Design of the ANal Cancer/HSIL Outcomes Research study (ANCHOR study): A randomized study to prevent anal cancer among persons living with HIV

It is well established that persons living with HIV (PLWH) have highly elevated rates of anal HSIL and anal cancer compared with those who are not living with HIV. The 5-year risk of anal cancer following anal HSIL has been reported to be as high as 14.1% among PLWH compared with 3.2% among those who are not living with HIV. To address these concerns, the AIDS Malignancy Consortium completed a large-scale, randomized trial to compare strategies for the prevention of anal cancer among PLWH with anal HSIL. The objective of the study was to determine whether treating anal HSIL was effective in reducing the incidence of anal cancer in PLWH compared with active monitoring. This paper describes the design of the ANal Cancer/HSIL Outcomes Research Study (ANCHOR) with respect to estimating the anal cancer event rate in this high risk population.

Incremental healthcare resource utilization and costs for patients with cervical, vaginal, vulvar, anal, and oropharyngeal cancer in the United States

INTRODUCTION

Human papillomavirus (HPV) cause cancers in a variety of anatomic sites presenting at various stages of disease. Current economic assessments rely on HPV-related cancer cost estimates from data prior to the launch of the nonavalent HPV vaccine (2014). The goal of the present study was to assess and describe the current direct medical care burden of HPV-related cancers in the US.

METHODS

Using Clinformatics Data Mart, patients in the US who were newly diagnosed with cervical, vulvar, vaginal, anal, and oropharyngeal cancers between 2012 and 2015 were compared to non-cancer matched (propensity score) controls. Health care resource utilization and direct medical cost (2020 USD) were assessed over a 2-year follow-up period following index diagnosis from a payer perspective. The cost for censored time was estimated using generalized linear model while adjusting for survival probability using cox-proportional hazard model. Confidence intervals were calculated with bootstrapping technique.

RESULTS

The analyses included 4128 cervical, 1580 vulvar, 538 vaginal, 1827 anal, and 6106 oropharyngeal cancers and matched controls. Cases and controls had similar baseline clinical characteristics and length of follow-up. The 2-year incremental direct medical costs were $93,272, $81,676, $141,096, $129,366, and $134,045 for cervical, vulvar, vaginal, anal, and oropharyngeal cancers respectively. Outpatient care costs was the biggest driver of the total incremental medical costs. Most cancer costs were incurred during the first 6 months of follow-up and then stabilized during follow-up.

CONCLUSION

HPV-related cancers are responsible for substantial health care expenditure each year.

Xpert HPV as a Screening Tool for Anal Histologic High-Grade Squamous Intraepithelial Lesions in Women Living With HIV

BACKGROUND

Women living with HIV (WLWH) experience high rates of anal cancer. Screening using anal cytology, high-resolution anoscopy (HRA) with biopsies, can histologically diagnose anal cancer precursors called high-grade squamous intraepithelial lesions (HSIL). The low specificity of screening using anal cytology results in HRA referral for many WLWH without HSIL. Screening using high-risk human papillomavirus (HR-HPV) may improve specificity.

METHODS

Two hundred seven WLWH (63% non-Hispanic black) were screened for anal histologic HSIL (hHSIL) using cytology, HRA-guided biopsies, and Xpert HPV. Xpert performance for predicting anal hHSIL was compared with that of cytology. Usng Xpert 5 HPV genotypic results and accompanying cycle thresholds, receiver operator characteristic curve and recursive partitioning analyses were used to create predictive models for hHSIL.

RESULTS

The performance of Xpert to predict hHSIL was not different from that of cytology with a sensitivity (Sn) of 89% and specificity (Sp) of 49%. Interpretation of Xpert was modified using genotypic results and receiver operator characteristic curve analysis, which produced a screen with an Sn and Sp of 75% and 84% for hHSIL, respectively. Another reinterpretation of Xpert was created using recursive partitioning and cycle thresholds, which predicted hHSIL with an Sn and Sp of 75% and 86%, respectively. The detection of HPV-16 was highly predictive of hHSIL in all analyses. These modified screening tests would reduce HRA referral in this population by almost half compared with anal cytology.

CONCLUSIONS

Xpert HPV is an alternative to anal cytology to screen for anal HSIL and can be optimized to reduce the number of unnecessary HRAs performed in WLWH.

Abstract 62: An Assessment of Cervical Cancer Prevention and Treatment Infrastructure in Belize

Purpose: Belize has among the highest cervical cancer incidence and mortality rates of Latin American and Caribbean countries despite efforts to increase access to prevention and treatment services. This study evaluates the policies, infrastructure, and workforce of the cervical cancer management system in Belize to inform the strengthening of sustainable screening and treatment programs.

Methods: In 2018, health facility assessments were conducted across the 6 districts of Belize at the national pathology facility and 12 public facilities identified by Ministry of Health as critical to cervical cancer control. We used a standardized instrument to assess human resources, physical infrastructure, and existing policies related to cervical cancer management.

Results: The public cervical cancer screening workforce in Belize consists of 75 nurses and physicians (1 per 1,075 screening-eligible women), and 44% (n=33) are members of the outreach workforce who serve rural areas (1 per 2,537 screening-eligible women). All districts have at least 1 screening facility, 50% (n=6) of which perform screening services including visual inspection with acetic acid and cervical cytology 1 day per week. Cervical cancer diagnosis and treatment service availability differ across districts. At the national pathology facility, 38% (n=5) of essential equipment (e.g. microtomes) were available and functional, 23% (n=3) of equipment were available but non-functional, and 38% (n=5) of equipment were unavailable. Regarding essential pathology supplies (e.g. hematoxylin and eosin), 30% (n=6) of supplies were out of stock at the time of assessment and 75% (n=15) were out of stock at one point in the past 12 months.

Conclusion: Public sector cervical cancer management services differ between districts of Belize, with tertiary service availability concentrated in the largest district. Screening, outreach, and pathology are limited by resource availability, and although no standard benchmarks exist for contextualization, this insight into current capacity pinpoints health system components for future investment.

