Phase II study of MLN8237 (Alisertib) in advanced/metastatic sarcoma

BACKGROUND

Aurora kinase A (AURKA) is commonly overexpressed in sarcoma. The inhibition of AURKA by shRNA or by a specific AURKA inhibitor blocks in vitro proliferation of multiple sarcoma subtypes. MLN8237 (alisertib) is a novel oral adenosine triphosphate-competitive AURKA inhibitor.

PATIENTS AND METHODS

This Cancer Therapy Evaluation Program-sponsored phase II study of alisertib was conducted through the Alliance for Clinical Trials in Oncology (A091102). Patients were enrolled into histology-defined cohorts: (i) liposarcoma, (ii) leiomyosarcoma, (iii) undifferentiated sarcoma, (iv) malignant peripheral nerve sheath tumor, or (v) other. Treatment was alisertib 50 mg PO b.i.d. d1-d7 every 21 days. The primary end point was response rate; progression-free survival (PFS) was secondary. One response in the first 9 patients expanded enrollment in a cohort to 24 using a Simon two-stage design.

RESULTS

Seventy-two patients were enrolled at 24 sites [12 LPS, 10 LMS, 11 US, 10 malignant peripheral nerve sheath tumor (MPNST), 29 Other]. The median age was 55 years; 54% were male; 58%/38%/4% were ECOG PS 0/1/2. One PR expanded enrollment to the second stage in the other sarcoma cohort. The histology-specific cohorts ceased at the first stage. There were two confirmed PRs in the other cohort (both angiosarcoma) and one unconfirmed PR in dedifferentiated chondrosarcoma. Twelve-week PFS was 73% (LPS), 44% (LMS), 36% (US), 60% (MPNST), and 38% (Other). Grade 3-4 adverse events: oral mucositis (12%), anemia (14%), platelet count decreased (14%), leukopenia (22%), and neutropenia (42%).

CONCLUSIONS

Alisertib was well tolerated. Occasional responses, yet prolonged stable disease, were observed. Although failing to meet the primary RR end point, PFS was promising.

TRIAL REGISTRATION ID

NCT01653028.

High-risk features in radiation-associated breast angiosarcomas

BACKGROUND

Radiation-associated breast angiosarcoma (RT-AS) is an uncommon malignancy with an incidence of less than 1 % of all soft tissue sarcomas. The overall prognosis is quite dismal with high rates of recurrences and poor overall survival. There is an obvious paucity of data regarding clinical outcomes of patients with breast RT-AS.

METHODS

We identified all patients with RT-AS treated at the Memorial Sloan-Kettering Cancer Center between 1982-2011 and collected their correlative clinical information.

RESULTS

We identified 79 women with RT-AS with a median age of 68 (range 36-87). The median interval between radiation and development of RT-AS was 7 years (range 3-19). The median time to local and distant recurrence was 1.29 years (95 % CI 0.72-NA) and 2.48 years (95 % CI 1.29-NA), respectively. The median disease-specific survival was 2.97 years (95 % CI 2.21-NA). Independent predictors of worse disease-specific survival included age 68 years (HR 3.11, 95 % CI 1.20-8.08, P=0.020) and deep tumors (HR 3.23, 95 % CI 1.02-10.21, P=0.046.)

CONCLUSION

RT-AS has high local/distant recurrence rates, limited duration on standard chemotherapy and poor disease-specific survival.

Phase II study of the HSP90-inhibitor BIIB021 in gastrointestinal stromal tumors

BACKGROUND

HSP90 inhibition leads to proteosomal degradation of activated KIT and has in vitro activity against gastrointestinal stromal tumors (GIST). BIIB021 is an oral non-ansamycin HSP90 inhibitor. We carried out a phase II study of BIIB021 in patients with GIST refractory to imatinib and sunitinib.

PATIENTS AND METHODS

The primary end-point was metabolic partial response (mPR) as assessed by fluorodeoxyglucose positron emission tomography (FDG-PET). The secondary end-points were pharmacokinetic assessments of BIIB021 and pharmacodynamic assessments of HSP70. Twenty-three patients were treated on two schedules: 12 pts received 600 mg twice a week (BIW) and 11 patients received 400 mg three times a week (TIW). All had prior imatinib and sunitinib but stopped>14 days before starting BIIB021.

