A Phase I-II multicenter trial with Avelumab plus autologous dendritic cell vaccine in pre-treated mismatch repair-proficient (MSS) metastatic colorectal cancer patients; GEMCAD 1602 study

BACKGROUND

Immune check-point blockade (ICB) has shown clinical benefit in mismatch repair-deficient/microsatellite instability high metastatic colorectal cancer (mCRC) but not in mismatch repair-proficient/microsatellite stable patients. Cancer vaccines with autologous dendritic cells (ADC) could be a complementary therapeutic approach to ICB as this combination has the potential to achieve synergistic effects.

METHODS

This was a Phase I/II multicentric study with translational sub-studies, to evaluate the safety, pharmacodynamics and anti-tumor effects of Avelumab plus ADC vaccine in heavily pre-treated MSS mCRC patients. Primary objective was to determine the maximum tolerated dose and the efficacy of the combination. The primary end-point was 40% progression-free survival at 6 months with a 2 Simon Stage.

RESULTS

A total of 28 patients were screened and 19 pts were included. Combined therapy was safe and well tolerated. An interim analysis (Simon design first-stage) recommended early termination because only 2/19 (11%) patients were disease free at 6 months. Median PFS was 3.1 months [2.1-5.3 months] and overall survival was 12.2 months [3.2-23.2 months]. Stimulation of immune system was observed in vitro but not clinically. The evaluation of basal RNA-seq noted significant changes between pre and post-therapy liver biopsies related to lipid metabolism and transport, inflammation and oxidative stress pathways.

CONCLUSIONS

The combination of Avelumab plus ADC vaccine is safe and well tolerated but exhibited modest clinical activity. Our study describes, for the first-time, a de novo post-therapy metabolic rewiring, that could represent novel immunotherapy-induced tumor vulnerabilities.

Colon capsule endoscopy versus CT colonography in FIT-positive colorectal cancer screening subjects: a prospective randomised trial-the VICOCA study

BACKGROUND

Colon capsule endoscopy (CCE) and CT colonography (CTC) are minimally invasive techniques for colorectal cancer (CRC) screening. Our objective is to compare CCE and CTC for the identification of patients with colorectal neoplasia among participants in a CRC screening programme with positive faecal immunochemical test (FIT). Primary outcome was to compare the performance of CCE and CTC in detecting patients with neoplastic lesions.

METHODS

The VICOCA study is a prospective, single-centre, randomised trial conducted from March 2014 to May 2016; 662 individuals were invited and 349 were randomised to CCE or CTC before colonoscopy. Endoscopists were blinded to the results of CCE and CTC.

RESULTS

Three hundred forty-nine individuals were included: 173 in the CCE group and 176 in the CTC group. Two hundred ninety individuals agreed to participate: 147 in the CCE group and 143 in the CTC group. In the intention-to-screen analysis, sensitivity, specificity and positive and negative predictive values for the identification of individuals with colorectal neoplasia were 98.1%, 76.6%, 93.7% and 92.0% in the CCE group and 64.9%, 95.7%, 96.8% and 57.7% in the CTC group. In terms of detecting significant neoplastic lesions, the sensitivity of CCE and CTC was 96.1% and 79.3%, respectively. Detection rate for advanced colorectal neoplasm was higher in the CCE group than in the CTC group (100% and 93.1%, respectively; RR = 1.07; p = 0.08). Both CCE and CTC identified all patients with cancer. CCE detected more patients with any lesion than CTC (98.6% and 81.0%, respectively; RR = 1.22; p = 0.002).

CONCLUSION

Although both techniques seem to be similar in detecting patients with advanced colorectal neoplasms, CCE is more sensitive for the detection of any neoplastic lesion.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02081742 . Registered: September 16, 2013.

Do we need adjuvant therapy in rectal cancer with complete pathologic response (ypT0N0) after induction chemoradiation and laparoscopic mesorectal excision?