Citation Format: Shane Neibart, Tiffany Smith, Jennifer Fang, Taylor Anderson, Abha Kulkarni, Jennifer Tsui, Shawna Hudson, Gregory Peck, Joseph Hanna, Natalia Largaespada Beer, Mark Einstein. An Assessment of Cervical Cancer Prevention and Treatment Infrastructure in Belize [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 62.

Abstract 5218: Inhibition of γ-secretase decreases Notch signaling and cell migration in uterine carcinosarcoma

Carcinosarcoma (CS) is a rare and aggressive type II endometrial adenocarcinoma (EmCa) accounting for less than 5% of all uterine malignancies, but accounting for a disproportionately high disease-specific mortality rate. Notch signaling is an evolutionarily conserved pathway with oncogenic roles in several cancers. Notch proteins are expressed in Type I and Type II EmCa, cell lines, and human tissue, but Notch function has not been characterized in CS. To determine whether inhibiting Notch signaling may be a therapeutic target in CS we assessed expression of Notch family genes and the impact of γ-secretase inhibition on cellular migration in the CS cell line, CS-99, and compared to lower risk Type I EmCa cell line (HEC-1-A). Expression of Notch receptors, ligands and effectors was determined using RT-PCR. We determined the impact of exposure to DAPT, a γ-secretase inhibitor, vs DMSO (vehicle control) on cell viability with a MTT assay. The ability of DAPT to inhibit Notch signaling was assessed by quantitative (q) RT-PCR for the Notch effector, HES1. The relative expression level of each target gene was normalized to 18s rRNA. Cellular migration after exposure to DAPT was assessed using a scratch assay for CS-99 and HEC-1-A. The extent of cell migration was measured using ImageJ (NIH Bethesda, MD). CS-99 and HEC-1-A, expressed receptors NOTCH1-4, ligands DLL4, JAG1, JAG2, and effectors HES1, HEY1, and NRARP. The MTT assay revealed >88% cellular viability after 24 hr exposure to 10µM in CS-99 and 50µM DAPT in HEC-1-A. Exposure to DAPT significantly decreased expression HES1 in CS-99 and HEC-1-A. Migration was decreased in CS-99 and unchanged in HEC-1-A with 10µM and 50 µM of DAPT, respectively. Inhibition of Notch signaling activity decreased cellular migration in CS-99 cell line suggesting that Notch signaling may impact disease growth in CS. Unchanged HEC-1-A cellular migration suggests that Notch signaling might not impact disease growth in Type I EmCa. Inhibition of Notch signaling may be a promising therapeutic target in CS.

Inhibition of Notch signaling in CS-99 and HEC-1-A with a γ-secretase inhibitor (median + IQR)*HEC-1-A + DMSOHEC-1-A + DAPT 50μMP-valueCS-99 + DMSOCS-99 + DAPT 10μMP-valueHES1 (normalized fold change)0.94 (0.83-1.3)0.35 (0.25-0.41)0.0220.99 (0.84-1.2)0.19 (0.16-0.23)0.002% wound closure (0-6h)12.5 (8.5-15.5)24.1 (10.5-33.0)0.1311.4 (9.7-11.5)11.3 (9.1-11.4)0.7% wound closure (0-24h)38.1 (31.4-46.1)63.0 (33.6-100.0)0.2473.3 (66.6-73.9)61.7 (52.6-64.7)0.05

Citation Format: Sofia D. Gabrilovich, Yasmin Abedin, Sreevidya Santha, Tracy Wu, Mark Einstein, Nataki C. Douglas, Jenna Z. Marcus. Inhibition of γ-secretase decreases Notch signaling and cell migration in uterine carcinosarcoma [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5218.

Sex hormone, insulin, and insulin-like growth factor signaling in recurrence of high stage endometrial cancer: Results from the NRG Oncology/Gynecologic Oncology Group 210 trial

5509

Background: Sex hormone and insulin/insulin-like growth factor (IGF) axis signaling pathways play an important role in endometrial cancer development but their role in endometrial cancer recurrence is unknown. In this study GOG-8015 we evaluated these pathways in a prospective cohort of patients diagnosed with the most common type of endometrial cancer, endometrioid adenocarcinoma. Methods: Stage II-IV endometrioid endometrial adenocarcinoma patients (N = 816) enrolled in the GOG-210 study with pre-treatment specimens were tested for tumor mRNA and protein expression levels of IGF1, IGF2, IGF binding proteins ( IGFBP) -1and -3, the insulin (IR) and IGF-I receptors (IGF1R), and phosphorylated (activated) IR/IGF1R as well as estrogen (ER) and progesterone receptors (PR) using quantitative PCR and immunohistochemistry (IHC). Serum concentrations of insulin, IGF-I, IGFBP-3, estradiol, estrone and sex hormone binding globulin were measured using ELISAs. Hazard ratios (HR) and 95% confidence intervals (CI) for risk of recurrence were obtained from multivariable Cox proportional hazard’s models with adjustment for age, stage and grade. Results: Recurrence occurred in 280 (34%) cases during a mean of 5.4 years of follow-up. ER-positivity (HR 0.67, 95% CI 0.47-0.95), IR-positivity (HR 0.53, 95% CI 0.29-0.98) and serum IGF-I levels (highest versus lowest quartile, HR 0.66, 95% CI 0.47-0.92) were inversely associated with recurrence risk. Conversely, circulating estradiol (highest versus lowest tertile, HR 1.55, 95% CI 1.02-2.36) and insulin (per 10 uU/ml, HR 1.52, 95% CI 1.12-2.06) and phosphorylated IGF1R/pIR expression (HR 1.40, 95% CI 1.02-1.92) were associated with increased risk of recurrence. Conclusions: We identified novel sex hormone and insulin/IGF axis tissue and circulating biomarkers of recurrence in a prospective study of high stage endometrioid endometrial cancer. Circulating insulin and estradiol, and tissue phosphorylated (activated) IGR1R/IR were independently associated with recurrence. These findings support prioritizing studies to establish their clinical utility as prognostic biomarkers and to investigate new strategies that target these pathways for prevention and treatment of endometrial cancer recurrence.

