Impact of age and gender on the efficacy and safety of upfront therapy with panitumumab plus FOLFOX followed by panitumumab-based maintenance: a pre-specified subgroup analysis of the Valentino study

BACKGROUND

The safety and efficacy outcome of elderly metastatic colorectal cancer (mCRC) patients fit enough to receive combination chemotherapy plus biological agents is an issue of growing interest. Also, gender-specific differential toxicity and efficacy of anti-epidermal growth factor receptor (EGFR)-based upfront treatments need to be explored.

PATIENTS AND METHODS

Valentino was a multicenter, randomized, phase II trial, investigating two panitumumab-based maintenance strategies following first-line panitumumab plus FOLFOX in RAS wild-type mCRC patients. We carried out a subgroup analysis, aimed at assessing the differences in efficacy, safety and quality of life (QoL) according to age (<70 versus ≥70 years) and gender (male versus female). Efficacy endpoints were progression-free survival (PFS), overall survival (OS) and overall response rate (ORR); safety endpoints were rates of any grade and grade 3/4 adverse events (AEs).

RESULTS

No significant differences in terms of PFS, OS and ORR were observed between patients aged <70 or ≥70 years and the effect of the maintenance treatment arm on survival outcomes was similar in the two subgroups. The safety profile of both induction and maintenance treatment and the impact on QoL were similar in elderly and younger patients. No significant differences in PFS, OS, ORR or clinical benefit rate were observed according to gender. A significantly higher rate of overall grade 3/4 AEs (P = 0.008) and of grade 3/4 thrombocytopenia (P = 0.017), any grade and grade 3/4 neutropenia (P < 0.0001) and any grade conjunctivitis (P = 0.033) was reported in female as compared to male patients. Conversely, we reported a significantly higher incidence of any grade skin rash (P = 0.0007) and hypomagnesemia (P = 0.029) in male patients.

CONCLUSIONS

The upfront choice of an anti-EGFR-based doublet chemotherapy followed by a maintenance strategy represents a valuable option in RAS wild-type mCRC irrespective of gender and age, though a careful evaluation of patients to maximize the risk/benefit ratio is warranted.

Germinal BRCA1-2 pathogenic variants (gBRCA1-2pv) and pancreatic cancer: epidemiology of an Italian patient cohort

OBJECTIVE

Germline BRCA1-2 pathogenic variants (gBRCApv) increase the risk of pancreatic cancer and predict for response to platinating agents and poly(ADP-ribose) polymerase inhibitors. Data on worldwide gBRCApv incidence among pancreatic ductal adenocarcinoma (PDAC) patients are sparse and describe a remarkable geographic heterogeneity. The aim of this study is to analyze the epidemiology of gBRCApv in Italian patients.

MATERIALS AND METHODS

Patients of any age with pancreatic adenocarcinoma, screened within 3 months from diagnosis for gBRCApv in Italian oncologic centers systematically performing tests without any selection. For the purposes of our analysis, breast, ovarian, pancreas, and prostate cancer in a patient's family history was considered as potentially BRCA-associated. Patients or disease characteristics were examined using the χ2 test or Fisher's exact test for qualitative variables and the Student's t-test or Mann-Whitney test for continuous variables, as appropriate.

RESULTS

Between June 2015 and May 2020, 939 patients were tested by 14 Italian centers; 492 (52%) males, median age 62 years (range 28-87), 569 (61%) metastatic, 273 (29%) with a family history of potentially BRCA-associated cancers. gBRCA1-2pv were found in 76 patients (8.1%; 9.1% in metastatic; 6.4% in non-metastatic). The gBRCA2/gBRCA1 ratio was 5.4 : 1. Patients with gBRCApv were younger compared with wild-type (59 versus 62 years, P = 0.01). The gBRCApv rate was 17.1% among patients <40 years old, 10.4% among patients 41-50 years old, 9.2% among patients 51-60 years old, 6.7% among patients aged 61-70 years, and 6.2% among patients >70 years old (none out of 94 patients >73 years old). gBRCApv frequency in 845 patients <74 years old was 9%. Patients with/without a family history of potentially BRCA-associated tumors had 14%/6% mutations.

CONCLUSION

Based on our findings of a gBRCApv incidence higher than expected in a real-life series of Italian patients with incident PDAC, we recommend screening all PDAC patients <74 years old, regardless of family history and stage, due to the therapeutic implications and cancer risk prevention in patients' relatives.

