated at a 1 cm radius. In patients in group 2, we aimed at three weekly sessions of 7 Gy each calculated at a 1 cm radius. External beam irradiation therapy had previously been given to 88% of patients in group 1 and to 85% of patients in group 2. Laser bronchoscopy was performed in 36% of patients in group 1 and in 24% of patients in group 2 before brachytherapy. Clinical or bronchoscopic improvement was noted in 72% of patients in group 1 and in 85% of patients in group 2 (p > 0.05). Complication rates were low and comparable. Survival was similar in both groups (median < 6 months). Although both low dose rate and high dose rate brachytherapy appear equally effective in palliation for malignant endobronchial obstruction, we are now practicing the latter exclusively.

Efficacy of short term versus long term tube thoracostomy drainage before tetracycline pleurodesis in the treatment of malignant pleural effusions

BACKGROUND

A study was undertaken to compare the efficacy of short term tube thoracostomy drainage with standard tube thoracostomy drainage before instillation of tetracycline for sclerotherapy of malignant pleural effusions.

METHODS

The study consisted of a randomised clinical trial in a sequential sample of 25 patients with malignant pleural effusions documented cytopathologically. Fifteen patients were randomly assigned to group 1 (standard protocol) and 10 to group 2 (short term protocol). Patients in group 1 had tube thoracostomy suction drainage until radiological evidence of lung re-expansion was obtained and the amount of fluid drained was < 150 ml/day, before tetracycline (1.5 g) was instilled. The chest tube was removed when the amount of fluid drained after instillation was < 150 ml/day. Patients in group 2 also had suction drainage, but the tetracycline (1.5 g) was instilled when the chest radiograph showed the lung to be re-expanded and the effusion drained, which was usually within 24 hours. The chest tube was removed the next day.

RESULTS

The response to tetracycline sclerotherapy in the two groups was the same (80%) but the duration of chest tube drainage was significantly shorter for patients in group 2 (median two days) than for those in group 1 (median seven days).

CONCLUSIONS

The duration of chest tube drainage before sclerotherapy for malignant pleural effusions need not be influenced by the amount of fluid drained daily but by radiographic evidence of fluid evacuation and lung re-expansion. Shorter duration of drainage will reduce the length of hospital stay without sacrificing the efficacy of pleurodesis.

Massive hemothorax associated with intrathoracic extramedullary hematopoiesis involving the pleura

Intrathoracic extramedullary hematopoiesis rarely involves the pleura and is usually asymptomatic. We report a 73-year-old woman with myelofibrosis who had pleural involvement with extramedullary hematopoietic tissue that produced a massive hemothorax. Before the diagnosis of extramedullary hematopoietic tissue was established, sclerosis with tetracycline was attempted, which accelerated pleural bleeding and required surgical evacuation. The bleeding was ultimately controlled by low-dose radiation therapy.

Spontaneous hemothorax. Report of 6 cases and review of the literature

We present 6 cases of spontaneous hemothorax and comprehensively review the medical literature on this subject. We categorize the reported causes and offer a rational diagnostic approach to patients with nontraumatic hemothorax. We recommend specific treatments for specific etiologies, and emphasize the importance of well-established surgical principles for the treatment of hemothorax. Our suggestions should enable physicians to accurately diagnose and expeditiously treat patients with spontaneous hemothorax.

Myocardial infarction caused by cardiac microvasculopathy in a patient with the primary antiphospholipid syndrome

Antiphospholipid antibodies occur in various clinical states, including the primary antiphospholipid syndrome. Clinical features in these conditions appear to be caused by vasculopathy associated with the presence of these antibodies. We report the case of a patient with primary antiphospholipid syndrome who experienced cardiac necrosis secondary to myocardial microvasculopathy in the absence of vasculitis. This case demonstrates unequivocally that noninflammatory myocardial microvasculopathy occurs in the primary antiphospholipid syndrome per se without any clinical or immunologic signs of systemic lupus erythematosus or other disease process. The histopathologic findings in the skin and myocardial biopsies showed a noninflammatory vasculopathy characterized by bland thrombi and lack of infiltration of the vessel wall by inflammatory cells. Ultrastructural examination of the myocardial biopsy confirmed the vascular thrombosis and endothelial activation and showed no deposits in basement membranes. The patient survived after appropriate treatment. Evidence presented here supports the concept that the vasculopathy in the antiphospholipid syndrome is distinct from other types of vascular occlusions seen in systemic lupus erythematosus. We suggest that myocardial biopsy can be crucial in showing an underlying myocardial ischemic process despite "normal" findings on coronary angiography. Results of the biopsy hastened the decision to use potentially lifesaving plasmapheresis and anticoagulation therapy in this patient.

Stimulation of fibroblast collagen and total protein formation by an endothelial cell-derived factor

We investigated the effect of medium conditioned by bovine aortic endothelial cells on collagen accumulation and total protein formation by human embryonic fibroblasts or bovine smooth muscle cells in cultures. The conditioned medium at a 1:10 dilution induced a twofold increase in collagen and total protein accumulation in fibroblast cultures. At low concentration (1:50 dilution), the conditioned medium stimulated collagen accumulation preferentially; at high concentration (1:10 dilution), overall protein synthesis also was increased. The increase in type I collagen accumulation was associated with an increase in the steady-state level of alpha 1 (I) mRNA for collagen. The conditioned medium increased the production of types I and III collagen without affecting the proportion of collagen types in both fibroblast and smooth muscle cell cultures. Partial purification of the endothelial cell-derived factor disclosed it to be a heat-stable protein with an apparent molecular weight of 8-10 kDa. The stimulation of protein formation by this substance was not inhibited by antibodies against transforming growth factor-beta or the insulinlike growth factor I receptor. The partially purified factor stimulated protein production without affecting fibroblast proliferation. This endothelial cell-derived protein may play a role in the remodeling of vascular connective tissue by stimulating collagen synthesis.

The principles and practice of morning report

Morning report is a traditional ritual on academic medical services. At morning report, house staff and faculty review case management and the principles of clinical medicine. To understand better the role and function of morning report and to assess its value for supervision, teaching, and evaluation of clinical knowledge and skills, a survey of academic departments of medicine was conducted. A questionnaire was sent to 124 departments of medicine represented by the membership of the Association of Professors of Medicine. The response rate was 94%. Morning report was important for teaching and was also useful for evaluation of resident performance and quality of clinical care. Some potential problems were identified when the conference is used for peer review and performance evaluation. Morning report stands out as the only large, formal conference generally used for the evaluation of case management and the performance of medical residents. As such, its limitations must be recognized. Recommendations are made for taking advantage of the unique educational opportunities available at morning report.

Lobular carcinoma of the breast in a patient with Klinefelter's syndrome. A case with bilateral, synchronous, histologically different breast tumors

A case of bilateral breast cancer in a patient with a Klinefelter mosaic syndrome is presented. The tumor in the left breast was an infiltrating lobular carcinoma with characteristic in situ component. To the knowledge of the authors, this is the first case in the English literature of lobular carcinoma of the breast in a phenotypic man. In fact, it was the pathologic diagnosis which led to the study of the chromosomal abnormality.