AIDS malignancy consortium (AMC) 095: A phase I study of ipilimumab (IPI) and nivolumab (NIVO) in advanced HIV-associated solid tumors (ST) with expansion cohorts in HIV-associated solid tumors and classical Hodgkin lymphoma (cHL)

TPS44

Background: Immune checkpoint blockade (ICB) using agents that target the priming phase (i.e. CTLA-4) and effector phase (e.g. PD-1) of host immunity, used individually or in combination, has emerged as a therapeutic strategy for cancers. However, little is known about the safety, tolerability and efficacy of ICB in patients (pts) with HIV infection and cancer. Methods: AMC 095 (NCT02408861) is a multicenter, international phase I study of the PD-1 inhibitor, nivo alone or in combination with a CTLA-4 inhibitor, ipi, in 2 cohorts stratified by CD4 counts (Stratum 1: CD4 counts≥200/uL and Stratum 2: CD4 count 100-200/uL) with additional expansion cohorts at the recommended phase II dose in pts with ST and cHL. The primary study objective is to determine the safety and feasibility of nivo alone and the nivo+ipi combination. Secondary objectives are to evaluate the effects of single agent nivo, and ipi+ nivo, on HIV replication and immune function (HIV viral load in plasma using conventional assay, CD4+, and CD8+ cells), and to obtain preliminary information regarding response. The trial was initiated in 8/15, as of 9/30/17, the study is ongoing, and 14 pts have been enrolled. Updated information on the safety and responses will be presented. Clinical trial information: NCT02408861. Funded by the NCI Grant #UM1CA121947.[Table: see text]

Eurogin 2016 Roadmap: how HPV knowledge is changing screening practice

Human papillomaviruses (HPVs) are the necessary cause of most cervical cancers, a large proportion of other anogenital cancers, and a subset of oropharyngeal cancers. The knowledge about HPV has led to development of novel HPV-based prevention strategies with important impact on clinical and public health practice. Two complementary reviews have been prepared following the 2015 Eurogin Conference to evaluate how knowledge about HPV is changing practice in HPV infection and disease control through vaccination and screening. This review focuses on screening for cervical and anal cancers in increasingly vaccinated populations. The introduction of HPV vaccines a decade ago has led to reductions in HPV infections and early cancer precursors in countries with wide vaccination coverage. Despite the high efficacy of HPV vaccines, cervical cancer screening will remain important for many decades. Many healthcare systems are considering switching to primary HPV screening, which has higher sensitivity for cervical precancers and allows extending screening intervals. We describe different approaches to implementing HPV-based screening efforts in different healthcare systems with a focus in high-income countries. While the population prevalence for other anogenital cancers is too low for population-based screening, anal cancer incidence is very high in HIV-infected men who have sex with men, warranting consideration of early detection approaches. We summarize the current evidence on HPV-based prevention of anal cancers and highlight important evidence gaps.

Physical activity for an ethnically diverse sample of endometrial cancer survivors: a needs assessment and pilot intervention

Objective

To determine the physical activity (PA) behavior, needs and preferences for underserved, ethnically diverse women with a history of endometrial cancer (EC).

Methods

Women with a history of EC (41 non-Hispanic black, 40 non-Hispanic white, and 18 Hispanic) completed a needs assessment during their regular follow-up appointments at Montefiore Medical Center in Bronx, NY, USA. An 8-week pilot PA intervention based on the results of the needs assessment was conducted with 5 EC survivors.

Results

Mean body mass index (BMI) among the 99 respondents was 34.1±7.6 kg/m², and 66% did not exercise regularly. Self-described weight status was significantly lower than actual BMI category (p<0.001). Of the 86% who were interested in joining an exercise program, 95% were willing to attend at least once weekly. The primary motivations were improving health, losing weight, and feeling better physically. Despite the high interest in participation, volunteer rate was very low (8%). However, adherence to the 8-week pilot PA intervention was high (83%), and there were no adverse events. Body weight decreased in all pilot participants.

Conclusion

These data show that ethnically diverse EC survivors have a great need for, and are highly interested in, PA interventions. However, greater care needs to be taken to assess and identify barriers to increase participation in such programs.

Abstract 3587: Effect of race on outcome in women with uterine cancers

Background: Incidence rates for malignant tumors of the uterine corpus have been reported to be lower among women of color than among whites, whereas mortality rates have been reported to be higher among African-American women and women of Latina origin. Reasons for the higher level of mortality among women of color are currently unknown. Methods: After Institutional Review Board approval, we accessed the prospective clinical databases in the Division of Gynecologic Oncology at our institution. We abstracted socio-demographic and survival data from all women who were diagnosed with endometrial cancer from January 1990-January 2010. Pathology records were reviewed and the final pathology confirmed. Results: Nine hundred and ninety patients were identified. Racial distribution was 381 (38%) white, 310 (31%) black, 231 (23%) Hispanic, 21 (2%) other, and 72 (3%) unknown or unclassified. Five hundred and ninety-six (60%) patients had Type I endometriod histological subtype. At time of censor, 269 (27%) were confirmed deceased. The hazard ratio for black verses white women was 1.91 (p&lt;0.001) when all histological subtypes were included. However, when patients were divided into Type I and Type II histological subtypes there was no significant difference in survival by race. Conclusion: Our data show no difference in survival among women of Asian, African-American/Caribbean, and Caucasian races with uterine cancer after control for histological subtype.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 3587. doi:1538-7445.AM2012-3587

Abstract 5026: Utilization of palliative medicine in a racially and ethnically diverse population of women with gynecologic malignancies

Objective: There is limited information regarding the role of a palliative care consultation for ethnically and racially diverse women with gynecologic malignancies. The purpose of this study was to determine the characteristics, clinical findings and outcomes of patients with gynecologic malignancies who were referred for hospital inpatient palliative medicine consultation.

