Gender differences in comorbidities of patients with COVID-19: An Italian local register-based analysis

In the current COVID-19 pandemic scenario, it is still necessary to understand if differences exist between genders in terms of patients' characteristics and clinical outcomes. For this reason, we retrospectively analyzed data obtained from a local register-based dataset of all SARS-CoV-2 positive patients diagnosed in the province of Catania (Italy). The main aim of this analysis was to understand any differences between genders in the distribution of previous medical conditions, and to evaluate which of them posed individuals at higher risk of death. With this purpose, we analyzed data from 1424 patients with at least one underlying medical condition, who were tested positive for SARS-CoV-2 infection from February 2020 to December 2021. Overall, males were 59.5% of the total population and significantly younger than females (median ages: 68 years vs. 72 years; p = 0.011). The age distribution of cases by gender confirms that individuals from 70 to 79 years were the most affected in both genders. The comparison of underlying comorbidities by gender shows significant differences for diabetes (p < 0.001), other metabolic diseases (p = 0.006), and obesity (p = 0.019). Accordingly, multivariable logistic regression analysis confirmed that diabetes was more likely to be present in males than in females (p = 0.001), while other metabolic diseases and obesity were less likely to be present (p = 0.003 and p = 0.005, respectively). Although no difference in mortality was evident between genders (p = 0.141), both male and female COVID-19 patients had a significantly higher risk of death if they had comorbidities such as CVDs, kidney diseases, or chronic neurological diseases. Moreover, diabetes and chronic respiratory diseases were significant risk factors for COVID-19 mortality among men, whereas cancer was a significant contributor among women. Our findings confirm gender-differences in pre-existing medical conditions of COVID-19 patients, which may influence the risk of death. Further studies, however, are needed to understand physiological and pathological mechanisms underpinning these differences.

[The importance of promoting adolescent mental health in schools.]

During adolescence, the summation of the "physiological" crisis to stressful or excessive demands from the environment can represent a source of significant discomfort and difficulties for the person. For mental health operators, and not only, it is always important to know how to distinguish, in the complexity that adolescence entails, the "typical" adolescence behaviours from risky behaviours or incipient signs of a mental disorder. Psychological distress can most frequently result when, together with difficulties in completing developmental tasks, individual vulnerabilities add up to inadequacy of an environmental system. To date, scientific evidence shows an earlier onset of many mental illnesses in the last decades. This explains the need and the usefulness of implementing interventions for promotion and prevention of mental health in this specific age group. The school, where teenagers spend most of their time, is the best place where provide information, skills and strategies to implement mental and physical well-being, resilience factors and identify fragilities. This article aims to make a survey of mental health promotion interventions carried out in schools nationally and internationally.

A Phase I study of the safety, pharmacokinetics and efficacy of navitoclax plus docetaxel in patients with advanced solid tumors

Aim: This Phase I study investigated safety of navitoclax and docetaxel in patients (n = 41) with advanced solid tumors. Patients & methods: Two navitoclax plus docetaxel dosing schedules (21 and 28 days) were evaluated. Maximum tolerated dose, dose-limiting toxicities and preliminary antitumor activity were assessed. Results: Ten (24%) patients experienced dose-limiting toxicities; dose-escalation cohorts: n = 7 (21-day schedule: n = 5; 28-day schedule: n = 2) and 21-day expanded safety cohort: n = 3. Navitoclax 150-mg days 1-5 every 21 days with docetaxel 75 mg/m² day 1 was the maximum tolerated dose and optimal schedule. Adverse events included thrombocytopenia (63%), fatigue (61%), nausea (59%) and neutropenia (51%). Four confirmed partial responses occurred. Conclusion: Navitoclax 150-mg orally once/day was safely administered with docetaxel. Myelosuppression limited dose escalation; antitumor activity was observed. Clinical trial registration: NCT00888108 (ClinicalTrials.gov).

ENGOT-cx11/KEYNOTE-A18: A phase III, randomized, double-blind study of pembrolizumab with chemoradiotherapy in patients with high-risk locally advanced cervical cancer

