Risk factors for disease severity among children with Covid-19: a clinical prediction model

BACKGROUND

Children account for a significant proportion of COVID-19 hospitalizations, but data on the predictors of disease severity in children are limited. We aimed to identify risk factors associated with moderate/severe COVID-19 and develop a nomogram for predicting children with moderate/severe COVID-19.

METHODS

We identified children ≤ 12 years old hospitalized for COVID-19 across five hospitals in Negeri Sembilan, Malaysia, from 1 January 2021 to 31 December 2021 from the state's pediatric COVID-19 case registration system. The primary outcome was the development of moderate/severe COVID-19 during hospitalization. Multivariate logistic regression was performed to identify independent risk factors for moderate/severe COVID-19. A nomogram was constructed to predict moderate/severe disease. The model performance was evaluated using the area under the curve (AUC), sensitivity, specificity, and accuracy.

RESULTS

A total of 1,717 patients were included. After excluding the asymptomatic cases, 1,234 patients (1,023 mild cases and 211 moderate/severe cases) were used to develop the prediction model. Nine independent risk factors were identified, including the presence of at least one comorbidity, shortness of breath, vomiting, diarrhea, rash, seizures, temperature on arrival, chest recessions, and abnormal breath sounds. The nomogram's sensitivity, specificity, accuracy, and AUC for predicting moderate/severe COVID-19 were 58·1%, 80·5%, 76·8%, and 0·86 (95% CI, 0·79 - 0·92) respectively.

CONCLUSION

Our nomogram, which incorporated readily available clinical parameters, would be useful to facilitate individualized clinical decisions.

Epidemiology, clinical characteristics and outcomes of multisystem inflammatory syndrome in children

BACKGROUND

We describe the epidemiology, clinical characteristics, and outcomes of multisystem inflammatory syndrome in children (MIS-C) among children from Negeri Sembilan, Malaysia.

METHODS

A retrospective, multicentre, observational study was performed among children ≤15 years old who were hospitalized for MIS-C between January 18, 2021 and June 30, 2023. The incidence of MIS-C was estimated using reported SARS-CoV-2 cases and census population data. Descriptive analyses were used to summarize the clinical presentation and outcomes.

RESULTS

The study included 53 patients with a median age of 5.7 years (IQR 1.8-8.7 years); 75.5% were males. The overall incidence of MIS-C was approximately 5.9 cases per 1,000,000 person-months. Pediatric intensive care unit (PICU) admission was required for 22 (41.5%) patients. No mortalities were recorded. Children aged 6-12 years were more likely to present with cardiac dysfunction/shock (odds ratio [OR] 5.43, 95% confidence interval [CI] 1.67-17.66), whereas children below 6 years were more likely to present with a Kawasaki disease phenotype (OR 5.50, 95% CI 1.33-22.75). Twenty patients (37.7%) presented with involvement of at least four organ systems, but four patients (7.5%) demonstrated single-organ system involvement.

CONCLUSION

An age-based variation in the clinical presentation of MIS-C was demonstrated. Our findings suggest MIS-C could manifest in a spectrum, including single-organ involvement. Despite the high requirement for PICU admission, the prognosis of MIS-C was favorable, with no recorded mortalities.

Liposomal docosahexaenoic acid halts atherosclerosis progression

Background

Atherosclerosis is the main cause underlying cardiovascular disease (CVD). Docosahexaenoic acid (DHA, 22:6n-3) is a hydrophobic polyunsaturated fatty acid that exerts anti-inflammatory and antioxidant activities. However, the beneficial effects of DHA on CVD have been controversial likely due to variations in bioavailability after oral intake.

Purpose

In this study, we aim to investigate the potential inhibiting properties of liposomal DHA on atherosclerosis progression upon intravenous administration.

Methods

Four weeks old ApoE−/− and LDLr−/− mice were fed on athero-inducing high fat diet for 4 weeks and then randomly divided into two groups. The mice received either control liposomes (control group) or liposomes containing DHA (liposomal DHA treatment group) via intravenous injection, twice a week for 8 weeks while still being fed on high fat diet. At the experiment endpoint, whole aortas were collected for Oil Red O staining to quantify plaque area or for biochemical analysis. Plasma was collected for total cholesterol measurement and lipidomic analysis. Aortic roots were used for histological analysis.

Results

Upon intravenous injection, as shown by IVIS imaging, DHA-containing liposomes accumulated preferentially in the atherosclerotic plaques. Compared to control liposomes, liposomal DHA treatment reduced the atherosclerotic plaque area in both atherosclerosis animal models, with the total plaque area decreased by 35.8% in ApoE−/− mice, (p<0.001) and by 22.4% in LDLr−/− mice (p<0.05). Plaque composition analysis revealed that liposomal DHA treatment increased collagen content and reduced the number of macrophages and neutral lipid within the plaques, resulting in a lower plaque vulnerability index (1.095 for liposomal DHA treated group vs. 1.692 for control group, p<0.05). Among those plaque macrophages, as demonstrated by immunohistology, M2 (anti-inflammatory) macrophages accounted for 4.44% in liposomal DHA treated mice and 2.24% in control liposomes treated mice (p<0.05). In agreement with the histology results, higher mRNA expression levels of anti-inflammatory markers (IL-10, CD206 and CD163) and collagen type 1 were determined in aortic tissue after liposomal DHA treatment. Moreover, liposomal DHA did not change total cholesterol level in the blood but significantly lowered plasma levels of several species of triglycerides. In vitro experiment with bone marrow derived macrophages showed that liposomal DHA was able to suppress lipopolysaccharide-induced inflammatory response and oxidative stress.

Conclusions

Our findings demonstrate that incorporation of DHA in injectable liposomes is an effective way to increase the inhibitory effects of DHA on halting the progression of atherosclerosis via lowering circulating triglycerides, reducing plaque inflammation, and enhancing plaque stability. Intravenous administration of liposomal DHA may become an efficacious strategy for the treatment of atherosclerosis.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): NUSMed Seed Fund

Comparison of Severe Viral Pneumonia Caused by SARS-CoV-2 and Other Respiratory Viruses Among Malaysian Children During the COVID-19 Pandemic

OBJECTIVES

We described the etiology of severe pneumonia in children during the height of the COVID-19 pandemic in Malaysia and compared the clinical features of severe SARS-CoV-2 to other respiratory viruses.

METHODS

This retrospective study included all children aged 12 years and below hospitalized with severe pneumonia in Negeri Sembilan, Malaysia, between 1 April 2021 and 31 October 2021. We extracted demographic and clinical data and used logistic regression to examine risk factors associated with severe SARS-CoV-2 or other viral pneumonia.

RESULTS

A total of 111 children were included. The median age was 15 months. Human rhinovirus/enterovirus, SARS-CoV-2 and respiratory syncytial virus were the most common etiology of severe pneumonia. Codetection of >1 viral pathogen was present in 14 (12.6%) patients. Children with severe COVID-19 presented early in the course of illness and had lower rates of pediatric intensive care admission. The presence of sick contact with an adult was a predictor for SARS-CoV-2, whereas adventitious breath sounds were predictive of other respiratory viruses.

CONCLUSIONS

The etiology of severe pneumonia in children evolved with the epidemic curve of COVID-19 and school closures. Children with severe pneumonia due to SARS-CoV-2 experienced a milder clinical course when compared to other respiratory viruses.

Prevalence and diagnostic yield of investigating t wave inversion in a large unselected pre-participation cohort of young Asian males

Background/Introduction

T wave inversion (TWI) is a potentially abnormal finding on pre-participation screening electrocardiography (ECG), as it may suggest an underlying cardiomyopathy that should be risk stratified appropriately to minimise the risk of sports-related sudden cardiac death. Existing international guidelines prescribe criteria for investigating TWI in athletes. However, it is not established if these criteria can be extrapolated to screening unselected individuals. There is also evidence recommending against investigating specific patterns of anterior TWI in certain subsets of athletes due to low diagnostic yield; whether these exemptions may apply to non-athletes is uncertain. Given the importance of physical activity for primary prevention of cardiovascular disease in the general population, more evidence to guide pre-participation ECG screening of unselected individuals is needed.

Purpose

Firstly, to determine the epidemiology of abnormal TWI in a large unselected pre-participation cohort of young males of predominantly Asian ethnicity. Secondly, to determine the diagnostic yield of an echocardiography-guided approach to investigating individuals with abnormal TWI for a cardiomyopathy.

Methods

All individuals who attended a national centre for pre-enlistment cardiac screening over 39 months from 2017 were examined. Demographic data, anthropometric data and standardised physical fitness test scores were collected. Resting 12-lead ECG was performed for all individuals. Those with abnormal TWI, defined as a negatively deflected T wave of at least 0.1 mV amplitude in two contiguous leads, were referred to tertiary centres for echocardiography.