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Background: Neoadjuvant chemo-radiotherapy (CRT) is the standard of care for patients (pts) with u>T3 by endoscopic ultrasound (EUS) rectal cancer. Although pts with complete pathological response (ypT0N0) fare well in multiple series, there is uncertainty of whether it’s due to the induction (CRT), due to the adjuvant chemotherapy (ACT) or due to the combination of both therapies. We have evaluated long-term outcomes in CRT-treated pts. Those with ypT0N0, were not treated with ACT. Methods: Pts with u>T3 rectal cancer, received neoadjuvant chemotherapy (225mg/m2/day 5-fluorouracil (FU)) in continuous infusion (CI) per 5 weeks (wks) and concomitant radiotherapy (45 Gy). Laparoscopic surgery (LAP) was planned after an interval of 5-8 wks. Pts achieving ypT0N0 were no treated with ACT. Pts with ypT>1 or N1 were treated with 3 gr/m2 FU in 48 hour CI and LV 200 mg/m2 every 2 wks x 6 cycles. Results: From November 2000 to November 2008, a cohort of 173 pts were treated with induction CRT and 167 pts underwent total mesorectal excision (LAP, n=158, open surgery n=9). Complete pathological response was achieved in 26/167 pts (15.5%). After a median follow-up of 58.3 months, pts with ypT0N0 have a 5-year disease-free survival and overall survival rate of 96% (95% CI 76 to 99%) and 100% (95% CI not estimable) respectively. Conclusions: Using these results, a clinical trial comparing observation versus adjuvant therapy in ypT0N0 after standard CRT, would need to enroll 3088 pts to show a HR of 0.75 in favor of ACT after 5 years of follow-up (alpha=.05, beta=.2). In case that the true DFS lied in the lower bound of the 95% CI, 636 patients would be needed under the same assumptions. These results do not support the administration of ACT to ypT0N0 patients.

EUS and magnetic resonance imaging in the staging of rectal cancer: a prospective and comparative study

BACKGROUND

Accurate locoregional staging is crucial in rectal cancer for deciding patient management because the administration of neoadjuvant therapy depends on it. EUS and magnetic resonance imaging (MRI) are used indistinctly in the pretherapeutic workup of rectal cancer.

OBJECTIVE

To prospectively compare the performance of EUS and MRI in the locoregional staging of rectal cancer in a large series of patients.

DESIGN

Prospective and comparative study.

SETTING

Tertiary center.

PATIENTS

Patients with histologically proven rectal cancer.

INTERVENTIONS

EUS and MRI were performed in all patients by a different operator unaware of the results of the other procedure.

MAIN OUTCOME MEASUREMENTS

Epidemiological, clinical, radiological, and echographic variables were evaluated. Pathological examination of the surgical specimen was used as the criterion standard.

RESULTS

Ninety patients (54 men and 36 women with a mean age of 68 ± 12 years; range 33-87 years) constitute the final sample of this study. Most of the tumors were stages T2-T3 (85%; 95% CI, 77%-92%). Twenty of them (22%; 95% CI, 14%-32%) were stenotic and 24 (27%; 95% CI, 18%-37%) had polypoid morphology. The accuracy of T staging was very similar for EUS and MRI for stage T2 (76%; 95% CI, 65%-84% and 77%; 95% CI, 67%-85%, respectively; P = not significant) and stage T3 (76%; 95% CI, 65%-84% and 83%, 95% CI, 73%-90%, respectively; P = not significant). MRI was not able to visualize any T1 tumor, whereas EUS understaged all T4 tumors. The univariate analysis showed that the polypoid morphology of the tumor inversely correlated with T staging on MRI. The accuracy of MRI for N staging was higher than that of EUS, although the difference did not reach statistical significance (79%; 95% CI, 65%-88% and 65%; 95% CI, 51%-78%, respectively). When performing the univariate analysis to assess the reasons for this difference, the presence of a stenotic tumor was the only parameter significantly related to a poorer performance of EUS in N staging.

LIMITATIONS

The small number of early and locally advanced lesions.

CONCLUSIONS

EUS and MRI have similar accuracy in the T and N staging in rectal cancer. The presence of stenosis and polypoid morphology is inversely associated with accuracy for either EUS or MRI.