TPS6096

Background: High-risk locally advanced cervical cancer has a poor prognosis, and more than half of patients recur in 2 y. External beam radiotherapy (EBRT) with concurrent chemotherapy followed by brachytherapy is the standard of care for locally advanced cervical cancer. The immunostimulatory activity of the PD-1 inhibitor pembrolizumab (pembro) may be enhanced by concurrent chemoradiotherapy (CRT). After the KEYNOTE-158 study, in which pembro showed durable antitumor activity, pembro monotherapy was approved for patients with PD-L1–positive recurrent or metastatic cervical cancer who progressed during or after chemotherapy. ENGOT-cx11/KEYNOTE-A18 (NCT04221945) is a phase III, randomized, placebo-controlled study evaluating pembro with concurrent CRT for the treatment of locally advanced cervical cancer. Methods: Approximately 980 patients with high-risk (FIGO 2014 stage IB2-IIB with node-positive disease or stage III-IVA), locally advanced, histologically confirmed cervical cancer who have not received systemic therapy, immunotherapy, definitive surgery, or radiation will be randomized 1:1 to receive either 5 cycles of pembro 200 mg every 3 wk (Q3W) + CRT followed by 15 cycles of pembro 400 mg Q6W or 5 cycles of placebo Q3W + CRT followed by 15 cycles of placebo Q6W. The CRT regimen includes 5 cycles (with optional 6th dose) of cisplatin 40 mg/m2 Q1W + EBRT followed by brachytherapy. Randomization is stratified by planned EBRT type (intensity-modulated radiotherapy [IMRT] or volumetric-modulated arc therapy [VMAT] vs non-IMRT or non-VMAT), cancer stage at screening (stage IB2-IIB vs III-IVA), and planned total radiotherapy dose. Treatment will continue until the patient has received 20 cycles of pembro (5 cycles 200 mg Q3W, 15 cycles 400 mg Q6W) vs placebo (~2 y) or until disease progression, unacceptable toxicity, or withdrawal. Primary endpoints are PFS per RECIST v1.1 by blinded independent central review and OS. Secondary endpoints are PFS at 2 y, OS at 3 y, complete response at 12 wk, ORR, PFS and OS in PD-L1–positive patients, EORTC QLQ-C30 and QLQ-CX24, and safety. Enrollment is ongoing. Clinical trial information: NCT04221945.

ENGOT-OV43/KEYLYNK-001: A phase III, randomized, double-blind, active- and placebo-controlled study of pembrolizumab plus chemotherapy with olaparib maintenance for first-line treatment of BRCA-nonmutated advanced epithelial ovarian cancer

TPS5603

Background: There is a significant unmet need to develop new regimens for BRCA1/2-nonmutated advanced ovarian cancer (OC). The PARP inhibitor olaparib is approved for women with platinum-sensitive, recurrent OC regardless of BRCA1/2 status and, more recently, for newly diagnosed women with BRCA-mutated OC. In the TOPACIO/KEYNOTE-162 study, the combination of the PD-1–blocking antibody pembrolizumab (pembro) and niraparib demonstrated efficacy in platinum-resistant relapsed OCirrespective of BRCA1/2 status. ENGOT-OV43/KEYLYNK-001 (ClinicalTrials.gov, NCT03740165) is a phase 3, randomized, double-blind, active- and placebo-controlled study of pembro plus paclitaxel-carboplatin chemotherapy (CT) followed by olaparib maintenance for first-line treatment of patients with BRCA1/2-nonmutated advanced epithelial OC (EOC). Methods: Patients with stage III or IV BRCA-nonmutated EOC, primary peritoneal cancer, or fallopian tube cancer will be stratified by surgery status (no residual tumor after primary debulking surgery [PDS], residual tumor after PDS, or planned interval debulking), bevacizumab use, and PD-L1 status (combined positive score < 10 or ≥10). After one lead-in cycle of CT, patients will be randomized 1:1:1 to receive: CT + pembro followed by olaparib maintenance; CT + pembro followed by placebo; or CT + placebo followed by placebo. The CT regimen will be administered for 5 cycles, and pembro 200 mg Q3W will be administered for 35 infusions. Olaparib 300 mg BID maintenance therapy will start after the end of CT as concomitant treatment with pembro until discontinuation or for 2 years if the patient has a complete response. Bevacizumab use is permitted at investigator’s discretion and determined prerandomization. Primary endpoints are investigator-assessed progression-free survival (PFS) per RECIST 1.1 criteria and overall survival. Key secondary endpoints are PFS per RECIST 1.1 assessed by blinded independent central review, PFS after next-line treatment, and safety. Enrollment is currently ongoing. Clinical trial information: NCT03740165.

A study of motivations and expectations of patients seen in phase 1 oncology clinics

BACKGROUND

To better inform clinical practice, this study was aimed at capturing patients' motivations for enrolling in phase 1 trials and at quantifying their expectations of the benefits, risks, and commitment associated with clinical trials and the impact of the initial consultation on their expectations.

METHODS

This was a single-center, prospective, quantitative study of newly referred adult patients considering their first phase 1 oncology trial. Participants completed questionnaires before they were seen and an abbreviated follow-up version after their consultation.

RESULTS

Questionnaires were completed by 396 (99%) and 301 (76%) before and after the clinic, respectively. Participants ranked the possibility of tumor shrinkage (84%) as the most important motivation for considering a phase 1 trial; this was followed by no alternative treatments (56%), their physician's recommendation (44%), and the fact that the research might benefit others (38%). When they were asked about the potential personal benefit, 43% predicted tumor shrinkage initially. After the consultation, this increased to 47%. Fourteen percent of patients expected a cure. When asked about risks, 71% of the participants expected moderate side effects. When asked about expectations of time commitments, a majority of patients did not anticipate weekly visits, although this was understood by 93% of patients after the consultation. Overall, patients were keen to consider trials and when asked before and after the consultation 72% and 84% were willing to enroll in studies, respectively.