Results

69,714 consecutive males of mean age 17.9±1.1 years were screened. 562 individuals (0.8%) displayed abnormal TWI. Better aerobic fitness, but not muscular strength, was associated with a higher prevalence of abnormal TWI in general and specifically in the anterior territory, although not beyond leads V1-V2. Aerobic fitness had no association with abnormal TWI in the inferior territory or lateral territory. Of those with abnormal TWI, 12 individuals (2.1%) were newly diagnosed with a cardiomyopathy. Significant factors associated with a cardiomyopathy diagnosis were abnormal TWI in the lateral territory, abnormal TWI in the anterior territory beyond lead V2, deeper maximum TWI depth, presence of hypertension and higher body mass index. No individual presenting with TWI restricted to solely leads V1-V2 and/or two inferior leads without abnormal TWI in other contiguous leads was diagnosed with a cardiomyopathy.

Conclusion

Investigating abnormal TWI in an unselected pre-participation cohort of young Asian males had a significant yield, particularly in individuals manifesting abnormal TWI in the lateral territory and the anterior territory beyond lead V2. The ECG finding of anterior TWI in an unselected population may not be as benign as that in athletic populations.

Funding Acknowledgement

Type of funding sources: None. Abnormal TWI: Prevalence and Yield

Simulation and validation for count-based binary decision of target blood pressure achievement in home blood pressure monitoring data analysis for clinical practice

Introduction

Home blood pressure monitoring (HBPM) is a useful tool to identify hypertension and to decide whether a patient's blood pressure (BP) is controlled. The use of automatized oscillometric BP measurement devices has become increasingly popular with help of information technology and internet of things to the devices. However, applying HBPM to daily clinical practices is still challenging, because most patients with hypertension are in age groups not familiar to digital devices and internet and high BP criteria using average home BP values are often useless in outpatient clinics without easily accessible average BP calculation tools. Therefore, we developed a simple and straightforward method to interpret HBPM through counts of BP ≥135/85 mmHg.

Methods

We simulated 400 cases of HBPM using a random number generator function in statistical software. The simulated average home systolic BP (SBP) and its standard deviation (SD) were 125±15 mmHg and 12±5 mmHg and the number of HBP readings was 24 times. The simulated diastolic BP (DBP) was randomly selected to 50–75% of the SBP. The validation of the binary interpretation method was conducted using actual HBPM data from 386 subjects in a rural area of South Korea. Receiver operating characteristics curve analysis was conducted, and linear regression and logarithmic models were fitted between the numbers of home BP ≥135/85 mmHg and mean BP. Hypertension was defined with average home BP ≥135/85 mmHg.

Results

In the simulated cohort, hypertension was presented in 197 cases (49.3%). The C-index of the numbers of BP readings ≥135/85 mmHg was 0.994 (95% confidence interval [CI] 0.990–0.998), and ≥12 of 24 BP readings ≥135/85 mmHg showed a sensitivity of 95.4%, a specificity of 95.1% and an accuracy of 95.3% for the diagnosis of hypertension. In validation cohort, the numbers of home BP measurements varied from 8 to 81 times. The validation cohort similarly showed that the C-index of the ratio between the number of high BP readings (≥135/85 mmHg) to the number of BP measurements (R-NHBP/NBP) was 0.985 (95% CI, 0.976–0.994) and the best accuracy was shown at R-NHBP/NBP of ≥0.45. R-NHBP/NBP of ≥0.5 showed a sensitivity of 0.957, a specificity of 0.907 and an accuracy of 0.927. The accuracy of the R-NHBP/NBP of ≥0.5 decreased as SD and the range of SBP increased, whereas it did not change with the number of measurements (Figure 1). R-NHBP/NBP <0.2 predicted normotension and R-NHBP/NBP >0.8 predicted hypertension in 95% confidence. Mean widths of the 95 prediction intervals for the average SBP and DBP were 18.2 mmHg and 12.6 mmHg, respectively (Figure 2).

Conclusion

Counting the number of BP ≥135/85 mmHg can provide accurate assessments for the BP levels. R-NHBP/NBP of ≥0.5 is a simple and accurate marker of high BP in HBPM, and R-NHBP/NBP could be a useful tool to assess BP levels in patients practicing HBPM.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

A randomized phase III trial comparing adjuvant single-agent S1, S-1 with oxaliplatin, and postoperative chemoradiation with S-1 and oxaliplatin in patients with node-positive gastric cancer after D2 resection: the ARTIST 2 trial☆

BACKGROUND

Adjuvant chemotherapy and chemoradiotherapy are some of the standards of care for gastric cancer (GC). The Adjuvant chemoRadioTherapy In Stomach Tumors (ARTIST) 2 trial compares two adjuvant chemotherapy regimens and chemoradiotherapy in patients with D2-resected, stage II or III, node-positive GC.

PATIENTS AND METHODS

The ARTIST 2 compared, in a 1:1:1 ratio, three adjuvant regimens: oral S-1 (40-60 mg twice daily 4 weeks on/2 weeks off) for 1 year, S-1 (2 weeks on/1 week off) plus oxaliplatin 130 mg/m² every 3 weeks (SOX) for 6 months, and SOX plus chemoradiotherapy 45 Gy (SOXRT). Randomization was stratified according to surgery type (total or subtotal gastrectomy), pathologic stage (II or III), and Lauren histologic classification (diffuse or intestinal/mixed). The primary endpoint was disease-free survival (DFS) at 3 years; a reduction of 33% in the hazard ratio (HR) for DFS with SOX or SOXRT, when compared with S-1, was considered clinically meaningful. The trial is registered at clinicaltrials.gov (NCT0176146).

RESULTS

A total of 546 patients were recruited between February 2013 and January 2018 with 182, 181, and 183 patients in the S-1, SOX, and SOXRT arms, respectively. Median follow-up period was 47 months, with 178 DFS events observed. Estimated 3-year DFS rates were 64.8%, 74.3%, and 72.8% in the S-1, SOX, and SOXRT arms, respectively. HR for DFS in the control arm (S-1) was shorter than that in the SOX and SOXRT arms: S-1 versus SOX, 0.692 (P = 0.042) and S-1 versus SOXRT, 0.724 (P = 0.074). No difference in DFS was found between SOX and SOXRT (HR 0.971; P = 0.879). Adverse events were as anticipated in each arm, and were generally well-tolerated and manageable.

CONCLUSIONS

In patients with curatively D2-resected, stage II/III, node-positive GC, adjuvant SOX or SOXRT was effective in prolonging DFS, when compared with S-1 monotherapy. The addition of radiotherapy to SOX did not significantly reduce the rate of recurrence after D2 gastrectomy.

Impact of genomic alterations on lapatinib treatment outcome and cell-free genomic landscape during HER2 therapy in HER2+ gastric cancer patients

Background

To identify predictive markers for responders in lapatinib-treated patients and to demonstrate molecular changes during lapatinib treatment via cell-free genomics.

Patients and methods

We prospectively evaluated the efficacy of combining lapatinib with capecitabine and oxaliplatin as first line neoadjuvant therapy in patients with previously untreated, HER2-overexpressing advanced gastric cancer. A parallel biomarker study was conducted by simultaneously performing immunohistochemistry and next-generation sequencing (NGS) with tumor and blood samples.

Results

Complete response was confirmed in 7/32 patients (21.8%), 2 of whom received radical surgery with pathologic-confirmed complete response. Fifteen partial responses (46.8%) were observed, resulting in a 68.6% overall response rate. NGS of the 16 tumor specimens demonstrated that the most common co-occurring copy number alteration was CCNE1 amplification, which was present in 40% of HER2+ tumors. The relationship between CCNE1 amplification and lack of response to HER2-targeted therapy trended toward statistical significance (66.7% of non-responders versus 22.2% of responders harbored CCNE1 amplification; P = 0.08). Patients with high level ERBB2 amplification by NGS were more likely to respond to therapy, compared with patients with low level ERBB2 amplification (P = 0.02). Analysis of cfDNA showed that detectable ERBB2 copy number amplification in plasma was predictive to the response (100%, response rate) and changes in plasma-detected genomic alterations were associated with lapatinib sensitivity and/or resistance. The follow-up cfDNA genomics at disease progression demonstrated that there are emergences of other genomic aberrations such as MYC, EGFR, FGFR2 and MET amplifications.

Conclusions

The present study showed that HER2+ GC patients respond differently according to concomitant genomic aberrations beyond ERBB2, high ERBB2 amplification by NGS or cfDNA can be a positive predictor for patient selection, and tumor genomic alterations change significantly during targeted agent therapy.

Phase III randomized study of second line ADI-PEG 20 plus best supportive care versus placebo plus best supportive care in patients with advanced hepatocellular carcinoma

Background

Arginine depletion is a putative target in hepatocellular carcinoma (HCC). HCC often lacks argininosuccinate synthetase, a citrulline to arginine-repleting enzyme. ADI-PEG 20 is a cloned arginine degrading enzyme-arginine deiminase-conjugated with polyethylene glycol. The goal of this study was to evaluate this agent as a potential novel therapeutic for HCC after first line systemic therapy.

Methods and patients

Patients with histologically proven advanced HCC and Child-Pugh up to B7 with prior systemic therapy, were randomized 2 : 1 to ADI-PEG 20 18 mg/m2 versus placebo intramuscular injection weekly. The primary end point was overall survival (OS), with 93% power to detect a 4-5.6 months increase in median OS (one-sided α = 0.025). Secondary end points included progression-free survival, safety, and arginine correlatives.

