First-line levetiracetam versus enzyme-inducing antiseizure medication in glioma patients with epilepsy

OBJECTIVE

This study aimed to directly compare the effectiveness of first-line monotherapy levetiracetam (LEV) versus enzyme-inducing antiseizure medications (EIASMs) in glioma patients.

METHODS

In this nationwide retrospective observational cohort study, Grade 2-4 glioma patients were included, with a maximum duration of follow-up of 36 months. Primary outcome was antiseizure medication (ASM) treatment failure for any reason, and secondary outcomes were treatment failure due to uncontrolled seizures and due to adverse effects. For estimation of the association between ASM treatment and ASM treatment failure, multivariate cause-specific cox proportional hazard models were estimated, adjusting for potential confounders.

RESULTS

In the original cohort, a total of 808 brain tumor patients with epilepsy were included, of whom 109 glioma patients were prescribed first-line LEV and 183 glioma patients first-line EIASMs. The EIASM group had a significantly higher risk of treatment failure for any reason compared to LEV (adjusted hazard ratio [aHR] = 1.82, 95% confidence interval [CI] = 1.20-2.75, p = .005). Treatment failure due to uncontrolled seizures did not differ significantly between EIASMs and LEV (aHR = 1.32, 95% CI = .78-2.25, p = .300), but treatment failure due to adverse effects differed significantly (aHR = 4.87, 95% CI = 1.89-12.55, p = .001).

SIGNIFICANCE

In this study, it was demonstrated that LEV had a significantly better effectiveness (i.e., less ASM treatment failure for any reason or due to adverse effects) compared to EIASMs, supporting the current neuro-oncology guideline recommendations to avoid EIASMs in glioma patients.

1029 Anthracycline and trastuzumab-induced subclinical cardiac damage and its prevention in the SAFE trial. Myocardial strain imaging and 3D echo interim analysis data

Background

Benefit of anthracyclines and trastuzumab therapies on disease-free survival in breast cancer is well known. Cardiotoxicity is a feared potential complication of both drugs. It usually progresses from cardiomyocyte injury to silent left ventricular dysfunction (LVD) which often becomes symptomatic and irreversible. Therefore, its prevention and early detection are of paramount importance in these cancer patients.

Purpose

SAFE trial (CT registry ID: NCT2236806) is a randomized phase 3, four-arm, single-blind, placebo-controlled study that aims to evaluate the effects of Bisoprolol (B) (5 mg, twice daily), Ramipril (R) (5 mg, twice daily) or the combination of the two (R + B), compared to placebo (P), on subclinical heart heart damage. Interim data of left ventricular function monitored with 3D Echo and Myocardial Strain Imaging are presented.

Methods

Out of 225 patients asked to participate, 191 were enrolled (mean age 48.9 ± 9.0 years). Follow-up monitoring (at 3, 6, 12 months[m]) comprised 3D ejection fraction (3D-LVEF) and Global Longitudinal Strain (GLS). One patient had sub-acute anthracyclines cardiotoxicity. Data at one year of 123 patients were available (34 P, 28 R, 31 B, 30 R + B).

Results

At time 0, no significant differences in age, body mass index, hemodynamic parameters were observed among arms. Data of 3D-LVEF and GLS at time 0 and during follow-up are reported in the figure (p level versus time 0 – GLS repeated measures). There was a significant reduction in 3D LVEF and increase in GLS in P arm (3D LVEF: 3m: -3.3%, 6m: - 5.2%, 12m: -3.7%; GLS: 3m: +5,7%, 6m: +7.8%, 12m: + 7,1%). A similar, though less significant, worsening of 3D LVEF (-2.4%,-1.9%,-2.2% at 3, 6, 12m, respectively) and GLS (+2.7%, +3.2% at 3 and 6m, respectively) was found in R arm. In B and B +R arms there was a worsening at 6m (3D LVEF -2.5%, GLS +2.7%), whereas at 12m only GLS increased (+3.2%) in B, not in B + R. Arm differences were significant (repeated measures two ways) both for 3D LVEF (two-way repeated measures ANOVA, p level = 0.038, observed power 0.855) and GLS (p level = 0.002, observed power 0.973).