CONCLUSIONS

This study reports that more than 80% of patients enroll in early-phase clinical oncology trials motivated by the potential of a clinical benefit, with approximately half expecting tumor shrinkage and approximately a tenth anticipating a cure. The typical phase 1 response rate is 4% to 20%, and this discrepancy exemplifies the challenges faced by patients and healthcare professionals during their interactions for phase 1 studies. Cancer 2016;122:3501-3508. © 2016 American Cancer Society.

Characterisation of the Phosphatidylinositol 3-Kinase Pathway in Non-Small Cell Lung Cancer Cells Isolated from Pleural Effusions

OBJECTIVES

We hypothesised that it was possible to quantify phosphorylation of important nodes in the phosphatidylinositol 3-kinase (PI3K) pathway in cancer cells isolated from pleural effusions of patients with non-small cell lung cancer (NSCLC) and study their correlation to somatic mutations and clinical outcomes.

MATERIALS AND METHODS

Cells were immunomagnetically separated from samples of pleural effusion in patients with NSCLC. p-AKT, p-S6K and p-GSK3β levels were quantified by ELISA; targeted next-generation sequencing was used to characterise mutations in 26 genes.

RESULTS

It was possible to quantify phosphoproteins in cells isolated from 38/43 pleural effusions. There was a significant correlation between p-AKT and p-S6K levels [r = 0.85 (95% confidence interval 0.73-0.92), p < 0.0001], but not p-AKT and p-GSK3β levels [r = 0.19 (95% confidence interval -0.16 to 0.5), p = 0.3]. A wide range of mutations was described and p-S6K was higher in samples that harboured at least one mutation compared to those that did not (p = 0.03). On multivariate analysis, p-S6K levels were significantly associated with poor survival (p < 0.01).

CONCLUSION

Our study has shown a correlation between p-AKT levels and p-S6K, but not GSK3β, suggesting differences in regulation of the distal PI3K pathway by AKT. Higher p-S6K levels were associated with adverse survival, making it a critically important target in NSCLC.

First-in-Human Pharmacokinetic and Pharmacodynamic Study of the Dual m-TORC 1/2 Inhibitor AZD2014

PURPOSE

AZD2014 is a novel, oral, m-TORC 1/2 inhibitor that has shown in vitro and in vivo efficacy across a range of preclinical human cancer models.

EXPERIMENTAL DESIGN

A rolling six-dose escalation was performed to define an MTD (part A), and at MTD a further cohort of patients was treated to further characterize toxicities and perform pre- and posttreatment biopsies (part B). AZD2014 was administered orally twice a day continuously. Flow cytometry, ELISA, and immunohistochemistry were used to quantify pharmacodynamic biomarkers. Pharmacokinetic analysis was carried out by mass spectrometry.

RESULTS

A total of 56 patients were treated across a dose range of 25 to 100 mg. The MTD was 50 mg twice daily. The dose-limiting toxicities were fatigue and mucositis. At the MTD, the most common adverse events (AE) were fatigue (78%), nausea (51%), and mucositis (49%), but these were equal to or greater than grade 3 in only 5% of patients. Drug levels achieved at the MTD (AUC SS: 6686 ng·h/mL, Cmax ss 1,664 ng/mL) were consistent with activity in preclinical models. A reduction in p-S6 levels and Ki67 staining was observed in 8 of 8 and 5 of 9 evaluable paired biopsy samples. Partial responses were seen in a patient with pancreatic cancer and a patient with breast cancer, who were found to have a PDGFR and ERBB2 mutation, respectively.

CONCLUSIONS

The recommended phase II dose for further evaluation of AZD2014 is 50 mg twice daily, and at this dose it has been possible to demonstrate pharmacologically relevant plasma concentrations, target inhibition in tumor, and clinical responses.

An unblinded, randomised phase II study of platinum-based chemotherapy with vitamin B12 and folic acid supplementation in the treatment of lung cancer with plasma homocysteine blood levels as a biomarker of severe neutropenic toxicity

Background

Vitamin B₁₂ and folic acid (referred to as vitamin supplementation) improves the toxicity profile of pemetrexed containing regimens. Low baseline vitamin B₁₂ and folate levels are reflected in a raised total homocysteine level (HC). Studies have suggested that pretreatment HC levels predict neutropenia toxicity. We have tested supplementation with vitamin B₁₂ and folate in non-pemetrexed platinum-based regimens to decrease treatment-related toxicity and looked for a correlation between toxicity and change in homocysteine levels.

Patient and method

Eighty-three patients with advanced lung cancer and malignant mesothelioma were randomly assigned to receive platinum-based chemotherapy with (arm A) or without (arm B) vitamin B₁₂ and folic acid supplementation. The primary end point was grade 3/4 neutropenia and death within 30 days of treatment. Secondary end points included quality of life, overall survival (OS) and the relationship between baseline and post supplementation HC levels and toxicity.