Results

A total of 635 patients were enrolled: median age 61, 82% male, 60% Asian, 52% hepatitis B, 26% hepatitis C, 76% stage IV, 91% Child-Pugh A, 70% progressed on sorafenib and 16% were intolerant. Median OS was 7.8 months for ADI-PEG 20 versus 7.4 for placebo (P = 0.88, HR = 1.02) and median progression-free survival 2.6 months versus 2.6 (P = 0.07, HR = 1.17). Grade 3 fatigue and decreased appetite occurred in <5% of patients. Two patients on ADI-PEG 20 had ≥grade 3 anaphylactic reaction. Death rate within 30 days of end of treatment was 15.2% on ADI-PEG 20 versus 10.4% on placebo, none related to therapy. Post hoc analyses of arginine assessment at 4, 8, 12 and 16 weeks, demonstrated a trend of improved OS for those with more prolonged arginine depletion.

Conclusion

ADI-PEG 20 monotherapy did not demonstrate an OS benefit in second line setting for HCC. It was well tolerated. Strategies to enhance prolonged arginine depletion and synergize the effect of ADI-PEG 20 are underway.

Clinical Trial number

www.clinicaltrials.gov (NCT 01287585).

Capecitabine plus oxaliplatin versus gemcitabine plus oxaliplatin as first-line therapy for advanced biliary tract cancers: a multicenter, open-label, randomized, phase III, noninferiority trial

BACKGROUND

Capecitabine plus oxaliplatin (XELOX) has shown modest activity and tolerable toxicity in a phase II trial for biliary tract cancers (BTCs). Meanwhile, gemcitabine plus oxaliplatin (GEMOX) has been the reference arm in recent phase II and III trials for BTCs. We aimed to investigate the efficacy of XELOX versus GEMOX as first-line therapy for advanced BCTs.

PATIENTS AND METHODS

In this open-label, randomized, phase III, noninferiority trial, we randomly selected patients with metastatic BCTs to receive GEMOX (gemcitabine 1000 mg/m2 on days 1 and 8, and oxaliplatin 100 mg/m2 on day 1) or XELOX (capecitabine 1000 mg/m2, twice daily, on days 1-14 and oxaliplatin 130 mg/m2 on day 1) as first-line treatment, given every 3 weeks, totaling eight cycles. The primary end point was to prove the noninferiority of XELOX to GEMOX in terms of 6-month progression-free survival (PFS) rate.

RESULTS

In total, 114 patients randomly received GEMOX and 108 randomly received XELOX. The median PFS was 5.3 months for the GEMOX group and 5.8 months for the XELOX group. The 6-month PFS rate was 44.5% for the GEMOX group and 46.7% for the XELOX group. The 95% confidence interval of the 6-month PFS rate difference between both groups was -12% to 16%, meeting the criteria for noninferiority of XELOX to GEMOX. There was no difference in objective response (P=0.171) and median overall survival (P=0.131) between both groups. The most common grade three to four adverse events were neutropenia and thrombocytopenia. No patient died of treatment-related causes. The XELOX group had significantly lower frequencies of hospital visits than the GEMOX group (P<0.001).

CONCLUSION

XELOX showed significant noninferiority to GEMOX in terms of 6-month PFS rate. Thus, XELOX could be an alternative first-line treatment of BCTs.

TRIAL REGISTRATION

This study was registered in ClinicalTrials.gov (number NCT01470443).

Maximising yield of peripheral blood flow cytometry for chronic lymphoproliferative disorders

INTRODUCTION

Flow cytometry is used in the diagnosis of haematological diseases including chronic lymphoproliferative disorders. This audit aims to ascertain the real-world indications for peripheral blood (PB) flow cytometry and which of these are associated with higher diagnostic yields.

METHODS

All PB flow cytometry requests for chronic lymphoproliferative disorders from 1 January 2014 to 31 December 2014 were identified using the laboratory information system. Data including patient demographics, specialty of requestor, lymphocyte count and blood film report (if available), indications for tests and subsequent diagnosis were collected.

RESULTS

A total of 185 requests with median patient age of 60 years were analysed. The main requestor was the Haematology Unit (n = 109; 58.9%) although the diagnostic yield of their requests was not significantly better than other units combined (16.5% vs 13.2%, P = .49). Factors that significantly improved the diagnostic yield of testing were older age, the presence of atypical lymphocytes on the blood film and lymphocytosis (P < .01). Constitutional symptoms and cytopenias were not found to influence the diagnostic yield.

CONCLUSION

PB flow cytometry is a useful tool when used in the appropriate clinical setting. Rationalisation of testing is important to reduce the futility of testing and unnecessary health costs.

Streptococcus Constellatus Spondylodiscitis in a Teenager: A Case Report

Streptococcus constellatus is an extremely rare cause of pyogenic spondylodiscitis. Literature search yielded only one case report in an elderly 72 years old man with spontaneous T10-T11 S. constellatus spondylodiscitis. It is virtually unheard of in young teenage. We report the case of a 14 years old male teenager who presented with worsening low back pain for one year with no neurological deficit. Imaging studies were consistent with features of L4-L5 spondylodiscitis. CT guided biopsy grew a pure culture of streptococcus constellatus sensitive to penicillin and erythromycin. He showed full recovery with six weeks of intravenous antibiotics. Due to the insidious onset, this case highlight the importance of high clinical suspicion and early diagnosis, with image guided biopsy followed by treatment with appropriate intravenous antibiotics to enable full recovery without further neurological deterioration.

Rapamycin-insensitive companion of mTOR (RICTOR) amplification defines a subset of advanced gastric cancer and is sensitive to AZD2014-mediated mTORC1/2 inhibition

Background

Targeting oncogenic genomic aberrations is an established therapeutic strategy in multiple tumor types. Molecular classification has uncovered a number of novel targets, and rapamycin-insensitive companion of mTOR (RICTOR) amplification has been identified in lung cancer. Further investigation assessing the therapeutic potential of RICTOR amplification as a novel target across advanced cancers is needed.

Patients and methods

Tumor samples from 640 patients with metastatic solid tumors, primarily gastrointestinal and lung cancers were prospectively subjected to a next-generation sequencing (NGS) assay to identify molecular targets. Samples with NGS-detected RICTOR amplification were confirmed with FISH. A RICTOR-amplified patient-derived cell (PDC) line was generated and used to investigate the effectiveness of selective AKT, mTORC1, and mTORC1/2 inhibition.

Results

NGS identified 13 (2%) of 640 patients with RICTOR-amplified tumors (6 gastric, 3 NSCLC, 1 SCLC, 1 CRC, 1 sarcoma, 1 MUO). Of the 13 patients, seven patients had RICTOR protein overexpression by IHC. The prevalence of RICTOR amplification in gastric cancer by NGS was 3.8% (6/160). FISH testing confirmed amplification (RICTOR/control >2) in 5/13 (38%) of samples, including four gastric cancers and one lung cancer. Treatment of a RICTOR amplified PDC with a selective AKT (AZD5363), selective mTORC1 (everolimus), dual mTORC1/2 (AZD2014), and the multi-target kinase inhibitor pazopanib demonstrated preferential sensitivity to the mTORC1/2 inhibitor (AZD2014). Knockdown of RICTOR reversed PDC sensitivity to AZD2014, validating the importance of RICTOR amplification to the PDC line.

Conclusions

RICTOR amplification is a rare but therapeutically relevant genomic alteration across solid tumors. Our results support further pre-clinical and clinical investigation with AZD2014 in RICTOR amplified gastric cancer and highlights the importance of genomic profiling.

MAP2K1 Mutation in Colorectal Cancer Patients: Therapeutic Challenge Using Patient-Derived Tumor Cell Lines

BACKGROUND: The MAP2K1 K57T mutation is known to be a potential mechanism of primary and secondary resistance to EGFR inhibitors in metastatic colorectal cancer (CRC) and has also been reported to promote resistance to BRAF and MEK inhibitors. It is important to overcome therapeutic resistance to EGFR inhibitors to improve the treatment outcomes of metastatic CRC. METHODS: We established patient-derived tumor cells (PDCs) from metastatic lesions that newly appeared during treatment with a BRAF inhibitor (LGX-818) plus an EGFR inhibitor (cetuximab) in a patient with BRAF-mutant CRC. To investigate therapeutic options to overcome acquired resistance due to MAP2K1 mutation in BRAF-mutant CRC, we performed cell viability assays using the PDCs. RESULTS: We tested whether the PDCs were resistant to an EGFR inhibitor (cetuximab) and a BRAF inhibitor (sorafenib) as these cells were established at the time of resistance to the EGFR plus BRAF inhibitors. Moreover, the anti-tumor effect of AZD6244 (MEK inhibitor) was evaluated because PDCs harbored a MAP2K1 mutation at the time of resistance to the EGFR plus BRAF inhibitors. MTT proliferation assays showed that monotherapy with cetuximab, sorafenib, or AZD6244 did not suppress cell viability. We next tested viability of the PDCs to combination treatment with cetuximab plus AZD6244 and sorafenib plus AZD6244. Proliferation of PDCs was significantly inhibited by sorafenib and AZD6244, but not by cetuximab plus AZD6244. Investigation of the combined effect of sorafenib and AZD6244 using the calculated combination index (CI) showed synergistic effects of sorafenib and AZD6244 in combination therapy applied to PDCs with the MAP2K1 K57T mutation. CONCLUSION: Our results suggest that combination treatment with BRAF and MEK inhibitors might be a novel treatment strategy for MAP2K1 K57T-mutant CRC. This finding will be helpful to guide treatment of patients with CRC that is resistant to EGFR inhibitors.