Methods: Patients with gynecologic malignancies were identified who requested a Palliative Medicine consultation from January 1, 2007 to June 1, 2010. Their medical records were reviewed for information including demographics, disease status, reasons for the consultation, clinical findings, interventions, and outcomes.

Results: 84 evaluable patients were identified. Forty-five percent (n=38) of patients were referred by their primary Gynecologic Oncologist. The average age was 63 years (range 22-96). The disease site was: uterus/endometrium (n=37, 44%), ovary (n=24, 29%), cervix (n=15, 18%), and vulva (n=5, 6%). Racial distribution included, African American (n=3, 39%), Caucasian (n=33, 28%), and Hispanic (n=13, 16%). Reasons for consultation were pain (n = 41; 45%), future goals of care (n=42; 46%) nausea/vomiting (n = 1; 1%), bowel obstruction (n=3, 3.3%) and dyspnea (n=4, 4%). Seventy-five percent of patients had medical co-morbidities, 27% had psychiatric co-morbidities and six patients were identified to have altered mental status at the time of interview. Eighty percent of patients were on narcotic medications at the time of consultation; however pain was adequately controlled in only 45% of patients. In 81% of the consultations, pharmacologic interventions were advised. The median number of days from consultation to death was 31. Hospice referral was recommended for 19 patients and thirty-eight patients were transitioned to “do not resuscitate” (DNR) status after consultation. The median number of days from DNR status to death was 19, and the median number of days from consult to DNR was 8. Sixteen patients (19%) died in the hospital setting.

Conclusion: This patient population represents a unique perspective of racial diversity and predominantly advanced or recurrent gynecologic cancers. Pharmacologic interventions were advised in the majority of consults, however end-of-life decision making was a common reason for consultation. The consultation team proved effective in transitioning patients to DNR status, however there may be barriers to early palliative intervention and symptom control as the median time of intervention to death was only one month. Pain and symptom control remain a significant challenge that earlier intervention may alleviate. This diverse, minority and low socio-economic status population may be resistant and/or unable to seek palliative care outside the hospital or their home.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 5026. doi:10.1158/1538-7445.AM2011-5026

The impact of human papillomavirus vaccination on cervical cancer prevention efforts

OBJECTIVES

To review concepts, information, obstacles, and approaches to cervical cancer screening and prevention as vaccination against human papillomavirus (HPV) types 16 and 18 is adopted.

METHODS

Expert forum, conducted September 12-13, 2008, hosted by the Society of Gynecologic Oncologists, including 56 experts in cervical cancer and titled Future Strategies of Cervical Cancer Prevention: What Do We Need to Do Now to Prepare?

RESULTS

The current approach to cervical cancer screening in the U.S. is limited by its opportunistic nature. If given to women before exposure, a vaccine against HPV 16,18 can decrease cervical cancer risk by up to 70%. The impact on abnormal cytology and cervical intraepithelial neoplasia (CIN) will be less but still substantial. As the prevalence of high-grade CIN falls, fewer women with positive screening tests will have truly preinvasive disease. To minimize harm from false positive tests in women who are at low risk for cancer because of early vaccination, later initiation of and longer intervals between screenings are ideal. However, the vaccine is less effective when administered after first intercourse, and delivering and documenting HPV vaccination to girls at optimal ages may prove difficult.

CONCLUSIONS

Until population-based data on the performance of cytology, HPV testing, and alternate screening or triage interventions become available, modifying current screening guidelines is premature. Current recommendations to initiate screening as late as age 21 and to screen less often than annually are appropriate for young women known to have been vaccinated before first intercourse.

Intravenous administration of Reolysin, a live replication competent RNA virus is safe in patients with advanced solid tumors

BACKGROUND

Reolysin is reovirus serotype 3-Dearing strain, a double-stranded replication-competent RNA non-enveloped icosahedral virus. It induces cytopathic and anti-cancer effects in cells with an activated ras pathway due to inhibition of the dsRNA-activated protein kinase.

METHODS

This was a single center dose escalation trial of Reolysin administered intravenously every 4 weeks in doses ranging from 1 x 10(8) to 3 x 10(10) tissue culture infective dose (TCID)(50). Serum for neutralizing antibody, and serum, stool, saliva, and urine for viral shedding were collected. Tumor samples were analyzed for activating mutations in the ras and braf oncogenes.

RESULTS

Eighteen patients received 27 doses of Reolysin in 6 dose cohorts accomplishing a 300 fold dose escalation without a protocol-defined dose limiting toxicity. Drug related grade 2 toxicities included fatigue and fever (1 patient each). All patients developed neutralizing antibody during the course of the study. Viral shedding was observed in 6 patients. One patient with anthracycline and taxane refractory breast cancer experienced a partial response (PR) and her tumor had a ras G12A mutation. Biopsy from her chest wall mass showed evidence of necrosis and viral replication by electron microscopy. Overall clinical benefit (1 PR + 7 stable disease) rate was 45%, and appeared higher in patients with viral shedding (67%) than those without (33%).

CONCLUSION

Reolysin administered monthly as a one-hour infusion is safe and well-tolerated even in multiple doses. Reolysin has anti-tumor activity as a single agent warranting further evaluation, including in combination with chemotherapy. Viral shedding may suggest intrapatient replication yielding a benefit and should be studied carefully in future studies.