Results

In the intention-to-treat population, no significant difference was seen between the two groups with respect to chemotherapy-induced grade 3/4 neutropenia and death within 30 days of chemotherapy (36% vs 37%; p=0.966, emesis (2% vs 6%; p=0.9) or OS (12.3 months vs 7 months; p=0.41). There was no significant difference in survival rates by baseline HC level (p=0.9). Decrease in HC with vitamin supplementation was less frequent than expected. High baseline HC levels decreased with vitamin supplementation in only 9/36 (25%) patients (successful supplementation). Post hoc analysis showed that patients in arm A who were successfully supplemented (9/36=25%) had less neutropenic toxicity (0% vs 69%; p=0.02) compared to unsupplemented patients.

Conclusions

The addition of vitamin B₁₂ and folic acid to platinum-containing regimens did not overall improve the toxicity, quality of life or OS. Rates of grade 3/4 neutropenia at 36/37% was as predicted. Further studies to increase the rate of successful supplementation and to further test the biomarker potential of post supplementation HC levels in predicting chemotherapy-induced neutropenia in platinum-based chemotherapy are warranted.

Trial registration number:

EudracCT 2005-002736-10 ISRCTN8734355.

AKT inhibition synergistically enhances growth-inhibitory effects of gefitinib and increases apoptosis in non-small cell lung cancer cell lines

OBJECTIVES

EGFR inhibitors are ineffective against most EGFR wild-type non-small cell lung cancer, for which novel treatment strategies are needed. AKT signalling is essential for mediating EGFR survival signals in NSCLC. We evaluated the combination of gefitinib and two different AKT inhibitors, the allosteric inhibitor AKTi-1/2 and the ATP-competitive pan-AKT inhibitor AZD5363, in EGFR-mutant (HCC-827 and PC-9) and -wild-type (NCI-H522, NCI-H1651), non-small cell lung cancer cell lines.

MATERIALS AND METHODS

Drug interaction was studied in two EGFR mutant and two EGFR wild-type non-small cell lung cancer cell lines by calculating combination index (CI) using median effect analysis. The effects on p-EGFR, p-ERK, p-AKT, p-S6 and apoptosis were studied by Western blot analysis.

RESULTS

The combination of gefitinib and AKTi-1/2 or AZD5363 showed synergistic growth inhibition in all cell lines. CI values for the combination of gefitinib and AKTi-1/2 were 0.35 (p=0.0048), 0.56 (p=0.036), 0.75 (p=0.13) and 0.64 (p=0.0003) in NCI-H522, NCI-H1651, HCC-827 and PC-9 cell lines, respectively; CI values of 0.45 (p=0.0087) and 0.22 (p<0.0001) were observed in NCI-H522 and PC-9 cells, respectively, when gefitinib was combined with AZD5363. Additive inhibition of signalling output through AKT and key downstream proteins (S6) and increased apoptosis were demonstrated.

CONCLUSION

Dual inhibition of EGFR and AKT may be a useful up-front strategy for patients with EGFR-mutant and -wild-type non-small cell lung cancer.

Abstract 2441: Evaluation of combination of an EGFR and AKT inhibitor in EGFR mutant and EGFR wild type non-small cell lung cancer cells lines

Background: Epidermal growth factor receptor (EGFR) inhibition with tyrosine kinase inhibitors (TKIs) has proven successful in the management of patients with non small cell lung cancer (NSCLC). However, clinical benefit is predominantly limited to the subgroup of patients with an activating EGFR mutation (10%). Treating the remaining 90% of patients with wild type (wt) EGFR is an unmet clinical need. Aim: To evaluate the effect of an allosteric AKT inhibitor (AKTi 1/2) in combination with the EGFR inhibitor gefitinib on cell proliferation, apoptosis and signalling output in EGFR mutant/wt NSCLC cell lines. Methods: Four NSCLC cell lines were selected: NCI-H522 and NCI-H1651 (EGFR wt and K-RAS wt), PC9 and HCC827 (EGFR mutant). The 96hr sulphorhodamine assays was used to assess the effect of gefitinib and AKTi 1/2 on growth inhibition, and median effect analysis to calculate combination indices (CIs) to assess the effect of both drugs in combination. The expression of p-EGFR, p-AKT, p-S6, p-ERK and cleaved PARP were studied by Western blotting in the EGFR wt NCI-H522 and the EGFR mutant PC9 cell lines. Results: EGFR wt cell lines NCI-H522 and NCI-H1651 were relatively resistant to gefitinib (IC50 values of 7.0 ± 2.5 uM and 8.8 ± 0.9 uM, respectively) compared with the EGFR mutant cell lines PC9 and HCC827 (IC50 values of 0.07 ± 0.03 uM and 0.004 ± 0.0005 uM, respectively). The combination of gefitinib and AKTi 1/2 produced synergistic inhibition of growth in both EGFR wild type and mutant cell lines. Synergism was more marked in EGFR wt cell lines with CI values (ED50) of 0.53 ± 0.28 and 0.49 ± 0.17 for NCI-H522 and NCI-H1651 respectively, compared with 0.74 ± 0.11 and 0.76 ± 0.14 for the EGFR mutant cell lines PC9 and HCC827, respectively. Concomitant exposure of cells to gefitinib and AKTi 1/2 for 24 hrs caused incremental inhibition of p-AKT, p-S6 and p-ERK in both the EGFR wt (NCI-H522) and EGFR mutant (PC9) cell lines. Gefitinib alone resulted in partial inhibition of AKT phosphorylation in PC9 cells and up-regulation in NCI-H522 cells. Incremental induction of cleaved PARP, a marker of apoptosis, was seen in PC9 cells treated with the combination of gefitinib and AKTi 1/2. Conclusions: These results demonstrate synergistic growth inhibition of EGFR wt and mutant NSCLC cell lines by the combination of gefitinib with AKTi 1/2. Additional pre-clinical studies are investigating this further. Clinical studies of the combination doublet are warranted to expand the utility of EGFR TKI in EGFR wt NSCLC.