Ten years of cerebral venous thrombosis: male gender and myeloproliferative neoplasm is associated with thrombotic recurrence in unprovoked events

Cerebral venous thrombosis (CVT) is a rare venous thrombotic event. We review our local experience in the management of CVT in comparison to other venous thromboembolism (VTE) with specific focus on risk factors for thrombotic recurrence. Retrospective evaluation of consecutive CVT presentations from January 2005 to June 2015, at two major tertiary hospitals in Northeast Melbourne, Australia. This population was compared to a separate audit of 1003 consecutive patients with DVT and PE. Fifty-two patients (30 female, 22 male) with a median age of 40 (18-83) years, presented with 53 episodes of CVT. Twenty-nine episodes (55 %) were associated with an underlying risk factor, with hormonal risk factors in females being most common. The median duration of anticoagulation was 6 months with 11 receiving life-long anticoagulation. Eighty-one percent had residual thrombosis on repeat imaging, which was not associated with recurrence at the same or distant site. Nine (17 %) had CVT-related haemorrhagic transformation with two resultant CVT-related deaths (RR 22.5; p = 0.04). All three VTE recurrences occured in males with unprovoked events (RR 18.2; p = 0.05) who were subsequently diagnosed with myeloproliferative neoplasm (MPN). Compared to the non-cancer VTE population, non-cancer CVT patients were younger, had similar rate of provoked events and VTE recurrence, although with significantly higher rate of MPN diagnosis (RR 9.30 (2.29-37.76); p = 0.002) CVT is a rare thrombotic disorder. All recurrences in this audit occurred in male patients with unprovoked events and subsequent diagnosis of MPN, suggesting further evaluation for MPN may be warranted in patients with unprovoked CVT.

Substantial variation in post-engraftment infection prophylaxis and revaccination practice in autologous stem cell transplant patients

There is a paucity of evidence supporting the necessity or duration of Pneumocystis jirovecii and antiviral prophylaxis as well as revaccination following autologous stem cell transplant (ASCT). A survey aimed at evaluating these policies was distributed to 34 ASCT centres across Australasia. The 26 survey respondents demonstrated significant heterogeneity in their infection prophylaxis and revaccination strategy post-transplant despite the availability of consensual guidelines.

A randomised, double-blind, placebo-controlled multi-centre phase III trial of XELIRI/FOLFIRI plus simvastatin for patients with metastatic colorectal cancer

Background:

The purpose of this randomised phase III trial was to evaluate whether the addition of simvastatin, a synthetic 3-hydroxy-3methyglutaryl coenzyme A reductase inhibitor, to XELIRI/FOLFIRI chemotherapy regimens confers a clinical benefit to patients with previously treated metastatic colorectal cancer.

Methods:

We undertook a double-blind, placebo-controlled phase III trial of 269 patients previously treated for metastatic colorectal cancer and enrolled in 5 centres in South Korea. Patients were randomly assigned (1 : 1) to one of the following groups: FOLFIRI/XELIRI plus simvastatin (40 mg) or FOLFIRI/XELIRI plus placebo. The FOLFIRI regimen consisted of irinotecan at 180 mg m⁻² as a 90-min infusion, leucovorin at 200 mg m⁻² as a 2-h infusion, and a bolus injection of 5-FU 400 mg m⁻² followed by a 46-h continuous infusion of 5-FU at 2400 mg m⁻². The XELIRI regimen consisted of irinotecan at 250 mg m⁻² as a 90-min infusion with capecitabine 1000 mg m⁻² twice daily for 14 days. The primary end point was progression-free survival (PFS). Secondary end points included response rate, duration of response, overall survival (OS), time to progression, and toxicity.

Results:

Between April 2010 and July 2013, 269 patients were enrolled and assigned to treatment groups (134 simvastatin, 135 placebo). The median PFS was 5.9 months (95% CI, 4.5–7.3) in the XELIRI/FOLFIRI plus simvastatin group and 7.0 months (95% CI, 5.4–8.6) in the XELIRI/FOLFIRI plus placebo group (P=0.937). No significant difference was observed between the two groups with respect to OS (median, 15.9 months (simvastatin) vs 19.9 months (placebo), P=0.826). Grade ⩾3 nausea and anorexia were noted slightly more often in patients in the simvastatin arm compared with with the placebo arm (4.5% vs 0.7%, 3.0% vs 0%, respectively).

Conclusions:

The addition of 40 mg simvastatin to the XELIRI/FOLFIRI regimens did not improve PFS in patients with previously treated metastatic colorectal cancer nor did it increase toxicity.

Randomized phase II study of axitinib versus placebo plus best supportive care in second-line treatment of advanced hepatocellular carcinoma

BACKGROUND

The efficacy and safety of axitinib, a potent and selective vascular endothelial growth factor receptors 1-3 inhibitor, combined with best supportive care (BSC) was evaluated in a global, randomized, placebo-controlled phase II trial in patients with locally advanced or metastatic hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

Patients with HCC and Child-Pugh Class A who progressed on or were intolerant to one prior antiangiogenic therapy were stratified by tumour invasion (presence/absence of extrahepatic spread and/or vascular invasion) and region (Asian/non-Asian) and randomized (2:1) to axitinib/BSC (starting dose 5 mg twice-daily) or placebo/BSC. The primary end point was overall survival (OS).

RESULTS

The estimated hazard ratio for OS was 0.907 [95% confidence interval (CI) 0.646-1.274; one-sided stratified P = 0.287] for axitinib/BSC (n = 134) versus placebo/BSC (n = 68), with the median (95% CI) of 12.7 (10.2-14.9) versus 9.7 (5.9-11.8) months, respectively. Results of prespecified subgroup analyses in Asian versus non-Asian patients or presence versus absence of tumour invasion were consistent with the overall population. Improvements favouring axitinib/BSC (P < 0.01) were observed in secondary efficacy end point analyses [progression-free survival (PFS), time to tumour progression (TTP), and clinical benefit rate (CBR)], and were retained among Asian patients in the prespecified subgroup analyses. Overall response rate did not differ significantly between treatments and patient-reported outcomes favoured placebo/BSC. Most common all-causality adverse events with axitinib/BSC were diarrhoea (54%), hypertension (54%), and decreased appetite (47%). Baseline serum analyses identified potential new prognostic (interleukin-6, E-selectin, interleukin-8, angiopoietin-2, migration inhibitory factor, and c-MET) or predictive (E-selectin and stromal-derived factor-1) factors for survival.

CONCLUSIONS

Axitinib/BSC did not improve OS over placebo/BSC in the overall population or in stratification subgroups. However, axitinib/BSC resulted in significantly longer PFS and TTP and higher CBR, with acceptable toxicity in patients with advanced HCC.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01210495.

Axitinib versus sorafenib in advanced renal cell carcinoma: subanalyses by prior therapy from a randomised phase III trial

BACKGROUND

In the AXIS trial, axitinib prolonged progression-free survival (PFS) vs sorafenib in patients with advanced renal cell carcinoma (RCC) previously treated with sunitinib or cytokines.

METHODS

In post hoc analyses, patients were grouped by objective response to prior therapy (yes vs no), prior therapy duration (< vs ⩾median), and tumour burden (baseline sum of the longest diameter < vs ⩾median). PFS and overall survival (OS), and safety by type and duration of prior therapy were evaluated.

RESULTS

Response to prior therapy did not influence outcome with second-line axitinib or sorafenib. PFS was significantly longer in axitinib-treated patients who received longer prior cytokine treatment and sorafenib-treated patients with smaller tumour burden following sunitinib. Overall survival with the second-line therapy was longer in patients who received longer duration of prior therapy, although not significant in the sunitinib-to-axitinib sequence subgroup; OS was also longer in patients with smaller tumour burden, but not significant in the cytokine-to-axitinib sequence subgroup. Safety profiles differed modestly by type and duration of prior therapy.

CONCLUSIONS

AXIS data suggest that longer duration of the first-line therapy generally yields better outcome with the second-line therapy and that lack of response to first-line therapy does not preclude positive clinical outcomes with a second-line vascular endothelial growth factor-targeted agent in patients with advanced RCC.

A randomized phase II study of PEP02 (MM-398), irinotecan or docetaxel as a second-line therapy in patients with locally advanced or metastatic gastric or gastro-oesophageal junction adenocarcinoma

BACKGROUND

PEP02 is a novel highly stable liposomal nanocarrier formulation of irinotecan. This randomized phase II study evaluated the efficacy and safety of single agent PEP02 compared with irinotecan or docetaxel in the second-line treatment of advanced oesophago-gastric (OG) cancer.