Design and endpoints of clinical and translational trials in advanced colorectal cancer. a proposal from GROUP Español Multidisciplinar en Cancer Digestivo (GEMCAD)

Meta-analytic reviews of Randomized Clinical Trials (RCT) have reached contradictory conclusions regarding the benefit of medical interventions in Advanced Colorectal Cancer (ACRC). Surrogate markers of survival benefit, such as response rate (RR) and progression free-survival (PFS) often show contradictory and highly variable correlations. These contradictions can be due to differences in 1) the studies analysed (sources), 2) the quality of clinical trials (intrinsic bias in the design, biased data analysis, heterogeneous PFS definitions) and 3) the second-line strategies between arms. PFS is a more vulnerable target than overall survival (OS), but the latter can also be affected by different biases and additional medical interventions such as secondary resection of metastases or second-line therapies. Therefore the correlation between PFS and survival must be clearly stated if PFS is to be considered as a primary endpoint. Of the differences between studies, only the quality of clinical trials can be improved by a deeper knowledge of both the area of study (i.e. colorectal cancer) and the methodology needed (i.e., clinical and translational trials). The aim of this manuscript is to offer the basic resources to develop experimental trials in ACRC. To this end, techniques for diagnosis and for response assessment are discussed, prognostic factors and treatment standards are critically exposed, and notes about how to design useful translational studies are provided.

Pathogenesis of Eimeria praecox in chickens: virulence of field strains compared with laboratory strains of E. praecox and Eimeria acervulina

The pathogenesis in chickens of the apicomplexan Eimeria praecox was compared with that of Eimeria acervulina, using intestinal lesions, mucosal integrity, body weight gain (BWG) and the feed conversion ratio (FCR) as criteria. Characteristics of each species were described by combinations of polymerase chain reaction assays and classic parasitological signs. There were considerable overlaps in lengths, breadths, shape indices and volumes of the oocysts of each species. Both species caused statistically significant reductions in BWG at the lowest inocula tested (500,000 sporulated oocysts per bird of E. praecox and 250,000 of E. acervulina). E. praecox was observed for the first time to cause actual body weight loss and marked increases in FCR, as did E. acervulina. E. acervulina caused gross, white pathognomonic lesions, but E. praecox caused micro-lesions, visible in fresh tissue only with a dissecting microscope. Occasionally, lesions of the Houghton strain of E. acervulina were observed to be rounded, rather than typically "ladder-like". Both species caused villous erosion and atrophy. No mortality occurred in birds receiving up to 1 million sporulated oocysts of either species. Using BWG and FCR as criteria, the virulence of recent field strains of E. praecox from Wales (Tynygongl) and the USA (Raleigh) was compared with English laboratory strains of E. praecox (Houghton) and E. acervulina (Houghton). E. praecox (Tynygongl) was markedly more virulent than E. acervulina (Houghton), which was more virulent than E. praecox (Raleigh) and E. praecox (Houghton).

Comparison of endoscopic ultrasonography and magnetic resonance cholangiopancreatography in the diagnosis of pancreatobiliary diseases: a prospective study

OBJECTIVES

To compare the diagnostic value of endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP) in: (a) patients with a dilated biliary tree unexplained by ultrasonography (US) (group 1), and (b) the diagnosis of choledocholithiasis in patients with nondilated biliary tree (group 2).

METHODS

Patients were prospectively evaluated with EUS and MRCP. The gold standard used was surgery or EUS-FNA and ERCP, intraoperative cholangiography, or follow-up when EUS and/or MRCP disclosed or precluded malignancy, respectively. Likelihood ratios (LR) and pretest and post-test probabilities for the diagnosis of malignancy and choledocholithiasis were calculated.

RESULTS

A total of 159 patients met one of the inclusion criteria but 24 of them were excluded for different reasons. Thus, 135 patients constitute the study population. The most frequent diagnosis was choledocholithiasis (49% in group 1 and 42% in group 2, P= 0.380) and malignancy was more frequent in group 1 (35%vs 7%, respectively, P < 0.001). When EUS and MRCP diagnosed malignancy, its prevalence in our series (35%) increased up to 98% and 96%, respectively, whereas it decreased to 0% and 2.6% when EUS and MRCP precluded this diagnosis. In patients in group 2, when EUS and MRCP made a positive diagnosis of choledocholithiasis, its prevalence (42%) increased up to 78% and 92%, respectively, whereas it decreased to 6% and 9% when any pathologic finding was ruled out.