Citation Format: Martina Puglisi, Parames Thavasu, Adam Stewart, Jaishree Bhosle, Sanjay Popat, Mary E R O'Brien, Udai Banerji. Evaluation of combination of an EGFR and AKT inhibitor in EGFR mutant and EGFR wild type non-small cell lung cancer cells lines. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2441. doi:10.1158/1538-7445.AM2013-2441

Creatinine clearance is associated with toxicity from molecularly targeted agents in phase I trials

Objectives

This study aimed to evaluate any correlations between baseline creatinine clearance and the development of grade 3/4 toxicities during treatment within oncology phase I trials of molecularly targeted agents where entry criteria mandate a serum creatinine of ≤1.5 × the upper limit of normal.

Methods

Documented toxicity and creatinine clearance (calculated by the Cockcroft-Gault formula) from all patients treated with molecularly targeted agents in the context of phase I trials within our centre over a 5-year period were analyzed.

Results

Data from 722 patients were analyzed; 116 (16%) developed at least one episode of grade 3/4 toxicity. Patients who developed a late-onset (>1 cycle) grade 3/4 toxicity had a lower creatinine clearance than those who did not (82.69 ml/min vs. 98.97 ml/min; p = < 0.001).

Conclusion

Creatinine clearance (even when within normal limits) should be studied as a potential factor influencing late toxicities in the clinical trials of molecularly targeted anti-cancer drugs.

Defining the risk of toxicity in phase I oncology trials of novel molecularly targeted agents: a single centre experience

BACKGROUND

This study defined the risk of serious toxicity in phase I trials of molecularly targeted agents (MTA).

PATIENTS AND METHODS

A retrospective analysis of toxicity data from patients treated in phase I trials of MTAs was carried out to define the rate of treatment-related grade 3/4 toxic effects, deaths and risk factors associated with grade 3 or more toxicity.

RESULTS

Data from 687 patients [median age, 59.1 years (range 12.5-85.5)] treated in 36 trials were analysed. Two hundred and eleven patients were of Eastern Cooperative Oncology Group performance status (PS) zero, 432 of PS one, 38 of PS two and 6 unknown. The rate of grade 3 and 4 events was 14.1% (n=97) and 1.9% (n=13), respectively. Twenty-four percent of events were gastrointestinal, 22% constitutional and 20% metabolic. PS two was associated with a higher risk of toxicity [odds ratio (OR), 2.6; 95% confidence interval (CI) 1.1-6.1; P=0.032] as was receiving >100% of maximum tolerated dose or maximum administered dose (OR 2.5; CI 1.6-3.9; P<0.001). Mortality rate was 0.43% (n=3).

CONCLUSIONS

Therapy with novel MTAs in phase I trials is associated with a moderate risk of significant toxicity. This appears less than in phase I studies involving cytotoxic agents, particularly in relation to grade 4 toxicity. The risk of death is low.

First-in-human phase I trial of the dual mTORC1 and mTORC2 inhibitor AZD2014 in solid tumors