Impact of age and gender on the safety and efficacy of chemotherapy plus bevacizumab in metastatic colorectal cancer: a pooled analysis of TRIBE and TRIBE2 studies

BACKGROUND

The phase III TRIBE and TRIBE2 studies randomized metastatic colorectal cancer patients to first-line FOLFOXIRI/bevacizumab or a doublet (FOLFIRI or FOLFOX)/bevacizumab. The studies demonstrated a significant benefit from the triplet at the price of an increased incidence of chemotherapy-related adverse events (AEs). In both trials, males and females aged between 18 and 70 years with ECOG PS ≤2 and between 71 and 75 years with ECOG PS = 0 were eligible. We investigated the effect of FOLFOXIRI/bevacizumab versus doublets/bevacizumab according to age and gender.

PATIENTS AND METHODS

Subgroup analyses according to age (<70 versus 70-75 years) and gender were carried out for overall response rate (ORR), progression-free survival (PFS), and AE rates.

RESULTS

Of 1187 patients, 1005 (85%) were aged <70 years and 182 (15%) 70-75 years; 693 (58%) were males and 494 (42%) females. There was no evidence of interaction between age or gender and the benefit provided by the intensification of the upfront chemotherapy in terms of ORR and PFS, or the increased risk of experiencing G3/4 AEs. Elderly patients and females experienced higher rates of overall G3/4 AEs (73% versus 60%, P < 0.01 and 69% versus 57%, P < 0.01, respectively). Notably, in the FOLFOXIRI/bevacizumab subgroup, G3/4 diarrhea and febrile neutropenia occurred in 27% and 16% of elderly patients, respectively, while females reported high incidences of any grade nausea (67%) and vomiting (50%).

CONCLUSIONS

The improvements in terms of ORR and PFS of FOLFOXIRI/bevacizumab versus doublets/bevacizumab are independent of gender and age, with a similar relative increase in AEs among elderly patients and females. Initial dose reductions and possibly primary G-CSF prophylaxis should be recommended for patients between 70 and 75 years old treated with FOLFOXIRI/bevacizumab, and a careful management of antiemetic prophylaxis should be considered among females.

Epidemiological, clinical and pathological characteristics of gastric neoplasms in the province of Cremona: the experience of the first population-based specialized gastric cancer registry in Italy

BACKGROUND

The gastric cancer incidence rate differs widely across geographical areas. In Italy, in the province of Cremona the incidence is high, compared to the national situation. For this reason a specialized population-based registry was set up.

METHODS

The collection encompasses all gastric cancers diagnosed in the three districts of the province since January 1, 2010. The main data sources were the pathological and Hospital Discharge Records and patient clinical charts. Only diagnoses of primary gastric cancer were considered. For each case the following variables were registered: personal data, medical history and symptoms at diagnosis; imaging assessments performed, details on surgery and other treatments received; genetic background and biomolecular characteristics; social and environmental factors.

RESULTS

As of November 2017, 1087 cases were collected; of which 876, diagnosed up to December 2015, were analyzed. Male/female ratio was 1.4. The European Age-standardized Incidence Rate was 41.4 for males and 28.3 for females as compared to a national average of 33.3 and 17.0 respectively. Median age at diagnosis was 73 for male and 78 for female. Helicobacter Pylori infection was present in fewer than 20% of cases. HER-2 gene was amplified in about 25% of cases. Primary tumour location was the gastro-esophageal junction or cardia in 17.5% in males and 8.3% in females. The majority of cases (58.3%) were diagnosed at an advanced stage and overall only 41.2% underwent surgery. Median overall survival was 14.8 months for men and 18.5 for women. Age standardized 5-year relative survival was 31.4% for men and 40.5% for females. Neoadjuvant treatment was performed in fewer than 10% of patients who underwent surgery, and the rate of postoperative therapy adherence was low.

DISCUSSION

This study shows a high gastric cancer incidence in the province of Cremona, with a geographical spread across different districts. Moreover, a high percentage of gastric cancers were detected at an advanced stage of disease and a low rate of 5-year relative survival was registered. Based on these findings, effective preventive interventional health strategies and screening procedures need to be implemented to reduce the impact of this pathology in this geographical area.