RESULTS

The median age was 59 years (33-88 years), 61% male, 44% Eastern Cooperative Oncology Group 1 (ECOG1). The best response was PR by FDG-PET for five patients (3/12 at 600 mg BIW and 2/9 at 400 TIW) for an overall response rate of 22%. The response duration was 25-138 days. Adverse events (AEs) were mild to moderate. The mean Cmax was 1.5 µmol and the mean AUC was 2.9 µmol h. Cmax>1.5 µmol was associated with a decrease in standardized uptake value (SUVmax). HSP70 increased substantially following treatment.

CONCLUSIONS

This study met its primary end-point. BIIB021 leads to objective responses in refractory GIST patients. Pharmacodynamic studies confirmed HSP90 inhibition. Further evaluation of BIIB021 in GIST is warranted.

A phase I clinical trial of FOLFIRI in combination with the pancyclin–dependentkinase (CDK) inhibitor flavopiridol

e14511

Background: Preclinical data indicate that sequential treatment with flavopiridol (F) increases irinotecan- and 5-FU-induced apoptosis. Clinically, F showed promising activity when combined with irinotecan (Shah et al CCR 2005). Methods: We conducted a phase I trial of FOLFIRI + F every 2 weeks in patients (pts) with advanced solid tumors. Based on sequence- dependent inhibition, F was given 3 h after irinotecan but before 5-FU. Two maximum tolerated doses (MTD) were determined: MTD1 (F over 1 h) and MTD2 (F 30-min bolus + 4 h infusion). F pharmacokinetics (PK) were determined. Results: Of 74 pts treated, 63 were evaluable for toxicity and 56 for response. Pt characteristics: median age 60 (range 19–83), KPS 90 (70–90), prior regimens 3 (1–10). 39 pts received prior irinotecan. Tumor types: colorectal, gastric, HCC, GE junction, small bowel, pancreas, bile duct, breast, bladder, ovarian, sarcoma, melanoma, anal, urethral, thymic, head & neck, unknown primary. MTD1: F 80mg/ m2 with irinotecan 180mg/m2, LV 400mg/m2, 5FU: 400mg/m2 bolus + 2400mg/m2 over 48 h. Dose-limiting toxicities (DLT) were diarrhea, fatigue, neutropenia, neuropathy. MTD2: F 35mg/m2 bolus + 35mg/m2 over 4 h with the same FOLFIRI dose. DLTs were diarrhea, neutropenia, and fatigue. Clinical activity included 2 partial responses (small bowel cancer, 10.3 m; bladder cancer, 10 m) and 1 complete response (mucosal melanoma 10.3 m). 22 pts had stable disease (median 5.9 m; range 1.5–25.7 m). Clinical benefit rate (CR + PR + SD for > 3 m) was 39% (22/56). Of 25 pts with colorectal cancer, 11 had as best response SD for > 3m (median 6 m, range 4.2–15.4 m), despite failing ≥ 1 irinotecan-containing regimen. 6 of those had significant decreases (36–78%) in CEA. F PK showed interpatient variability with no significant interaction between FOLFIRI dose and F Cmax. F Cmax increased with increasing F dose. At MTDs, there was higher Cmax in pts who experienced DLT (3.48μM) vs those who did not (2.21μM). Conclusions: F can be safely given as a bolus (80mg/m2) or split dose (35mg/m2 bolus + 35mg/ m2 over 4 h) in combination with irinotecan 180mg/m2, LV 400mg/m2, 5FU: 400mg/m2 bolus + 2400mg/m2 over 48 h. Promising clinical activity is seen in mucosal melanoma and irinotecan-refractory colon cancer. (Supported by NCI R01CA67819)

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Acute colonic pseudo-obstruction after caesarean section

A 32-year-old patient developed pseudo-obstruction of the large bowel following elective caesarean section. The association of this rare postoperative complication with anaesthesia is discussed. Pseudo-obstruction of the large bowel (Ogilvie's Syndrome), is characterised by an adynamic mechanically unobstructed bowel which may progress to marked dilatation of the caecum. The reported mortality varies from 14-30% rising to 40-50% if there is caecal perforation. The underlying mechanism is thought to be an imbalance of the autonomic nervous system.