3004

Background: AZD2014 is a potent, dual mTORC1/mTORC2 inhibitor with clear activity in in vivo and in vitro experimental models. Methods: This 2-part study consisted of "rolling six" dose escalation (Part A) and expansion (Part B) phases. Part A: 3–6 pts per cohort received an oral solution of AZD2014 BD starting at 50 mg. A further 6 pts were treated in Part A below the MTD to study changes in pharmacodynamic (PD) biomarkers. Part B: additional pts were dosed at the MTD, including a group of ER+/PR+ or HER2+ patients with breast cancer. Primary endpoint: safety and tolerability; secondary endpoints: pharmacokinetics (PK), PD and efficacy. Biomarkers assessed: mTORC1: pS6 (S235/236) and p4EBP1 (T37/46); mTORC2: pAKT (S473). Results: 50 pts have been enroled in this ongoing study and interim data are reported: Part A, n=23 (25 mg, n=6; 50 mg, n=8; 70 mg, n=5; 100 mg, n=4; all BD); Part B, n=27. The MTD was 50 mg BD. DLTs were seen at both 100 mg (Gr 2 and 3 lethargy/fatigue, n=4/4) and 70 mg (Gr 3 mucositis, Gr 2 lethargy, n=2/4); no DLTs were seen at 25 mg or 50 mg. The most common AEs in order of incidence were fatigue, stomatitis, decreased appetite, nausea and diarrhea. Seven SAEs (nausea, vomiting, lethargy, abdominal pain, mucositis) reported by 3 pts were considered ‘possibly related’ to the study drug by investigators. AZD2014 is rapidly absorbed following single and BD multiple doses with a short t1/2 of ~3 h. At 50 mg (n=32), preliminary data show geometric mean AUCss=7.4 µg.h/ml and Cmax ss=1.7 µg/ml. One pt with acinar pancreatic cancer had a RECIST partial response. pAKT and p4EBP1 reductions were observed between 2–8 h in platelet-rich plasma and peripheral blood mononuclear cells respectively. Target modulation in paired tumor biopsies was seen at the MTD. Reduction in the phosphorylation of S6 and 4EBP1 was evident in 8/10 and 3/9 paired biopsies respectively. pAKT was reduced in 3/6 evaluable paired biopsies. As opposed to rapalogs, pAKT was not upregulated in any of the evaluable post-treatment biopsies. Conclusions: The MTD for AZD2014 is 50 mg BD. Further clinical evaluation of AZD2014 is now warranted based on the safety, PK and proof-of-mechanism PD data, as well as its preliminary clinical activity. Updated results will be presented.

Therapeutic uses of topotecan for thoracic malignancies

Topotecan, a topoisomerase 1 inhibitor (topo1-i), is a semi-synthetic derivative of camptothecan with wellestablished cytotoxic properties. It is licensed for the treatment of relapsed, sensitive small cell lung cancer (SCLC) and for second line treatment in ovarian cancer. Studies have also shown this drug to be an effective first line treatment for SCLC with either cisplatin or in combination with a topoisomerase 2 inhibitor (topo2-i), etoposide; both combinations have shown similar efficacy. Oral and parenteral formulations of topotecan have proven to be equivocal in relapsed SCLC patients. The parenteral form showed reduced rates of severe haematological toxicities and better symptom control than an anthracycline combination (CAV). In relapsed SCLC, a randomised phase III trial of oral topotecan versus best supportive care showed a statistically significant increase in overall survival. In the second line treatment of non-small cell lung cancer (NSCLC), oral topotecan was not inferior to the current standard iv docetaxel for 1 year survival rates. Worthwhile potential investigations include combining oral topotecan with other oral agents to design treatments for different lines of therapy. The new oral formulation of topotecan also lends itself to testing with small molecule tyrosine kinase inhibitors. The myelosuppressive toxicity profile needs to be vigorously monitored and managed. The trials with oral topotecan have also highlighted the need to reassess the utility of the terms ‘sensitive’ and ‘resistant’ in the selection of patients with relapsed small cell lung cancer.

A phase II study of ¹⁸F-fluorodeoxyglucose PET-CT in non-small cell lung cancer patients receiving erlotinib (Tarceva); objective and symptomatic responses at 6 and 12 weeks

BACKGROUND

The aim of this study was to assess if (18)F-fluorodeoxyglucose (FDG) Positron Emission Tomography (PET)-CT scanning could minimise the time non-responding patients were exposed to erlotinib (Tarceva).

METHODS

Patients were selected for clinical factors that would predict response to erlotinib. A FDG PET-CT and diagnostic contrast-enhanced (traditional) CT scan were carried out at baseline, and then a FDG PET-CT at 6 weeks and a traditional CT at 12 weeks were repeated. The primary end-point was rate of early progression in patients after 6 weeks, of which a minimum 12 out of 35 were required to make the study worthwhile. The responses at 6 (PET-CT) and 12 weeks (traditional CT) were compared and correlated with symptomatic response at both these time points.

RESULTS

Forty seven patients were recruited with 38 and 33 patients assessable by FDG PET-CT at 6 weeks and traditional CT at 12weeks, respectively. There was good correlation between Partial response (PR) at both time points and all 10 patients who had a PR at 12 weeks had a PR at 6 weeks. Of the 13 patients with progressive disease (PD) at 12 weeks, seven had PD at 6 weeks and could have had their treatment stopped early. No evaluable patient with stable disease (SD) (8/38) or PD (9/38) on FDG PET-CT at 6 weeks went on to have a later response. Symptomatic response at 6 or 12 weeks did not correlate well with objective response on scanning at either time point.