First Report of Bacterial Panicle Blight of Rice Caused by Burkholderia gladioli in Ecuador

Burkholderia gladioli is one of the causal agents of bacterial panicle blight of rice (BPB). Although B. glumae is considered the main pathogen responsible of BPB, B. gladioli can also cause this disease in rice (3). B. gladioli is also of clinical importance because of the ability of some strains to cause respiratory infections in humans (2). Symptoms in rice plantations of Palestina city, like upright panicles with grayish-straw color, grain rot, and vain grains were observed in July 2013, although similar symptoms were first noticed as early as 2012 in other regions of Ecuador. Since then, similar symptomatology has been reported by farmers in coastal provinces, possibly affecting 75% of the crops. One of the causal agents was recently identified as B. glumae but other bacteria were observed in infected rice (1). Plants showing BPB symptoms were collected from Palestina and bacteria were isolated from panicle twigs using the semi selective SPG agar (KH₂PO₄ 1.3 g, Na₂HPO₄ 1.2 g, (NH₄)₂SO₄ 5 g, MgSO₄·7H₂O 0.25 g, Na₂MoO₄·2H₂O 24 mg, EDTA-Fe 10 mg, L-cystine 10 μg, D-sorbitol 10 g, pheneticillin potassium 50 mg, ampicillin sodium 10 mg, cetrimide 10 mg, methyl violet 1 mg, phenol red 20 mg, agar 15 g/liter distilled water). Colonies were then transferred to PDA. Presumptive B. gladioli colonies were classified into two groups according to their color on PDA. Colonies from group one (six strains) were dull yellow, whereas those from group two (two strains) were olive colored. Both groups produced fluorescent colonies with smooth, shiny surfaces on PDA. All cells were gram-negative rods with the following dimensions: 0.8 to 2.0 × 0.4 to 0.6 μm (group one) or 1.5 to 2.5 × 0.4 to 0.7 μm (group two). All colonies were subjected to biochemical tests (API 20NE) and shared a 99% or higher similarity (APIWEB) with B. gladioli. To confirm identity, genomic DNA was extracted (gDNA extraction kit from Invitrogen) and a portion of the 16s rDNA was amplified by PCR using the primers 536F: 5'-GTGCCAGCMGCCGCGGTAATAC-3' and 1492R: 5'-GGTTACCTTGTTACGACTT-3' followed by sequencing. Sequences of group one strains shared 100% similarity with B. gladioli strain OM1 (GenBank Accession No. EU678361) while the sequences from group two strains were 100% similar to B. gladioli strain BgHL-01 (JX566503). Sequences of the Ecuadorian strains were deposited into NCBI GenBank (group one: KF669879 to KF669882, KF669884, and KF669885; group two: KF669883 and KF669886). Pathogenicity was confirmed by submerging rice seeds in a cell suspension with 10⁸ CFU of the pathogen for 24 h. Seeds were germinated at 28°C and about 70% RH on autoclaved peat. Inoculated seeds yielded plants with BPB symptoms 6 days after planting. Re-isolated strains shared a 99.9% similarity with B. gladioli by APIWEB. To the best of our knowledge, this is the first report of B. gladioli as a rice pathogen in Ecuador. References: (1) C. Riera-Ruiz et al. Plant Dis. 98:988, 2014. (2) C. Segonds et al. J. Clin. Microbiol. 47:1510, 2009. (3) H. Ura et al. J. Gen. Plant Pathol. 72:98, 2006.

First Report of Burkholderia glumae Causing Bacterial Panicle Blight on Rice in Ecuador