Conclusions

This interim analysis of the SAFE trial shows that demonstration of subclinical cardiotoxicity is feasible with 3D echo and myocardial strain imaging. Significant subclinical damage potentially leading to LVD is present at one year. Both B alone on in combination with R may be a successful cardioprotective strategy in patients treated with anthracyclines and trastuzumab.

Abstract 1029 Figure. Time course of GLS and 3D LVEF

Hierarchical mixture models for biclustering in microarray data

In the last few years, model-based clustering techniques have become widely used in the context of microarray data analysis. In this empirical context, a potential purpose for statistical approaches is the identification of clusters of genes that are co-expressed under subsets of experimental conditions. We discuss a hierarchical mixture model to combine advantages of allowing for dependence within gene clusters and for simultaneous clustering of genes and experimental conditions. Thanks to the adopted hierarchical structure, we may distinguish gene clusters from mixture components, where the latter may represent intra-cluster gene-specific extra-Gaussian departures. To cluster experimental conditions, instead, we suggest a suitable parameterization of component-specific means by using a binary row stochastic matrix representing condition membership. The performance of the proposed approach is discussed on both simulated and real datasets.

Model-based approaches to synthesize microarray data: a unifying review using mixture of SEMs

Several statistical methods are nowadays available for the analysis of gene expression data recorded through microarray technology. In this article, we take a closer look at several Gaussian mixture models which have recently been proposed to model gene expression data. It can be shown that these are special cases of a more general model, called the mixture of structural equation models (mixture of SEMs), which has been developed in psychometrics. This model combines mixture modelling and SEMs by assuming that component-specific means and variances are subject to a SEM. The connection with SEM is useful for at least two reasons: (1) it shows the basic assumptions of existing methods more explicitly and (2) it helps in straightforward development of alternative mixture models for gene expression data with alternative mean/covariance structures. Different specifications of mixture of SEMs for clustering gene expression data are illustrated using two benchmark datasets.

A mixture model with random-effects components for classifying sibling pairs

In healthy aging research, typically multiple health outcomes are measured, representing health status. The aim of this paper was to develop a model-based clustering approach to identify homogeneous sibling pairs according to their health status. Model-based clustering approaches will be considered on the basis of linear mixed effect model for the mixture components. Class memberships of siblings within pairs are allowed to be correlated, and within a class the correlation between siblings is modeled using random sibling pair effects. We propose an expectation-maximization algorithm for maximum likelihood estimation. Model performance is evaluated via simulations in terms of estimating the correct parameters, degree of agreement, and the ability to detect the correct number of clusters. The performance of our model is compared with the performance of standard model-based clustering approaches. The methods are used to classify sibling pairs from the Leiden Longevity Study according to their health status. Our results suggest that homogeneous healthy sibling pairs are associated with a longer life span. Software is available for fitting the new models.

The DOC combination in advanced gastric cancer: Preliminary data of a phase II study

104

Background: We describe activity of first line chemotherapy in advanced gastric carcinoma with docetaxel (DTX), oxaliplatin (OHP) and capecitabine (CAP).

Methods: Patients (pts) were enrolled in the phase II study, if they had the main subsequent criteria: histologically confirmed diagnosis of advanced gastric cancer (AGC) (local advanced or metastatic disease); normal renal and hepatic function; no myocardial infarction or angina pectoris; no uncontrolled severe diseases or active infections. Treatment schedule: DTX at fixed dose of 65 mg/m2 on day 1, OHP at fixed dose of 110 mg/m2 on day 1, CAP at fixed dose of 1,600 mg/ m2 with crhonomodulation in trhee daily administration from day 1 to day 14, every 3 weeks. Dose-limiting toxicity (DLT): G3 non-haematological or G4 haematological. Study design: Simon two-stage phase II optimal design with power (1- b) 80%, error a 5%, error b 20%, P0 40%, P1 60%. Planned sample size: I stage 7/16, II stage 23/46. Primary endpoint was response rate (RR). Secondary endpoints were time to progression (TTP), overall survival (OS), toxicity and quality of life.