CONCLUSIONS

The primary end-point of this study was met as >12 (15/38) patients could have stopped treatment early on the basis of the FDG PET-CT scan result. A FDG PET-CT evaluable response of SD or PD at 6 weeks does predict future lack of response. No correlation was found between response and symptomatic response at either 6 or 12 weeks.

Randomized trial of two induction chemotherapy regimens in metastatic colorectal cancer: an updated analysis

BACKGROUND

In a randomized trial with a median follow-up of 18.4 months, 6 months of induction chemotherapy with a three-drug regimen comprising 5-fluorouracil (by continuous infusion)-leucovorin, irinotecan, and oxaliplatin (FOLFOXIRI) demonstrated statistically significant improvements in response rate, radical surgical resection of metastases, progression-free survival, and overall survival compared with 6 months of induction chemotherapy with fluorouracil-leucovorin and irinotecan (FOLFIRI).

METHODS

From November 14, 2001, to April 22, 2005, we enrolled 244 patients with metastatic colorectal cancer. To evaluate if the superiority of FOLFOXIRI is maintained in the long term, we updated the overall and progression-free survival data to include events that occurred up to February 12, 2009, with a median follow-up of 60.6 months. We performed a subgroup and a risk-stratified analysis to examine whether outcomes differed in specific patient subgroups, and we analyzed the results of treatment after progression. Survival curves were estimated by the Kaplan-Meier method. Multivariable Cox regression models were fit to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). All statistical tests were two-sided.

RESULTS

FOLFOXIRI demonstrated statistically significant improvements in median progression-free survival (9.8 vs 6.8 months, HR for progression = 0.59, 95% CI = 0.45 to 0.76, P < .001) and median overall survival (23.4 vs 16.7 months, HR for death = 0.74, 95% CI = 0.56 to 0.96, P = .026) with a 5-year survival rate of 15% (95% CI = 9% to 23%) vs 8% (95% CI = 4% to 14%). The improvements in progression-free survival and, to a lesser extent, in overall survival were evident even when the analysis excluded patients who received radical resection of metastases. With regard to the risk-stratified analysis, FOLFOXIRI results in longer progression-free survival and overall survival than FOLFIRI in all risk subgroups.

CONCLUSIONS

Six months of induction chemotherapy with FOLFOXIRI is associated with a clinically significant improvement in the long-term outcome compared with FOLFIRI with an absolute benefit in survival at 5 years of 7%.

[Lymphadenectomy in differentiated thyroid carcinoma]

Differentiated thyroid carcinoma accounts for 90% of all thyroid cancers and occurs as papillary carcinoma in 90% of cases. It was shown as this is characterized by an excellent long-term prognosis, although in follow-up long series, were described recurrence rates up to 35%. Although in the past has not been attributed prognostic significance to the lymph nodes, in the last decade has shown how these can affect the rate of locoregional recurrence of differentiated thyroid carcinoma. This renewed interest in lymph node metastatic disease has prompted a shift in surgical treatments more aggressive, with a view to achieving a low incidence of locoregional recurrence. Analyzing the more recent guidelines formulated at the international level, we can highlight how we gradually consolidated the role of prophylactic central compartment lymphadenectomy in the surgical treatment of patients with differentiated thyroid carcinoma. The aim of this treatment, in fact, is not only to reduce the mortality of patients, but to obtain an adequate staging, facilitate radiotherapy treatment, obtain undetectable thyroglobulin levels, avoiding the need for repeated reiterventi, made more simple follow-up. All these objectives can be achieved by careful surgery. Total thyroidectomy associated with prophylactic lymphadenectomy of the central compartment was found to achieve these objectives, although in the absence of data from randomized trials, its role remains controversial.

Histology classification is not a predictor of clinical outcomes in advanced non-small cell lung cancer (NSCLC) treated with vinorelbine or gemcitabine combinations

BACKGROUND

Until recently, histology has not been clearly or consistently described in the literature as a prognostic or predictive variable in advanced NSCLC studies. We have categorised patients treated with vinorelbine and gemcitabine based first line chemotherapy regimes for advanced NSCLC as either squamous or non-squamous, and also as either adenocarcinoma and non-adenocarcinoma, and compared outcome.

MATERIAL AND METHODS

420 patients treated with platinum/gemcitabine, platinum/vinorelbine or single agent gemcitabine or vinorelbine as first line chemotherapy for advanced NSCLC were identified. The influence of pathology on progression free survival (PFS) and overall survival (OS) has been investigated by means of a Cox regression analysis. Hazard ratios with 95% CIs have been given for each pathological type after adjusting for the effects of age, gender, stage (III vs. IV), PS (0/1 vs. 2/3) and treatment type (platinum doublet vs. single agent).