Rice (Oryza sativa L.) is one of the leading crops and the basis of most diets in Ecuador and other countries. Diseases such as bacterial panicle blight (BPB), also known as seedling rot or grain rot, have the potential to threaten rice production worldwide. Burkholderia glumae, a causal agent of BPB, has severely affected the rice industry in many countries of Africa, Asia, and the Americas (1,2,4), but no report of this bacteria in Ecuador can be found in the literature. Rice plantations showing BPB-like symptoms including upright panicles with stained and vain grains were spotted in Palestina city, one of Ecuador's most extensive rice areas, in July 2013, but similar symptoms have been observed in the region since early 2012. Six symptomatic plants from two different groves were collected. Samples were plated on the semi-selective medium S-PG (KH₂PO₄ 1.3 g, Na₂HPO₄ 1.2 g, (NH₄)₂SO₄ 5 g, MgSO₄·7H₂O 0.25 g, Na₂MoO₄·2H₂O 24 mg, EDTA-Fe 10 mg, L-cystine 10 μg, D-sorbitol 10 g, pheneticillin potassium 50 mg, ampicillin sodium 10 mg, cetrimide 10 mg, methyl violet 1 mg, phenol red 20 mg, agar 15 g/liter distilled water) and axenic colonies were transferred to potato dextrose agar (PDA) to test for fluorescence (3). Colonies of the potential pathogen were 1 mm, circular, entire margin, with a smooth and shiny surface. When cultured in PDA, isolates showed a moist texture, dull yellow color, and displayed fluorescence with exposure to UV light. Cells were bacterial gram-negative rods of 1 to 2 × 0.5 μm. Twelve presumptive isolates were submitted to biochemical tests (API 20NE). The biochemical profile (APIWEB) showed that all the isolates belonged to the Burkholderia genus with a 99.9% similarity. To determine the bacterial species, colonies were submitted to ELISA tests using specific antibodies for B. glumae from Agdia, Inc. The two isolates that were positive for B. glumae were sequenced using a part of the 16s rDNA amplified by the primers 536F: 5'-GTGCCAGCMGCCGCGGTAATAC-3' and 1492R: 5'-GGTTACCTTGTTACGACTT-3'. The obtained sequences (deposited into GenBank as KF601202) shared 100% similarity with several B. glumae strains after a BLAST query. Isolates were then diluted to 10⁸ UFC/ml and used to inoculate healthy rice plants. Inoculated plants produced BPB-like symptoms including upright panicles with stained vain grains and the bacterium was re-isolated from symptomatic plants. To the best of our knowledge, this is the first report of B. glumae in Ecuador. Further research is ongoing to identify and determine the pathogenicity of the remaining Burkholderia strains that tested negative for B. glumae. References: (1) J. Luo et al. Plant Dis. 91:1363, 2007. (2) R. Nandakumar et al. Plant Dis. 93:896, 2009. (3) T. Urakami et al. Int. J. Syst. Bacteriol. 44:235, 1994. (4) X.-G. Zhou. Plant Dis. 98:566, 2014.

Transvaginal color Doppler ultrasound for de novo ovarian carcinoma. How a good chance can be missed

Early de novo ovarian cancer is one of the most challenging entities in gynecologic oncology as early diagnosis is extremely difficult. We describe the case of a 77-year woman who had incidental diagnosis of normally shaped ovaries with low resistance blood flow. Despite the suspicious finding and despite the documentation of elevated serum CA 125 levels she did not undergo surgery. Twelve months later she was found with an enlarged ovary. Laparotomy documented a stage IIIB ovarian carcinoma. Lack of communication among subspecialists and incomplete acceptance of new diagnostic aids contributed to this disappointing case.

Mammography with synchrotron radiation: phase-detection techniques

The authors evaluated the effect on mammographic examinations of the use of synchrotron radiation to detect phase-perturbation effects, which are higher than absorption effects for soft tissue in the energy range of 15-25 keV. Detection of phase-perturbation effects was possible because of the high degree of coherence of synchrotron radiation sources. Synchrotron radiation images were obtained of a mammographic phantom and in vitro breast tissue specimens and compared with conventional mammographic studies. On the basis of grades assigned by three reviewers, image quality of the former was considerably higher, and the delivered dose was fully compatible.

[Hemodynamic variable analysis in patients with systemic arterial hypertension undergoing physical exercise]

PURPOSE

To verify the exercise-induced hemodynamic changes in moderate hypertensive patients.

METHODS

Twenty nine patients were studied and they were submitted to cycloergometer supine exercise (50w and 100w) during cardiac catheterization. The hemodynamic variables were measured: cardiac index (CI), stroke volume (SV), systemic arterial resistance (SAR), pulmonary arterial resistance (PAR), wedge pressure (WP), right atrial pressure (RA), systolic arterial pressure (SP), diastolic arterial pressure (DP), mean arterial pressure (MP) and heart rate (HR). To evaluate the cardiac function, the patients were divided in two groups: GI with CI > 2.5 ml/min/m2 and GII CI < 2.5 ml/min/m2.