CONCLUSIONS

EUS and MRCP are extremely useful in diagnosing or excluding malignancy and choledocholithiasis in patients with dilated and nondilated biliary tree. Therefore, they are critical in the approach to the management of these patients.

Preoperative evaluation of biliary anatomy in adult live liver donors with volumetric mangafodipir trisodium enhanced magnetic resonance cholangiography

Accurate preoperative depiction of biliary anatomy is not always adequately accomplished by imaging techniques in living donor liver transplantation (LDLT). We present the results of a prospective study designed to evaluate the ability of mangafodipir trisodium (Mn-DPDP)-enhanced magnetic resonance (MR) cholangiography (MRC) for this purpose in a series of 25 adult living liver donors (LLDs). We also analyze if a simple or a more complex surgical procedure can be preoperatively suggested for biliary reconstruction in the recipients. Findings on MRC were compared with operative cholangiography (OC). A conventional distribution with a right hepatic duct (RHD) longer than 1 cm anticipated a simple procedure (duct-to-duct anastomosis or hepaticojejunostomy [HJ]). A shorter RHD or any variant were predictors of a more complex surgery (bench ductoplasty or multiple anastomoses). Agreement between MRC and OC in assessing the biliary anatomy was measured using the kappa statistic, and differences between the kind of surgery predicted at MRC and the biliary anastomosis performed were evaluated with Fisher's exact test. Normal variants were present in 16 / 25 donors (64%). MRC was accurate in depicting the pattern of bile duct distribution observed at OC in 22 / 25 (88%) donors (kappa = .831), and correctly predicted the complexity of biliary anastomosis in the recipient in 22 / 25 (88%) donors. No significant differences were observed between complexity of biliary surgery proposed at MRC and the final surgery performed (P = .002). In conclusion, Mn-DPDP-enhanced MRC is highly accurate in depicting the biliary duct anatomy and can be used preoperatively for surgical planning in LDLT.

Evaluation of hepatocellular carcinoma using SonoVue, a second generation ultrasound contrast agent: correlation with cellular differentiation

The appearance of hepatocellular carcinoma (HCC) with contrast-enhanced ultrasound (CEUS) in the vascular phase is described and evaluated as to whether the enhancement pattern correlates with the degree of cellular differentiation. One hundred four HCCs were prospectively evaluated with CEUS using coherent-contrast imaging (CCI) and SonoVue with a low mechanical index (<0.2). The enhancement of HCCs in the vascular phase was analyzed according to the degree of pathological differentiation obtained by fine-needle biopsy. In the arterial phase, all HCCs except for four well differentiated ones (96.2%) showed enhancement ( P<0.05). Histological differentiation of hypoechoic lesions in the early portal phase (7 HCCs; 16%) significantly differed from hyperechoic (1 HCC; 1%) or isoechoic lesions (87 HCCs; 83.6%) ( P<0.05), with a significant probability of a worse differentiation in hypoechoic lesions. Histological differentiation of isoechoic lesions in the late phase (30 HCCs; 28.8%) significantly differed from hypoechoic lesions (74 HCCs; 71.2%) ( P<0.05), with a significant probability of a better differentiation in isoechoic lesions. CEUS using CCI and SonoVue revealed enhancement in the arterial phase in >95% of HCCs, with a few well-differentiated cases not being diagnosed due to the absence of enhancement. Echogenicity in the portal and late phases correlated with cellular differentiation.

Contrast-enhanced power Doppler sonography and helical computed tomography for assessment of vascularity of small hepatocellular carcinomas before and after percutaneous ablation

PURPOSE

We compared the usefulness of Levovist-enhanced power Doppler imaging (PDI) and helical CT in the depiction of tumor vascularity before and after percutaneous ablation of small hepatocellular carcinomas (HCCs).

METHODS

Thirty-one cirrhotic patients with solitary unresectable HCCs smaller than 5 cm (mean size, 2.7 +/- 0.8 cm; range, 1.5-5.0 cm) recruited over a 15-month period were treated with percutaneous ethanol injection (n = 9) or radiofrequency ablation (n = 22). PDI, contrast-enhanced PDI (using Levovist), and multiphase contrast-enhanced helical CT were performed before and after percutaneous ablation, and vascularity findings were compared.