Dose escalation and pharmacodynamic study of intravenous adminstration of Reolysin, a live replication competent RNA virus in patients with advanced solid tumors

3583

Background: Reolysin is reovirus serotype 3 - Dearing strain, a double-stranded replication- competent RNA non-enveloped icosahedral virus. It induces cytopathic and anti-cancer effects in cells with an activating mutation in the ras proto-oncogene. Methods: This was a single center dose escalation trial of Reolysin administered intravenously every four weeks in doses ranging from 1X108 to 3X1010 tissue culture infective dose (TCID)50. Serum for neutralizing antibody, and serum, stool, saliva, and urine for viral shedding were collected. Tumor samples were analyzed for activating mutations in the ras and braf oncogenes. Results: Eighteen patients received 27 doses of Reolysin in 6 dose cohorts accomplishing a 300 fold dose escalation without a protocol-defined dose limiting toxicity. Drug related grade 2 toxicities included fatigue and fever (1 patient each). All patients developed neutralizing antibody during the course of the study. Viral shedding was observed in 6 patients [urine (5), serum (4), saliva (3), and stool (2)]. One patient with anthracycline and taxane refractory breast cancer experienced a partial response (PR) and her tumor had a mutation in the ras oncogene. Biopsy from a chest wall mass showed evidence of necrosis and viral replication by electron microscopy. The overall clinical benefit rate was 45% and appeared higher in patients with viral shedding (67%) than those without (33%). Conclusions: Reolysin administered as a one hour infusion on a monthly schedule is safe and well-tolerated even in multiple doses. Reolysin has anti-tumor activity as a single agent warranting further evaluation, including in combination with chemotherapy. Viral shedding may suggest intrapatient replication yielding a benefit and should be studied carefully in future studies.

[Table: see text]

A phase I safety and dose escalation trial of docetaxel combined with GEM231, a second generation antisense oligonucleotide targeting protein kinase A R1alpha in patients with advanced solid cancers

PURPOSE

GEM231 is a second-generation antisense oligonucleotide targeting the mRNA of the R1alpha regulatory subunit of cAMP dependent protein kinase A. Preclinical studies have demonstrated synergistic antitumor activity when GEM231 is combined with docetaxel. This trial assesses the safety of this combination.

EXPERIMENTAL DESIGN

Docetaxel was administered once every three weeks (one-cycle) at doses between 50-75 mg/m2. GEM231 was administered twice weekly at 220 mg/m2 for 3 (schedule-A), or 2 (schedule-B) weeks.

RESULTS

Twenty patients with chemotherapy-refractory advanced cancer received a total of 39 cycles of therapy. Six patients in schedule-A received docetaxel 50 mg/m2, and 14 patients in schedule-B received docetaxel 50-75 mg/m2. In schedule-A, 2 of 6 patients developed cycle-1 dose limiting toxicity (DLT)-grade-3 fatigue or grade-3 serum transaminase elevation. In schedule-B, 1 of 4 patients developed cycle-1 DLT at the highest dose of docetaxel tested (75 mg/m2)--grade-3 febrile neutropenia. Subsequent dose escalations were not pursued since the overall incidence of grade-3 toxicities (including those that occurred after cycle 1) was 75%, and this dose was close to the single agent MTD of docetaxel. Grade-3 toxicities included fatigue (2 patients), transaminase elevation (4 patients), and altered mentation (1 patient). The mean post-infusion aPTT was significantly higher than the pre-infusion value [14.8 seconds; p<0.001]; however, there were no hemorrhagic episodes.

CONCLUSIONS

The recommended dose for further development of the combination of docetaxel and GEM231 is 75 mg/m2 and 220 mg/m2, respectively. It is important to administer GEM231 twice weekly for 2 consecutive weeks followed by a one-week break.

A phase II trial of the mTOR inhibitor AP23573 as a single agent in advanced endometrial cancer

5516

Background: There are few effective therapies for women with advanced or recurrent endometrial cancer. Targeted therapies such as AP23573, a novel mTOR inhibitor, may result in clinical benefit with fewer side effects. Preliminary results of a trial of single agent AP23573 in patients with progressive endometrial cancer who may have had up to 2 prior regimens of cytotoxic chemotherapy are reported. Methods: The trial is an open-label, Simon 2-stage, single-arm study enrolling patients who have advanced endometrial cancer with documented progression in the 3 months prior to entry. Patients receive 12.5mg AP23573 QDx5 as a 30-min. intravenous infusion every other week for 28-day cycles. The primary efficacy endpoint is Clinical Benefit Response (CBR), defined as a complete or partial response or prolonged stable disease (= 16 weeks) by modified RECIST guidelines. Results: Seven of the first 19 patients achieved CBR, allowing expansion to the second stage. Enrollment is now complete (45 patients). Demographic data are available for 35 (median 66 yrs.; range 46–89) patients who received treatment: 23 adenocarcinomas, 5 carcinosarcomas, 6 papillary serous carcinomas (UPSC) and 1 clear cell carcinoma. Thirty-four patients had prior chemotherapy including doxorubicin, taxanes or platinum agents. Fourteen of the 26 patients with available history had prior pelvic radiotherapy. Nine of 27 (33%) patients evaluable for response had CBRs, including 2 partial responses (PRs). One CBR had UPSC, the remaining patients, including the PRs, had adenocarcinomas. Seven of the patients achieving CBR are still on treatment. Eighteen of the 27 patients discontinued treatment before 4 cycles because of progressive disease (14), consent withdrawal (1) or unrelated adverse events (3). Adverse event data are available for 27 patients. The most common adverse events are fatigue, anemia (33% each), mouth sores and nausea/vomiting (30% each). There have been 16 grade 3/ 4 treatment related adverse events (2 hyperglycemia, 14 separate events similar to those reported in other AP23573 trials). Conclusions: AP23573 shows encouraging single-agent activity in pretreated patients with advanced, progressive endometrial cancer and is well tolerated.

No significant financial relationships to disclose.