RESULTS

During exercise, patients from GI and GII were similar-according to MAP, RA, WP, and HR. On the other hand, GI and GII exhibited different (#) behavior regarding SV, PAR and SAR. During the three exercise conditions, rest (R), 50w and 100w it was observed: a) PAR-R = 50 = 100 (GI); b) MP, PAR, WP, SV, SAR-R #50 #100 (GI); c) HR, PAR and SAR-R #50 #100 (GII). There was no correlation between the cardiac function (CI, SV) and the circulatory adjustment (PAR and SAR) or the pressure curve (SP, DP, MP) and HR.

CONCLUSION

The results suggest that the cardiac function of GI patients depends, mainly, on the inotropism, while in GII patients it depends on the decrease of the afterload (PAR and SAR). Those changes may appear even in the late exercise stage (100w), with a bias to attain the GI levels. Those observations suggest functional changes in vasomotor tone of GII patients.

[Randomized study comparing mitral valve replacement with and without preservation of mitral ring chordae tendinae papillary continuity]

PURPOSE

To demonstrate the importance of the preservation of mitral annulus-chordae tendineae-papillary muscles continuity in mitral valve replacement.

METHODS

We studied 21 patients who were submitted to mitral valve replacement, divided in two randomized groups: group 1, 12 cases who undergone mitral valve replacement, with preservation of the posterior leaflet and correspondent chordae tendineae; and group 2-9 cases who undergone conventional mitral valve replacement, excising the mitral valve apparatus. The left ventricular function was studied both, in the pre and post operative period, by echocardiography, cardiac catheterization, and radioisotopic study. The statistical analysis was done by the Wilcoxson's test.

RESULTS

There were no early post operative deaths. Analyzing the results of the ejection fraction by the radioisotopic study we found a significant difference (p = 0.03) between the percentual decrease of the two groups. The results of the fractional shortening were higher in group 1 than in group 2, however not significant. The left ventricular diastolic diameters average was lower in group 1 than in group 2, so as the left atrium diameter. We found a decrease in left ventricular end-diastolic pressure in group 1, however there was an increase in group 2, by the cardiac catheterization. There was a proportional increase in group 1 both in lung artery and lung capillary pressures. There was a significant difference (p = 0.05) between the average values of right ventricular diastolic pressure.

CONCLUSION

There is better preservation of left ventricular function in group 1.

[Immunosuppressive drugs for the treatment of active myocarditis in children. Hemodynamic evaluation]

PURPOSE

To analyse hemodynamic parameters (left ventricles ejection fraction, cardiac index, mean pulmonary wedge pressure and left ventricle diastolic diameter, in a group of children with active myocarditis (diagnosed by endomyocardial biopsy) pre and post treatment with conventional therapy and immunosuppressive drugs (isolated prednisone or prednisone associated with azathioprine or cyclosporine).

PATIENTS AND METHODS

Forty-four pediatric patients with active myocarditis were studied. Twenty males and 24 females from 10 months to 15 years old (median = 1.3 years). All patients were submitted to hemodynamic study and endomyocardial biopsy. The hemodynamic parameters mentioned above were analysed before and after the proposed therapy. The patients were distributed in group according to the admission in the protocol, group I (9 pts)--conventional therapy (CT); group II (12 pts)--CT plus prednisone; group III (16 pts)--CT plus prednisone plus azathioprine; group IV (13 pts)--CT plus prednisone plus cyclosporine.

RESULTS

Forty-four patients were submitted to four different groups of therapeutic protocol. The hemodynamic parameters were analysed in each of them. Left ventricle ejection fraction were no significantly different in the pre and post therapeutic scheme in group I and II, they were significantly higher (p less than 0.05) in group III and IV. The same happened with cardiac index. The mean pulmonary wedge pressure no presented statistical differences in group I and II before and after treatment but significantly lower lends were observed in group III and IV. The same behavior were noted in the left ventricle end diastolic diameter.

CONCLUSION

The association of azathioprine or cyclosporine to prednisone presented better results in the left ventricle function, when compared with conventional drugs or isolated use of prednisone, based in the analysis of same hemodynamic parameters.