Human keratinocytes that express hTERT and also bypass a p16(INK4a)-enforced mechanism that limits life span become immortal yet retain normal growth and differentiation characteristics

Normal human cells exhibit a limited replicative life span in culture, eventually arresting growth by a process termed senescence. Progressive telomere shortening appears to trigger senescence in normal human fibroblasts and retinal pigment epithelial cells, as ectopic expression of the telomerase catalytic subunit, hTERT, immortalizes these cell types directly. Telomerase expression alone is insufficient to enable certain other cell types to evade senescence, however. Such cells, including keratinocytes and mammary epithelial cells, appear to require loss of the pRB/p16(INK4a) cell cycle control mechanism in addition to hTERT expression to achieve immortality. To investigate the relationships among telomerase activity, cell cycle control, senescence, and differentiation, we expressed hTERT in two epithelial cell types, keratinocytes and mesothelial cells, and determined the effect on proliferation potential and on the function of cell-type-specific growth control and differentiation systems. Ectopic hTERT expression immortalized normal mesothelial cells and a premalignant, p16(INK4a)-negative keratinocyte line. In contrast, when four keratinocyte strains cultured from normal tissue were transduced to express hTERT, they were incompletely rescued from senescence. After reaching the population doubling limit of their parent cell strains, hTERT(+) keratinocytes entered a slow growth phase of indefinite length, from which rare, rapidly dividing immortal cells emerged. These immortal cell lines frequently had sustained deletions of the CDK2NA/INK4A locus or otherwise were deficient in p16(INK4a) expression. They nevertheless typically retained other keratinocyte growth controls and differentiated normally in culture and in xenografts. Thus, keratinocyte replicative potential is limited by a p16(INK4a)-dependent mechanism, the activation of which can occur independent of telomere length. Abrogation of this mechanism together with telomerase expression immortalizes keratinocytes without affecting other major growth control or differentiation systems.

The intravascular migration of an epidural catheter

The intravascular migration of an endhole epidural catheter in a child is described. We suggest measures to reduce the risk of inadvertent intravenous administration of local anaesthetic and means of reducing the effects of this with particular relevance to paediatric practice.

A resource kit for women with breast cancer: development and evaluation

PURPOSE/OBJECTIVES

To describe the development and evaluation of the Resource Kit for Women With Breast Cancer, designed to facilitate adaptation to diagnosis, treatment, and recovery.

DATA SOURCES

Distributed to more than 200 women with newly diagnosed breast cancer. Derived from the Roy Adaptation Model of Nursing and the literature.

DATA SYNTHESIS

The kit may be helpful, particularly for women who are too overwhelmed by their situations to retain the vast amount of new information to which they are exposed.

CONCLUSIONS

The kit has the potential to assist women to adapt physically, emotionally, functionally, and interpersonally by concisely combining numerous relevant resources in one place, thereby facilitating the location and review of specific information.

IMPLICATIONS FOR NURSING PRACTICE

The kit is a complete package that can be used independently of any professional support as a guide for women during individualized professional telephone support or as an adjunct to formal breast cancer support groups.

Comparison of single, end-holed and multi-orifice extradural catheters when used for continuous infusion of local anaesthetic during labour

Single, end-holed and multi-orifice extradural catheters were compared in terms of efficacy and complications when used for infusion of 0.1% bupivacaine during labour. In this study of 364 patients there was no difference in unilateral block after an initial bolus dose (18 (11.5%) for single, end-holed and 16 (10.9%) for multi-orifice catheters). Unilateral block recurred with seven (4.0%) single, end-holed and with eight (4.8%) multi-orifice catheters. Unilateral blocks, arising for the first time during infusion of local anaesthetic, occurred significantly more frequently when single, end-holed catheters were used (29 (16.4%)) compared with multi-orifice catheters (14 (8.4%)) (P < 0.05).

Extension of epidural blockade for emergency caesarean section. Assessment of a bolus dose of bupivacaine 0.5% 10 ml following an infusion of 0.1% for analgesia in labour

A safe and predictable method by which an epidural infusion sufficient for pain control in labour can be rapidly converted to a more intense block adequate for emergency Caesarean section continues to present a challenge. A prospective study was undertaken. The routine use of a bolus dose of 10 ml of 0.5% bupivacaine was assessed as a top-up for emergency Caesarean section following a 0.1% infusion for labour. This produced an adequate block in 11 out of 18 patients. There were no significant differences in duration of infusion, cumulative local anaesthetic dose or pre-existing block height in these patients when compared with the remaining seven patients who required an additional top-up.