Results: 38 pts were enrolled: 24 men and 14 women, median age of 58 years (range 50-67). Median number of cycles per pts was 4,5 (range 3-6). Total cycles administered: 41. Cumulative G3-4 toxicities were: neutropenia 21%, anemia 14%, asthenia 9%. G1-2 toxicities were: diarrhea 22%, neurotoxicity 18%. Median received-DI of DTX: 20 mg/mq/week (93% of recommended-DI), OHP 35 mg/mq/week (95%), CAP 7,000 mg/mq/week (94%) per patient, respectively. Overall pts were assessable (according to intent-to-treat analysis) with 58% (a0.05, CI + 29) of objective responses (OR): 7 partial responses, 4 stable disease and 1 progression. The disease control rate (DCR) was 91%. TTP and OS not done because median follow-up was of 8 months (2-15) only.

Conclusions: The combination DOC is tolerable without G3-4 toxicity and preliminary data show very high activity.

No significant financial relationships to disclose.

Triplet schedule of weekly 5-fluorouracil and alternating irinotecan or oxaliplatin in advanced colorectal cancer: a dose-finding and phase II study

A weekly administration of alternating irinotecan or oxaliplatin associated to 5-Fluorouracil in advanced colorectal cancer was planned in order to evaluate a new schedule maintaining dose intensities of each drug as in double combinations and tolerability of the triplet association. The following weekly schedule was administered: irinotecan, days 1 and 15; oxaliplatin, days 8 and 22; 5-fluorouracil (5-FU) over 12-h (from 10:00 p.m. to 10:00 a.m.) timed flat infusion, days 1-2, 8-9, 15-16 and 22-23, every 4 weeks. Dose- finding and phase II study were planned. Thirteen patients were enrolled in the dose-finding study and 23 in the phase II study. The recommended doses of our study are: irinotecan 160 mg/m(2); oxaliplatin 80 mg/m(2); 5-FU 900 mg/m(2). The dose-limiting toxicity was diarrhea (35% of patients) but no cases of febrile neutropenia were observed. In 30 patients assessable for response two complete (6.7%) and 18 partial (60%) responses were observed, for an overall response rate of 66.7% (alpha 0.05, CI+/-17). The triplet association using this weekly alternating schedule is an active and well-tolerated outpatient regimen. Surgical removal of residual disease was considered in 5 patients and a radical resection was performed in 5 patients (147 %).

The safety of dose-dense liposomal-encapsulated doxorubicin in association with docetaxel (MyTax) in breast cancer