RESULTS

Levovist significantly increased baseline intratumoral Doppler signals on PDI compared to non-contrast PDI. The most frequent tumor vascularity pattern was heterogeneous (45%). Vascularity was identified in all tumors by both contrast-enhanced PDI and helical CT before ablation. After percutaneous ablation, intratumoral vascularity was detected in 11 tumors by contrast-enhanced PDI and in 15 tumors by CT. The sensitivity, specificity, and diagnostic accuracy of contrast-enhanced PDI in demonstrating intratumoral vascularity, with CT being the gold standard, were 66%, 93%, and 81%, respectively. There was significant agreement between the 2 modalities in the depiction of tumor vascularity after ablation (kappa = 0.6, p = 0.001). However, there were 5 false negatives and 1 false positive with contrast-enhanced PDI. Complete tumor necrosis was achieved in 21 patients (68%).

CONCLUSIONS

There was a good concordance between contrast-enhanced PDI and helical CT in the depiction of HCC vascularity before and after percutaneous ablation. However, although contrast-enhanced PDI may be useful for real-time guidance of treatment, its low sensitivity makes it inadequate to accurately assess the completeness of ablation.

A major isoform of the maize plasma membrane H(+)-ATPase: characterization and induction by auxin in coleoptiles

The plasma membrane (PM) H(+)-ATPase has been proposed to play important transport and regulatory roles in plant physiology, including its participation in auxin-induced acidification in coleoptile segments. This enzyme is encoded by a family of genes differing in tissue distribution, regulation, and expression level. A major expressed isoform of the maize PM H(+)-ATPase (MHA2) has been characterized. RNA gel blot analysis indicated that MHA2 is expressed in all maize organs, with highest levels being in the roots. In situ hybridization of sections from maize seedlings indicated enriched expression of MHA2 in stomatal guard cells, phloem cells, and root epidermal cells. MHA2 mRNA was induced threefold when nonvascular parts of the coleoptile segments were treated with auxin. This induction correlates with auxin-triggered proton extrusion by the same part of the segments. The PM H(+)-ATPase in the vascular bundies does not contribute significantly to auxin-induced acidification, is not regulated by auxin, and masks the auxin effect in extracts of whole coleoptile segments. We conclude that auxin-induced acidification in coleoptile segments most often occurs in the nonvascular tissue and is mediated, at least in part, by increased levels of MHA2.

Structural organisation of microsatellite families in the Leishmania genome and polymorphisms at two (CA)n loci

In the present study, we have analysed the frequency and distribution of several microsatellite DNAs [(CA)n, (GGT)n and (GCA)n] in the genome of Leishmania. Hybridisation analysis on the molecular karyotypes of different Leishmania strains showed the presence of these three microsatellites on all chromosomes of the parasite. The number of microsatellite clusters appeared grossly similar among strains from different Old World complexes. However, these three microsatellite families showed an uneven distribution among heterologous chromosomes of the same strain. Moreover, restriction analysis of chromosome I in various strains of Leishmania infantum showed a strong clustering of these microsatellites in the same chromosomal region. A partial genomic library was screened with a (CA)n probe, and 21 positive clones were isolated. The sequencing of these clones confirmed the association of various microsatellites such as (CA)n, (CT)n, and (GCA)n. Finally, specific polymerase chain reaction amplification of two cloned (CA)n loci demonstrated allelic size polymorphisms among strains within L. infantum and Leishmania donovani. Most of the 34 strains analysed were found to be monoallelic, while two alleles were found in a small number of strains. The interest of these sequences for studies on ploidy and population genetics of the parasite is discussed.

Expression of a maize cell wall hydroxyproline-rich glycoprotein gene in early leaf and root vascular differentiation

The spatial pattern of expression for a maize gene encoding a hydroxyproline-rich glycoprotein (HRGP) was determined by in situ hybridization. During normal development of roots and leaves, the expression of the gene was transient and particularly high in regions initiating vascular elements and associated sclerenchyma. Its expression was also associated with the differentiation of vascular elements in a variety of other tissues. The gene encoded an HRGP that had been extracted from the cell walls of maize suspension culture cells and several other embryonic and post-embryonic tissues. The gene was present in one or two copies in different varieties of maize and in the related monocots teosinte and sorghum. A single gene was cloned from maize using a previously characterized HRGP cDNA clone [Stiefel et al. (1988). Plant Mol. Biol. 11, 483-493]. In addition to the coding sequences for the HRGP and an N-terminal signal sequence, the gene contained a single intron in the nontranslated 3' end.