RESULTS

Neither univariate nor multivariate analysis suggested that there was a significant difference in the response rates for adenocarcinoma vs. non-adenocarcinoma or between squamous and non-squamous pathology. There was no difference in PFS between adenocarcinoma and non-adenocarcinoma pathologies until 8 months (p = 0.98), and there was a statistically significant advantage in PFS for squamous vs. non-squamous pathologies (p = 0.04). Using multivariate Cox regression analysis to adjust for the effects of age, gender, stage, PS, and treatment type, the pathology subtype was not significant. There was no difference in OS in any group.

CONCLUSIONS

These results suggest that histology may not be considered as a predictor of clinical outcome using these drugs.

Treatment options for small cell lung cancer - do we have more choice?

Small cell lung cancer (SCLC) is a significant health problem worldwide because of its high propensity for relapse. This review discusses existing and future therapies for the treatment of SCLC.

The combined endoscopic therapy (band ligation and sclerosis) in the eradication of the esophageal varices in the cirrhotic patient: our experience

AIM

In course of liver cirrhosis, esophageal varices develop with an incidence of 8-15% a year, and they constitute a sign of seriousness of portal hypertension. The risk of bleeding is estimated around 10-15% a year. The varices hemorrhage causes a high rate of mortality (around 30-35% for every hemorrhagic event). It follows that it is necessary to plan prophylactic strategies for all the cirrhotic patients, who are at risk of bleeding, or have already bled. Medical treatment with beta-blockers is indicated in the prophylaxis of the first bleeding, while endoscopic treatment represents now the most effective methodology either in acute bleeding, or in the prophylaxis of hemorrhage relapses. The available endoscopic methodologies are the sclerosis or band ligation of esophageal varices. However, unanimous consent about the greater effectiveness of a methodology compared to the other one doesn't exist. As far as the varices eradication is concerned, the authors have done a research to verify if the combined techniques, proposed in various studies appeared in literature, can have some advantages, in comparison with the single methodologies.

METHODS

Thirty-seven patients have been treated: 27 only with sclerosis and 10 with combined methodology (band-ligation followed by sclerosis of the small residual varices).

RESULTS

The group treated with the combined therapy have shown a reduction in relapses and in the main side effects and a better patients' compliance.

CONCLUSIONS

The combination of the two methodologies can have some advantages as for security, easiness of execution, reduction in complications, in varices relapse and, therefore, in the hemorrhagic relapses.

Role of Helicobacter pylori in patients with portal hypertensive gastropathy by liver cirrhosis hepatitis C virus-related

AIM

Portal hypertensive gastropathy (PHG) defines a pathological endoscopic picture characterized by the presence of alterations of the gastric mucosa found in patients with hepatopathy associated to an initial or evident portal hypertension. Gastropathy appears with two forms of different seriousness: the mild form, characterized by diffused congestion, petechiae of gastric mucosa (scarlatina type rash) and by the presence of typical hyperemic and edematous polygonal areas, delimited by a thin snake skin reticulation. In the severe form, together with such aspects, mucosal erosion, red spots, or a diffused hemorrhagic gastropathy are added. The pre-eminent pathogenetic element of such lesions seems to be the pathological increase of the portal pressure. The role of the Helicobacter pylori (H. pylori) in the development of these alterations, in terms of prevalence of infection in hepatopathic subjects, is still controversial. The authors have performed a research to verify if the H. pylori infection is correlated to the presence and/or to the gravity of PHG.

METHODS

One-hundred and nine patients, all suffering from hepatitis C virus (HCV)-correlated liver cirrhosis, with clinical and/or instrumental signs of portal hypertension have been analysed.

RESULTS

The histological prevalence of the infection from H. pylori in our statistical analysis was of 23.8% (26/109 patients).

CONCLUSIONS

The H. pylori infection appears to be not significant for the determination and the preservation of PHG.

[13 cases of angiodysplasia of the digestive system]

OBJECTIVE

This clinical study assesses the diagnostic and therapeutic problems entailed in so-called gastrointestinal angiodysplasias. Summary back ground data: the topic presents numerous, still unresolved, issues: classification (its clinical presentation and classification); anatomo-pathological identification; diagnosis and localization; treatment of patients with acute massive bleeding; long-term outcomes.

MATERIALS AND METHODS

Thirteen patients, equally distributed between both sexes an with a mean age of 54 years (range = 23-75), were observed and operated over a nearly 20 year period. All patients had acute massive bleeding localized to the stomach, duodenum, ileum, colon and rectum. Diagnosis and localization were previously obtained in nine patients, mostly using selective angiography. With the exception of two rectal localizations treated with embolization, all patients underwent surgical resection. In two cases operated on without previous diagnosis, (rebleeding occurred).

CONCLUSION

The data available in the literature are broadly substantiated, even if the mean age reported seems somewhat lower (54 yrs). Localizations were detected in nearly all segments of the gastrointestinal tract, and the indication to surgical resection possibly after detection of the angiodysplasia and source of bleeding is confirmed. The best diagnostic technique is selective angiography.