A Phase II, Randomized, Double Blind, Placebo Controlled Study of the Safety and Efficacy of a Caffeine-Based Antifibrosis Cream in Patients with Breast Cancer Undergoing Radiation Therapy

PURPOSE/OBJECTIVE(S)

Radiation induced fibrosis (RIF) is a common long term adverse event in patients undergoing post-mastectomy radiation therapy (PMRT) which can cause capsular contracture, implant loss, and reconstruction complications in women with implant-based breast reconstruction. At a molecular level, adenosine is a driver of RIF. Preclinical data have shown that pharmacologic blockade of the adenosine A2A Receptor (A2AR) in mice as well as an A2AR knockout mouse model prevented skin fibrosis associated with radiation injury. Caffeine is an A2AR antagonist which has been shown to block the development of hepatic fibrosis in liver disease patients. We present a phase II placebo controlled clinical trial to evaluate whether a caffeine-based cream can prevent RIF and thus reduce the rates of reconstructive complications in patients with tissue expander-based reconstruction requiring PMRT.

MATERIALS/METHODS

Women ≥ 18 years old with breast carcinoma stage 0-III status post mastectomy with tissue expander-based reconstruction who require PMRT to the chest wall +/- the regional nodes are being enrolled. The target accrual is 60 patients. Boost field to the chest wall, scar and/or nodal region is allowed. Patients with inflammatory breast cancer or those requiring skin bolus are excluded. Prior to starting radiation, patients will be randomized to placebo vs. caffeine cream and they will be instructed to apply the cream twice a day starting on the first day of radiation treatment and continuing daily for the duration of radiation until the removal of tissue expanders. The primary study endpoint is reconstructive complications requiring rehospitalization or reoperation by 2 years post radiation including reconstructive failure with or without reconstruction. A safety endpoint of grade ≥ 2 acute radiation dermatitis will also serve as a co-primary endpoint. Secondary endpoints are wound infection/cellulitis, hematoma, seroma, threatened exposure, wound dehiscence, implant leakage, rupture, and or deflation, and capsular contracture that do not meet criteria for the primary endpoint. Clinician rated cosmesis, local recurrence, regional recurrence, distant metastasis and survival up to 4 years are additional secondary endpoints. Exploratory endpoint includes the use of shear wave elastography (SWE) as a potential tool to quantitatively measure post irradiation fibrosis. Correlative aims include assessing epidermal thickness and fat layer thickness from tissue obtained at time of implant exchange for association with the development of fibrosis. The primary efficacy endpoint will be estimated using Kaplan Meier methods from date of randomization. Treatment comparisons will be based on a 2-sided log rank chi-square test and the hazard ratio will be estimated with 95% confidence intervals. The study started accruing in 12/2019 and is estimated to end by 04/2024. As of January 2023, 67% (40/60 patients) of the planned patients have been enrolled.

RESULTS

To be determined.

CONCLUSION

To be determined.

Cognitive functioning in Lesch-Nyhan syndrome: a 4-year follow-up study

Lesch-Nyhan syndrome (LNS) is a rare disorder of metabolism caused by a defective gene on the X chromosome. It is typically characterized by choreoathetosis, hypertonia, hyperreflexia, and self-mutilation. The present study is a 4-year follow-up investigation of the cognitive status of six subjects with a mean age of 17 years 10 months (range 14 years 9 months to 23 years). The Stanford-Binet Intelligence Scale: IV was used. Each of the four domains assessed by this battery (verbal reasoning, abstract/visual reasoning, quantitative, and short-term memory) was compared with previous findings of the same subjects at their initial test and 2-year follow up; the aim being to gain further insight into the clinical course of LNS over time. The results suggest that while the subjects generally continued to acquire new information and skills over time, their standardized scores declined, indicating that a plateau was reached in their skill levels relative to their peers, as also seen in other developmental disabilities. Deficits were noted in working memory, particularly on tasks that involve considering multiple features simultaneously.

Cognitive functioning in Lesch-Nyhan syndrome

The present study represents the first effort to assess systematically the cognitive functioning of a population of individuals with Lesch-Nyhan syndrome using standardized psychometric instruments. Seven residents from a special hospital setting participated. They ranged in age from 10 years 1 month to 22 years 3 months (mean 13 years 7 months). Using the Stanford-Binet Intelligence Scale: IV, scores in each of the four domains assessed by this battery (Verbal Reasoning, Abstract/Visual Reasoning, Quantitative and Short-Term Memory), as well as the general composite score, ranged from moderately mentally retarded to low average. Areas of weakness included attention, the manipulation of complex visual images, the comprehension of complex or lengthy speech, mathematical ability, and multi-step reasoning.

Pilot study of adriamycin and amsacrine (m-AMSA) in patients with advanced breast cancer

Twelve patients with recurrent and metastatic breast cancer were treated with a combination of adriamycin and amsacrine (m-AMSA) to evaluate its efficacy and toxicity. Adriamycin was given at 40 mg/m2 i.v. and m-AMSA at 50 mg/m2 i.v. every 3 weeks. No response was observed. One patient received an escalated m-AMSA dose at 70 mg/m2 and the same dose of adriamycin. She died of treatment-related leukopenia and infection. We conclude that the combination of adriamycin and amsacrine at the dose and schedule used in our trial has little antitumor effect in the treatment of advanced breast cancer.

Sequential chemotherapy of advanced colorectal cancer with standard or high-dose methotrexate followed by 5-fluorouracil

Thirty patients with advanced measurable colorectal cancer were randomized to receive either methotrexate (MTX) 200 mg/m2 or 40 mg/m2, followed in four hours by 5-fluorouracil (5-FU) 600 mg/m2. Patients receiving the higher dose MTX were given leucovorin rescue 24 hours later. Eight of 13 patients treated with 200 mg/m2 MTX + 5-FU developed severe hematologic toxicity, leading to two toxic deaths. In addition, 9/13 developed mild azotemia, and three patients had severe gastrointestinal toxicity. No patients with prior chemotherapy responded to either regimen. Among those without prior chemotherapy, there were two of six and three of eight partial responses, respectively, in the 200 mg/m2 and 40 mg/m2 MTX regimens. Sequential 200 mg/m2 MTX followed by 5-FU after four hours has unacceptable toxicity. Sequential treatment with standard dose MTX + 5-FU is tolerable and merits further study.