Cyclooxygenase and lipoxygenase-like activity in Drosophila melanogaster

To determine the possible activity of cyclooxygenase and lipoxygenase like enzymes in Drosophila melanogaster, we have investigated whether fly homogenates can biosynthesize prostaglandins and HETEs. Incubation of fly extracts with AA yields a mixture of 15- 12- 9- and 8-HETE as detected by selected ion monitoring GC-MS. Also the combination of HPLC-RIA using a PGE antibody shows the presence of endogenous PGE2 immunoreactivity in the extracts (405 pg/g in males and 165 pg/g in females). We have also detected the presence of lipoxygenase like immunoreactivity in the reproductive male system by using immunocytochemical techniques in whole body sections of the fly as well as reactivity in the digestive system of both males and females. Finally, we have not been able to detect endogenous AA in the fly by GC-MS methods. However, estimates by GC-MS of the total body fatty acids indicate substantial amounts of potential AA precursors.

Effect of postnatal anoxia on bilirubin levels in rat brain

The effects of a period of anoxia 18-24 h after birth on bilirubin levels in rat brain were investigated during anoxia, recovery, and development. Postnatal anoxia induces a significant, temporary increase (up to 200% with respect to control values) in newborn rat brain bilirubin levels during anoxia and short-term recovery. Pretreatment of the newborn rats with a single dose of the drug sulfixosazole markedly enhances bilirubin accumulation in the brain of the anoxic rats. A second rise in brain bilirubin concentration is detected in a group of the newborn rats 3-6 days after oxygen deprivation. Autoradiographic localization of radiolabeled bilirubin following in vivo experiments suggests that this substance is preferentially accumulated in some areas of the newborn rat brain as a consequence of postnatal anoxia, and indicates, together with the effect of sulfixosazole, that as a result of anoxia, a displacement of unbound bilirubin from blood to the nervous tissue occurs. Our results confirm the importance of anoxia as a risk factor for the development of bilirubin-induced encephalopathy. The possible relevance of intracerebral hemorrhages caused by perinatal asphyxia producing delayed bilirubin accumulation in the newborn rat brain is suggested.

Enkephalin-like immunoreactivity in Drosophila melanogaster

Enkephalin-immunoreactive neurons have been identified in the central nervous system of the fruit fly Drosophila melanogaster by immunocytochemical techniques. Analyses of fly extracts by high performance liquid chromatography and radioimmunoassay show a relatively complex pattern of immunoreactive compounds. The most prominent among them has chromatographic properties similar to those of met-enkephalin from which can, however, be distinguished by high-resolution chromatographic techniques.

Chemical and conformational changes in chromosome regions being actively transcribed

U.V. microspectrophotometry has been used to calculate quantities of nucleic acids and proteins of complete polytene chromosomal sets and specific regions of these chromosomes. It has been found that in chromosomes the ratio of DNA to proteins is approximately 1:4. This ratio however changes when specific regions are compared. The average ratio of DNA to proteins in a puffed region (2-48B4C5) increases to 1:16 in contrast to 1:6 from the same region but in non puffed state. At the same time the RNA quantity increases by a factor of 2. thermal denaturation profiles of formaldehyde fixed chromosomes show that the Tm of this region in puffed and non puffed state differ by 10 degrees C. Moreover these profiles suggest that a large fraction of histone-bound DNA is destabilized during puffing.

DNA distribution and intrachromosomal organization of moderately repetitive sequences

The DNA content of individual subregions along the 4th chromosome of Drosophila hydei has been measured. 51% of the subregions have a DNA content averaging 0.7-0.8 pg; 31% a mean DNA content of 0.25-0.35 pg and 18% a mean DNA content of 1.7 pg. Moreover the structural chromosomal distribution of moderately repetitive DNA is not random since the specific activity of the chromosomal segments in terms of those sequences is not the same. 9% of the subregions are very poor in repetitive sequences and 18% rich in repetitive DNA while being very poor in DNA.