PATIENTS AND METHODS

Patients with locally advanced/metastatic disease who had failed one prior chemotherapy regimen were randomly assigned to PEP02 120 mg/m(2), irinotecan 300 mg/m(2) or docetaxel (Taxotere) 75 mg/m(2) every 3 weeks. The primary end point was objective response rate (ORR). Simon's two-stage design was used and the ORR of interest was 20% (α = 0.05, type II error β = 0.10, null hypothesis of ORR was 5%).

RESULTS

Forty-four patients per arm received treatment, and 124 were assessable for response. The ORR statistical threshold for the first stage was reached in all arms. In the intent-to-treat (ITT) population, ORRs were 13.6% (6/44), 6.8% (3/44) and 15.9% (7/44) in the PEP02, irinotecan and docetaxel arms, respectively. The median progression-free survival (PFS) and overall survival were similar between the trial arms. Commonest grade 3-4 adverse event reported was diarrhoea in the PEP02 and irinotecan groups (27.3% versus 18.2%).

CONCLUSION

The ORR associated with PEP02 was comparable with docetaxel and numerically greater than that of irinotecan. PEP02 warrants further evaluation in the advanced gastric cancer setting.

Identification of triple-negative and basal-like canine mammary carcinomas using four basal markers

Molecular-based classification of canine mammary carcinomas (CMCs) has been a recent research focus. In human breast cancer, triple-negative and basal-like phenotypes are distinct molecular subgroups that are known for their poor prognosis, but these tumours are not yet well defined in the dog. The aim of this study was to determine whether CMCs include triple-negative and basal-like phenotypes by immunohistochemical assessment of expression of the oestrogen receptor (OR), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2) and four basal markers, cytokeratin (CK) 14, CK5/6, p63 and the epidermal growth factor receptor (EGFR). In this study of 241 CMCs, 45 triple-negative tumours (OR(-), PR(-) and HER2(-)) were identified and this phenotype was associated with an unfavourable prognosis. In these tumours, the expression of CK14, CK5/6 and EGFR was related to clinicopathological parameters, while the expression of p63 was not relevant. The majority of the triple-negative tumours were of the basal-like phenotype, given that 75.6% of them expressed more than two basal markers. However, three of the basal markers were not uniformly expressed; therefore, the proportion of the basal-like phenotype was altered on the basis of the selection of the markers. Although both triple-negative and basal-like phenotypes are distinct entities in CMC, further study is needed to differentiate one from the other.

Multicenter phase II study of sunitinib in patients with non-clear cell renal cell carcinoma

BACKGROUND

Retrospective and molecular biologic data suggest that sunitinib may be effective in patients with non-clear cell renal cell carcinoma (nccRCC).

PATIENTS AND METHODS

Eligibility criteria included advanced nccRCC except for collecting duct carcinoma and sarcomatoid carcinoma without identifiable renal cell carcinoma subtypes. Patients were treated with 50 mg/day oral sunitinib for 4 weeks, followed by 2 weeks of rest. The primary end point was overall response rate (RR).

RESULTS

Thirty-one eligible patients were enrolled. Twenty-four patients (77%) had prior nephrectomy. By Memorial Sloan-Kettering Cancer Center criteria, 8 patients (26%) had poor risk and 14 (45%) had intermediate risk. Twenty-two patients had papillary renal cell carcinoma (RCC), and three had chromophobe RCC. Eleven patients had partial response with a RR of 36% (95% confidence interval (CI) 19% to 52%) and an additional 17 patients (55%) had stable disease. Median duration of response was 12.7 months (95% CI 6.3-19.1 months), and median progression-free survival was 6.4 months (95% CI 4.2-8.6 months). At a median follow-up duration of 18.7 months (95% CI 13.7-23.7 months), 13 patients (42%) had died, resulting in an estimated median survival of 25.6 months (95% CI 8.4-42.9 months). Toxicity profiles were commensurate with prior reports.

CONCLUSIONS

Sunitinib has promising activity in patients with nccRCC (NCT01219751).

Randomised phase II trial of docetaxel and sunitinib in patients with metastatic gastric cancer who were previously treated with fluoropyrimidine and platinum

BACKGROUND

Docetaxel is widely used as a chemotherapeutic agent for gastric cancer treatment. A combined regimen with sunitinib demonstrated a synergistic antitumour effect in a preclinical model. The aim of this study was to evaluate the efficacy and safety of this combination in patients with unresectable or metastatic advanced gastric cancer following failure of treatment with a fluoropyrimidine and platinum combination.

METHODS

This open-label, phase II, randomised trial enrolled patients with unresectable or metastatic gastric cancer. Patients were assigned to either a docetaxel monotherapy arm (D only arm: 60 mg m(-2), every 3 weeks) or a combination arm (DS arm: docetaxel+sunitinib 37.5 mg every day). The primary end point of the study was time to progression and the secondary end points were overall response rate, disease control rate, overall survival, and toxicity profile. A pharmacokinetic study was also performed.

RESULTS

A total of 107 patients were entered into the study. The TTP was not significantly prolonged in the DS arm when compared with the D only arm (DS vs D only arm: 3.9 months (95% confidence interval (CI) 2.9-4.9) vs 2.6 months (95% CI 1.8-3.5) (P=0.206). The hazard ratio for TTP was 0.77 (95% CI 0.52-1.16). However, the objective response rate was significantly higher in the DS arm (41.1% vs 14.3%, P=0.002). Patients in the DS arm experienced stomatitis, diarrhoea, and hand-foot syndrome more frequently.

CONCLUSION

The addition of sunitinib to docetaxel did not significantly prolong TTP, although it significantly increased response.

Anatomical Analysis of Computed Tomography Images for Determining the Optimal Oblique Fluoroscope Angle for Percutaneous Coeliac Plexus Block

This retrospective study used abdominal computed tomography (CT) scan images to determine the optimal safe oblique angle for fluoroscopy in fluoroscope-assisted coeliac plexus block (CPB). Abdominal CT scans from 131 patients were included in the study: 42 patients with cancer of the pancreas head, 45 with cancer of the pancreas body and tail and 44 with chronic pancreatitis. The oblique angle and entry distance from the midline were measured at the T12 and L1 levels, and the safe angle range that avoided puncture of the organs was also measured. The optimal angle varied between the T12 and L1 levels, and between the right and left sides at the T12 level. There was no difference in the oblique angle between the patient groups. The optimal oblique angle for fluoroscopy was determined to be 17° for right T12, 18° for left T12, and 19° for both left and right L1.

Recurrent epistaxis as a presenting sign of androgen-sensitive metastatic prostate cancer

Prostate cancer is a common cancer, especially among elderly men. It is sometimes not diagnosed until it has metastasised. Disseminated intravascular coagulopathy (DIC) can be the presenting manifestation of prostate cancer, and can present with bleeding (varying from isolated epistaxis to generalised haemorrhage), intravascular thrombosis, or both. A case of recurrent epistaxis from DIC due to metastatic prostate cancer occurring in an 84-year-old Caucasian man is presented, and the pathophysiology and management of DIC in association with androgen-sensitive prostate cancer are discussed.

Evaluation of ER and Ki-67 proliferation index as prognostic factors for survival following neoadjuvant chemotherapy with doxorubicin/docetaxel for locally advanced breast cancer

BACKGROUND

The aim of the study was to identify reliable predictive biological markers for treatment outcome following neoadjuvant adriamycin/docetaxel (AT) chemotherapy in locally advanced breast cancer patients.

MATERIALS AND METHODS

This study was a phase II study on AT neoadjuvant chemotherapy in locally advanced breast cancer patients. Patients received 50 mg/m(2) of doxorubicin intravenously (IV) over 15 min followed by docetaxel 75 mg/m(2) infused over 1 h, repeated every 3 weeks for three cycles. Surgery was performed within 3-4 weeks following the last cycle of chemotherapy. We analyzed the pre-treatment and post-treatment expression levels of ER, PgR, HER-2, Ki-67 proliferation index, and p53 and examined the correlation between the markers and clinical parameters with treatment response, overall survival and relapse-free survival following neoadjuvant treatment.

RESULTS

From July 2001 to September 2004, 61 patients were enrolled. The meaningful parameters adversely influencing survival were post-treatment ER(-) status (P = 0.013) and post-treatment Ki-67 index above 1.0% (P = 0.013). At the multivariate level, the post-treatment Ki-67 proliferation index < or = 1.0 was the only meaningful prognostic factor for better survival (P = 0.033). Notably, tumors with Ki-67 index < or = 1.0 were more likely to express ER with statistical significance (P = 0.002). Tumors with ER(+) and Ki-67 index < or = 1.0 showed the highest survival rate, followed by ER(+) and Ki-67 index > 1.0%, ER(-) and Ki-67 < or = 1.0%, and ER(-) and Ki-67 > 1.0% with the worst survival (P = 0.033).

CONCLUSION

Collectively, post-treatment ER status and Ki-67 proliferation index were prognostic of overall survival following neoadjuvant AT chemotherapy.

Prognostic model to predict survival following first-line chemotherapy in patients with metastatic gastric adenocarcinoma

BACKGROUND

This study was to devise a prognostic model for metastatic gastric cancer patients undergoing first-line chemotherapy.

PATIENTS AND METHODS

A retrospective analysis was carried out on 1455 gastric cancer patients, who received first-line chemotherapy from September 1994 to February 2005.