Pharmacodynamic and safety study of reolysin in patients with advanced solid tumors

14004

Background: Reolysin is an intravenous formulation of reovirus serotype 3 - Dearing strain which is a double stranded RNA non-enveloped icosahedral virus capable of inducing cytopathic effects in cancer cells that have an activating mutation in the ras protooncogene. Pre clinical testing has identified cancer cell lines as being susceptible to reovirus infection. Methods: This was an open- label single center phase I safety and dose escalation trial of reolysin administered intravenously over 1 hour on day 0 in a 28 day cycle. Dose escalations were in half log increments. Serum for neutralizing antibody (NA) was drawn at baseline, and days (d) 1, 7, 14, 21, and 28, and serum, stool, saliva, and urine for viral shedding (by RT-PCR) were sampled on d 1,7,14,21, and 28. Response was assessed by imaging studies after 1, 3, 5, and 7 cycles. Results: 18 patients (pt); median age 57 (40–72) years; performance status 0–1; diagnoses - ovarian (6), colorectal (5), and others (7) received 27 cycles of reolysin (median 1, range 1–7) in 6 dose cohorts of 1x108, 3x108, 1x109, 3x109, 1x1010, and 3x1010 tissue culture infective dose (TCID)50. No protocol defined dose limiting toxicities were observed. Drug related grade 2 toxicities included chills (2 pt), and fatigue (3 pt). The only grade 3 event was fever in cycle 7 in a 57 year old woman with progressive breast cancer, treated at a dose of 1x1010 TCID50. She was noted to have 28.5% shrinkage in objective tumor volume. An additional 7 pt had stable disease (SD). No NA was detectable in the serum in any pt at baseline; however all pt developed NA (on d 5 in 5 pt, d 8 in 11 pt, d 14 in 1 pt, and d 28 in 1 pt) during the course of the study. Viral shedding was observed in serum - 5 pt, stool - 3 pt, saliva - 3 pt, and urine - 4 pt. Of interest, 4 of 5 pt with viral shedding had SD as their best response. However, there was no observed relationship between NA formation and SD. Conclusion: Reolysin administered as a one hour infusion on a monthly schedule is safe and well-tolerated even in multiple doses. This preliminary data suggests there is anti-tumor activity of reolysin as a single agent, and warrants further studies either alone or in combination with cytotoxic chemotherapy.

[Table: see text]

Pharmacokinetic and safety study of weekly irinotecan and oral capecitabine in patients with advanced solid cancers

BACKGROUND

Capecitabine and irinotecan have demonstrated in vitro synergistic anti-cancer activity, and both are substrates for carboxyl esterases (CES). We conducted a study to identify a safe dose and potential drug-drug interactions of this combination.

METHODS

This was an open-label phase I dose escalation trial. Irinotecan was given as a 30 min infusion on days 1 and 8, and capecitabine on days 1-14 of a 21-day cycle. Plasma for pharmacokinetic analyses was drawn on days 1 and 8.

RESULTS

Forty-seven patients with advanced solid tumors received 202 cycles of chemotherapy in 6 dose cohorts. At the highest dose tested, 1 of 3 patients developed fatal neutropenia and gram-negative sepsis. At dose level 5 (100/2000), 2 of 28 patients developed cycle 1 DLT-grade 3 diarrhea/vomiting, and grade 3 diarrhea. Responses were observed in 9 of 35 (5 of 9 ovarian cancer) evaluable patients. The AUC((0-last)) of irinotecan, SN-38G, and APC were similar on days 1 and 8. However, SN-38 T(max) was longer on Day 8 (0.88 h vs. 1.23 h, p = 0.012). While SN-38 AUC((0-last)) was lower on day 8 by 35%, this was not statistically significant (p = 0.123).

CONCLUSIONS

Capecitabine results in a significantly delayed conversion of irinotecan to SN-38, suggesting drug-drug interaction at the level of CES. This suggests caution should be used when irinotecan is combined with substrates of CES, and warrants further study. The combination of irinotecan and capecitabine is safe and well tolerated at 100/2000, and warrants further evaluation in ovarian and breast cancer.

Pharmacokinetic (pk) and safety study of irinotecan (Ir) and capecitabine (Cp) administered on a weekly schedule

2061

Background: In vitro studies show synergy between Cp and Ir. Since both drugs are metabolized by carboxyl esterases (CE), the potential for competitive inhibition is possible. We conducted a study to identify a safe dose and potential drug-drug interactions of this combination. Methods: This was an open-label phase I dose escalation trial. Ir was given as a 30 min infusion on days 1 and 8, and Cp on days 1–14 of a 21 day cycle. Plasma for pk analyses was drawn on days 1 and 8, at 0, 15, 30, 45, 60, 90, 120, 240, 360 min, and 24 hr, for total CPT-11, SN-38, SN-38-glucuronide (G), and APC. Results: 47 patients (pt) - median age 60 (32–83) years; performance status 0–1 (96%); diagnoses- ovarian (10), breast (5), cervical (5), colorectal (10) and others (17) received 202 (median 4, range 1–18) cycles in 6 dose cohorts - Ir (mg/m2)/Cp (mg/m2/day in 2 divided doses) 75/1500, 85/1500, 85/1750, 100/1750, 100/2000, 115/2000. At the highest dose tested (115/2000), 1 of 3 pt developed grade (G) 4 neutropenia with fatal gram-negative sepsis. At dose level 5 (100/2000), 2 of 21 patients developed cycle 1 DLT - G 3 diarrhea/vomiting and G 3 diarrhea. Across all doses and patients, the G 3–4 toxicities observed were diarrhea (12 pt), vomiting (2 pt), fatigue (5 pt), hand-foot syndrome (1 pt), neutropenia (6 pt), anemia (4 pt), thrombocytopenia (2 pt) and elevation of AST/ALT (1 pt). Anti-tumor responses include partial response in 8 of 35 evaluable (23%) pts (3 breast, 4 ovarian, 1 cervical), a minimal response (1 breast), and a 90% decline in PSA (1 pt). Detailed pk analyses show that AUC(0-∞) of Ir, SN-38G, and APC were similar on days 1 and 8. However, SN-38 Tmax was longer on Day 8 (0.87 hr vs. 1.22 hr, p = 0.012). While SN-38 AUC (0-∞) was higher on day 1 by 45%, this was not statistically significant (p = 0.167). Conclusions: Cp results in a delayed conversion of Ir to SN-38, suggesting competitive inhibition of CE at a molecular level without clinical significance. This could portend a drug-drug interaction when Ir is combined with substrates of CE, and warrants further study. The combination of Ir and Cp is safe and well tolerated at 100/2000, and warrants further evaluation in breast, cervical, ovarian and other malignancies.