Abstract #2157

Background: Liposomal-Encapsulated Doxorubicin (LED) shows equivalent efficacy, better cardiac tolerability at higher cumulative dose than conventional anthracyclines in breast cancer treatment.
 Methods: Sixteen pts were enrolled in a dose-finding study of LED (TLC-D99 Myocet ®) associated to Docetaxel (TXT). Twelve pts were treated with a fixed TXT dose (50 mg/m2) and TLC-D99 at three dose levels, 40-45-50 mg/m2, days 1 and 15 every 2 weeks using an intra- and inter-patient approach; four pts wrere treated at the TLC-D99 recommended dose (50 mg/m2). Cardiac monitoring of LVEF was performed every two cycles; Precursor Brain Natriuretic Peptide (proBNP) and cardiac Troponin (c-TnI) before and after 24 h chemotherapy was evaluated.
 Results: Breast cancer (BC) disease extension: metastatic (MBC), 8; locally advanced BC, 5; T2-T3 BC, 3. Previous chemotherapy: untreated, 11 pts; adjuvant, 5 pts. Enrolled pts for each dose-level: I, 7; II, 9; III, 14. Newly treated pts: I dose-level, 7; II dose-level, 3; III dose-level, 6. Valuable cycles for each dose-level in a total 77 cycles: I, 14; II, 21; III, 42. DLTs were observed in 3 pts, 21%, and 3 cycles, 4%: 2 cardiac, characterized by a 19% LVEF decrease and a symptomatic arrhythmia; one G4 hematologic resistant to G-CSF. DLTs for each dose-level by pts and cycles, respectively: I, 14% (1/7 pts) and 7% (1/14 cycles); II, no DLT in 9 pts and 21 cycles; III, 14% (2/14 pts) and 5% (2/42 cycles). Cumulative G3-4 toxicities by pts and cycles, respectively: cardiac arrhythmia 6% and 1,3%, cardiac general (symptomatic LVEF decrease), 6% and 1,3%; alopecia 81% and 65%; neutropenia resistant to G-CSF, 6% and 1,3%. Cardiac DLTs were observed in 2 elderly pts (>65 y). The 2 cardiac DLTs were observed in 2 out of 3 pts with pre-existing diastolic dysfunction. No pathologic increase of c-TnI levels was detected. Seven pts showed increased pro-BNP after chemotherapy; 1 of these with increased pro-BNP after chemotherapy, persistent the day 1 of each subsequent chemotherapy showed a DLT;
 G2 toxicities by patients and cycles, respectively: asthenia 37% and 18%, stomatitis/mucositis 12% and 5%, nausea 31% and 12%. Median rDI of TLC-D99 was 25 mg/m2/w and TXT 25 mg/m2/w for pts, respectively. Preliminary efficacy in 16 assessable pts: LA-BC and MBC, 1 CR (pCR) 7 PR (OR 62%), 4 SD and 1 PD; T2-T3 BC, 2 PR and 1 SD.
 Conclusion: dose-dense TLC-D99/Docetaxel association can be safely recommended at the dose of 50 mg/m2 for each drug. Docetaxel intensification is ongoing.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2157.

The role of transvaginal ultrasound in early diagnosis of tamoxifen-related endometrial cancer: An Italian experience

11021

Background: women treated with tamoxifen for ER-positive early breast cancer are at a two to seven fold increased risk of endometrial cancer. Even though published data fail to support the use of transvaginal ultrasound (TVU) for screening of endometrial cancer, this is still a very common clinical practice in this subset of patients (pts). Methods: we have conducted a retrospective analysis to investigate the value of TVU in early detection of tamoxifen-related endometrial cancer. The screened population consists of pts treated with adjuvant tamoxifen in our institution from January 1999 up to December 2003 receiving a TVU annually or in case of gynaecologic symptoms. Results: 491 evaluated pts performed a total of 1634 TVUs in asymptomatic conditions. FIGO stage I endometrial cancers have been diagnosed in 3 patients (0.32%) who are still alive after total hysterectomy. A vaginal bleeding anticipated the examination in 33 women (3.2%) and represented the first symptom in two cases of tumor. Only one endometrial cancer has been detected with the screening procedure. Median increase of endometrial thickness has been 7.6 mm (range 1–34 mm) and those patients with abnormal images at TVU underwent an hysteroscopy with endometrial biopsies (169) resulting in a benign histology (polyps, cystic atrophy, hyperplasia) in most cases. Conclusions: therefore we have performed more than 1500 transvaginal ultrasound to detect only one asymptomatic cancer so we agree with literature in supporting that women receiving tamoxifen should undergo only an annual gynaecologic examination reserving the TVU to patients with vaginal bleedings or discharges.

No significant financial relationships to disclose.

Novel P53 mutations detected by FAMA in colorectal cancers

BACKGROUND

The aim of the study was to identify p53 gene mutations by FAMA (fluorescence-assisted mismatch analysis) in colorectal cancers.

PATIENTS AND METHODS

Analytical scanning of the p53 gene (exons 5-9) was performed in colon cancer samples from 44 consecutive patients by FAMA. FAMA is a semiautomatic scanning approach based on the chemical cleavage of the mismatch in fluorescently labeled heteroduplex DNA, obtained from the combination of a normal and a mutated allele. FAMA has already shown optimal levels of diagnostic accuracy and sensitivity in detecting gene mutations (nucleotide substitutions, insertions/deletions) both at the germline and somatic level. The peculiar feature of FAMA is its ability to detect and localize mutations, by a redundant pattern of signals due to fluorescent DNA fragments generated by chemical cleavage. Moreover, previous data have demonstrated that normal contaminating DNA from stromal cells in the sample does not affect the sensitivity of the procedure, leading to the identification of the mutation even when the ratio mutant/normal allele is 10%.