RESULTS

At multivariate level, poor prognostic factors were no previous gastrectomy [P = 0.003; relative risk (RR), 1.191; 95% confidence interval (CI) 1.061-1.338], albumin < 3.6 g/dl (P = or <0.001; RR, 1.245; 95% CI 1.106-1.402), alkaline phosphatase > 85 U/l (P = or <0.001; RR, 1.224; 95% CI 1.092-1.371), Eastern Cooperative Oncology Group performance status of two or more (P = or <0.001; RR, 1.690; 95% CI 1.458-1.959), the presence of bone metastases (P = 0.001; RR, 1.460; 95% CI 1.616-1.836), and the presence of ascites (P = or < 0.001; RR, 1.452; 95% CI 1.295-1.628). Of 1434 patients, 489 patients (34.1%) were categorized as low-risk group (zero to one factors), 889 patients (62.0%) as intermediate-risk group (two to four factors), and 56 patients (3.9%) as high-risk group (five to six factors). Median survival durations for low, intermediate, and high-risk groups were 12.5 months, 7.0 months, and 2.7 months, respectively.

CONCLUSIONS

This model should facilitate the individual patient risk stratification and thus, more appropriate therapies for each metastatic gastric cancer patient.

Three-week schedule of irinotecan plus cisplatin in patients with previously untreated extensive-stage small-cell lung cancer

Irinotecan and cisplatin demonstrated promising outcomes in extensive-stage small-cell lung cancer. According to the dosage and schedule of irinotecan, efficacy and toxicity profiles showed subtle differences. This study was designed to evaluate efficacy and toxicity of 3-week schedule of irinotecan/cisplatin in patients with previously untreated extensive-stage small-cell lung cancer. The primary objective was to evaluate response rate and secondary objectives were overall survival and progression-free survival. Patients with previously untreated extensive-stage small-cell lung cancer were enrolled. Irinotecan 65 mg m-2 was administered on days 1 and 8 and cisplatin 60 mg m-2 on day 1. Treatment was repeated every 3 weeks. Seven out of 54 patients (13.0%) had complete response, and partial response was observed in 33 (61.1%). The overall response rate was 74.1% (95% CI; 62.0-82.2%). Stable disease was observed in eight (14.8%) and no progressive disease was observed. After a median follow-up duration of 28.7 months, the median overall survival and progressive-free survival were 13.6 and 6.5 months, respectively. Major grade 3/4 toxicities were neutropenia (50.0%), anorexia (42.6%), diarrhoea (29.6%), fatigue (29.6%) and vomiting (13.0%). There was one treatment-related death owing to pneumonia. Three-week schedule of irinotecan/cisplatin showed effective antitumour activity and moderate toxicities in patients with previously untreated extensive-stage small-cell lung cancer.

Phase II trial of irinotecan plus oxaliplatin and 5-fluorouracil/leucovorin in patients with untreated metastatic gastric adenocarcinoma

BACKGROUND

This nonrandomized open label phase II study evaluated the efficacy and safety of FOLFOXIRI in metastatic or recurrent gastric cancer patients.

PATIENTS AND METHODS

Patients with histologically proven, metastatic gastric adenocarcinoma, aged 18-70 years, performance status zero to two, no prior chemotherapy, and with signed written informed consent were eligible. Treatment consisted of irinotecan 150 mg/m2 day 1, oxaliplatin 85 mg/m2 day 1, leucovorin 100 mg/m2 day 1, and 5-fluorouracil 2000 mg/m2 as a 48-h continuous infusion starting on day 1, which was repeated every 2 weeks.

RESULTS

From August 2004 to August 2005, 48 patients were prospectively enrolled. The median age was 54 years (24-69). In total, 386 cycles were administered with a median of nine cycles per patient (range 1-12 cycles) and 45 of 48 patients were assessable for treatment response. An independent review of tumor responses resulted in overall response rate of 66.7% (95% confidence interval=53.4% to 80.0%) by intent-to-treat analysis with one complete response and 31 partial responses. The median survival of all patients was 14.8 months and the median time to progression was 9.6 months. Most common grade 3/4 toxic effects were neutropenia (12% of all cycles) and emesis (8% of all cycles). Grade 2 peripheral neuropathy occurred in five patients. One (2%) patient had severe tumor bleeding and five (10%) patients experienced grade 3 diarrhea.

CONCLUSIONS

The modified FOLFOXIRI combination chemotherapy showed a very promising preliminary antitumor activity and was generally well tolerated as a first-line treatment of patients with metastatic gastric cancer.

Ramosetron for the prevention of cisplatin-induced acute emesis: a prospective randomized comparison with granisetron

Control of nausea and vomiting is very important in determining patient compliance with cisplatin chemotherapy. A multicentre, randomized, single-blind study was conducted to compare the tolerability and efficacy of ramosetron with those of granisetron over 24 h following cisplatin administration to cancer patients. In eight study centres, a total of 194 adult patients were randomly assigned to receive either intravenous ramosetron 0.3 mg or intravenous granisetron 3.0 mg. The anti-emetic effect of ramosetron determined from the no-vomiting rate lasted longer, but there was no significant difference in the number of acute vomiting episodes or the severity of nausea between the two groups. In the tolerability evaluation, there were no statistically significant differences between the two groups, except for a higher incidence of dull headache in the granisetron group. Ramosetron and granisetron appear to have equivalent efficacy and tolerability profiles, but the effects of ramosetron on the prevention of acute vomiting in patients undergoing cisplatin chemotherapy were longer lasting.

Murine keratocytes function as antigen-presenting cells

Keratocytes express MHC class I molecules constitutively, and keratocytes stimulated with IFN-gamma express MHC class II molecules. Unstimulated keratocytes constitutively express B7-1 and ICAM-1, as well as low levels of CD40 and 4-1BBL. These findings indicate that keratocytes may deliver both antigen-specific and costimulatory signals to CD4(+) and CD8(+) T cells. To demonstrate that keratocytes expressing B7-1 provide a costimulatory signal to T cells, CD4(+) or CD8(+) mouse T cells were incubated with anti-CD3 mAb and irradiated keratocytes. Enhanced proliferation of both CD4(+) and CD8(+) T cells occurred, and could be inhibited by anti-B7-1 mAb, indicating T cell costimulatory activity by B7-1 on the keratocytes. To demonstrate that keratocytes can deliver an antigen-specific signal, CD4(+) and CD8(+) T cells from herpes-infected mice were incubated with HSV-1-infected, irradiated keratocytes. The resulting T cell proliferation and production of Th1 cytokines (IL-2, IFN-gamma) indicated T cell activation by antigens presented by the infected keratocytes. These results show that keratocytes in the corneal stroma of the mouse can function as antigen-presenting cells and, thus, may play a role in immune-mediated stromal inflammation such as herpetic stromal keratitis.

Vascular endothelial growth factor in the serum of patients with non-small cell lung cancer: correlation with platelet and leukocyte counts

BACKGROUND

Vascular endothelial growth factor (VEGF) is a potent angiogenic peptide expressed in a wide variety of tumors, and it stimulates angiogenesis and increases vascular permeability. Increased expression of VEGF may be associated with advanced stage and poor prognosis in patients with non-small cell lung cancer (NSCLC).

METHODS

Using enzyme-linked immunosorbent assay, the levels of VEGF were determined in serum from 41 patients with untreated NSCLC (Stage: IIB, 3; IIIA, 6; IIIB, 17; IV, 15;

HISTOLOGY

squamous cell carcinoma, 18; adenocarcinoma. 14; undetermined, 9).

RESULTS

The median VEGF level was 312 pg/ml, ranging from 70 to 1440 pg/ml. Patients were divided into high VEGF (>312 pg/ml) and low VEGF (< or =312 pg/ml) groups using the median value as a cut-off. There were no significant associations between the serum VEGF levels and various clinicopathologic characteristics including age, gender, histologic type, stage and treatment. A significant positive correlation was found between serum VEGF levels and platelet counts (r=0.495; P=0.001). In addition, serum VEGF levels also correlated with leukocyte counts (r=0.478; P=0.002). In seven patients with measurement of follow-up serum VEGF levels at the end of treatment (chemotherapy and/or radiotherapy), the median serum VEGF level significantly decreased after the treatment (416 pg/ml; range, 96-812 pg/ml vs. 185 pg/ml; range, 49-487 pg/ml; P=0.028). However, the median platelet count (317,000/microl; range, 190,000-395,000/microl vs. 246,000/microl; range, 72,000-271,000/microl; P=0.028) and leukocyte count (10,000/microl; range, 8700-17,200/microl vs. 5100/microl; range, 3900-9500/microl; P=0.018) also decreased after the treatment. There was no statistically significant difference in the median survival of the patients between high VEGF group and low VEGF group (8 months vs. 9 months, P=0.647).

CONCLUSIONS

Although serum VEGF level was significantly associated with platelet and leukocyte counts in NSCLC patients, it did not correlate with tumor burden and prognosis of the patients.