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Recurrent small cell lung cancer presenting as bilateral adnexal masses

BACKGROUND

Small cell lung cancer (SCLC) carries a very poor prognosis, although recent advances in chemotherapy have produced some long-term survivors. Despite this, recurrences are common, and these patients require a high level of surveillance. Given that the female gender is a favorable prognostic factor in patients with SCLC and that more women are becoming lung cancer survivors, it is important to consider sites of metastasis that are restricted to women.

CASE

This is a presentation of a 42-year old previously diagnosed with SCLC who presented with an isolated recurrence of SCLC in the ovaries. This is a case report of an isolated recurrence of SCLC in the ovaries with a review of the literature.

CONCLUSION

Although systemic relapses and recurrences often occur in these patients, isolated metastasis such as this can occur and should be considered in female patients with a history of small cell lung cancer.

Two on-farm data collection methods to determine dynamics of swine compositional growth and estimates of dietary lysine requirements

An experiment was conducted to evaluate the use of two real-time ultrasound data-collection methods to develop a dynamic assessment of live weight growth, protein and lipid accretions, and lysine requirement curves on two commercial swine operations. For the first method, pigs (40 barrows and 40 gilts) were weighed (ranging from 18 to 121 kg) and scanned ultrasonically to collect backfat depth and longissimus muscle area measurements every 3 wk in the finishing facility on two farms (serial method). For the second method, pigs (200 gilts and 200 barrows) of similar corresponding ages on the same two farms were weighed and scanned on 1 d (mass scan) at three different times (February, April, and May). Thirty-two pigs/sex were measured at approximately the same ages as with the serial scans. Pigs on farm 1 grew faster and had smaller backfat depths and larger longissimus muscle areas (P < 0.01) than those on farm 2, irrespective of method. These measurements were used to predict empty-body protein and lipid contents using nonlinear functions, which then were converted to accretion rates and lysine requirements at each BW. Protein accretion (g/d) and daily lysine requirements increased and then decreased for each sex on each farm and were higher on farm 1 than on farm 2. Data from the individual mass scans had larger standard errors for modeled live weight growth than data from the serial scans. Combining data from the three mass scans yielded growth curves with standard errors similar to those for the curves from the serial scans. For the protein accretion curves, the standard errors of the combined mass scans were approximately 20% lower than the standard errors of the serial scans. The standard errors for the modeled lysine:calorie ratio requirement from the serial scans were approximately 1% of the requirement at each BW. These results indicated that either the serial or mass scan data-collection method is a practical means of determining on-farm growth and daily protein and lipid accretion rates, which can be used to determine the farm-specific lysine requirements of growing-finishing pigs.

Partial restoration of lutropin activity by an intersubunit disulfide bond: implications for structure/function studies

Gonadal function is controlled by lutropins and follitropins, heterodimeric cystine knot proteins that have nearly identical alpha-subunits. These heterodimeric proteins are stabilized by a portion of the hormone-specific beta-subunit termed the "seatbelt" that is wrapped around alpha-subunit loop 2 (alpha 2). Here we show that replacing human chorionic gonadotropin (hCG) alpha 2 residue Lys51 with cysteine or alanine nearly abolished its lutropin activity, an observation that implies that alpha Lys51 has a key role in hormone activity. The activity of the heterodimer containing alpha K51C, but not that containing alpha K51A, was increased substantially when beta-subunit seatbelt residue beta Asp99 was converted to cysteine. As had been reported by others, heterodimers containing alpha K51C and beta D99C were crosslinked by a disulfide. The finding that an intersubunit disulfide restored some of the activity lost by replacing alpha Lys51 suggests that this residue is not crucial for receptor binding or signaling and also that hCG and related hormones may be particularly sensitive to mutations that alter interactions between their subunits. We propose the unique structures of hCG and related family members may permit some subunit movement in the heterodimer, making it difficult to deduce key residues involved in receptor contacts simply by correlating the activities of hormone analogs with their amino acid sequences.

Immunohistochemical localization of types 1 and 2 5alpha-reductase in human scalp

The predominant form of 5alpha-reductase (5aR) in human scalp is 5aR1. None the less, clinical studies have shown that finasteride, a selective inhibitor of 5aR2, decreases scalp dihydrotestosterone and promotes hair growth in men with androgenetic alopecia. Immunolocalization studies were thus carried out to examine 5aR isozyme distribution within scalp and, in particular, to determine whether 5aR2 might be associated with hair follicles. 5aR2 was localized using both a rabbit polyclonal and a mouse monoclonal antibody. 5aR1 was detected with a mouse monoclonal antibody. The specificity of these reagents was demonstrated both by immunofluorescence and Western blot analyses of COS cells overexpressing human 5aR1 or 5aR2. When cryosections of scalp from men with androgenetic alopecia were stained with antibody against 5aR2, using immunoperoxidase avidin-biotin complex methodology, immunostaining was observed in the inner layer of the outer root sheath and, in more proximal regions of the follicle, in the inner root sheath. Staining was also prominent in the infundibular region of the follicle, with less intense staining extending throughout the granular layer of the epidermis. Some staining was also seen in sebaceous ducts. Similar results were obtained with both the polyclonal and monoclonal 5aR2 antibodies. In contrast, in scalp cryosections stained with antibody to 5aR1, no immunostaining was observed within hair follicles. Intense staining for the type 1 isozyme was, however, detected within sebaceous glands. Our immunolocalization data suggest that the results seen in clinical trials of men with male pattern hair loss treated with finasteride may be due, at least in part, to local inhibition of 5aR2 within the hair follicle.