[Simulated epileptiform discharges during the replay of a lengthy EEG recording]

Reviewing a longterm-EEG magnet-recording on the video system of the play-back unit "Mobile Oxford Medilog 9000" EEG patterns appeared, which imposed as epileptiform discharges. They seemed to correlate with the paroxysmal clinical disturbances the patient had experienced and noted in a diary, and could be printed out on a normal EEG-apparatus. Following investigations demonstrated the artificial origin of this EEG patterns: They appeared in fact only using the switches of the play-back unit for the fast back- and forward winding. The time-correlation between clinical and electroencephalographic episodes was simulated by the search of selected EEG-sequences based on the clinical episodes noted from the patient.

[Surgical treatment of tetralogy of Fallot associated with an anomalous coronary vessel]

Anomalous coronary arteries crossing the outflow tract of the right ventricle in tetralogy of Fallot have a prominent surgical importance in total correction. The unintentional section of these arteries is followed by a high mortality. In the period between 1977 and 1987, 475 patients with tetralogy of Fallot were operated on. Fourteen of these patients had anomalous coronaries crossing the right ventricle. Three of the patients were less than one year of age. Eleven patients were male. Diagnosis was performed in the operating room in 13 patients. Twelve patients had the anterior descending artery originating from the right coronary, and two presented single left coronary arteries. During the surgical procedure two patients had the anomalous coronary artery divided; in one a saphenous vein bypass graft was used and in the second and end-to-end anastomosis was performed. In the remaining 12 cases, a transverse ventriculotomy (one case), extensive dissection of the anomalous coronary artery (two cases), a palliative procedure (one case), a valved conduit between the right ventricle and the pulmonary artery (one case) and total correction through the atriopulmonary approach (seven cases) were performed. No immediate mortality was observed and there was one late death. The authors suggest that, whenever anatomical conditions permit, the atriopulmonary approach should be preferred in the repair of tetralogy of Fallot associated to anomalous coronary arteries.

Impaired in vitro growth of PHA induced T lymphocyte colonies in hemodialyzed renal failure patients

Using an in vitro method that allows the study of the colony forming capacity of phytohemagglutinin stimulated peripheral blood T lymphocytes, we have detected an impaired T cell colony formation in hemodialyzed renal failure patients. By contrast a near normal pattern of responses was observed in patients treated with a conservative therapy. The poor in vitro T cell responsiveness of hemodialyzed patients was not corrected by supplementing the cultures with an adherent cell contitioned medium prepared from normal donors. We conclude that an intrinsic defect of the T cell colony forming capacity exists in hemodialyzed patients.

[Disseminated intravascular coagulation. II. Therapeutic problems]

The treatment of DIC often presents problems that are not easily solved given the difficulty of interpreting symptoms and haematological findings, the seriousness of the clinical situation and the rapid development of disease phenomena. Diagnostic questions must be answered before physiopathologically rational therapy can be applied. The identification and cure of the condition which triggers coagulation are also of primary importance in selecting a therapeutic response. Apart from specific treatment of the causal disease, the treatment of DIC is based on the one hand on the use of anticoagulants (heparin) to halt intravascular coagulation and transfusional integration with haemoderivatives and platelet concentrates to correct the haemostasis deficiency secondary to such massive consumption. On the other, direct methods are needed to control the state of shock, cardiorespiratory compromise and acute renal insufficiency which often complicate the course of the defibrination syndrome. Therapeutic success depends on timely intervention allied to the employment of adequate measures for each individual case.

Erythrocytosis associated with a dermoid cyst of the ovary and erythropoietic activity of the tumour fluid

A patient with dermoid cyst of the ovary and erythrocytosis is described. Surgical removal of the tumour was followed by a progressive decrease of the red cell mass with remission of the haematological abnormalities. Tumor fluid contained significant erythropoietic stimulating activity. This seems to be the first documented case of erythrocytosis associated with ovarian cyst.

Multiple myeloma without detectable Ig synthesis

A case of nonproductor myeloma is reported. The diagnosis was supported by the radiological findings, the heavy marrow infiltration of malignant plasma cells, the absence of a monoclonal component in the serum or urine and the failure to demonstrate intracytoplasmic immunoglobulins with immunoifluorescent techniques. The clinical findings of our patient are similar to those reported for the 5 cases of nonproductor myeloma described so far, indicating that there are no characteristic features differentiating nonproductor myeloma from productor myelomas.