Structural Insights into Cdk5 activation by a neuronal Cdk5 activator

Although Cdk5 shows high sequence identity to Cdk1 and Cdk2, it can be fully activated by its neuronal activators p35/p25(nck5a) and p39(nck5ai) in a phosphorylation-independent manner. To understand structural basis of the Cdk5/p25(nck5a) activation, the complex is modelled to assume either an obstructed or an opened conformation based on X-ray structures of the unphosphorylated or the phosphorylated Cdk2/cyclin A complex, respectively. Comparison and analysis of the two models, along with mutagenesis studies of p25(nck5a), suggest that the opened form represents more closely the structure of active Cdk5/p25(nck5a). The results provide a rationale basis for understanding the phosphorylation-independent activation of Cdk5/p25(nck5a).

Increased expression of cyclooxygenase-2 protein in human gastric carcinoma

Gastric adenocarcinoma is one of the most common malignancies in the world, and yet little is known about its molecular process of development and progression. Recent studies have suggested that ingestion of nonsteroid anti-inflammatory drugs reduces the risk of colon cancer, presumably by inhibiting the cyclooxygenase (COX) enzyme. COX-2, one isoform of the COX enzyme, is the rate-limiting enzyme in prostaglandin synthesis, and the function of this enzyme is thought to relate to inflammatory processes and carcinogenesis. To understand the role of COX enzyme in gastric cancer, we measured COX-2 expression in 104 human gastric carcinoma tissues by immunohistochemical analysis. We obtained tissue specimens from 104 surgically resected gastric adenocarcinoma patients. We performed immunohistochemical stain for human COX-2 with polyclonal antibody in gastric carcinoma. After curative resection and extensive lymph node dissection, all patients received adjuvant chemotherapy containing 5-fluorouracil. Expression of COX-2 showed cytoplasmic staining, not only in cancer cells but also in precancerous lesions such as metaplastic and adenomatous cells. We confirmed up-regulation of COX-2 in gastric cancer tissues compared with normal paired mucosa using Western blot analysis. There was no correlation between clinicopathological characteristics of gastric cancer patients and intensity of COX-2 protein expression. This study indicates that COX-2 protein over-expression may contribute to an early event of gastric cancer development, and it further suggests that selective inhibition of COX-2 may provide a chemopreventive effect against gastric carcinogenesis.

Changes of telomerase and telomere lengths in paired normal and cancer tissues of breast

To attain the immortal phenotype, cancer cells must overcome the mitotic clock. Telomerase activity has been identified to be activated in malignant tumors including breast cancer. Telomerase activity was evaluated in 71 breast cancer tissues and paired normal tissues with the TRAP (telomerase repeat amplification protocol) assay. Telomerase activity was calculated and translated into arbitrary units by computer-assisted densitometry with the control of telomerase activity in the 293 control cell line. In 59 paired breast tissues with telomerase activity, terminal restriction fragment (TRF) lengths were measured using Southern blotting. Relative inhibition (RI), the ratio of inhibited telomerase activity in each tumor tissue compared to that of the 293 control cell line after pre-treatment with 150 microg/ml of RNAse A, was measured. Sixty-three of 71 cancer tissues showed telomerase activity (88.7%) with 75.3+/-17.9 units in densitometry, while no telomerase activity was detected in their paired normal tissues. Telomerase activity was correlated to node metastasis (p=0.02) and stage (p=0.005), but not to tumor size or the hormonal receptor status. TRF lengths were 11. 0+/-4.7 kb in 59 tumor tissues and 11.7+/-2.2 kb in paired normal tissues. TRF lengths did not correlate to any of the clinical parameters. However changes of TRF lengths in tumor tissues compared to those of normal tissues correlated to telomerase activity. RI in the tumor tissues was proportional to telomerase activity without RNAse A pre-treatment. In breast cancer, telomerase activity was specific to tumor tissues and increased with tumor progression. Telomerase activity and changes in TRF lengths can be used as guidelines in detecting candidates for the telomerase inhibitor.

Detection of transforming growth factor-alpha in the serum of gastric carcinoma patients

Transforming growth factor-alpha (TGF-alpha) is a ligand for epidermal growth factor receptor (EGFR) and it is overexpressed in various malignancies including lung, esophageal, colorectal, ovarian and gastric carcinomas. In patients with gastric carcinoma, its overexpression may be associated with advanced stage or poor prognosis. We have recently demonstrated that the mean serum level for EGFR in gastric carcinoma patients was significantly elevated compared with that of healthy controls. Using the enzyme-linked immunosorbent assay, the levels of TGF-alpha were determined in serum from 40 patients with gastric carcinoma (5 patients with stage I, 2 stage II, 4 stage III, and 29 stage IV patients) and 33 healthy controls. The mean serum level for TGF-alpha in the gastric carcinoma patients was significantly elevated as compared with that of healthy controls (104 +/- 235 vs. 22 +/- 16 pg/ml; p = 0.03). Eleven patients with gastric carcinoma (27.5%) showed elevated serum TGF-alpha levels above the cutoff value of 54 pg/ml (defined as 2 standard deviations above the mean of the control group). No significant association was noted between the positivity of TGF-alpha and clinicopathologic characteristics including gender, age and stage. However, poorly differentiated adenocarcinoma showed a higher positivity of serum TGF-alpha (43.8%) compared with other histologic types, which was marginally significant (p = 0.06). These results suggest that serum TGF-alpha could be useful as a tumor marker of gastric carcinoma for predicting prognosis and follow-up after surgery in patients whose initial serum TGF-alpha levels are elevated.

A different mode of entry by dengue-2 neutralisation escape mutant virus

Entry processes were compared between dengue-2 (DEN-2) virus and a DEN-2 neutralisation escape mutant virus in baby hamster kidney (BHK) cells. The mutant virus (mu6B2) was resistant to neutralisation by a monoclonal antibody, MAb 6B2. Infection of BHK cells by the wild-type DEN-2 virus resulted in direct penetration of the virions into the cytoplasm whereas the mutant virus entered cells by endocytosis. The continual presence of the monoclonal antibody might have asserted some pressure for the mutant to adopt a different mode of entry.

Prospective randomized trial of corticosteroids for the prevention of restenosis after intracoronary stent implantation

BACKGROUND

Inflammatory responses have been implicated as one of the major contributors to neointimal hyperplasia after coronary stenting. The aim of this study was to evaluate the effect of pretreatment with single-dose intravenous methylprednisolone on preventing in-stent restenosis.

METHODS

One hundred and forty consecutive patients for elective coronary stenting (focal, de novo lesion and reference diameter >/=3 mm) were randomly assigned to either a methylprednisolone or a placebo group. Either 1 g methylprednisolone or placebo was intravenously infused 6 to 12 hours before stenting with one of two types of stents. Follow-up angiography was performed at 6 months and clinical evaluation made at regular intervals.

RESULTS

Baseline characteristics were similar between both groups. Stenting was successful in all patients, and in-hospital events did not occur in any patients. Follow-up angiography was performed in 127 patients (follow-up rate of 91.4%). The minimal lumen diameter increased from 0.86 +/- 0.50 mm before intervention to 3.34 +/- 0.42 mm after intervention (P =.02). At follow-up, minimal lumen diameter decreased to 2.14 +/- 0.78 mm (P <. 01). Angiographic restenosis rate was 17.5% in the steroid group and 18.8% in the placebo group (P =.85), with no differences between the 2 types of stent. Clinical follow-up was available in all patients (10.3 +/- 2.5 months) and clinical events during the follow-up period were similar in both groups.

CONCLUSIONS

Single-dose pretreatment with intravenous methylprednisolone before coronary stenting had no effect on the change in minimal lumen diameter at a mean follow-up time.

Improvement in exercise capacity and exercise blood pressure response after transcoronary alcohol ablation therapy of septal hypertrophy in hypertrophic cardiomyopathy

Transcoronary alcohol ablation (TAA) therapy of septal hypertrophy was recently proposed as a therapeutic modality for obstructive hypertrophic cardiomyopathy (HC). However, questions remain about the effect of TAA on exercise performance. We performed a time-course analysis of exercise capacity and exercise hemodynamics in 20 patients with symptomatic obstructive HC after TAA. Symptom-limited bicycle exercise testing was performed before and 3 and 12 months after TAA, and cardiac catheterization at 3-month follow-up. The pressure gradient of the left ventricular outflow tract immediately decreased from 58 +/- 8 to 4 +/- 1 mm Hg at rest (p <0.01) and from 143 +/- 11 to 30 +/- 6 mm Hg after extrasystole (p <0.01), but partially recovered at 3-month follow-up (14 +/- 4 and 40 +/- 9 mm Hg, respectively). Left ventricular end-diastolic pressure was not changed after TAA. Peak oxygen consumption increased from 19 +/- 2 to 23 +/- 1 ml/kg/min (p < 0.01) and exercise duration from 573 +/- 47 to 742 +/- 46 seconds (p <0.01) at 3-month follow-up, but thereafter reached a plateau. Abnormal patterns of exercise blood pressure response were shown in 9 patients but normalized after TAA. Major complications occurred in 4 patients: no reflow to the left anterior descending coronary artery in 2 patients and ventricular tachycardia requiring cardioversion in 2 patients. During the follow-up period, all patients survived with symptomatic improvement in 17 patients. Thus, TAA is a promising therapeutic modality with improvement in exercise capacity and abnormal exercise blood pressure response in obstructive HC. However, potential serious complications should be considered in the application of TAA.