RESULTS

Eighteen mutations (12 missense, one nonsense, two deletions, three nucleotide substitutions at the level of the splice-junctions) and two polymorphisms were detected by FAMA in 17 patients (39%) and then confirmed by automated sequence analysis. Six of 18 mutations (33%) were not previously reported for colon cancer samples and two of 18 lesions (11%) were identified as novel p53 mutations.

CONCLUSIONS

Analytical scanning of the p53 gene by FAMA in DNA from colon cancer samples provides a sensitive, accurate and specific diagnostic procedure for routine clinical application.

[Can analysis of the molecular status of the p53 gene contribute to improving the therapeutic strategy for breast carcinoma?]

The occurrence of mutations in the p53 tumor suppressor gene is a specific and recurring genetic event in solid tumors. P53 plays a pivotal role in multiple cellular processes such as cell growth control, DNA repair and programmed cell death. Genotoxic damage, also induced by chemotherapy or radiotherapy, induces p53 overexpression in order to control the rate of proliferating damaged cells, thus triggering the mismatch repair or apoptotic pathways. P53 inactivation determines a condition of genetic instability, justifying the subsequent susceptibility to acquire mutations of different other genes. P53 mutations are associated with worse prognosis and with chemo/radioresistance, due to the inability to trigger p53-dependent programmed cell death. Molecular diagnostic strategies show 32% p53 mutations in breast cancer. The analysis of the p53 gene performed by FAMA (Fluorescence Assisted Mismatch Analysis) in high-risk breast cancer patients with > or = 10 involved axillary nodes may help identify a subset of very high risk BC patients (vHR-BC) with poorer prognosis and a subset with better prognosis, potentially responsive to medical treatments. The accurate evaluation of the p53 status can predict prognosis and sensitivity to chemotherapy, thus representing the first step toward better definition of therapeutic strategies according to the molecular characterization of the individual patient.

[A case of watermelon stomach]

The authors describe a case of antral Watermelon Stomach (WS) in a seventy-eight year old woman with severe iron-deficient chronic anemia, liver cirrhosis and diabetes mellitus. Endoscopy was diagnostic on the 3rd-4th examination because of the disease's rarity and the concomitance of systemic pathologies, such as portal hypertension, in which often a congestive gastropathy with similar aspects is associated. Whether out of clinical evolution, or capillary thrombosis, or vertical fibromuscular hyperplasia of the lamina propria were considered distinctive elements. By means of literature review it wasn't possible to establish the portal hypertension's prevalence out of the WS cases, but it could be a chance factor. In this way some polycentric prospective trials could be useful. The endoscopic practice is important not only for diagnosis but also for therapeutical means, even if in our case surgery was the chosen treatment.

An ultrastructural study of six cases of chronic active C hepatitis. A comparison with chronic active B hepatitis

Liver biopsies from six patients affected by chronic active hepatitis (CAH) induced by hepatitis C virus (HCV) have been investigated ultrastructurally and their features compared with those of five cases of CAH induced by hepatitis B virus (HBV). Clusters of deeply packed nuclear inclusions (18 to 22 nm in diameter) were found in patients with HCV-CAH. They were irregularly round and ill-delimited. These inclusions were distinct from the regular round and well-delimited nuclear inclusions associated with HBV. HCV-associated nuclear inclusions were similar to a peculiar type of intranuclear particle described in non-A, non-B hepatitis before the HCV disease had been recognized as a distinct entity. These inclusions have never been hitherto reported in infections caused by HBV or other known hepatotropic viruses. Together, these data suggest that the occurrence of these inclusions can be related to HCV activity in hepatocytes. Changes in the microarchitecture of the liver cell and its microenvironment were similar in HCV- and HBV-CAH. They were heterogeneous in different cases and did not display a clear correlation with the severity of the disease.