Modern treatments of menorrhagia attributable to dysfunctional uterine bleeding

Menorrhagia (excessive uterine bleeding) affects some 20 percent of the women of reproductive age worldwide. The following review describes known and theorized etiologies of the disorder, followed by a discussion of treatment options that are currently in use as well as those on the horizon. There is much interest internationally in decreasing hysterectomy rates, particularly for those women with abnormal bleeding and anatomically normal uteri. It is these women who are the focus of this paper. Pharmacotherapy and surgery are the mainstay treatments for such patients with menorrhagia secondary to dysfunctional uterine bleeding. Most commonly, hormonal and nonhormonal medications are followed by dilatation and curettage, and ultimately, in many cases, hysterectomy. Endometrial ablation techniques have been evolving since the 1980s in response to the need for an efficacious, safer, and more cost-effective alternatives to hysterectomy. Hysteroscopic ablation achieves these goals but is difficult technically and requires significant additional training even for otherwise skilled and experienced gynecologists. The current decade has seen the development of many innovative approaches to performing endometrial ablation. These methods are intended to be much simpler to perform with less risk than electrosurgical or laser endometrial ablation. The final section of this article presents the published data to date on these new technologies, which should (in their refined state) revolutionize the treatment of menorrhagia secondary to dysfunctional uterine bleeding.

Symmetrical periumbilical extension of a midline incision: a simple technique

BACKGROUND

Periumbilical extension of midline incision often results in an irregular, unaesthetic scar with beveled edges.

TECHNIQUE

An Allis clamp is placed at the lateral margin of the umbilicus with subsequent medial traction. This straightens the proposed periumbilical incision, resulting in a symmetrical scar.

EXPERIENCE

We have used this technique extensively over the past several years with excellent results and no adverse sequelae.

CONCLUSION

This simple technique results in the symmetrically curvilinear, nonbeveled periumbilical extension of a midline incision.

Comparison of litter adjustment factors in Yorkshire and Landrace data

National Swine Improvement Federation (NSIF) adjustment factors presently used to standardize litter data for age at 21 d, number born alive (NBA), 21-d litter weight, and number after transfer (NAT) were evaluated using 104,884 litters in 1,348 Yorkshire herds and 20,370 litters in 197 Landrace herds. In addition, adjustment factors for number weaned were calculated for standardization of this trait. Number weaned is adjusted for parity and NAT. The mixed-model least squares, maximum likelihood computer program described by Harvey was used in the analyses. Yorkshire and Landrace data were combined to test for breed effects and interactions involving breed. Breed interactions were different (P < .05). Therefore, breed-specific adjustment factors were calculated for Yorkshire and Landrace data sets. Also, adjustment factors were calculated for combined data that might be appropriate to use for breeds without specific adjustments available. Parity adjustment factors for NBA and 21-d litter weight were different (P < .05) from current NSIF recommendations, as was the NAT adjustment for 21-d litter weight. The age-at-weaning multiplicative factors were not different (P > .05) from current NSIF values. However, in all three data sets, the intercepts and linear coefficients of the quadratic regression for age at weaning were different (P < .05) from NSIF's. A Student-Newman-Keuls (SNK) test was used to evaluate the NSIF groupings of parity and number after transfer.(ABSTRACT TRUNCATED AT 250 WORDS)

Expression cloning and characterization of human 17 beta-hydroxysteroid dehydrogenase type 2, a microsomal enzyme possessing 20 alpha-hydroxysteroid dehydrogenase activity

17 beta-Hydroxysteroid dehydrogenase (17 beta-HSD) is an enzyme crucial to the regulation of intracellular levels of biologically active steroid hormones in a variety of tissues. Here, we report the isolation, structure, and characterization of a cDNA encoding the human 17 beta-HSD type 2. A 1.4-kilobase cDNA was identified, and DNA sequence analysis indicated that 17 beta-HSD type 2 was a protein of 387 amino acids with a predicted molecular weight of 42,782. The protein contained an amino-terminal type II signal-anchor motif and a carboxyl-terminal endoplasmic reticulum retention motif, which suggested that 17 beta-HSD type 2 was associated with the membranes of the endoplasmic reticulum. 17 beta-HSD type 2 was capable of catalyzing the interconversion of testosterone and androstenedione as well as estradiol and estrone. The enzyme also demonstrated 20 alpha-HSD activity toward 20 alpha-dihydroprogesterone. The amount of 17 beta-HSD type 2 mRNA in placenta was found to be high. The data suggest that the 17 beta-HSD type 2 cDNA encodes the microsomal 17 beta-HSD of human placenta, described by several laboratories.

Blood chemistry of current and previous anabolic steroid users

While the use of anabolic-androgenic steroids appears to be increasing, little is known about the long-term effects of these drugs. This study compared selected blood profiles of current and former steroid-using athletes to expected values for non-drug-using populations. The results are consistent with previous research findings that steroids can have acute negative effects on liver function, lipoprotein fractions, and testosterone production. The results suggest that side effects vary widely among individuals and are drug and dose dependent. Normal function appears to return after drug use is discontinued. These data emphasize the difficulty physicians have interpreting clinical tests when dealing with those who use or have used anabolic steroids. Clearly more research is needed regarding the effects of these drugs.

Presence of antibodies to the major surface glycoprotein of Trypanosoma cruzi amastigotes in sera from Chagasic patients

The surface of amastigote forms of Trypanosoma cruzi is covered by a stage-specific glycoprotein, Ssp-4. We show that Y strain-derived Ssp-4 is recognized by antibodies in sera from Chagasic patients. All 51 sera reacted with the surface of amastigotes by indirect immunofluorescence assays and immunoprecipitated Ssp-4. The human antibodies inhibited the binding of monoclonal antibodies to Ssp-4 in immunoradiometric assays, suggesting that the corresponding region of the molecule may be conserved among distinct strains of the parasite.