Effects of percutaneous balloon mitral valvuloplasty and exercise training on the kinetics of recovery oxygen consumption after exercise in patients with mitral stenosis

AIMS

Kinetics of recovery oxygen consumption after exercise plays an important role in determining exercise capacity. This study was performed to assess the kinetics of recovery oxygen consumption in mitral stenosis and evaluate the effects of percutaneous balloon mitral valvuloplasty and exercise training on the kinetics.

METHODS AND RESULTS

Thirty patients with mitral stenosis (valve area < or =1.0 cm2) and same sized age- and size-matched healthy volunteers were included for this study. All subjects performed maximal upright graded bicycle exercise. Thirty consecutive patients who underwent successful percutaneous balloon mitral valvuloplasty (valve area > or =1.5 cm2 and mitral regurgitation grade < or =2), were randomized to an exercise training group or non-training group. The exercise group performed daily exercise training for 3 months. Half-recovery time of peak oxygen consumption was significantly delayed in mitral stenosis as compared to normal subjects (120+/-42 s vs 59+/-5, P<0.01). Peak oxygen consumption (ml x min(-1) x kg(-1)) was significantly increased in both the training (16.8+/-4.9 to 25.3+/-6.9) and non-training groups (16.3+/-5.1 to 19.6+/-6.0) 3 months after percutaneous balloon mitral valvuloplasty. Half-recovery time of peak oxygen consumption was significantly shortened in the training group (124+/-39 to 76+/-13, P<0.01), but not in the non-training group (114+/-46 to 109+/-44 s, P=0.12) at 3 months follow-up. The degrees of symptomatic improvement after percutaneous balloon mitral valvuloplasty were more closely correlated with the changes of the half-recovery time of peak oxygen consumption than those of peak oxygen consumption.

CONCLUSION

Kinetics of recovery oxygen consumption was markedly delayed in mitral stenosis, which was improved after exercise training but not after percutaneous balloon mitral valvuloplasty alone. These results suggest that adjunctive exercise training may be useful for improvement of recovery kinetics and subjective symptoms after percutaneous balloon mitral valvuloplasty.

Abdominal surgery in human immunodeficiency virus (HIV) infected patients--early local experience

The prevalence of human immunodeficiency virus (HIV) infection is increasing in Singapore. The surgical experience, however, remains limited. A retrospective review of 13 HIV-positive patients requiring abdominal surgery within Singapore was done. There were 4 females and 9 males with age ranging from 21 to 44 years. Operations included appendicectomy, colectomy, splenectomy, intestinal bypass, gastrostomy and exploratory laparotomy. Pathologic findings directly related to HIV infection were found in two-fifths (5 out of 13) of these patients. A low CD4+ count or signs of full-blown acquired immunodeficiency syndrome (AIDS) were not associated with a higher likelihood of HIV-related pathology; neither did it preclude a successful outcome. There were 2 early postoperative deaths, both with HIV-related pathology. Five of our patients who survived their abdominal surgery died on follow-up with a median survival of 17 months. In patients with typical surgical problems, e.g. appendicitis and torsion of the ovary, early surgery allows for rapid recovery similar to normal surgical patients. Care of these patients is best provided by surgeons with experience and interest in this condition together with infectious diseases physicians. Even palliative surgery offers a respite from acute and often severe problems and improves the quality of life significantly. Two patients with AIDS presented with sepsis and diffuse abdominal tenderness. Subsequent laparotomy revealed only primary bacterial peritonitis. For patients with AIDS and non-localizing abdominal signs, alternative non-invasive diagnostic modalities such as computed tomographic (CT) scan should be considered.

Alpha-fetoprotein-producing gastric cancer

We measured the sero-positivity rate of serum alpha-fetoprotein (alphaFP) of gastric cancer patients by ELISA assay; forty-two curatively resected patients, 14 palliatively resected patients, 8 who received explo-laparotomy or bypass surgery and 18 patients with systemic metastasis. The sero-positive rate was 9.8% (8/82) and the positivity increased with cancer progression. Sex, age and pathological type were similar between alphaFP-positive and -negative patients. The overall synchronous hepatic metastasis rates in alphaFP-positive and alphaFP-negative groups were 37.5% (3/8) and 12.2% (9/74), respectively (p=0.08). The predictability of synchronous liver metastasis in eight alphaFP-positive patients were as follows: 37. 5% of total patients (3/8), 50.0% (3/6) of unresectable patients, and 60.0% (3/5) of patients with systemic metastasis. In three alphaFP-positive patient with liver metastasis, all the hepatic lesions were intrahepatic and multiple, while in alphaFP-negative patients, 67% (6/9) of the hepatic lesions was single intrahepatic lesion or surface nodule. The predictability of both synchronous and metachronous liver metastasis in alphaFP-positive gastric cancer patients was 75%. These findings suggested that, in advanced stomach cancer patients, especially in stage IV, alphaFP can be used in predicting liver metastasis during follow-up.

Ambulatory anorectal surgery--is it feasible locally?

Currently, anorectal procedures are done in an inpatient setting in most local hospitals. This study examines the feasibility of performing these procedures in an outpatient setting. Patients (age range 16 to 65 years) with anorectal complaints requiring surgery were randomized into 2 groups of 40 patients each. Procedures performed included haemorrhoidectomy, fistulotomy, lateral sphincterectomy, excision of rectal polyps and examination under anaesthesia. The first group was managed in the conventional inpatient setting with regional anaesthesia. The second group was done on an ambulatory basis with local anal block. Intravenous and oral ketorolac was used for postoperative pain control and patients were discharged about 4 hours postoperatively. No complications were noted in the second group while the first group had 2 cases of acute urine retention requiring temporary catheterisation and 2 cases of significant bleeding requiring hospitalisation. Pain and satisfaction scores for both groups were similar. Anorectal surgery can be performed in an outpatient setting locally with safety and efficacy. The cost savings can be significant.

Identification of diphtheria toxin via screening as a potent cell cycle and p53-independent cytotoxin for human prostate cancer therapeutics

BACKGROUND

Metastatic human prostate cancer requires novel therapeutic strategies in order to overcome its low proliferative rate and its resistance to conventional chemotherapeutic agents. To identify potential cytotoxin gene products for use in experimental therapeutics such as in vivo gene therapy, an in vitro screen was designed.

METHODS

Eight recombinant cellular toxins were tested for activity against a spectrum of metastatic human prostate cancer cell phenotypes. Pseudomonas exotoxin A, ricin, tumor necrosis factor alpha (TNF-alpha), diphtheria toxin (DT), Crotalus durissus terrificus toxin, crotalus adamenteus toxin, Naja naja toxin, and Naja mocambique toxin were evaluated. Comparative survival distinguished the relative potencies of these cytotoxins for irreparable prostate cancer cell death.

RESULTS

Of the phospholipase A2 toxins, Crotalus durissus terrificus and Naja mocambique are active against the PSA secreting LNCaP cell line; however, the effect is reversible, and no other hormone refractory prostate cell line tested is sensitive. Screening identified toxin-specific differences: dose-dependent cytotoxic activity against all human prostate cancer cell lines tested was only identified for ricin and diphtheria toxin (DT) as highly potent. DT has an IC50 in the range of 20-00 pM by clonogenic survival and kills irreversibly by both apoptosis as well as nonapototic pathways. Acquisition of p53 mutant status conferred no reduction in sensitivity to DT cytotoxicity. Cell cycle arrest by aphidicolin did not protect human prostate cells from irreversible DT-induced cell death. TNF-alpha had modest cytostatic activity in the screen; however, the combination of TNF-alpha and DT resulted in marked acceleration of the time to prostate cancer cell death.

CONCLUSIONS

The rational screening of cytotoxins allows the identification of cell cycle-independent agents of variable potency against human prostate cancer. DT-mediated cell death is cell cycle independent, and p53 independent, making it particularly attractive for application to cytoreductive gene therapy, targeted monoclonal antibodies, and prodrug delivery of toxins applied to human prostate cancer therapeutics.

Prostate attenuated replication competent adenovirus (ARCA) CN706: a selective cytotoxic for prostate-specific antigen-positive prostate cancer cells

Prostate-specific antigen (PSA) is a widely used marker for the diagnosis and management of prostate cancer. Minimal enhancer/promoter constructs derived from the 5' flank of the human PSA gene (prostate-specific enhancer) were inserted into adenovirus type 5 DNA so as to drive the E1A gene, thereby creating a prostate-specific enhancer-containing virus, CN706. E1A was expressed at high levels in CN706-infected human PSA-producing LNCaP cells but not in CN706-infected DU145 cells, which are human prostate cells that do not express PSA. The titer of CN706 was significantly higher in LNCaP cells compared to several human cell lines that do not produce PSA (HBL100, PANC-1, MCF-7, DU145, and OVCAR3). Furthermore, in LNCaP cells, the yield of CN706 was dependent on exogenous androgen (R1881). CN706 destroyed large LNCaP tumors (1 x 10(9) cells) and abolished PSA production in nu/nu mouse xenograft models with a single intratumoral injection.